FINAL BSN MGRUENEWALD

Running head: ASK ME IF I WASHED MY HANDS 1
Ask me if I washed my hands: Empower patients, increase handwashing, decrease HAIs
Michelle Gruenewald
Grand Canyon University
Professional Capstone Project
NRS-441V
Ms. Gray
April 28, 2016

ASK ME IF I WASHED MY HANDS 2
Abstract
Hand hygiene (HH) is a problem in every healthcare facility in every city of the world. It
is impossible for management to monitor all healthcare personnel (HCP), patients, and visitors.
The gap lies in the HH habits of patients and the way HCP care for patients. For the patients at
the neurorehabilitation hospital, the goal for a decrease in hospital-associated infections lead to
this multimodal study that educated the staff and patients. A study was done in 2015, about the
four points in the patient’s day that they should wash their hands (Sunkesula, V. C., Knighton,
S., Zabarsky, T. F., Kundrapu, S., Higgins, P. A., & Donskey, C. J.). This seemed to work nicely
into the new patient education campaign. After the protocol was explained, the researchers
observed how the new protocol was being received. Educating and empowering the patients give
them the confidence needed to request all HCP perform HH before touching them. These
interventions also cut down the number of hospital-acquired infections (HAIs) as well as helping
to form good life-long habits. In addition, the patients felt invested enough in their own health to
ask their visitors perform HH; this is another step towards decreasing the HAI rate. The
interventions were not extensive; they included educating the healthcare teams, who then
educated and reinforced that education to the patients to make them more comfortable taking that
first step in asking that uncomfortable question. These interventions can only be positive, there
were no negative affects thus far, and none foreseeable of improved hand hygiene or educating
patients.
Key words: Handwashing, protocols, urinary tract infections, catheter-related, male,
female, bloodstream infection, adult, professional compliance, nurse, hospitals,
interventions, hand-sanitizer, adherence, compliance, health promotion

Ask me if I washed my hands: Empower patients, increase handwashing, decrease HAIs
Hospital patients only wash their hands about 30% of the time after using the bathroom
(Weller, 2014). Hospital-acquired infections (HAIs) are dangerous and preventable. According
to the Center for Disease Control (CDC), in 2011 there were 722,000 (HAIs) and of those,
75,000 patients died as a result (Division of Healthcare Quality Promotion (DHQP); National
Center for Emerging and Zoonotic Infectious Diseases (NCEZID); Centers for Disease Control
and Prevention [CDC], 2016). The biggest culprit in the spread of infectious disease at hospitals
or anywhere is hand hygiene compliance (HHC) King, Vlaev, Everett-Thomas, Fitzpatrick,
Darzi, and Birnbach (2016) This research project will begin the search for ways to fix HHC at
this nurse’s facility. For patients in the Neurorehabilitation unit, will educating them about the
importance of proper hand hygiene improve their compliance as well as their vigilance with the
staff (doctors, nurses, therapy, CNAs, housekeeping, etc..) who go in and out of their room all
day, thus reducing the spread of infection?
Problem
The study takes place at a small Long-term Acute Care and Neuro Rehab hospital in
Wisconsin, Lakeview Specialty Hospital. Only the Neurorehabilitation Unit was chosen because,
even though majority of the patients have suffered a traumatic brain injury (TBI), most of the
patients are completely alert and oriented, though slightly confused at times due to the TBI. As a
nurse on this unit, the one point that sticks out the most is the fact that patients rarely wash their
hands. Patients are in the habit of completely skipping the sink, even if they are in a wheelchair
and pushed up to it. There is also the concern of giving gentlemen a urinal to use in bed with no
hand wipes or sanitizer for them to use afterwards.

The employee hand hygiene compliance (HHC) is fair to average, however one would
not say the same for the patients or many of the visitors. This project is in no way meant to direct
blame on the patients but to take a step back and realize it is the job of the nurse to educate and
empower patients. When a patient lays in bed all day unable to get up independently, they rely
on the healthcare personnel (HCP) to give them everything they need. The members of the
interdisciplinary team that they come into contact with throughout the day were doctors, nurses,
nursing assistants, physical, occupational, respiratory, and speech therapists, and dietary
assistants. Both the patients and HCP do benefit from reminders. Patients require hand hygiene
(HH) in the hospital just as they do if they were doing everything independently. In addition, the
patients will be taught about the dangers of improper hand hygiene in the hospital, as well as at
home; they will also be encouraged to continue asking their visitors and the HCP to use HH to
protect themselves from infection.
The seemingly harmless concerns mentioned above could be the difference
between a bloodstream infection or going home healthy. This problem impacts the patient,
nurses, doctors, hospitals, and insurance companies, which in turn affects everyone when their
rates increase due to the unnecessary infections being spread. It also comes across negatively on
the staff and the facility, and most importantly making already compromised patients even more
vulnerable. The facility does get their fair share of patients with urinary tract infections (UTIs),
(Methicillin-resistant Staphylococcus aureus (MRSA), clostridium difficile (C-diff), and other
types of infections after being there for a while. This not only gives the impression of poor
quality nursing care because they are nurse sensitive indicators, but also Medicare will not cover
the cost of the treatment for these infections.
Solution

