Compliance with universal precautions among pediatric residents

Universal precautions

The purpose of this literature review is to consider key themes from empirical research relating to the knowledge and compliance of universal precautions amongst healthcare practitioners. Utilising international studies, strategies to improve universal precautions are analysed. The review identifies areas of limited knowledge, synthesises existing research and suggests aspects of universal precautions that need to be studied further.

A literature search of studies listed in the Cumulative Index of Nursing and Allied Health Literature (CINAHL) database was conducted from 1990–2003, using a number of key words. Review, analysis and synthesis of selected studies were performed.

The findings of this review showed that universal precautions are considered an effective means of protecting patients and staff and controlling infection. The consensus from this body of evidence is that, globally, knowledge of universal precautions is inadequate and compliance low. Studies from many countries have shown that specific intervention strategies, such as education, are influential in improving knowledge and compliance.

This review concludes that it is imperative that future research examines how the attitudes and beliefs of practitioners can be influenced and changed to reenforce adherence to universal precautions within the clinical practice setting. There remains a lack of evidence on the long-term benefits of practice interventions to improve compliance, and what specific barriers are influential in affecting how healthcare practitioners adopt universal precautions more effectively in their practice.

Perceptions of infection control practices among health professionals

Infection control practice is a cornerstone of modern health care. However, there is minimal research into health professionals' perception of infection control practices and how those perceptions influence staff compliance with recommended protocols. The objective of this study was to explore health care professionals' perceptions of infection control practices in relation to the management of infectious diseases. A grounded theory approach was used as the research framework. Semi-structured interviews were completed with a sample of 16 nurses and doctors working at hospitals in Western Australia. Four major categories emerged from the data. These were: knowledge, culture, conflict, and risk assessment. The findings indicate the importance of both individual and organisational factors in determining clinicians' levels of compliance with recommended infection control practices. Identification of the factors that influence health professionals' level of compliance can be used to develop strategies to support long-term compliance with infection control practices.

Understanding practice: factors that influence physician hand hygiene compliance

OBJECTIVE

To identify the behavioral determinants--both barriers and enablers--that may impact physician hand hygiene compliance.

DESIGN

A qualitative study involving semistructured key informant interviews with staff physicians and residents.

SETTING

An urban, 1,100-bed multisite tertiary care Canadian hospital.

PARTICIPANTS

A total of 42 staff physicians and residents in internal medicine and surgery.

METHODS

Semistructured interviews were conducted using an interview guide that was based on the theoretical domains framework (TDF), a behavior change framework comprised of 14 theoretical domains that explain health-related behavior change. Interview transcripts were analyzed using thematic content analysis involving a systematic 3-step approach: coding, generation of specific beliefs, and identification of relevant TDF domains.

RESULTS

Similar determinants were reported by staff physicians and residents and between medicine and surgery. A total of 53 specific beliefs from 9 theoretical domains were identified as relevant to physician hand hygiene compliance. The 9 relevant domains were knowledge; skills; beliefs about capabilities; beliefs about consequences; goals; memory, attention, and decision processes; environmental context and resources; social professional role and identity; and social influences.

CONCLUSIONS

We identified several key determinants that physicians believe influence whether and when they practice hand hygiene at work. These beliefs identify potential individual, team, and organization targets for behavior change interventions to improve physician hand hygiene compliance.

Patient involvement in patient safety: the health-care professional's perspective

BACKGROUND

Despite increasing recognition that patients could play an important role in promoting the safety of their care, little is known on this issue regarding health-care professionals' (HCPs') attitudes toward patient involvement.

OBJECTIVES

To investigate physicians' and nurses' attitudes toward patient involvement in safety-related behaviors, both through their eyes as a health-care professional and as a potential patient.

DESIGN

Cross-sectional exploratory study using 2 surveys. Survey 1 addressed HCPs' attitudes toward supporting patient participation in safety-related behaviors. Survey 2 addressed HCPs' reported willingness to participate in safety-related behaviors (as a patient).

PARTICIPANTS

Eighty health-care professionals (40 physicians and 40 nurses) from an inner city London teaching hospital.

