Infection Control in Pediatric Units: Translational Research

Introduction

Translational research is a fast-growing field of nursing practice with the help of which it is possible to transform recent scientific findings into new clinical processes. The results may vary, including the possibility to stabilize patient care, promote public health, and reduce the gap between evidence and application (Titler, 2018). In this paper, the problems of the lack of parental involvement and hand hygiene that challenge infection control in a pediatric setting will be discussed. The models found in reliable studies will be used to create a guide for the implementation of this change in a healthcare setting. Ethical issues, potential barriers, and expected benefits will be discussed to prove hand hygiene and parental involvement intervention as an effective means to improve current nursing practice.

Current Nursing Practice Identification

In modern healthcare settings, the role of nurses is frequently discussed by many researchers and theorists. Any nursing process consists of a number of practices that are directed to providing care for patients and their families, communicating existing problems, and evaluating human health and assigned treatment plans. Infection control is one of the current nursing practices to prevent or stop the spread of infections that may cause harm to patients or healthcare workers (World Health Organization, n.d.). The most common areas of work include hand hygiene, antimicrobial resistance, infection response and recovery, and sepsis prevention. In the pediatric healthcare setting under analysis, the staff does not pay special attention to all the aspects of infection control. Pediatricians and the nursing staff experience a lack of time and resources to coordinate patients and their caregivers (Katkin et al., 2017). As a result, infection-related problems occur, decreasing the quality of care and influence the overall health condition of patients.

The lack of hand hygiene practices and parental involvement create the main problem for analysis. It is not enough to provide the staff with the necessary theoretical knowledge. It is important to understand what practical steps can be effective in removing the consequences of the already identified problems and how to prevent and control new cases of infections among pediatric patients. Communication with parents or caregivers, training for nurses, and the introduction of the necessary equipment are the major aspects of the nursing practice that have to be changed. There are many ways of how to control infections, and the pediatric healthcare setting should focus on promoting hand hygiene programs for the staff, patients, their families, and other visitors. Koutlakis-Barron and Hayden (2016) explained the importance of ensuring caregivers’ knowledge, skills, and resources to perform the hygienic practice. In the chosen healthcare setting, education steps are missed because it is expected that parents and patients already possess the necessary awareness. Nurses have to find enough time to explain the basics of hand hygiene to their ambulatory patients and their families as a part of a program to reduce infection-related complications.

Key Stakeholders

In this translational research, the goal is to gather enough material about the chosen nursing practice and understand how to change the work of the staff to achieve the desired positive results. Infection control change is associated with several stakeholders who perform a key role in implementing and accepting the change. Along with the nursing staff, patients, and their parents, the role of a CEO must be recognized. This person is responsible for approving the need for the necessary material in the change process. He or she should evaluate the current financial situation of the pediatric care unit and clarify if the purchase of new hand hygiene equipment is justified.

Nurses are the key stakeholders who support the proposed practice change and directly participate in its implementation. First, they must learn the current guidelines and practices connected with hand hygiene that is appropriate for pediatric patients. Recent studies, newspaper articles, and online forums are the best sources to increase nurses’ awareness of the subject. Second, they should create or distribute the already created brochures with information about hand hygiene importance to predict infections. These may be one-page reports with a number of bullet points to facilitate a reading process. It should not take much time for a person to read this information. Still, the context must be clear and informative for any reader. Finally, nurses will communicate with patients and their caregivers (parents) and explain the basics of the practice, answering questions, if any. It is hard for children or even parents to comprehend the urgency of the information they receive via brochures. They accept the material as something not important and neglect the lessons offered. Face-to-face communication is a good chance to clarify if hand hygiene is defined as an urgent and obligatory practice in the pediatric healthcare setting.

Pediatric patients or their legal representatives (parents or other caregivers) are also the stakeholders whose role must be underlined. Despite the existing forms of control and support offered by nurses and other medical staff, parents should encourage their children to follow simple hygiene standards. However, when a person is a patient or visitor in a hospital, hygiene norms vary. Vermeil et al. (2018) investigate the need to replace soap and water handwashing with using alcohol-based hand rubs. Still, new options may appear suddenly, and parents or pediatric patients, as direct contributors to infection control, should follow the most recent rules and guidelines.

Evidence Critique Table.