The main goal of the plan is to educate and empower patients, but it is actually
multifaceted. Initially all staff will watch a PowerPoint (see Appendix A for a complete version
of the slides) on the company’s learning software to get everyone on the same page. The “leader”
recruited a handful of advocates to help with the kick-off the campaign and answer questions in
the leader’s absence. Nurses will be responsible for the education, thus making them more aware
of hand hygiene. CNAs also will become more cognizant as they reinforce the teaching; having
more patient contact than any other discipline. The other therapies will be required to view the
educational software, as well as security, dietary and environmental staff. The doctors will also
be given information regarding the study and asked to be more mindful of their hand hygiene.
Since the patients will be armed with the new knowledge and power to ask “Did you wash your
hands?” in a sense, the patients will become the “watch dogs” and the enforcers for the visitors
(and doctors) at the same time. Most of the patients remain at this facility for at least three to four
weeks, which is enough time to form a habit.
Nursing Theory
Even though, this research is based in a hospital, it requires more of a community health
approach. “Models of Prevention” more specifically the “Tannahill Model of Health Promotion”
theory consists of some basic tenets that are crucial to the hand hygiene project such as:
 Health education- Education is huge part of hand hygiene, especially for patients and
visitors.
 Health protection- Staff, patients, and visitors will need to abide by the hospital and
government policies.
 Prevention- The biggest part of this campaign refers to HHC. Proper hand hygiene
alone can prevent an unnecessary infection outbreak.

The initial teaching PowerPoint presentation (see Appendix A) will educate the staff
about the details of the Hand Hygiene (HH) Campaign. The staff will be educated and instructed
to perform HH with the patient at the “Four Moments for Patient Hand Hygiene” (see Appendix
B for more information, (Sunkesula et al., 2015, figure 1)) including:
 Entering and exiting the patient’s room
 Before meals
 Before and after touching any wound or devices
 After using the bathroom
Past studies have shown that when HCP educate patients about HH, they become more self-
conscious about HH as well, thus adding to the decrease in infections (Fox, C., Wavra, T., Drake,
D. A., Mulligan, D., Bennett, Y. P., Nelson, C., ... Bader, M. K. 2015).
Problems with hand hygiene compliance (HHC) is not unique to this nurse’s workplace,
it is unfortunately quite common everywhere. One of the objectives of the Healthy People 2020
Campaign is to “prevent, reduce, and ultimately eliminate healthcare-associated infections”
(Healthy People 2020, 2014, para. 1). Besides the responsible prescribing of antibiotics, infection
control, and hand hygiene are the most important factors in helping to meet that objective. The
IPN at this nurse’s facility had recently recognized a need for better HHC and began the early
stages of an observational study by enlisting several “secret agents” who would observe and
record the HHC habits of fellow co-workers.
After searching through many articles about different ways that hand hygiene is not being
met, and infection rates were still not meeting the goals for the “Healthy People 2020” the
decision was clear that there had to be a new angle. Hand hygiene was taught to nurses from day
one; why were there still so many HAIs? Where was the missing link? What if it was not in fact

the nurses’ hands that were carrying the infection-causing agents? Could they be coming from
the patients’ hands? While doing more research on this topic, there was another thought… about
visitors. What is to stop visitors from bringing infectious diseases into the hospital? If a visitor
gets a patient sick, leaving the hospital to believe it is a “hospital-acquired infection” because the
patient was in the hospital over three days when the visitor brought the community acquired
infection into the hospital. The same could go in reverse; after talking this over with the IPN, the
topic was settled on patient hand hygiene. The best way to do this was to verbally teach as well
as demonstrate, along with continuous reinforcement and encouragement.
Evidence to support the interventions chosen for this proposal include articles about
previous studies where from certain interventions have been adapted. The specific HHP “Four
moments in patient hand hygiene” was used in another study where pre-intervention only 10% of
the 606 observations showed the patients performing HH, while post-intervention, the results
ranged from 51-79% (Sunkesula, Knighton, Kundrapu, Higgins, & Donskey, 2015). An article
regarding patient empowerment (McGuckin & Govednik, 2014), relates how patients do not
have a realistic view of the HHC of HCP and also most do not feel comfortable asking their
HCPs to perform HH just before touching them. This writer saw teaching opportunity here for
patient self-advocacy. Several other studies showed proof that there was an adequate gap in
knowledge for hand hygiene among patients, as well as visitors, and health care workers could
always use a brush-up (Birnbach et al., 2012) (King et al., 2016).
Implementation
The facility is rather small with only two hospital wings, one with less than 39-beds
between the Neurorehabilitation (NRH) and the LTACH. This study focused on the NRH wing
because many of the patients on the other wing were much more critical. Since the hospital is so

