Description
EBP Plan for Change
Attached Files:
EBP Paper Rubric S22.pdf EBP Paper Rubric S22.pdf – Alternative Formats (161.441 KB)
Example of EBP Paper.docx Example of EBP Paper.docx – Alternative Formats (35.796 KB)
Work with your group to develop the Plan for Change. It’s important to make sure this section is thorough and demonstrates critical thinking. This section of the paper should be added into your already developed EBP paper and goes directly under the Methods section with a level 1 heading titled, “Plan for Change”.
In this section, you need to describe in detail a step-by-step plan to develop a change in practice. The following components should be included.
1. Identify current practice or practices.
2. Describe the goal and intended outcome measures clearly. Who is the target population for the change?
3. Describe the actual change in detail such as when, where, how that would happen. Include any benchmark details. Identify the key persons for the project.
4. Identify the facilitating forces necessary to make the change and include any barriers and challenges in the change process (Look at Kurt Lewin’s Change theory. Think of the forces that are resisting the change and forces that are motivating to make the change).
This section should be at least four paragraphs. Add it and any new references to the updated EBP paper. I will offer feedback and suggestions. Please make recommended changes each week to stay on top of this assignment.
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The Effectiveness of Antimicrobial Curtains in Preventing Transmission of Pathogens
First Name and Last Names
NURS 363: Nursing Theory and Research
Department of Nursing, Minot State University
Sandra Groth
February 21, 2020
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Abstract
Leave Blank
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The Effectiveness of Antimicrobial Curtains in Preventing Transmission of Pathogens
Infection is a huge concern in the health care setting. One way in which infection is
spread is through direct contact with textiles. Some examples of textiles found in patient rooms
include curtains, gowns, bed sheets, towels, etc. Various different types of bacteria are found on
textiles. Some multidrug-resistant organisms (MDROs) commonly found are methicillinresistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and
clostridium difficile (C. diff). Shek et al. (2017) found in their study that out of 23 curtains, 63
different isolates were cultured.
Curtains are frequently found in patient rooms to provide privacy in shared rooms. Cheng
et al. (2015) found in their study that linens and curtains are the fifth and sixth most frequently
touched surfaces in the patient’s room. Curtains are frequently touched by not only healthcare
staff, but also patients and visitors as well. However, not many studies have been conducted
concerning curtains and the spread of infection specifically.
The focus of this study was on the prevention of the transmission of healthcare acquired
infections (HCAI). Using antimicrobial curtains compared to standard curtains will reduce the
number of pathogens found on curtains in the inpatient hospital setting.
Literature Review
A thorough literature review was conducted. Five articles were used on topics that ranged
from the number of times surfaces were contacted, different types of care given by healthcare
workers (HCWs), and cultures of pathogens found on curtains. A brief summary, the limitations,
and the article’s relation to the Evidence Based Practice (EBP) project will be discussed for each
article.
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Contact Assessment of Surfaces in Healthcare
An article discussed an observational study that was performed in Hong Kong. Near the
beginning of the article, the authors plainly stated that the goal of the study was to “enumerate
the number of hand-touch contacts by patients, HCWs and visitors with any hospital
environmental items” (Cheng et al., 2015, p. 220). Two infection control nurses observed
activities in a cubicle of six beds at a university-affiliated hospital over 33 working days to see
how often people in the healthcare environment touched objects present in the observed
healthcare setting. Cheng et al. (2015) found the top ten most frequently touched items to be the
bedside rail, bedside table, patient body, patient file, linen, curtains, bed frame, locker, blood
pressure cuff, and syringes. They also found that nursing staff and supporting staff had the
highest rate of contact, making up almost 73% of recorded contacts.
The article also discussed the frequency of replacing linens and curtains. Linens are
commonly changed when they are dirty or when a patient is discharged. Cheng et al. (2015) said
that hospital curtains were changed about once a month, or before that if they were soiled. Cheng
et al. (2015) discussed a study in which over 90% of hospital curtains showed contamination
within one week of being cleaned, and that the bacteria found on the curtains included resistant
organisms such as MRSA and VRE. Both of these organisms can cause infections that are quite
difficult to treat.