Author and Date Title Evidence Type Sample Size Study Findings Limitations Evidence Hierarchy/Quality
Bellissimo-Rodrigues, F., Pires, D., Zingg, W., & Pittet, D. (2016) Role of parents in the promotion of hand hygiene in the paediatric setting: A systematic literature review A systematic literature review 1645 articles (562 duplicates), and 11 met the inclusion criteria Many parents are poorly aware of hand hygiene indications but eager to remind healthcare workers about it to reduce healthcare-associated infections The literature on hand hygiene in pediatric settings remains scarce. I A (High Quality)
Koutlakis-Barron, I., & Hayden, T. A. (2016) Essentials of infection prevention in the pediatric population. A review article Not applicable The authors proved the importance of infection prevention and control knowledge and underlined the need for adherence to healthcare standards in an infection-free environment. There is limited research on some aspects of infection control, and the improvement of childcare should occur at different levels. I B (good quality)
Lastinger, A., Gomez, K., Manegold, E., & Khakoo, R. (2017) Use of a patient empowerment tool for hand hygiene A quantitative study 114 pediatric patients and parents, 108 adult patients, 29 resident physicians, and 60 attending physicians participated in a cross-sectional survey (an anonymous, self-administrated questionnaire) A patient empowerment movement is highly appreciated by physicians to remind them about the importance of hand hygiene. A sample size that included the participants of one hospital only is the major limitation. III A (High Quality)
Saharman, Y. R., Fares, D. A., El-Atmani, S., Sedono, R., Aditianingsih, D., Karuniawati, A…. Severin, J. A. (2019) A multifaceted hand hygiene improvement program on the intensive care units of the National Referral Hospital of Indonesia in Jakarta A quantitative study (an observational, prospective, before-and-after study) Two nurses and one physician were involved in improvement strategies for a 1200-bed university hospital. Significant improvement of hand hygiene knowledge and compliance was proved to be possible through continuous interventions. The measurement of hand hygiene compliance, the choice of the study design, and the length of observations limit the results of the project. III A (High Quality)
Vermeil, T., Peters, A., Kilpatrick, C., Pires, D., Allegranzi, B., & Pittet, D. (2019) Hand hygiene in hospitals: Anatomy of a revolution A literature review Not applicable The evaluation of recent developments and the history of hand hygiene improved an understanding of hand hygiene interventions in healthcare settings. The need for new recommendations and campaigns was proved, but no clear steps and strategies except the collaboration of non-profit organizations were offered. 1 C (Low Quality)

Evidence Summary

The effectiveness of pediatric care depends on a number of factors, including the level of parental involvement, the quality of the medical staff, and the resources available for everyday usage. In their article, Bellissimo-Rodrigues et al. (2016) aimed to review the studies where hand hygiene promotion is proved as a necessary intervention for pediatric settings. It is important for parents to stay involved in a child’s care, and a partnership between a parent and a healthcare worker is one of the steps to be taken. The authors used a systematic literature review as a method to clarify how to enhance good hand hygiene practices in healthcare settings. Addressing such databases like MEDLINE, EMBASE, and SciELO, Bellissimo-Rodrigues et al. (2016) found out that not many parents are aware of the indications to succeed in hand hygiene. In addition, parents do not feel comfortable about reminding healthcare experts about the importance of this practice, which resulted in poorly developed parent-staff relationships.

As soon as the worth of hand hygiene promotion is proved, it is recommended to focus on the elements of intervention and appropriate standards of care. Koutlakis-Barron and Hayden (2016) introduced a review article, the goal of which was to evaluate infection prevention and control practices for the pediatric populations. Using the results of the systematic literature review, care standards were divided into within-the-healthcare-system and outside-of-the-healthcare setting (Koutlakis-Barron & Hayden, 2016). Hand hygiene was defined as one of the common practices to establish safe and infection-free environments for children. At the same time, communication with parents was mentioned, proving the correctness of the chosen practice change.

There are many approaches and strategies to promote hand hygiene in pediatric settings. Lastinger et al. (2017) aimed to investigate the worth of a patient empowerment tool (PET) as one of the crucial components of care quality improvement. The attitudes of adult patients and parents (caregivers of pediatric patients) towards the PET were analyzed via surveys. It was discovered that many parents are eager to discuss hand hygiene details with providers and control how it should be performed. However, communication remains the best solution for the establishment of trustful and fair relationships between patients, providers, and parents.

The compliance of hand hygiene is always a serious issue for discussion in many hospitals in the United States and around the globe. The investigations by Saharman et al. (2019) proved low rates in following the necessary instructions either by healthcare providers or parents of pediatric patients. Their program included such tasks as education, feedback, reminders, and interviews to property distinguish role models (Saharman et al., 2019). Such a multifaceted improvement practice turned out to be an effective tool for nurses. Still, continuous improvements and repeated reminders cannot be ignored in the care processes offered to children.

Finally, it is necessary to admit that hand hygiene was promoted through ancient times, and it is the task of the staff to recognize its urgency in healthcare settings. The ideas of hand hygiene practices as a global phenomenon through different periods of time were examined by Vermeil et al. (2019). The replacement of the soap-and-water method with alcohol-based handrub was explained as a significant part of the improvement strategy. The systematic review of the World Health Organization, as well as other stakeholders, showed that many hospitals and clinics demonstrated their positive attitudes towards the offered technique.