small, the approval process for this study consisted of coordinating with the Infection Prevention
Nurse (IPN). The IPN had a pivotal role in this operation during the planning stages and had
approved the project ideas as the concept was being developed. The IPN also had access to the
software set-up, color copier, laminator, and funding for the project.
Resources Needed
The resources needed for the implementation stage of this project:
 PowerPoint to educate staff (see Appendix A)
 Copies of the poster “Four moments for patient hand hygiene” (see Appendix B)
(Sunkesula et al., 2015, figure 1).
 Hand Hygiene Saves Lives: A Patient’s Guide (CDC, 2016) (Appendix C)
 Custom pin-on buttons that read, “Ask me if I washed my hands” (see Appendix
D)
All of the supplies cost less than $50 out of the Infection Prevention Fund. The buttons
speak to “the encouragement and empowerment of patients” part of the project. The patients
seeing this sign [on the button] that literally tells them to ask the staff this question helps the
them become more comfortable in doing so.
The resources needed for the kick-off of the campaign are explained in the prior section.
The Information Technology department was contacted regarding the proper time to start the
PowerPoint for all employees to view on the company’s learning software system. The posters
were printed, laminated and pinned up on the bulletin boards in patient rooms. The “Ask me…”
buttons were distributed to staff to wear while working. Once the nursing staff is informed of the
campaign content, they are able to get started.
Evaluating the Project

It is essential to evaluate the outcome and effects of any new intervention after the
implementation; and even more importantly to report them to as many stakeholders as possible.
The faster high-quality evidence reaches the right people, the quicker evidence-based practice
influences nurses’ practice and helps them to give their patients the best possible care.
Evaluation Methods
The main method used to evaluate the new protocol will be observation in the early
stages of thin intervention. This method is not scientific or exact, the observers will simply watch
for nurses, CNAs, and other staff to be wearing the buttons saying, “Ask me if I washed my
hands”, and record it on a dated sheet in the charge nurse office. The observers will also be
watching for patients that are performing hand hygiene, whether it be alone, asking a caregiver
for it, or caregiver offering it to them. They will also be listening for the nurses teaching the
patients about hand hygiene. This nurse, the Charge Nurse and the IPN will also make rounds to
the alert and oriented patients to unobtrusively ask questions regarding how staff is doing with
the project. Staff will be recognized for their support with a token of thanks, “Let’s give--insert-
name--a hand” written on a paper cut-out of a hand and placed on a bulletin in a central location
for recognition.
The research team has long-term goals to compare HAI numbers from baseline the month
prior to intervention to month six as well as comparing invoices for soaps, hand sanitizer, and
hand wipes from baseline the month prior to the subsequent months to determine if more product
is being used. In addition, the team will continue observing patients and staff, with routine
interviews with patients. The goal is to keep the program going if there is a significant difference
after six months.
Variables to be Assessed

Unfortunately, there are many variables that could affect this study. The staff could either
accept it or reject it. How the staff perceives it could also affect the way they portray it to the
patients. Regardless of how the nurses portray the new protocol to the patients, there is bound to
be a strong pushback, because in general people just do not like change. So another variable is
the way the patients perceive the protocol and choose to accept or reject it. This will affect the
visitors, as well as the healthcare staff. If the patients love the idea and make everybody wash
their hands, visitors, doctors and staff may get irritated with this nurse for empowering them in
the first place. If the patients refuse, and the staff are really trying hard to make the protocol
work, they may get frustrated.
Educational Tools
This project is about knowledge, education, and empowerment. The education of
patients which requires the education of staff first. Educating the staff cannot be done by this
nurse alone because there are too many employees and this nurse works only two to three days
per week. Therefore, the first item on the agenda is to gain staff resources to use as advocates of
the program to help encourage, teach, answer questions, and act as a point person for the
program leader in this nurse’s absence. There were several advocates chosen before the kick-off
who were explained the idea behind the program, the education, and the components. They all
agreed to take on that position in this nurse’s absence. The next tool is the general education
PowerPoint that was added to Relias (www.reliaslearning.com), the company’s teaching
software that reaches out to each and every employee and keeps record of who reads the
education and who does not. All of the main points from the PowerPoint (see Appendix A) will
be what the nurses need to educate patients and the rest of the staff need to reinforce that

teaching. This information will also be available in the lobby on the huge bulletin board so all
staff, visitors, doctors, and administrators could see and be prompted to perform hand hygiene.
The bulletin board has several components including specific slides from the PowerPoint
(see Appendix A), the poster (see Appendix B), brochure, and button. In addition, there are also
some cut-outs of hands. The poster is the “Four Moments of Patient Hand Hygiene” (see
Appendix B) (Sunkesula et al., 2015, figure 2) that are the same ones as the printed and
laminated posters from the patients’ room for teaching. This explains the four times for patients
to remember to wash their hands. The brochure, was a free download found on the CDC (see
Appendix C) website called, Hand Hygiene Saves Lives: A Patient’s Guide (2016). The button
(see Appendix D) that was ordered from Imprint.com for employees and doctors to wear in order
to help empower patients to feel comfortable asking healthcare workers to perform hand-hygiene
before touching them which read, “Ask me if I washed my hands”. Lastly, the cut-out paper
hands, purchased at Hobby Lobby, with the names of written on them to recognize the
employees who were especially helpful with the kick-off as well as those who were willingly and
whole-heartedly in support of the campaign.
As with any nursing intervention, there must be an effective evaluation to decide if the
desired effect is, in fact, being achieved. The evaluation is also looking for how it is being
received. There may be a big resistance, by staff, by patients, or it may be very well received.
This is the step that allows the researcher to stop and take a look at these things and make
changes if needed. The more closely evaluated in this step, may save some time and steps in a
later stage.
Dissemination of Project Results

