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American Journal Of Emergency Medicine

In a journal club, research articles are reviewed and critiqued. General and specific questions help to aid journal club participants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications for practice.

When critically appraising this issue's AJCC journal club article, "Hand Hygiene Behavior in a Pediatric Emergency Department and a Pediatric Intensive Care Unit Using 2 Dispenser Systems," consider the questions and discussion points listed below.

Study Synopsis: The purpose of this study was to compare the frequency of hand hygiene practices in a pediatric emergency department and a pediatric intensive care unit (PICU) using manually operated or touch-free dispensers. A crossover study design was used with the emergency department and PICU using both types of dispensers, each during different data collection intervals. During two 2-month periods, total hand hygiene episodes per hour were monitored using manual and touch-free dispensers for alcohol sanitizer. Direct observations were used to determine indications for hand hygiene and electronic counting devices installed in each dispenser provided a count of hand hygiene episodes per hour. The study results revealed that there were significantly more total hand hygiene episodes per hour with the touch-free dispensers compared with the manual alcohol dispensers (P=.04). The most frequent indications for hand hygiene were "before direct contact with patient," "after touching patient's intact skin," "after contact with inanimate objects in patient vicinity," and "after removing gloves." The results indicate that the dispensing system is an important factor in hand hygiene. Yet, the overall hand hygiene compliance rate was low (38.4%), indicating that other efforts to improve hand hygiene need exploration.

A. Description of the Study

* What was the purpose of the research?

* Why is the problem significant to nursing?

B. Literature Evaluation

* What has previous research on hand hygiene measures explored?

C. Methods and Design

* Describe the procedure used to collect data on frequency of hand hygiene episodes, episodes of actual hand hygiene, and number of hand hygiene opportunities.

* What would be the rationale for the use of a crossover study design?

D. Results

* What were the findings of the research?

* What were the most frequent indications for hand hygiene?

* What indications for hand hygiene had the higher compliance rates?

F. Clinical Significance

* What are implications of the study for clinical nursing?

Information From the Authors: Elaine Larson, RN, Plan, lead author of this journal club article, provided additional information about the study. Larson explained that the idea for the study came about from examining the literature on previous research on hand hygiene. She reported, "Adherence to hand hygiene is generally poor in every study conducted. Although alcohol hand hygiene products have been shown to improve adherence, it is still poor. We wanted to assess the impact of an equipment change on adherence." Larson explained that the study was designed to specifically compare staff use of alcohol sanitizer using a manually operated or touch-free dispenser. Larson added, "Staff were informed of the study both verbally and with written posters and announcements placed in the units." She shared that the decision was made to test use of the 2 dispensers at different time frames and added, "In previous work, we have noted that some dispensers, because of their location, are used considerably more than others, so it would not have been possible to, for example, use dispensers in every other site. Another option might have been to put the 2 types of dispensers side by side and let staff choose. However, that would have meant considerable more expense and disruption in already busy and high risk units. Also, the walls would have needed to be repainted or touched up after removing one or both dispensers, so the hospital requested that we simply replace one dispenser type with the other in the same location. Hence, there were practical and cost considerations, but also we avoided confounding the study by not changing the dispenser location."

Implications for Practice: According to the study results, the use of touch-free alcohol dispensers resulted in significantly more hand hygiene episodes per hour, and more dispenser use per day. Larson reported that the most surprising finding of the study was the low rate of hand hygiene compliance (38.4%). She explained, "Even though hand hygiene improved with the touch-free dispenser and even though staff knew that observations were being made, hand hygiene frequency was still so low." It becomes evident that additional research is needed to examine factors influencing hand hygiene behaviors. Larson concluded, "Even the best products and equipment have little chance of improving patient outcomes if they are not used!"

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