Limitations and Level of Evidence
The article specifically mentioned four limitations to this study. These limitations
included variations between the observations of the two nurses, omission of recording
performing hand hygiene and donning gloves, observation solely in the acute care setting, and
underestimation of the activities of visitors, as this study was completed during a time when
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visitation time was restricted. Even with all these limitations, the study itself would still probably
be considered as good in terms of quality. Since it was observational in design, it could be
categorized as level III evidence.
Findings Related to Curtains
This article specifically addresses how curtains can increase the transmission of
infectious agents. Linens and curtains were found to rank fifth and sixth in the top ten frequently
touched items. Cheng et al. (2015) mentions that these two items are often touched not only by
HCWs, but also patients and visitors. This means that even if organisms are not getting onto the
items from HCWs’ hands, they may still be finding their way onto these items from someone
else’s hands.
The Benefits of Using Disposable Sporicidal Privacy Curtains
An article discussed a study that took cultures from the standard hanging curtains and
compared it with the use of disposable sporicidal hanging privacy curtains. They tested 14
hanging curtains over the span of half a year. They swabbed them, and they were recorded with
zone of inhibition and contact inhibition (Kotsanas et al., 2014). These hanging sporicidal
privacy curtains are marketed to hang for 6 – 12 months. To see if any antimicrobial
deterioration happened over the six months span, they tested the curtains at one, two, three, and
six-month intervals (Kotsanas et al., 2014). The standard curtains were the control. Swabs were
dipped in normal saline and rubbed over the curtains before being sent the laboratory. The swab
samples were then described as environmental, skin, or pathogen after being spread onto horse
blood agar aerobically for 48 hours at 35 degrees celsius. They then looked at the curtains and
noted any soiling, wear and tear, and damage (Kotsanas et al., 2014). Lastly, they examined the
cost of using sporicidal disposable curtains compared to the standard curtains. The cost is
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reported in the Australian dollar (AUD). The Australian dollar and United States dollar (USD)
are close to the same in value. The conversion is approximately $1 AUD to $0.93 USD. Standard
curtains are $5.05/curtain AUD while the new disposable curtains are $78.50/curtain pair AUD.
The approximate cost of labor for hanging the curtains would be $40/hour AUD, and it would
take about 15 minutes to hang a curtain pair (Kotsanas et al., 2014). It costs more at first, but it
saves money in the long run with the six month hanging time.
Limitations and Level of Evidence
The study had limitations. Kotsanas et al. (2014) stated that, “Our study had some
limitations: primarily that molecular typing of VRE recovered from patient and curtain was not
conducted, and, therefore, we cannot be sure of the origin of contamination” (p. 370). Screening
the patients for the four pathogens when they arrived, during their stay, and before discharge
could have helped determined better rates of when the contamination occurred. Replacing the
sporicidal curtains after six months’ time offered a savings of $AUD 1,431.40, and HCWs felt
better about the appearance and the privacy provided (Kotsanas et al., 2014). However, the
evidence is considered high-quality, level III evidence because of the data collection and the use
of a control over a decent amount of time. This research is quasi-experimental, so there is no
randomization.
Findings Related to Curtains
Four pathogens were tested: Staphylococcus aureus, VRE, carbapenem-resistant
Enterobacteriaceae, and C. diff. At day zero, the standard curtains did not show any zone of
inhibition and contact inhibition but did show heavy confluent growth of all of the test
microorganisms, so these curtains did not need to be tested again (Kotsanas et al., 2014). When
the sporicidal disposable curtains were tested, they did not show any MRSA, CRE, or C. diff, but
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VRE was found three times from two different curtain sites (Kotsanas et al., 2014). When
looking at the VRE that was recovered, the researchers found that the two rooms where it was
located had been inhabited by VRE patients. Overall the sporicidal curtains appeared cleaner
when compared to the standard curtains, but by six months six of the curtains showed slight
discoloration or marks (Kotsanas et al., 2014). These findings could lead to more research
regarding disposable sporicidal curtains and lead to changes in what curtains are used in
healthcare facilities.