Dissemination of the results are one of, if not, the most important step in the research
process. The manner in which results are shared, and to whom, can be the deciding factor for
whether the information reaches nurses and patients at the clinical level. Since the ultimate goal
of nursing research is to improve patient care with evidence-based practice, the results must
reach as many stakeholders and in as many modes as possible.
Dissemination to Stakeholder
The first step is to brainstorm, making a list of all stakeholders: public, private, corporate,
civil, and interest groups including:
 Those who may be affected by the results
 Those involved in getting started on making the changes happen
 Anyone who may benefit from this knowledge and use it (CDC, 2012) (see Appendix
C)
Once the targets are known the dissemination can begin via mail, corporate e-mail, intranet and
fliers, external e-mail, personal connections, social media, professional forums, and even special
interest groups if it applies.
Dissemination to Greater Nursing Community
Getting the research out to the greater nursing community is more than just sharing with
nurse friends and coworkers. It is a shame to work so hard on research, not to let as many nurses
or patients as possible benefit from it as soon as possible. Nursing journals reach the nursing
community and are well-known all over the world; although they are the timeliest, they are the
most extensive. Journals are used as a reference for other research projects for years and decades
to come.
Conclusion

In conclusion, a multimodal approach to educating staff and patients about the
importance of hand hygiene and infection prevention helps to heighten awareness. However,
further studies need to be done to find new ways to empower patients and help them feel
confident enough to speak up on their own behalf.

Appendix A
Figure 1.
Figure 2.
Figure 3.
Figure 4.

Figure 5.
Figure 6.

Figure 7.
Figure 8.

Appendix B
Figure 9. This poster was laminated and used as a teaching tool for patients. (Sunkesula
et. al., 2015, figure 1)

Appendix C
http://www.cdc.gov/handhygiene/PDF/CDC_HandHygiene_Brochure.pdf

Appendix D
Figure 10. Pin-on Button for all staff to wear, "Ask me if I washed my hands" in hopes to
make patients more comfortable asking staff to perform hand hygiene before touching the

Review of Literature
Ardizzone, L. L., Smolowitz, J., Kline, N., Thom, B., & Larson, E. L. (2013). Patient hand
hygiene practices in surgical patients. American Journal of Infection Control, 41, 487-91.
http://dx.doi.org/http://dx.doi.org.lopes.idm.oclc.org/10.1016/j.ajic.2012.05.029
This article is about hand hygiene on post-surgical patients. The researchers did a pre-
intervention observation which showed poor results for patient hand hygiene. The
researchers then did some education for the nursing staff regarding doing patient hand
hygiene and returned after 30 days to observe again. The results were better but not great.
According to questions answered by nursing staff, they do not think about asking the
patients to wash their hands, they are rushed, or they forget. Patients do not think about it,
do not find full containers, or are not offered the opportunity. The educators came back
again two more times and did two more observations with the patients and nurses, trying
to determine if this is what was needed. The study was done because studies are always
focused on the hand hygiene of nurses, doctors, and other staff. No responsibility ever
lies on the patient himself. When surgical patients get a surgical site infection or SSI, the
fault lies completely on the hospital. A SSI is an infection of the skin in and the tissue
around the surgical incision within 30 days after surgery, when there is no implant, or one
year with an implant (Journal compilation Royal Australasian College of Surgeons, n.d.).
This is considered a hospital-acquired infection (HAI), an indication of quality nursing.
However, if we increase the education to patients about the importance of hand hygiene
and how it affects the SSI, we can then make the patient our partner by making them
accountable for their own health care.

The research design was quasi experimental, consisting of different parts,
observations, surveys, and questions of both the patients and the nurses to get the
perspective from both sides. The particular patient population consisted of only surgical
patients over 18 from one of three surgical units at a busy teaching hospital in an urban
area. The strengths were the consistency in using the same educators, the same observers,
the size of the sample and keeping the research subjects completely anonymous.
Limitations would be that surveying patients about memories of their experiences in the
hospital may not always be very accurate. In addition, the convenience sample cannot be
generalized because it is a small sample of nurses. The nursing staff also may tend to
skew the results not realizing how few times they actually do offer hand hygiene.
The research means that there is an opportunity for improvement in infection
control that lies on educating the patient to use hand hygiene, and to advocate for
themselves with staff. There is an opportunity with the staff to encourage compliance
with offering hand hygiene to patients, and more education to perhaps “drive it home” to
the staff the magnitude of their actions. The point being the patients need to be assisted
with hand hygiene, have access to soap and running water, hand sanitizer, or wipes in
addition to the current implications for health care professionals.
Barnett, A. G., Page, K., Campbell, M., Brain, D., Martin, E., Rashleigh-Rolls, R., ... Graves, N.
(2014, August). Changes in healthcare-associated Staphylococcus aureus bloodstream
infections after the introduction of a national hand hygiene initiative. Infection Control
and this article describes an observational quasiexperimental design study that took place
throughout 38 hospitals in six states of Australia. The test subject was actually Australia’s
new National Hand Hygiene Initiative. Throughout the six hospitals, there were twelve