Best Practice from Evidence Summary

Based on the evidence summary developed in the previous section, it may be concluded that the reduction of infection-related problems in pediatric patients is possible. Some authors recommended hand hygiene as a part of a multifaceted program, some researchers preferred to focus on technical aspects of the problem, and in several cases, cooperation between people became a significant factor. All the propositions are defined as helpful contributions to the nursing problem and deserve the right to be an intervention in this translational research. Still, the idea of parental involvement and education as a part of a multifaceted program is the best one.

Quality improvement is a continuous process, and it is necessary to prepare the staff, as well as other participants, for certain changes. In terms of this project, an improvement program will include such practices as the education of parents as the major caregivers in pediatric settings, nurse-parent communication, and the presence of reminders. These are the elements of the intervention offered by Saharman et al. (2019) for a hospital in Indonesia. Along with the investigations obtained by Bellissimo-Rodrigues et al. (2016) from their systematic review, a high-quality plan of change can be developed for the prevention of infections in pediatric healthcare settings in different countries. Parental involvement and cooperation with the nursing staff should also be defined as the major aspects of intervention because education and reminders enhance hand hygiene compliance. The more sources of information about hand hygiene in pediatric units are identified, the better results and high quality of care can be achieved in the future.

Practice Change Model

A rapidly changing healthcare environment promotes the necessity to introduce new practices and models. Despite the fact that the representatives of the fields of medicine, health care, and nursing have already known a lot about change management and the process of its implementation, change remains challenging. Therefore, to predict possible difficulties and get a clear guideline, it is recommended to follow a particular practice change model for evidence-based practice. At this moment, medical institutions and students have access to a variety of models and plans. The most frequently used are Stetler’s model of research utilization, the Iowa model to promote quality care, the John Hopkins nursing model, and the ACE Star model of knowledge transformation (White, 2016). The Academic Center for Evidence-Based Practice (ACE) Start model was developed by Katheleen Stevens as a framework to comprehend “the cycles, nature, and characteristics of knowledge” in EBP processes (White, 2016, p. 17). Old and new concepts of care have to be integrated into a list of recommendations for a particular healthcare setting.

Justification of the Model

At the beginning of the 2000s, the ACE Star model was one of the most effective improvements to nursing as it implied the conversion of the already discovered findings to positive health outcomes. There are five main stages in the chosen model, including knowledge discovery, evidence summary, translation into practice recommendations, integration into practice, and evaluation (White, 2016). The point is that knowledge may exist in a variety of forms. Sometimes, it is easy to define what information plays a key role in practice and make the right choice with a minimum of effort. In some cases, nurses and other healthcare workers have to spend much time and evaluations to understand the basics of a change process. The worth of the ACE Star model is knowledge transformation when EBP processes are put into action in a clear and well-defined way. The expected result is a possibility to understand how the offered care contributed to the creation of the necessary health outcomes.

In the chosen nursing practice, the goal is to reduce the number of infections in pediatric settings by means of hand hygiene intervention. The role of parents and healthcare workers must be evaluated to determine the need for collaboration and communication. The offered practice change model is justified due to the possibility to combine knowledge and practical skills and use the approaches that are appropriate for a particular setting. The ACE Star model helps to clarify what pediatric patients and their parents know about hand hygiene and how they can share information with other caregivers. At the same time, this change defines the weak aspects of care and introduces the steps that must be taken. Finally, all the participants are able to understand their roles in knowledge transformation and reduce infection-related problems in children.

Implementation of the Model

Due to clearly defined stages of the ACE Star model, no serious problems are expected during the implementation of the proposed practice change. First, scientific inquiry is applied to discover new knowledge and combine it with the already obtained facts. Primary research is the core of a discovery stage to build a solid basis for clinical actions. The second stage focuses on the creation of an evidence summary. It helps remove unnecessary information and reduce biases for the current practice. Although some people believe that the absence of nonscientific data in the ACE Star model is its shortage, in this case, the offered approach is not a weakness but strength to increase efficiency and generalizability. The third stage is based on evidence translation according to which the analysis of the offered material is developed in regard to the available time, costs, and standards. Hand hygiene practice varies in healthcare settings, and this change in a pediatric unit depends on what the staff and parents know about this intervention and how it is applied.

The next stage includes integration when individual and organizational practices undergo specific changes. The most effective channels are used to share information and current knowledge in order to change the system and expect some improvements to occur in the established time period. Although knowledge is not a critical variable in this translational research, its role should not be ignored because it determines what participants can and cannot do. Finally, the evaluation stage occurs when the results of EBP are analyzed. Patient health outcomes (infection rates among pediatric patients) are identified and compared with those obtained before the intervention (during the discovery stage). If the number of infections and related diseases is decreased because of hand hygiene intervention, the offered change is defined as a successful one. Sometimes, the repetition of the process is required to clarify and prove the efficiency of the results.