Relationship Between Surface Contacts, Care Type, and Hand Hygiene
An article discussed an observational study focused on the transmission of pathogens
(King et al., 2016). The study involved auxiliary nurses and registered nurses being observed as
they carried out six types of cares. These six types of care included direct care (ex. taking vitals),
housekeeping, mealtimes, medication rounds, miscellaneous (ex. answering call light), and
personal care. According to King et al. (2016), “During each care episode, the surfaces touched
by the HCW and the order in which this occurred were recorded” (p. 49). The surfaces
mentioned in the quote include the patient, equipment, hygiene items, near-bed items (TV/chair),
and far-bed items (door handles/light switch) (King et al., 2016). Each “care episode” lasted
from the time the health care professional entered the room to when they came out. The
observations were made from outside of the room only when there was a clear view (King et al.,
2016). Each time hand hygiene was performed it was recorded, and the type of antisepsis was
recorded. Over 400 care episodes were observed throughout the study (King et al., 2016).
Through this observational study, it was determined that the type of care being provided
influenced the kind of hand asepsis used (King et al., 2016). HCWs were more likely to wash
with soap and water after performing personal care on patients. According to King et al. (2016),
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“For all other care types, the choice of antisepsis method was almost equal between soap and
water or alcohol gel” (p. 49). The study also found that the incidence of hand washing increased
with the number of surface contacts HCWs had. However, no correlation was found when
comparing the time the HCW spent in the room to the amount of times he/she washed their
hands (King et al., 2016).
Limitations and level of evidence
This study was observational which puts it under the level III category when looking at
levels of evidence. The article didn’t specifically have a section for limitations; however, that
doesn’t mean there weren’t any. Limitations found through reading and analyzing included the
study only being based in one setting, the study not being randomized, the study not having
measured the effectiveness of hand hygiene, and the study not stating whether HCWs were
compliant with the study (King et al., 2016). Even with these limitations, the article still provided
valuable research information.
Finding Related to Curtains
The article didn’t directly mention curtains; however, the study still relates to the topic of
how curtains can aid in the transmission of pathogens. The study focused on different surfaces
that HCWs touch in a patient room (King et al., 2016). Curtains are an example of a surface that
has the chance to be contaminated if a HCW doesn’t wash their hands. According to King et al.
(2016), “On average, it was found that even if hand hygiene occurred, the patient was often
touched again before the HCW left the room” (p. 50). Any contact with the patient or other
surfaces after performing hand hygiene replants potential disease producing organisms. An
example of how this could directly affect curtains is if the HCW washes their hands, helps their
patient with C. diff to the bathroom, and then closes the curtain on their way out of the room.
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Everything that was touched while taking their patient (with a contagious disease) to the
bathroom would be directly transmitted to that curtain and would then have the possibility of
being transported, further spreading the infectious agents.
Effects of Copper Impregnated Textiles on HCAIs.
An article discussed a study that focused on how textiles can become breeding grounds
for bacteria that aren’t easily destroyed. It compared HCAI rates between patient rooms that
were using regular non-biocidal linens and rooms that replaced those regular linens with copper
oxide-impregnated biocidal linens. It has been demonstrated that both copper-oxide
linens/textiles and hard surfaces aid in the decreased rate of HCAIs. Copper is known to contain
biocidal properties capable of killing multiple organisms, including antibiotic resistant bacteria
(Butler, 2018). The results showed a dramatic drop in HCAI rates amongst those using the
copper oxide-impregnated biocidal linens.
The study was conducted at six Sentara hospitals in North Carolina and Virginia. All of
these facilities replaced their regular non-biocidal linens and other textiles with the copper-oxide
impregnated linens/textiles. Regular hard surfaces were also replaced with biocidal products
because although bacteria can’t really multiply on these surfaces (as they typically need an
environment with heat and moisture to grow, e.g. patient gowns), they can still exist and remain
on the surface for an extended period of time. The rates were based on 90, 180 and 240 day
increments and also based on 1000 or 10000 patient-days.
Based on 1000 patient days, the total reduction of MDRO rates due to use of the copperoxide impregnated linens/textiles were 59.8% after 90 days, 39.9 % after 180 days and 37.2%
after 240 days (Butler, 2018). It was also shown that the effectiveness of these new textiles did
not reduce over time. Due to these results, Sentara Healthcare System decided to replace all 12
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of their facilities’ regular, non-biocidal linens/textiles and hard surfaces with the copper-oxide
linen/textiles and hard surfaces to prevent the growth and transmission of nosocomial pathogens.