FINDINGS

Attitudes were affected by the type of behavior, who the HCP is interacting with, and the participants own professional role. Overall, both professions held positive attitudes toward patient involvement, although in general, nurses versus physicians were more willing to both support patient involvement and participate themselves as a patient.

CONCLUSION

Compared with other research on "lay" patients' attitudes, our data suggest that when HCPs are patients in hospital, they may be more willing to participate in safety-related behaviors. Promisingly, our data also suggest HCPs are willing to support patient involvement in safety-related behaviors, which may suggest they are happy to participate in interventions aimed at encouraging patient involvement in this area. Further in-depth research is needed to investigate the roles that HCPs (as both a patient and HCP) believe are appropriate for patients to participate in, under what circumstances and why.

Improving physician hand hygiene compliance using behavioural theories: a study protocol

BACKGROUND

Healthcare-associated infections affect 10% of patients in Canadian acute-care hospitals and are significant and preventable causes of morbidity and mortality among hospitalized patients. Hand hygiene is among the simplest and most effective preventive measures to reduce these infections. However, compliance with hand hygiene among healthcare workers, specifically among physicians, is consistently suboptimal. We aim to first identify the barriers and enablers to physician hand hygiene compliance, and then to develop and pilot a theory-based knowledge translation intervention to increase physicians' compliance with best hand hygiene practice.

DESIGN

The study consists of three phases. In Phase 1, we will identify barriers and enablers to hand hygiene compliance by physicians. This will include: key informant interviews with physicians and residents using a structured interview guide, informed by the Theoretical Domains Framework; nonparticipant observation of physician/resident hand hygiene audit sessions; and focus groups with hand hygiene experts. In Phase 2, we will conduct intervention mapping to develop a theory-based knowledge translation intervention to improve physician hand hygiene compliance. Finally, in Phase 3, we will pilot the knowledge translation intervention in four patient care units.

DISCUSSION

In this study, we will use a behavioural theory approach to obtain a better understanding of the barriers and enablers to physician hand hygiene compliance. This will provide a comprehensive framework on which to develop knowledge translation interventions that may be more successful in improving hand hygiene practice. Upon completion of this study, we will refine the piloted knowledge translation intervention so it can be tested in a multi-site cluster randomized controlled trial.

Poor compliance with standard precautions against infections during minor gynaecological procedures

BACKGROUND

Splash injuries occurring during minor surgical procedures are associated with a significant infective risk to the operator. It is a common misconception that minor operations carry low risks.

AIM

To determine the prevalence of the practice of Standard Precautions by medical staff in the obstetric and gynaecology (O & G) units of two hospitals in New Zealand, and to assess self-observed splash injury rates.

METHOD

A cross-sectional survey of all doctors working in the O & G units of two public hospitals servicing a population of 435 000. A self-administered questionnaire was provided to 43 doctors with questions related to the use of Standard Precautions, perceived likelihood of infection from a splash and splash injuries sustained during procedures.

RESULTS

The response rate was 76.6% (n = 33/43). Of the respondents, only 30.3% (n = 10) used Standard Precautions during minor procedures. Sixty-four per cent (n = 21) routinely used goggles/visor for eye protection. Forty-five per cent (n = 15) thought they were likely to get an infection from a splash, and 55% (n = 18) of clinicians had experienced a splash injury. Of the minor procedures during which splash injuries had occurred, repair of episiotomy 45.8% (n = 11) was the commonest.

CONCLUSIONS

This survey shows poor compliance with guidelines for Standard Precautions to protect from infection despite self-reported rates of splash injury being high at 55%. Effective interventions are needed to increase compliance and prevent infection.

Standard precautions in the pediatric emergency department: knowledge, attitudes, and behaviors of pediatric and emergency medicine residents

OBJECTIVES

To determine if pediatric residents (PRs) and emergency medicine residents (EMRs) differ in their knowledge, attitudes, and behaviors about standard precautions (SPs) in the pediatric emergency department and to identify any differences in perceived obstacles to adherence to SPs.

METHODS

A cross-sectional survey of PRs and EMRs from 1 program was conducted. The survey addressed 4 domains: knowledge, attitudes, behaviors, and obstacles to adherence to SPs.