possible patterns researchers had planned until they reached the one that worked best to
reduce the rate of infection. Limitations include no control hospitals, and there is no way
to tell if the other employees changed their habits to skew the results. The campaign
proved quite successful, with reduction of infection 17%, 28% immediately, another two
had a reduction of 8% and 11% gradually throughout the year, and the other two had no
change. One point that needs to be made, however is those two hospitals already had
extremely low infection rates already.
Bimbach, D. J., Nevo, I., Barnes, S., Fitzpatrick, M., Rosen, L. F., Everett-Thomas, R., ...
Arheart, K. L. (2012, May). Do hospital visitors wash their hands? Assessing the use of
alcohol-based hand sanitizer in a hospital lobby. American Journal of Infection Control,
40(4), 340-343.
http://dx.doi.org/http://dx.doi.org.lopes.idm.oclc.org/10.1016/j.ajic.2011.05.006 .
This article discusses an observational study regarding the role hospital visitors
play in the cause or spreading of infections that patients acquire during their stay in the
hospital, otherwise known as hospital-acquired infections (HAIs). Although, if the cause
is a visitor, it would not be fair to call it hospital acquired. This controlled study tried a
targeted approach, education, and ideal dispenser locations. The findings of the study
concluded that two very important factors are crucial to gain compliance, especially with
visitor, but also with the health care workers (HCW), those are positive cues and
incentives. For the 3000 observations pre and post intervention, the change was about
10% to the positive, which is still significant. According to Bimbach et al., (2012),
enlisting hospital visitors in the fight against the spread of infection, educational
interventions must be implemented, as well as assurance of their compliance.

Fakhry, M., Hannah, G. B., Anderson, O., Holmes, A., & Nathwani, D. (2012, May).
Effectiveness of an audible reminder on hand hygiene adherence. American Journal of
Infection Control, 40(4), 320-320.
This article discusses an 8-month pre-interventional and post-interventional study that
was carried out in an attempt to increase hand hygiene compliance (HHC), thus reducing
nosocomial infections. Said experiment took place at an acute care hospital where sensors
and automatic hand sanitizer machines were placed strategically at the entrance to the
hospital and at ward entrances to trigger a verbal reminder coming from the speakers, to
use hand-sanitizer. The World Health Organization’s (WHO) initiative, “Five moments to
hand hygiene” guidelines are multimodal, coming in different forms to educate patients,
families, visitors, and HCWs. They had videos playing in a loop on the televisions,
pamphlets, posters, and fliers in patient rooms. As in previous studies, visitors were also
recognized as being vectors of infection, both into and out of the hospital making HHC
that much more important. A total of 2,863 hand hygiene opportunities were observed.
Over the 8-month study period, with visitors being the group most widely represented.
All in all, compliance jumped from 7.6% pre-intervention to 49.9% post-intervention.
Flannigan, K. (2015, June 1). Asking for hand hygiene: Are patients comfortable asking, and, are
healthcare providers comfortable being asked? Canadian Journal of Infection Control,
30(2), 105-109. Retrieved from
https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&
db=ccm&AN=109838276&site=eds-live&scope=site

The article explains patients’ point of view about asking the HCW to wash their
hands. In addition, it speaks to the attitude of the HCW when they are asked to wash their
hands by the patients. All in all, patients feel comfortable asking if they know HCW do
not mind being asked; however, washing in front of the patient would work the best for
everyone. The study consisted of surveys that went out via email to the public and paper
copies were left in public places and were able to be dropped back off. The second part
was emails that went out to all of the doctors and nurses in that surrounding area as well
as in the physician newsletter regarding the comfort level of patients asking the HCW to
use HHC before touching them. The paper survey that were returned were added to the
computer and to the digital surveys. With 433 public answered they would not ask their
HCP to perform HH because they would not want to offend the HCP (58%) indicated it
may affect the level of care (32%). Of the HCP that answered, 95% of docs and nurses
were at least somewhat comfortable being asked. Other comments that came from the
survey: suggestions were to have the hand sanitizer or sink in sight of the patient, 86% of
the public believed they were at risk, even if the HCP not performed HH just prior to
seeing them.
Fox, C., Wavra, T., Drake, D. A., Mulligan, D., Bennett, Y. P., Nelson, C., ... Bader, M. K.
(2015, May 1). Use of a patient hand hygiene protocol to reduce hospital-acquired
infections and improve nurses’ hand washing. American Journal of Critical Care, 24(3),
216-224. http://dx.doi.org/doi: 10.4037/ajcc2015898
This research article describes a quality improvement study that took place in a
27-bed Cardiovascular Intensive Care Unit (CV-ICU) at Mission Hills Hospital in
California. The average daily census was 22.2 patients, based on acuity, nurses would

