“There is a huge missed opportunity for health care professionals to contribute to hand hygiene as they miss 1 in 2 of all hand cleaning opportunities. ” –WHO, 2006 “What kills women with childbed fever is you doctors who carry deadly microbes from sick women to healthy ones! ”—Louis Pasteur, 1870 1 . 1. Background of the Study 1. 1. 1. Nosocomial infection burden Nosocomial infections or healthcare acquired infections can truly be a grave toll for hospital management as much as it is for end-beneficiaries, customers, and stakeholders.
Mortality reaches 80,000 annually ; 3 patients die per minute ; 10-20% % incidence globally, and figures are expectedly higher in Third World settings. This is not to mention the corollary problem of emerging microorganisms resistant to overuse of prophylactic and anticipatory shotgun antibiotic therapy as empirical solution. The damage wrought is paramount, reaching a cost of one billion pounds per year in Europe alone, resulting from these. 1 excluding priceless, needless mortalities and morbidities 1 1. 1. 2.
Role of Hand Hygiene Institute of Medicine has identified nosocomial Infection to be the most common complication for hospital patients and hands are the most common mode of transmission. In 1991, Harvard Practice Study on adverse events in health care indicated that surgical site infections were the second most frequent type of adverse event for inpatients, constituting 13%. One study established an excess mortality caused by NI to as high as 44% in ICU patients. 2 In a local study at Makati Medical Center by Tupasi & Littaua, mortality rate was reported to be all NI cases documented 4. 6 % of n the intensive care unit , and authors conclude that risk factors included invasive and manipulative procedures. “Majority of deaths from NI were associated with the use of respiratory equipment and Foley catheters which were potentially preventable by strict adherence to aseptic techniques”. 3 1. 1. 3 Reality of Poor Compliance Despite it being a seemingly simple practice, and despite the acknowledged fact that proper hand hygiene is considered the most critical, the most cost-effective measure of adequate infection program, compliance behavior management has been a protracted managerial headache globally.
Indeed in our age of ever increasing sophistication, those seemingly simple practices but with grave implications ironically are difficult to address. While the techniques involved in hand hygiene are simple, the complex interdependence of factors that determine hand hygiene behavior makes the study and management of hand hygiene complex. 2 1. 1. 4. Hand Hygiene Compliance : A Managerial Challenge It is now recognized that improving compliance with hand hygiene recommendations depends on altering human behavior and managing the environment.
Input from behavioral and social sciences is essential when designing studies to investigate compliance. Interventions to increase compliance with hand hygiene practices must be appropriate for different cultural and social need4 Speaking for all levels of health care workers , probably the major reason this seemingly simple problem is always taken for granted is the reality that the impact of something not so visible daily to the naked eye will always be swept under the rug amidst more outright demands concerns in patient care.
The rest of the justifications like forgetfulness, lack of time, inconvenience, complications, etc. are simply alibis. Given this, the greater burden falls on health care managers to do something so that compliance can be improved, and for health sector in general to come up with more evidence-based materials to convince HCW as well as policy-makers and managers about its importance. 1. 1. 5 Nosocomial Infection & Patient Safety Nosocomial infection control is a large part of patient safety, whose importance is currently being highlighted in the light of increasing adverse events which are at most preventable.
Prior to this study, the researcher delved into assessing the patient safety culture profile of QMMC, as a general backgrounder, and as part of re-packaging a new approach to an old problem. 3 1. 2. Statement of the Problem Understanding the patient safety culture profile of Quirino Memorial Medical Center gives us the over-all conceptual perspective to the problem at hand. The researcher finds it convenient to discuss it in terms of the Donabedian theme. 1. 2. 1. The Macroenvironment’s Patient Safety Profile 1. 2. 1. 1.
The QMMC Patient Safety Structure In alignment with the recent health care thrust, QMMC has revised in 2008 its mission to being “ a tertiary hospital providing a safe, accessible, affordable quality specialized healthcare that is dynamically responsive to the needs of its patients. ” Its unwavering commitment is towards delivering health care to all its clients regardless of socio-economic status and to continuously upgrade the services offered in terms of technical expertise, support service, equipment and infrastructure. Patient safety is first and foremost in its goals.
Its core values include cleanliness in all aspects including the physical environ, and Its fourth priority is “ to develop and sustain a hospital environment that embraces and practices a culture of safety”. The 7 core values it internalizes include the 7Cs: clean physically, mentally, spiritually, Christ-centered, compassionate, competent, culture-friendly, community-oriented, communicative. At this time, the plus factor is having a medical director who is passionate about the cause, much involved in regular meetings with Department of Health advocates on the matter. “In QMMC, Dr.
