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AN EVIDENCE-BASED GUIDELINE
TO PREVENT NOSOCOMIAL INFECTIONS
IN INFANTS WITH ENTERAL FEEDING
LEUNG TSZ KWAN
M. NURSING DISSERTATION
THE UNIVERSITY OF HONG KONG
2012
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An evidence-based guideline to prevent
nosocomial infections in infants
with enteral feeding
By
Leung Tsz Kwan
BNurs (CUHK); RN
A dissertation submitted
in partial fulfillment of the requirements
for the Degree of master of Nursing
at The University of Hong Kong
August 2012
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Abstract of dissertation entitled
An evidence-based guideline to prevent
nosocomial infections in infants
with enteral feeding
Submitted by
Leung Tsz Kwan
for the degree of Master of Nursing
at The University of Hong Kong
in August 2012
ABSTRACT
Enteral feeding is commonly used in paedaitric patients. It helps to
improve the digestive, absorptive, immunologic and nutrition status. However,
poor handling in enteral feeding can lead to bacterial contaminations and
severe consequences resulting in significant morbidity and mortality. At
present, there are no definite guidelines on the handling of enteral feeding in
local setting, therefore developing evidence based guideline on enteral feeding
is critically important to eliminate inconsistent practices and prevent
nosocomial infections related to enteral feeding.
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This dissertation is a translational nursing research that aims at
developing evidence based guideline on enteral feeding in infants. The
objectives of this thesis are to search for existing literatures on enteral feeding;
perform a critical appraisal on the literatures; develop guideline on enteral
feeding in infants; assess the implementation potential of the proposed
guidelines, and develop the implementation and evaluation plans. The ultimate
goal is to reduce the nosocomial infections in infants with enteral feeding in an
acute hospital.
A systemic search for relevant and valid evidence was performed using
three electronic databases and nine relevant studies were retrieved. Critical
appraisals on the nine studies were performed and the level of evidence for
each study was graded according to the Scottish Intercollegiate Guidelines
Network (SIGN). By synthesizing the data from nine studies, it is concluded
that optimal hang time and proper hand hygiene appeared to have significant
effect in reducing nosocomial infections related to enteral feeding.
The implementation potential of the innovation was assessed in terms of
the transferability, feasibility and cost benefit ratio. After assessing the
implementation potential, it is found that the evidence is transferable and
feasible to implement the proposed guideline in the target paeditaric setting.
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An evidence based guideline on enteral feeding in infants was developed.
An implementation plan of the new guideline included a comprehensive
communication plan with both administration and nurses and a pilot test were
developed to ensure a smooth implementation and optimize the transferability
and effectiveness of the evidence based guideline in the target population.
A systematic evaluation plan on patient outcomes, health care provider
outcomes and systemic outcomes was developed. The evidence based
guideline on enteral feeding was expected to be implemented in the long run to
reduce the risk of nosocomial infections in infants with enteral feeding.
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DECLARATION
I declare that this dissertation represents my own work, except where due
acknowledgment is made, and that it has been previously included in a thesis,
dissertation or report submitted to this University or to any other institution for
a degree, diploma or other qualification.
Sign: ___________________
Leung Tsz Kwan
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ACKNOWLEDGEMENTS
Firstly, I would like to express my sincere appreciation to my supervisor,
Dr. Vivian Ngai, from the School of Nursing of the University of Hong Kong,
for her expertise, enlightenment, understanding and patience. I appreciate her
vast knowledge and skill in many areas and her guidance in writing this
dissertation.
Secondly, I would like to express my gratitude to the School of Nursing
of the University of Hong Kong, the Special Care Baby Unit, Neonatal
Intensive Care Unit and General Infant Unit of the Department of Pediatrics,
Queen Elizabeth Hospital, for their support during my study in the Master of
Nursing.
Thirdly, I would also like to thank my classmates in the Master of
Nursing for their encouragement to go through the difficult times and
overcome challenges; and sharing all the happiness and hardship throughout
my period of study.
Lastly, I would like to thank my family and friends; they have provided
me with ongoing love, patience, support and encouragement; without which I
would not have finished this dissertation.