have 1-2 patients each. Nurses were checked off on patient handwashing as well as their
own. The researcher were seeking the answers to two questions regarding infection
control: 1) Is the correlation between patient hand hygiene protocol (PHHP) associated
with decreased central line acquired blood stream infection (CLABSI) and catheter
associated urinary tract infections (CAUTI) rates in the ICU? 2) Is the PHHP associated
with an increased handwashing compliance among ICU nurses? The PHHP consists of a
treatment of 2% chlorhexidine (CHG) wipes applied to the patient’s hand three times per
day (TID) as per the electronic medication administration record (eMAR) at 0800, 1400,
and 2000 the eMAR would give an electronic reminder just as it would a medication that
is due.
The design consisted of three phases, a pre-experimental study design collecting
data from December 2009 to February 2012, a comparison phase 12-month period pre-
implementation, 10-week training protocol, a 12-month period during the
implementation. The number of CAUTIs decreased from 9.1 to 5.6 per 1000 catheter
days, not significantly different. CLABSIs decreased from 1.1 to 0.50 per 1000 per
catheter days which is also not significant. HHC for nurses went from 0to 86% when
entering the room, 41% to 87% which was not significantly different. Before the study,
the nurses were more focused on protecting themselves as evidenced by them washing
their hands more often when exiting the room versus entering. After the study, their
attitudes seemed to have changed.
King, D., Vlaev, I., Everett-Thomas, R., Fitzpatrick, M., Darzi, A., & Birnbach, D. J. (2016).
“Priming” hand hygiene compliance in clinical environments. American Psychological

Association, 35(1), 96-101.
http://dx.doi.org/http://dx.doi.org.lopes.idm.oclc.org/10.1037/hea0000239 .
This article is one of the first research studies to use the implicit memory
technique called “priming” in regards to changing a behavior in real world situations as
opposed to a laboratory setting. Priming as defined by www.explorable.com (2011), is
the effect in which exposure to a stimulus will influences response to a later stimulus.
This randomized controlled trial (RCT) took place in a surgical intensive care unit
(SICU) at a teaching hospital in Miami, FL between November 2012 and January 2013.
The 404 unsuspecting participants included nurses, doctors, ancillary staff, and visitors.
They were being unobtrusively observed by two researchers one inside and one outside
the glass doors to observe HHC at any time between entering the SICU and arriving at
the patient’s room.
The “primers” in this case were an “olfactory” primer of a clean fresh smell or a
“visual” primer of a photo of a pair of eyes half of the day they were male and the other
half the eyes were female, mounted above the gel dispenser. They were stern-looking
middle-aged which in other studies had shown the strongest effect.
If nothing else, this study again proves that HHC needs to be addressed. Only
15% of the participants in the control group adhered to HHC. The interventions did prove
to bring about a significant increase in HHC, the olfactory more than the visual, 46.9%
and 33.3% respectively. This study has many limitations, they did not ask the participants
why they chose to or not to perform HH, or whether they noticed the primers. The times
and days were randomized and the participants changed. There is much more research to

be done, but this was a good start. Helping to get HHC under control will certainly reduce
the HAIs facing patients currently.
McGuckin, M., & Govednik, J. (2013, July). Review: Patient empowerment and hand hygiene,
1997–2012. Journal of Hospital Infection, 84(3), 191-199.
http://dx.doi.org/10.1016/j.jhin.2013.01.014
This article is consistent with the research in that it reiterates the attitudes of the
health care workers (HCW) which is they believe to be washing their hands about three
times as much as they actually do. This gives reason for pause because everyone in the
hospital, including the patient and the staff need to be on board with hand hygiene to
prevent the spread of infection.
According to Rickard (2004), 10% of hospital patients acquire health-care
associated infections (HCAI) and of that it is estimated that one-third could be prevented
with proper hand The article does support the changes in this nurse’s proposal, although
the statistical information will not apply because it is estimated and outdated. The ideas
are still valid.
This article supports this nurse’s proposal of empowering patients to take
accountability for hand washing by educating them, letting the patients know that it is
okay to ask their nurse, doctor, therapist, or nursing assistant to perform hand hygiene
before touching them. According to this article, 69% of the 1,000 respondents believe
that compliance is at least 50% by HCW. This article concludes that consumers need to

be educated about their rights and hand hygiene to allow them to advocate for their own
safety. The ORC International is an organization very experienced in measuring
awareness and engagement among consumers, conducted this online survey via random
sample of the general population of the United States of America. This research suggests
that many consumers have blind faith in their HCWs, which may leave them vulnerable
at times or at risk for infection.
As previous studies by King, et al, Fox, et al, and the list goes on have proven,
HCWs are not flawless in HHC, in fact, quite the opposite. King suggests to come out
with an organized manner of letting the public know just how low HHC is in an effort to
empower them. Patients need to be educated to advocate for themselves when there is no
one else around to do it for them. Of the respondents who responded that they have in the
past, asked a HCW to use HH before touching them, 57% cited no particular source, but
24% said they learned it from their nurse, doctor, or other HCW. The limitations in this
study were such that the people who responded are only those that wanted to and that had
access to a computer.
Pelat, C., Kardas-Sloma, L., Birgand, G., Ruppe, E., Schwazinger, M., Andremont, A., ...
Yazdanpanah, Y. (2016, March). Hand hygiene, cohorting, or antibiotic restriction to
control outbreaks of multidrug-resistant Enterobacteriaceae. Infection Control and
Hospital Epidemiology, 37(3), 272. http://dx.doi.org/doi: 10.1017/ice.2015.284
Rickard, N. (2004, April). 8. British Journal of Nursing, 13(7), 404-410. Retrieved from
https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&
db=ccm&AN=106762309&site=eds-live&scope=site
hygiene. Hand hygiene: promoting compliance among nurses and health workers.