Rosalinda Arandia is seen as a charismatic figure in the improvement of health and medical 4 services offered by the hospital and in making recommendations on and implementing the hospital’s quality improvement program. ” 5 QMMC is a 350-bed national government hospital that stands in a 42,000-sqm lot between Katipunan Avenue and JP Rizal St, Project 4 Quezon City, Metro Manila. It has in recent years undergone a major upgrading and expansion of its buildings and facilities. Compared to the old infrastructure, the new building and facilities, provide a more sophisticated ambience.
Better equipment and architectural upgrading seem to inspire and motivate employees, and the architectural design seems to promote greater staff interaction and communication. Its occupancy rate is 120%. . QMMC is a corporatized government hospital, still waiting for complete privatization. When faced with budgetary constraints and too bureaucratic processes they generate their own resources through private solicitations, the biggest of which are donations and affiliation fees from training institutions.
As to equipment & supplies due to its being a government hospital, only about 60% of its equipment and supplies are provided for and is functioning at any given time. Maintenance and regular checks are being done and complied with as required. It has a total of 564 employees, 35% of whom are contractual. Among the permanent about half have worked for more than 10 years. Among the 549 employees, 159 are doctors (consultants, residents, interns) , 180 are nurses and 225 are administrative personnel. This number does not include those who are fielded from affiliate institutions for training, such as clinical clerks and allied 5 rofessions (nursing, pulmonary therapy, radiologic therapy, medical technology, dental, dietary, midwifery and caregiving). For the consultants and doctors, ratio to patient load is quite acceptable.
There are 69 resident physicians and 55 interns. In the wards, roughly the ratio is 1:5 per day; however in the out-patient department, the staff ratio is much higher 1:25 . In the intensive care unit, ratio can be improved to as good as 1:2 depending on the number of rotators from affiliate hospitals , for all professional groups. Attitudes of staff are an important aspects of culture. In QMMC, initial preliminary interviews ith staff revealed that there is some awareness of the concept of patient safety, in all levels of care and even administrative strata. Incident reporting is very minimal such as it is generally perceived that underreporting is rampant. 1. 2. 1. 2 The QMMC Patient Safety Process Profile Teamwork in respective clinical areas is perceived to be good by key administrators, although with the high rate of staff turnover due to training hospital affiliations, this is affected more often than not in a negative fashion. In terms of feedback and communication, there is no systematic evaluation of staff performance .
QMMC has been active in the Patient Safety Task Force of the Department of Health. Underway are devising standardized hospital forms, such as interdepartmental referral forms to enhance communication and lower risks of errors being committed in patient care. 6 In lieu of risk reduction, hand hygiene educational program has been recently revived by the Infectious Disease Team headed by Dr. James Tiu. Educational trainings as well as policy reinforcement are being conducted as the need arises among nursing staff. 1. 2. 1. 3. The QMMC Patient Safety Outcome Profile
At the time of study, there were no baseline data available as indicators such as compliance rates, nosocomial infection rates, or patient satisfaction surveys. There are no performance indicators that can be used as feedbacks to improve standards of care. This is a work in progress and hopefull this study becomes a tiny contribution. 1. 2. 2. QMMC’s UncontrolledNosocomial Infection Problem Analyzing the above profile of QMMC, and amidst the track record of physical and service upgrading efforts, the main problem of the hospital regarding patient safety is still nosocomial infection control.
Evidences of uncontrolled nosocomial infection are certain occurrences pointing to infection control problems in QMMC in the past 12 months have caused alarm, as follows: (a) Post-surgical wound dehiscence Anecdotal incidents of nosocomial infection getting out of control have been almost part of everyday work in a public hospital like QMMC. However, a situation that occurred last AugustOctober 2008 was particularly notable, wherein dehiscence occurred in a succession of ten postsurgical patients in two wards including the surgical ICU, during Day 5 to Day 11 of their hospital stay.
Culture studies revealed the usual notorious nosocomial Proteus microorganisms, E. coli, and 7 Staphylococcus areus , responsive to very expensive intravenous third generation cephalosporins and aminoglycosides, with or without re-suturing of the wounds (Appendix 1) . 6 Aside from the cost of these medications, the prolonged hospital stay with all its accompanying indirect costs to both patient and hospital were staggering. (b) Perennially high incidence of ICU pneumonias and urinary tract infections
Based on the latest QMMC Morbidity and Mortality Audit 2008, 7 among ICU patients hooked to ventilators for protracted duration, nosocomial pneumonias are still the leading cause of death. 1. 2. 3. Need for upgrading quality of hand hygiene practice During one root cause analysis done by the management, the Infectious Disease Committee, and the department concerned with the last year’s outbreak of dehiscence, the senior management surmised that the root problem or one of the root problems could be failure for proper andwashing among health staff. The intervention consisted of culture and sensitivity tests followed by proper antibiotic coverage. Policy on handwashing was also tightened up in terms of posting reminders on doors and walls and subsequent refresher educational modules by the Infectious Disease Head were conducted among nursing staff. However, no actual monitoring or evaluation of hand hygiene practices were done .