Limitations and Levels of Evidence
Limitations were not discussed in the article; however, one limitation that may need to be
addressed is the small sample size. It is quasi-experimental, therefore it is rated as level III. This
means it has been tested multiple times and is uncontrolled. This level is a fairly strong level of
confidence.
Findings Related to Curtains
Though the article does not specifically speak of curtains, it does refer to textiles, and
patient privacy curtains do fall under that category. Understanding how these copper infused
textiles prevent the growth and spread of diseases is important to patient safety and health. The
organisms this intervention helps reduce are easily spread. If a patient acquires an infection
because of these organisms, they are very difficult to treat, thus putting the patient’s health and
life in jeopardy. Another aspect to look into would be the cost of these copper-oxide products.
Even if these products are costly, it may still be cheaper to purchase these products rather than
pay the costs of treating patients with HCAIs, as those costs would have to be covered by the
hospital anyway.
Rate of Contamination of Hospital Privacy Curtains
An article presented a study about the presence of MRSA on curtains that were sampled.
According to Shek et al. (2017), samples were collected by pressing a replicate organism
detection and counting (RODAC) plate against the curtain for one minute, while holding a
RODAC plate lid covered with a paper towel on the opposite side of the curtain to ensure a tight,
flat contact between the RODAC plate and the curtain. Due to the heavy growth of bacteria on
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the first testing date, the decision was made to use MSA-oxacillin for screening for the second
testing date. Out of all the samples, about a third of them confirmed the presence of MRSA.
MRSA is a superbug that is very tough to treat because it is resistant to many antibiotics. This
study also talked about many methods of maintaining cleanliness of curtains without having to
buy new curtains all the time. Several of these methods include chemical sprays such as 3.1%
hydrogen peroxide, curtains that have built-in antimicrobial properties, and curtains that change
color upon contamination, which would encourage more efficient scheduling of curtain changes
(Shek et al., 2017).
Limitations and Levels of Evidence
This article is a cross-sectional study, which is an observational study. An observational
study falls under the level III category when looking at the levels of evidence. One limitation of
this article is that there were only two studies done, one in 2015 with 23 curtains and one in 2016
with 26 curtains. With the small sample size, it is not clear if the curtains can cause a definite
infection. Another limitation according to Shek et al. (2017) is that the length of time that the
curtains were hung was not accurately recorded, so the length of time during which curtains were
hung could not be correlated accurately to the degree of microbial contamination.
Findings Related to Curtains
Hand hygiene is always a big issue in hospitals. Even though workers are washing their
hands, the patient and family members may not be. If the patient or family member is sick and
touches a curtain, a healthcare provider may touch the same area and walk back into the hallway.
That HCW may not feel the need to wash their hands again when they leave the room as they did
not touch the patient. The HCW may then transfer the pathogen to the nurses’ station or into
another room. Patients get their linens and their rooms cleaned frequently, but the curtains are
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not frequently cleaned. Curtains can be environmental reservoirs of microbes and hospital
acquired infections.
Appraisal of Evidence
Several consistent themes can be identified throughout the literature review. One major
theme is that curtains can be a factor in the transmission of infectious agents because they are
frequently touched. The studies indicated that if this problem is not addressed, the health of both
the patients and the HCWs are put at risk. Another theme found throughout the articles is that
transmission of disease can be reduced through using treated curtains. Several treatments include
sporicidal, copper-oxide, and hydrogen peroxide.
The articles included in this literature review discuss either quasi-experimental or
observational studies. Each article can be identified as high quality level III evidence. This high
quality evidence will benefit patients and the healthcare facilities in which they are being cared
for. The research demonstrates that there needs to be more done to keep the curtains clean. New
materials need to be developed and accessible so that the curtains don’t harbor dangerous
pathogens.
There were a few limitations discovered while reviewing this research. First, there isn’t a
large amount of research out there being conducted on this particular topic, which puts a limit on
the amount of data able to be collected. Secondly, the research doesn’t have much
randomization, which may prevent the study from being generalized to other populations.
Lastly, the sample sizes are relatively small, which may hinder how well the study represents the
larger population.