This article is consistent with the research in that it reiterates the attitudes of the
health care workers (HCW) which is they believe to be washing their hands about three
times as much as they actually do. This gives reason for pause because everyone in the
hospital, including the patient and the staff need to be on board with hand hygiene to
prevent the spread of infection.
According to Rickard (2004), 10% of hospital patients acquire health-care
associated infections (HCAI) and of that it is estimated that one-third could be prevented
with proper hand hygiene The article does support the changes in this nurse’s proposal,
although the statistical information will not apply because it is estimated and outdated.
The ideas are still valid.
Schweon, S. J., Edmonds, S. L., Kirk, J., Rowland, D. Y., & Acosta, C. (2013). Effectiveness of
a comprehensive hand hygiene program for reduction of infection rates in a long-term
care facility. American Journal of Infection Control, 41, 39-44. http://dx.doi.org/DOI:
10.1016/j.ajic.2012.02.010
This article discusses research done in a Long-term Care Facility (LTCF) in an
effort to reduce lower respiratory tract infections (LRTI) and skin and soft tissue
infections (SSTIs) with increased compliance of hand hygiene by the health care
personnel (HCP) and the residents (Schweon, et al.,2013). This study was a pre and post
intervention experiment to determine how the impact of the pre-intervention soap and
water phase will hold up to the intervention. The intervention is quite comprehensive, but
not unrealistic, consisting of touch-free alcohol-based hand sanitizers (ABHR) in
multiple formats including: dispensers in high traffic areas, wipes on food trays,
educational program for all hcp (HCP), videos, and personal hand sanitizers for everyone.

Employees were recognized for strength in compliance, each month a “champion” was
chosen to be honored.
Sopirala, M. M., Yahle-Dunbar, L., Smyer, J., Wellington, L., Dickman, J., Zikri, N., ...
Mangino, J. (2014). Infection Control Link Nurse Program: An interdisciplinary
approach in targeting health care-acquired infection. American Journal of Infection
Control, 42, 353-9. http://dx.doi.org/10.1016/j.ajic.2013.10.007.
This article describes the difference one university hospital made to the rate of
HAIs by taking a cohort of nursing students and teaching them infection control with the
Infection Prevention Specialist at the hospital versus the way it had previously been done.
This liaison program was an effective interdisciplinary effort that efficaciously reduced
healthcare-acquired (HCA), methicillin-resistant Staphylococcus aureus (MRSA) in a
university hospital setting. The period from January 2006 to March 2008 was measured
as a baseline, and the intervention period was April 2008 to September 2009. Staff nurses
were trained to be infection prevention (IP) liaisons, with ongoing monthly education and
assignments.
The efforts paid off HCA-MRSA incidence decreased by 28% while HCA-MRSA
bacteremia decreased by forty-one percent. As a result of the efforts, total (HCA and non-
HCA) MRSA rate and MRSA bacteremia and HHC also increased significantly.
Herruzo, R., Yela, R., & Vizcaino, M. J. (2015, July 1). Lasting hand self-disinfection: A backup
for hospital hand hygiene? American Journal of Infection Control, 43(7), 697-701.
http://dx.doi.org/https://doi.org/10.1016/j.ajic.2015.03.014
The World Health Organization’s 5 Moments for Hand Hygiene are the basis for
which the health care facilities should try to comply. However, that does not always

work. This controlled trial tested six different antimicrobials against the control, in vivo
(in person), and in vitro (test tube). The strains of microbiota came from the ICU. The
goal was to determine the length of time the antimicrobial properties stay in effect. The
conclusion of the study was that 0.6% chlorhexidine plus isopropanol plus 0.1%
benzalconium chloride is the best option.
Squires, J. E., Linklater, S., Grimshaw, J. M., Graham, I. D., Sullivan, K., Bruce, N., ... Suh, K.
N. (2014, December). Understanding practice: Factors that influence physician hand
hygiene compliance. Infection Control and Hospital Epidemiology, 35(12).
http://dx.doi.org/https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/login.as
px?direct=true&db=ccm&AN=103920708&site=eds-live&scope=site
One domain that is sometimes overlooked as far as a means of infection control
are the physicians. Many times physicians see themselves as different and do not abide
by the same rules that everyone else does. There is no real reason for it, even if you ask
them, they cannot tell you why. This article examines a group of 42 physicians and
residents from medical and surgical units of one tertiary care hospital. This qualitative
study consists of many questions asked of these physicians to try and uncover just what
their thought process is at the time and possibly identify behavioral determinants that act
as both barriers and as enablers to using HHC. The study was guided by a theoretical
domain framework (TDF), which is a behavioral change theory. This was chosen because
it is widespread and may be possible to identify more of the problems. The interventions
will need to be more behavior and psychological because there are too many reasons or
excuses to mention, a knowledge gap, as well as a huge need for education regarding this
issue with the doctors. Future studies will need not be so broad.