Despite educational training interventions, and despite the presence institutional policies posted on walls and doors, compliance to the practice among QMMC hospital staff has persisted to be unsatisfactory. 8 1. 3. Objectives of the Study GENERAL OBJECTIVE This study aimed to demonstrate the impact of a hand hygiene intervention package to QMMC MICU and SICU, using comparison of intervention.
SPECIFIC OBJECTIVES In more detail, this study aimed to : (a) Characterize the current hand hygiene practices in QMMC ICU according to its using structure-process-outcome dimensions; (b) Craft and implement an intervention package addressing manipulable areas of the structure issues identified in the structure-process-outcome dimensions of hand hygiene practices; (c) Measure hand hygiene structure-process-outcome variables as a function of healthcare worker factors and work area factors , pre- and post-intervention, as a way to evaluate impact of above intervention. d) Formulate recommendations to the QMMC management and its stakeholders based on the findings and lessons learned. structure-process-outcome variables pre- and post- 9 1. 4. Significance of the Study The study is valuable in the following general areas of health concern: (a) Infection Control. The study’s advocacy counts very significantly in terms of contributing towards decreasing the grave toll on preventable morbidity and mortality burden on patients and their families.
As we see more systematically the outcome of our efforts towards hand hygiene as it impacts infection control, we learn to rely less on antibiotic use which also lead to emergence of resistant microorganisms that are and will be potentially harder to control eventually. This study will then be part of fulfilling what WHO advocates to be done , i. e. “for better monitoring of outcomes for hand hygiene studies, reduction of infection rates must be demonstrated, high complexity to evaluate, but high priority requirement. 8 (b) Preventive thrust. Hospitals’ mission is supposedly preventive as much as curative. However, review of literature shows that hospitals, even in the First World settings, tend to so conveniently rely on antibiotic use both prophylactically and empirically in managing and controlling nosocomial infections. Hospital care need not be a double-edged sword nor do we need to stop mitigating phenomena which are in our hands to control, if only we heed the evidence-based principles put forth.
Prevention remains to be the better direction that health care must devote its resources on. (c) Cost savings. According to WHO, “direct costs of intervention and indirect costs associated with hand hygiene time & its promotion corresponds to less than 1% of costs of managing nosocomial infection. Studies on the costs of nosocomial infection caused its toll in terms of protracted hospital stay, expensive drug and antibiotic acquisition in addition to intensive care 10 nit stay, hematological, biochemical, microbiological and radiological tests, extra surgical procedures and working hours. (d) Healthcare management learning. WHO asserts that “measurement of the compliance of health care workers to hand hygiene measures is a recommended performance indicator of the quality of care”. (e) Compliance behavior management has been a protracted universal problem, as lack of interventional studies to convince policy makers, esp. local, both government and private, predispose health care systems prevalent to sustain awareness and implementation.
With the lack of attention given to the problem’s facets and determinants, this study can be a humble contribution. Relevance of this study to the institution and its various stakeholders include the following: (a) Study institution. Often, organizations take action based on some comparison of their measures to a set of benchmark measures. Armed with specific incidents about the organization’s culture, effective action plans flow logically and integrate into existing change processes.
QMMC can better select programs and tailor-fit strategies that will be most beneficial to upgrade the attitudes and mindset of the employees, to design the working environment, and to align with its vision-mission pursuit of quality and safety , and better service to patients. It will be helped to see patient and hospital outcomes in a better light. It will eventually have a baseline which will be useful for tracking impact of certain interventions for a sense of comparison. As it uses internationally known research methods, it will provide 1 internal as well as external benchmarking, especially with national government hospitals, both international and local. (b) Leadership. Since QMMC under the present leadership is into the process of advocating patient safety as a goal, this study will help them examine alignments of their policies and systems with their vision-mission statements , goals and core values. Later on when like in international settings and patient safety will be a government regulatory requirement, this hospital can provide benchmarking. (c) Hospital staff.
This study provides the staff the much-needed feedback about themselves, the colleagues they work with, and the patients they serve. Feedback is the first step to change. Studies such as this are advantageous in themselves in that it just the simple process of assessment baseline will in itself raise awareness of not only patient safety, specifically, infection control, but of the need for structure (staff attitudes) as well as process variables (teamwork, communication) relevant to safety and other hospital performance.
Moreover, they themselves can be target victims of nosocomial infection, so that studies like this could help boost their safety as well. (d) Affiliate training healthcare institutions. The importance of good hand hygiene practice and its observance will be highlighted among the trainees from more than 20 various health care schools, a value that they will most likely carry back to their respected institutions .