The results from these studies can lead to better methods of preventing the spread of
pathogens. Standard curtains can harbor pathogens, are not changed often, and cost more in the
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long run. Use of antimicrobial curtains can lead to less contact contamination from HCWs’
hands. This can protect the health of both the patient and the HCWs. Antimicrobial curtains can
prevent the colonization of pathogens, which leads to less risk for HCAIs. Overall, this can
provide an improvement in the quality and safety of care provided. When conducting a study, it
is important to keep in mind that some patients may have certain values or beliefs regarding
being part of a study. They may choose not to participate, which would lead to a smaller sample
size. Some patients may not like or believe in the new curtains and may not want them hung in
their rooms. These patient preferences will be taken into account, as it is important to respect the
subjects’ wishes, values, and beliefs.
Methods
This study uses a quantitative quasi-experimental research design. There is
randomization involved in the study. Two types of curtains will be hung in hospital rooms for a
time period of 45 days. The two types of curtains will include antimicrobial curtains and regular
cloth curtains. Antimicrobial curtains are curtains that have been treated with chemicals to inhibit
the growth of pathogens. Regular curtains are curtains made of cloth that are commonly found in
patient rooms in the healthcare setting. Efforts will be made to have the two types of curtains
look as similar as possible. All curtains will be labeled with which category of curtain they fall
into and will be carefully handled prior to testing to avoid any additional contamination. Until
placement, the curtains will be kept in their original packaging to protect them from
contamination prior to testing.
Sample and Setting
For this study, a convenience sample will be used. This sampling method was chosen to
compare similar floors for rate and type of microorganisms found on the treated curtains and the
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untreated curtains. The study population will include all fourth and fifth floor rooms in the
Trinity Health West building in Minot, North Dakota. All rooms will be cleaned in the same
manner. All patient rooms on both floors will be included in this study, regardless of the patient’s
diagnosis. A potential difficulty for performing this study is purchasing the curtains and the
materials for culturing the pathogens at the completion of the study. This problem could be
addressed by applying for grants to offset this necessary cost.
All even numbered rooms will have a regular cloth curtain, and all odd rooms will have
an antimicrobial curtain. After 15 days, all curtains will be swabbed and cultured for pathogens.
The curtains will be swabbed and cultured again at 30 days and 45 days to assess the growth of
pathogens on the two types of curtains.
All researchers will be provided training regarding how to properly collect specimens to
prevent error. At the indicated time, RODAC plates will be handled by gloved researchers and
brought up to the room. The plate will be pressed against the curtain for one minute. This will be
completed in two locations, first near the edge of the hem near shoulder height on the side facing
the patient, then near the edge of the hem one foot down from the first location. At the end of the
collection period, an independent t-test will be used to compare the means of the bacteria counts
for the two types of curtains. A significance level of 0.05 would indicate the antibacterial
curtains reduce the amount of bacteria in the hospital room. The data collection tool is displayed
in the appendix.
Plan for Change
The current practice found regarding infection control related to hospital curtains was
both unclear and sickening. Hospital policy states that curtains are currently cleaned only when
visibly soiled or on a rotating basis (Trinity Health, 2019). However, the time frame of the
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rotating basis is not clearly stated anywhere in the policy. Due to the impact infection control has
on the rates of HCAIs, it is important that this policy be revised in the interest of the health of
staff, visitors, and patients.
Current research suggests that a consistent rotational policy be developed. The intended
outcome would be to reduce the spread of infection by utilizing antimicrobial curtains. Until all
curtains are antimicrobial, the regular curtains will be changed out after a specified amount of
time, even when they are not visibly soiled. The positive outcome of these goals will be
measured by the overall decrease in rates of HCAIs in the hospital. The target population for the
change would be any hospitalized patient.
Research indicates that it is in the best interest of both the hospital and the patients to
change the regular cloth curtains to antimicrobial curtains. This change could be implemented by
the infection control department of the hospital. As funding and time permits, the regular curtains
could be replaced by the antimicrobial curtains floor by floor. This task will be completed by the
infection control department. The antimicrobial curtains will be replaced every six months. Until
the antimicrobial curtains can be located on every floor, the regular curtains will be changed
every 15 days. This task will be completed by housekeeping. For both types of curtains, the date
the curtain was changed will be written on a piece of tape and stuck to the part of the curtain
farthest from the door to keep track of how long the curtains have been hung. The infection
control department will have half of the antimicrobial curtains hung six months from starting this
project, and all of the antimicrobial curtains hung in one year’s time.