Sunkesula, V. C., Knighton, S., Zabarsky, T. F., Kundrapu, S., Higgins, P. A., & Donskey, C. J.
(2015, August). Four moments for patient hand hygiene: A patient-centered, provider-
facilitated model to improve patient hand hygiene. Infection Control & Hospital
Epidemiology, 36(8), 986-989. http://dx.doi.org/10.1017/ice.2015.78
This study is a 3-phase study conducted to test the effects of the intervention:
Four moments for patient hand hygiene This initiative identified the following four
instances to focus on patient hand hygiene: 1) mealtime 2) entering and exiting the
patient’s room, 3) before and after contact with the patients’ catheter, devices or wounds,
and 4) after using the bathroom. Healthcare personnel (HCP) must be vigilant to make
this research work. The success of the study depends on some basic but important issues:
1) the nursing staff must educate the patients about hand hygiene and the four moments
that are of focus in this study 2) nursing must let the patients know it is their right and
their job to advocate for themselves if staff does not help them perform hand hygiene, 3)
they must adhere to the four moments, and 4) nursing and ancillary staff must also give
100% cooperation.
This research design was a survey with a convenience sample of 100 patients
from six different medical surgical units at the Cleveland VA Medical Center, a 215 bed
acute care facility. This survey lasted over 8 months with two independent investigators
also concurrently doing an observation (Sunkesula et al., 2015). Another 30-day survey
was conducted on a 36 bed surgical telemetry ward. The Middle range theory, Health
Promotion Model (HPM) (Burns & Grove, 2011) is the framework for this study which
will help the researcher to uncover cognitive-behavioral factors that will help to
determine behavioral outcomes (Sunkesula et al., 2015) to help modify HH behaviors in

the hospital. This study has many strengths, such as the large sample size, the length of
time observed, the data was collected over several sessions, the framework, and the fact
that there were two independent observers gathering data. However, the limitations
include the fact that the interventions require active participation from staff that may or
may not continue once the study is done. There should be further research done, to get
more definitive proof, after several studies are done and an expert in this field reviews it,
then it could be adopted as evidence-based practice. So, for now it is weak evidence, but
still interesting and important to this nurse’s research.

References
Ardizzone, L. L., Smolowitz, J., Kline, N., Thom, B., & Larson, E. L. (2013). Patient hand hygiene
practices in surgical patients. American Journal of Infection Control, 41, 487-91.
Barnett, A. G., Page, K., Campbell, M., Brain, D., Martin, E., Rashleigh-Rolls, R., ... Graves, N.
(2014, August). Changes in healthcare-associated Staphylococcus aureus bloodstream
infections after the introduction of a national hand hygiene initiative. Infection Control
and Hospital Epidemiology, 35(8).
http://dx.doi.org/https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/logi
n.aspx?direct=true&db=ccm&AN=103973888&site=eds-live&scope=site
Bimbach, D. J., Nevo, I., Barnes, S., Fitzpatrick, M., Rosen, L. F., Everett-Thomas, R., ... Arheart,
K. L. (2012, May). Do hospital visitors wash their hands? Assessing the use of alcohol-
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healthcare providers comfortable being asked? Canadian Journal of Infection Control,
30(2), 105-109. Retrieved from
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e&db=ccm&AN=109838276&site=eds-live&scope=site
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Herruzo, R., Yela, R., & Vizcaino, M. J. (2015, July 1). Lasting hand self-disinfection: A backup for
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control outbreaks of multidrug-resistant Enterobacteriaceae. Infection Control and
Hospital Epidemiology, 37(3), 272. http://dx.doi.org/doi: 10.1017/ice.2015.284
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453000-cases-29000-deaths
Schweon, S. J., Edmonds, S. L., Kirk, J., Rowland, D. Y., & Acosta, C. (2013). Effectiveness of a
comprehensive hand hygiene program for reduction of infection rates in a long-term
care facility. American Journal of Infection Control, 41, 39-44. http://dx.doi.org/DOI:
10.1016/j.ajic.2012.02.010
Sopirala, M. M., Yahle-Dunbar, L., Smyer, J., Wellington, L., Dickman, J., Zikri, N., ... Mangino, J.
(2014). Infection Control Link Nurse Program: An interdisciplinary approach in targeting

health care-acquired infection. American Journal of Infection Control, 42, 353-9.
http://dx.doi.org/10.1016/j.ajic.2013.10.007.
Squires, J. E., Linklater, S., Grimshaw, J. M., Graham, I. D., Sullivan, K., Bruce, N., ... Suh, K. N.
(2014, December). Understanding practice: Factors that influence physician hand
hygiene compliance. Infection Control and Hospital Epidemiology, 35(12).
http://dx.doi.org/https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/logi
n.aspx?direct=true&db=ccm&AN=103920708&site=eds-live&scope=site
Sunkesula, V. C., Knighton, S., Zabarsky, T. F., Kundrapu, S., Higgins, P. A., & Donskey, C. J.
(2015, August). Four moments for patient hand hygiene: A patient-centered, provider-
facilitated model to improve patient hand hygiene. Infection Control & Hospital
Epidemiology, 36(8), 986-989. http://dx.doi.org/10.1017/ice.2015.78
Weller, C. (2014). Hand washing rates too low among hospital patients, may spur hospital-
acquired infections. Retrieved from http://www.medicaldaily.com/hand-washing-rates-
too-low-among-hospital-patients-may-spur-hospital-acquired-infections-306494
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1(1), 67-79. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2682454/

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