Barriers

Applying an EBP process for practice change is characterized by a number of challenges. Some of them may be defined and controlled, and some of them remain unpredictable until a participant reveals a problem. As soon as a team of researchers, caregivers, or medical workers determine the importance of change, they have to recognize their values and skills. However, even if all the aspects of a change process are discussed and planned, it is necessary to be ready for some obstacles and new requirements. In the project of the chosen scope, time is one of the expected barriers. Lack of time is always easy to predict by creating schedules and meeting deadlines. However, communication with patients or involvement of the healthcare staff may require additional time and effort. Therefore, it is better to set the deadline and give extra space for unpredictable challenges. Lack of knowledge is another barrier that is based on the impossibility of appraising the offered material and review the literature systematically. To deal with this situation, it is possible to hire an expert in critiques or, at least, find several options to address for help.

Finally, stakeholders’ resistance cannot be ignored in a change implementation process. Even the most effective reasons and outcomes are defined and explained to participants, some of them may not be ready to accept new standards and requirements. People like to follow the already adopted rules, and changing their culture may be characterized by new emotions, behavioral changes, and disobedience. Communication with stakeholders and respect for their opinions are the major facilitators to implementing a change initiative.

Ethical Implications

Successful implementation of the proposed practice change has to be based on certain ethical standards. One of the initial steps is approval obtained from the appropriate research ethics committee. It is important to explain the worth of a change process for a particular healthcare setting. Initial contact with participants (either pediatric patients, their parents, or caregiver) has to be discussed with a hospital administrator or another manager. The purpose of the project, data collection and analysis processes, and time limitations have to be discussed with participants to get them prepared for changes and interventions. Informed consent is another crucial document with the help of which participants determine their rights and the way of how their personal information may be used.

Conclusion

In general, the implementation of change in a pediatric unit contains a number of significant steps. This translational research is devoted to hand hygiene as one of the possible interventions to improve the quality of care and reduce the number of infections observed in hospitals. Cooperation between parents and the healthcare staff is an obligatory step in the current nursing practice because it is an opportunity to share knowledge and exchange opinions. In addition, infections in pediatric units continue bothering many families, and if hand hygiene can change the situation and bring positive health outcomes, all the participants must follow a plan that is introduced through the ACE Star model. In this paper, the initial goals of the change, key stakeholders, and evidence are properly identified to take another step and implement a change practice to promote infection control. Past experiences and opinions of healthcare or nursing experts strengthen the project and explain how to deal with barriers and identify ethical implications to create an effective practice change.

References

Bellissimo-Rodrigues, F., Pires, D., Zingg, W., & Pittet, D. (2016). Role of parents in the promotion of hand hygiene in the paediatric setting: A systematic literature review. Journal of Hospital Infection, 93(2), 159-163.

Katkin, J. P., Kressly, S. J., Edwards, A. R., Perrin, J. M., Kraft, C. A., Richerson, J. E.,… Wall, L. (2017). Guiding principles for team-based pediatric care. Pediatrics, 140(2). Web.

Koutlakis-Barron, I., & Hayden, T. A. (2016). Essentials of infection prevention in the pediatric population. International Journal of Pediatrics and Adolescent Medicine, 3(4), 143-152.

Lastinger, A., Gomez, K., Manegold, E., & Khakoo, R. (2017). Use of a patient empowerment tool for hand hygiene. American Journal of Infection Control, 45(8), 824-829.

Saharman, Y. R., Fares, D. A., El-Atmani, S., Sedono, R., Aditianingsih, D., Karuniawati, A.,… Severin, J. A. (2019). A multifaceted hand hygiene improvement program on the intensive care units of the National Referral Hospital of Indonesia in Jakarta. Antimicrobial Resistance & Infection Control, 8(1). Web.

Titler, M. G. (2018). Translation research in practice: An introduction. The Online Journal of Issues in Nursing, 23(2). Web.

Vermeil, T., Peters, A., Kilpatrick, C., Pires, D., Allegranzi, B., & Pittet, D. (2019). Hand hygiene in hospitals: Anatomy of a revolution. Journal of Hospital Infection, 101(4), 383-392.

White, K. M. (2016). Evidence-based practice. In K. M. White, S. Dudley-Brown, & M. F. Terhaar (Eds.), Translation of evidence into nursing and health care (2nd ed.) (pp. 3-24). New York, NY: Springer.

World Health Organization. (n.d.). Infection prevention and control. Web.