Funding is a huge barrier to implementation of this change. The cost of the curtains could
be included in the hospital budget. In the long run, using antimicrobial curtains can be more cost
effective for the hospital and improve patient outcomes. Because of the long-term benefits of the
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antimicrobial curtains, it would be in the best interest of the hospital to implement this change as
soon as possible. Another potential barrier is obtaining permission from the hospital to change its
policy concerning infection prevention and control. Presenting the results of the study to the
infection control department could be the initial step of this process. Time needed to educate
housekeeping and the infection control department in regards to implementing this plan for
change could also be a potential barrier. The researchers can choose to make the education
available to the employees through an in-service training, through video presentation, through
email, or through a number or different ways.
Even with all these potential barriers, the proposed change has a strong driving force.
One of the strongest facilitating forces is the nurses’ priority of the best care for patients. The
ultimate goals of this plan for change is improvement in patient health quality and safety of
nursing. Through implementation of this change, these goals can be better achieved.
Conclusion
A study comparing the rate of growth of pathogens on both antimicrobial curtains and
regular cloth curtains would bring to light the role curtains play in transmission of pathogens in
the hospital setting. However, it does no good to know the information and do nothing about it.
The proposed plan for change includes both replacing regular curtains with antimicrobial
curtains and changing regular cloth curtains on a specified rotation until they can be replaced by
the antimicrobial curtains. Although the initial cost of the antimicrobial curtains may cause the
hospital to hesitate, the long-term cost effectiveness of this change and the effectiveness in
preventing infection makes this change worth the money. The health of patients, visitors, and
hospital staff can all benefit greatly by implementing these changes.
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References
Butler, J. P. (2018). Effect of copper-impregnated composite bed linens and patient gowns on
healthcare-associated infection rates in six hospitals. Journal of Hospital Infection,
(100)3, 130-134. doi: 10.1016./j.jhin.2018.05.013
Cheng, V. C. C., Chau, P. H., Lee, W. M., Ho, S. K. Y., Lee, D. W. Y., So, S. Y. C., … Yuen, K.
Y. (2015). Hand-touch contact assessment of high-touch and mutual-touch surfaces
among healthcare workers, patients, and visitors. Journal of Hospital Infection, 90(3),
220–225. https://doi.org/10.1016/j.jhin.2014.12.024
King, M.-F., Noakes, C. J., Sleigh, P. A., Bale, S., & Waters, L. (2016). Relationship between
healthcare worker surface contacts, care type and hand hygiene: An observational study
in a single-bed hospital ward. Journal of Hospital Infection, 94 (1), 48-51.
http://dx.doi.org/10.1016/j.jhin.2016.05.003
Kotsanas, D., Wijesooriya, W. R. P. L. I., Sloane, T., Stuart, R. L., & Gillespie, E. E. (2014). The
silver lining of disposable sporicidal privacy curtains in an intensive care unit. American
Journal of Infection Control, 42(4), 366–370. https://doi.org/10.1016/j.ajic.2013.11.013
Shek, K., Patidar, R., Kohja, Z., Liu, S., Gawaziuk, J. P., Gawthrop, M., & Logsetty, S. (2017).
Rate of contamination of hospital privacy curtains on a burns and plastic surgery ward: A
cross-sectional study. Journal of Hospital Infection, 96(1), 54-58.
https://doi.org/10.1016/j.jhin.2017.03.012
Trinity Health (2019). Cleaning, disinfection and sterilization, 51.25. (PolicyStat ID: 6703089).
http://trinityhealth.policystat.com/policy/6703089/
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Table 1
What is the
type of
curtain?
Curtain Type
#1
Is the curtain
in an even or
odd
numbered
room?
How many
days were
the curtains
hanging
before being
tested?
At 15 days
At 30 days
At 45 days
Curtain Type
#2
At 15 days
At 30 days
At 45 days
Which
pathogens
were present
on the
curtains?
How many
bacterial
colonies were
observed?
Purchase answer to see full
attachment