This is rather crucial and innovative as patient safety, specifically preventive practices to 12 nosocomial control such as hand hygiene are not yet that well-emphasized in the traditional medical and para-medical curricula. (e) Hospital management trainees. The results of this study can be a benchmarking study to compare, study and upgrade other hospitals, both local and international. The study becomes a venue to validate some of the tools that will be used for the first time locally.
Results of the study can be utilized by trainees for future research on patient safety and infection control and behavior modification techniques. (f) Healthcare community. This study will help control NI, emergence of resistant organisms for similar government hospitals. It provides significant research for Department of Health which is specific on approaching infection control through Total Quality Management assessment and strategies under their recent thrust on patient safety and quality assurance.
Since QMMC could very well be a good prototype of the other government hospitals , the results of this study can largely be of help in implementing the various enabling mechanisms stated in the Philhealth Benchbook. 9 (g) Patients. Above all, since awareness, education , and practice towards patient safety, specifically infection control will be highlighted in this study, the end beneficiary would ultimately be the patients and their families and guests whom this institution is servicing, no matter how indirect and long-term this impact would be. 3 1. 5 . Scope and Limitations of the Study • Being a primarily TQM research project, this study does not attempt to establish cause-and-effect relationship between hand hygiene and nosocomial infection . • This study does not include cost estimates and budgetary implications of intervention if eventually adopted by study institution. • Relative merits of the specific parts of the intervention is beyond the scope of the design.
• Time and budget constraints were real such that research design were limited in various ways and means. . 6. Definition of Terms and Acronyms TERMS: For purposes of clarity and reference in the discussions all throughout this study, the following definitions and acronyms would be used and referred to: Hand hygiene (HH)- refers to one of the areas in infection control that deals with systems of diminishing pathogenic microbe transmission through evidence-based philosophy and set of practices regarding the hands in relation to direct patient handling during the process of care. 0 14 Hand hygiene practice/practices (HHP) – refer/s to any form of action referable to disinfecting the hands prior to and after patient handling, in the most basic terms defined as “washing hands with soap/water or (rubbing with) disinfectant, for at least 15 seconds before and after patient contact, after any contact with a source of microorganism, and after removing gloves”. ( Healthcare Infection Control Practice Advisory ).
Hand hygiene event (HHE) – defined as the event involving any of the HH practices (washing, rubbing with disinfectant, donning with gloves) done before or after patient contact; (if both done before and after, they are considered independent events ; if both washing and donning with /removing gloves are done during one instance, it was counted as one event; this regardless of the correctness or adherence to other details as presently prescribed by currently available universal guidelines. 1 Hand hygiene opportunity (HH0) – defined as any event with a high-risk of microbial transmission, executed before and/or immediately after patient contact, regardless of whether gloves. They included all contact with body fluids, or involving manipulative contact with anything in the patient’s body or immediate environment .
Over-all hand hygiene compliance – includes all hand hygiene-related behavior in accordance with current institutional , (in this study, QMMC’s ) policy “ to wash hands before and after patient contact” regardless of its alignment with the most currently recommended international standards based on indication, technique, cleansing agent and duration ; this by strict classification based in literature definition, falls under “incomplete compliance”. 12 15
Complete compliance- refers to all hand hygiene-related practices aligned with the most-updated, most current evidence-based globally recommended guidelines, as required by WHO guidelines 2006 (with QMMC, being a government hospital). Hand hygiene structure-refers to staff factors and work area factors. Staff factors include inherent demographic characteristics, such as professional group, age, sex and duration of service. It also refers to more malleable factors such as staff attitude and training.
Work area factors refer to existing policies or specific protocol, logistic infrastructure and supplies, staff volume, patient volume, hospital type, work settings, organizational structure, etc. Hand hygiene process- refers to practice as to how it is done in terms of indication for method, duration, temporal relation to patient contact, cleansing and technique, and how it abides to the currently recommended evidence-based a guideline or protocol .
Hand hygiene outcome- refers to measurable events or indicators, for both patients, employees as well as organization; like overall healthcare worker compliance rates, as well as indirect outcomes of good hand hygiene proven in literature, such as nosocomial infection rates, transmission rates, colonization rates. ACRONYMS: For purposes of brevity of certain words and identities mentioned quite repeatedly all throughout the study, the following apply: 6 HCW- Healthcare worker; refers to any staff involved with direct handling of patients in a health facility NI- nosocomial infection; also HAI (healthcare acquired infection); refers to infection developing after 48 hours after admission or confinement in a health care facility. ABHR- alcohol-based hand rub-refers to a hand rub disinfectant with any alcohol of any concentration as the basic ingredient.
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