RESULTS

Seventy-five percent of PRs (80/106) and 80% of EMRs (28/35) responded to the survey. There were no significant differences identified in knowledge or attitudes about SPs. A significantly lower proportion of PRs reported compliance with using face masks (28% vs 56%, P = 0.01) and eye shields (34% vs 56%, P = 0.05) during at least 95% of all irrigations and using face masks (30% vs 66%, P = 0.001) and eye shields (31% vs 60%, P = 0.01) for at least 95% of all incision and drainage procedures. A significantly higher proportion of EMRs reported using gloves at least 95% of the time for venipuncture and intravenous catheter placement (84% vs 58%, P = 0.04). The following were identified as more likely to be an obstacle for PRs: interference of blood-drawing device with technical skill (74% vs 50%, P = 0.03), unsure which protective barrier to use (59% vs 32%, P = 0.01), and lack of familiarity with newer devices (75% vs 50%, P = 0.01).

CONCLUSIONS

The PRs report more unsafe practices than EMRs. Many of the obstacles noted by all residents are easily remedied.

A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions

AIMS

The review examines from international research: the extent to which practitioners comply with infection control precautions; the pertinent issues that are considered influential in compliance; what strategies have been evaluated to instigate positive behaviour changes amongst practitioners and the effect of these interventions.

BACKGROUND

Internationally, standard/universal precautions (UP) are regarded as fundamental in the prevention and control of infection, and effective in protecting practitioners and patients. However, adherence has been problematic and the practice of standard/UPs is globally suboptimal.

DESIGN AND METHODS

Literature review where relevant evidence was identified using several electronic databases, from 1994 to 2006, with number of key terms utilized. Data were extracted by using key headings, which facilitated analysis.

RESULTS

Thirty-seven studies were appraised. Twenty-four related to measuring practitioner compliance and 13 studies that evaluated the effect of a research intervention on compliance. In addition, other studies were included which examined the specific reasons for suboptimal compliance, or discussed infection control precautions generally.

CONCLUSIONS

Compliance to infection control precautions is internationally suboptimal. The evidence confirms that compliance to specific aspects of standard/UPs varies, and practitioners are selective in their application of recommended practice. Compliance does improve following a structured intervention; however, research fails to indicate for how long the intervention affects practitioner compliance, or whether compliance after a period of time returns to the norm. Several reasons for non-compliance are discussed, and recommendations for future research are suggested. Relevance to clinical practice. Suboptimal compliance has significant implications for staff safety, patient protection and the care environment. Infection control teams and researchers need to consider the reasons for non-compliance and provide a supportive environment that is conducive to the routine, long-term application of standard precautions.

A survey of doctors' and nurses' knowledge, attitudes and compliance with infection control guidelines in Birmingham teaching hospitals

This study investigated knowledge about infection control amongst doctors and nurses through a cross-sectional survey conducted between March and May 2001 in three Birmingham, UK teaching hospitals. Seventy-five doctors and 143 nurses, representing 7% and 4%, respectively, of potential respondents, participated in the study measuring knowledge of, attitudes towards, and compliance with universal precautions. Overall knowledge of risks of blood-borne virus (BBV) transmission from an infected patient after needlestick injury was low [44.0% for hepatitis B virus (HBV), 38.1% for hepatitis C virus (HCV), 54.6% for human immunodeficiency virus (HIV)]. There were significant differences between doctors and nurses concerning the estimations of HBV (e-antigen +) (P=0.006) and HIV (P<0.001) transmission risks. Eighty-six percent of nurses stated that they treat each patient as if they are carrying a BBV compared with 41% of doctors. Doctors and nurses differed significantly in their attitudes about and reported compliance with washing hands before and after patient contact and with wearing gloves when taking blood (P<0.001 for all). Doctors consistently de-emphasized the importance of, and reported poor compliance with, these procedures. Doctors were also more likely to state that they re-sheath used needles manually than were nurses (P<0.001). Thirty-seven percent of respondents reported that they had suffered a needlestick injury with a used needle, with doctors more likely to be injured than nurses (P=0.005). Twenty-eight percent of these doctors and 2% of the nurses did not report their needlestick injuries (P=0.004). Education, monitoring, improved availability of resources, and disciplinary measures for poor compliance are necessary to improve infection control in hospitals, especially amongst doctors.