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TABLE OF CONTENTS
Abstract …………………………………………………………………..……3
Declaration ……………………………………………………….…………...6
Acknowledgement ……………………………………………….……………7
Table of contents ………………………………………………………………8
List of appendices ……………………………………………………………13
CHAPTER ONE – INTRODUCTION
1.1 Background ………………………………………………...…………….15
1.2 Affirming the need ……………………………………………………….19
1.3 Formulating the review objectives and the research question …………...24
1.3.1 Review objectives ……………………………………………..….24
1.3.2 Research question ……………………………………………..….24
1.3.3 Significant of the study ……………………..…………………….24
CHAPTER TWO – CRITICAL APPRAISAL
2.1 Search and appraisal strategies…………………………………………...26
2.1.1 Search strategy ………………………………………………........26
2.1.2 Criteria for selecting studies for review ……………………….…27
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2.1.3 Methodology of the review ……………………………...……….27
2.2 Results and appraisal of studies .................................................................28
2.3 Summary and synthesis of data ……………………………………….…37
2.3.1 Research problem and purpose ……………………………...……37
2.3.2 Study type and level of evidence ……………………………...….38
2.3.3 Intervention .....................................................................................38
2.3.4 Internal validity ……………………………………………….….39
2.3.5 Synthesis of findings ……………………………………….…….40
CHAPTER THREE – IMPLEMENTATION POTENTIAL
3.1 Transferability ……………………………………………………..…….42
3.1.1 Target audience and setting ……………………………...……….42
3.1.2 Sufficient number of clients can be benefited from the new
innovation ………………………………………………………………43
3.1.3 Philosophy of care……………………………………………...…44
3.1.4 Implementation and evaluation time ……………………………..45
3.2 Feasibility ………………………………………………………………..47
3.2.1 Nurse related factors ……………………………………………...47
3.2.1.1 Freedom to carry out and terminate the innovation ……….47
3.2.1.2 Interference with current staff functions ………………….47
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3.2.1.3 Training and skills ………………………………………...48
3.2.2 Organization related aspects …………………………………..….49
3.2.2.1 Support from administration and organization ………...….49
3.2.2.2 Consensus among staff and administrators …………….....50
3.2.2.3 Equipments and facilities …………………………………50
3.2.3 Potential friction ………………………………………………….51
3.2.4 Measuring tools …………………………………………………..51
3.3 Cost benefits ratio of the innovation …………………………………….52
3.3.1 Potential benefits to children ……………………………………..52
3.3.2 Potential benefits to nursing staffs ……………………………….52
3.3.3 Potential benefits to the organization …………………………….53
3.3.4 Costs of innovation ……………………………………………….53
CHAPTER FOUR – EVIDENCE BASED PRACTICE GUIDELINE
4.1 Conceptual principle of the guideline ……………………………………56
4.2 Presentation of the guideline …………………………………………….56
4.3 Evidence based enteral feeding guideline in infants …………………….57
4.3.1 Hang time ………………………………………………………...57
4.3.2 Hand hygiene ……………………………………………………..58
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CHAPTER FIVE – IMPLEMENTATION PLAN
5.1 Communication plan …………………………………………………….61
5.1.1 Identify the stakeholders ………………………………………….61
5.1.2 Identify the problem ……………………………………………...63
5.1.3 Communication activities ………………………………………...63
5.1.3.1 Working committee ……………………………………….63
5.1.3.2 Propose to Ward Manager (WM) …………………………64
5.1.3.3 Propose to Department Operation Manager (DOM) ……...64
5.2 Pilot study ………………………………………………………………..65
5.2.1 Objectives ………………………………………………………...65
5.2.2 Subjects and procedure …………………………………………...66
5.2.3 Training workshops ………………………………………………67
5.2.4 Evaluation ………………………………………………………...68
5.3 Promotion to other paedaitric wards ……………………………………..68
CHAPTER SIX – EVALUATION PLAN
6.1 Outcomes to be achieved ………………………………………………...70
6.1.1 Patient outcomes ………………………………………………….70
6.1.1.1 Identification of patient outcomes measure ……………….70
6.1.1.2 Nature and number of patients involved ………………….70
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6.1.1.3 Outcomes measure – nosocomial infection rate …………..72
6.1.1.4 Outcomes measure – length of hospital stay ……………...72
6.1.2 Health care provider outcomes …………………………………...73
6.1.2.1 Identification of health care provider outcomes measure …73
6.1.2.2 Outcomes measure – satisfaction and confidence level …..73
6.1.2.3 Outcomes measure – enteral feeding technique and
compliance ………………………………………………………...73
6.1.3 System outcomes …………………………………………………74
6.1.4 Basis for an effective change of practice …………………………74
6.1.4.1 Patient outcomes …………………………………………..75
6.1.4.2 Healthcare provider outcomes …………………………….75
6.1.4.3 System outcomes ………………………………………….76
6.1.5 Dissemination and measure to sustain the change ……………….76
CHAPTER SEVEN – CONCLUSION
7.1 Conclusion ……………………………………………………………….78
APPENDICES ……………………………………………………………….80
REFERENCES ……………………………………………………………..143
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LIST OF APPENDICES
APPENDIX 1 – SEARCH STRATEGY …………………………………….80
APPENDIX 2 – TABLE OF EVIDENCE …………………………………..82
APPENDIX 3 – CRITICAL APPRAISAL ………………………………….92
APPENDIX 4 – INTERVENTION AND RESULT COMPONENTS …….124
APPENDIX 5 – EVIDENCE BASED
ENTERAL FEEDING GUIDELINE ………………………………………128
APPENDIX 6 – GRADING OF RECOMMANDATIONS ………………..130
APPENDIX 7 – COMMUNICATION PLAN ……………………………..132
APPENDIX 8 – QUESTIONNAIRE OF PILOT TEST EVAULATION …134
APPENDIX 9 – ENTERAL FEEDING SATISFACTION
QUESTIONNAIRE ………………………………………………………...137
APPENDIX 10 – ENTERAL FEEDING TECHNIQUE AND COMPLIANCE
AUDIT ……………………………………………………………………...139
APPENDIX 11 – TIME FRAME …………………………………………..141
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CHAPTER ONE
INTRODUCTION
Enteral feeding plays a major role in paediatric nursing. However, poor
handling of enteral feeding can lead to bacterial contamination and severe
complications. This will greatly increase the length of hospital stay, mobility
and mortality rate. Nurses have an important role and responsibility to protect
our patients free from nosocomial infections by providing proper enteral
feeding practice. The aim of this proposal is to translate the best nursing
research findings into evidence based guidelines and integrate into our daily
clinical practice. The background information of enteral feeding and the
significance and the needs for intervention will be addressed in Chapter One.
The critical appraisal of current literatures, the results and summary of the
critical appraisal and the synthesized recommendations will be presented in
Chapter Two. The implementation potential to translate the reviewed evidence
into real practice will be assessed in Chapter Three. The evidence based
guideline will be presented in Chapter Four. The implementation plan and
evaluation plan will be put forward to Chapter Five and Chapter Six. Finally,
the conclusion will be addressed in Chapter Seven.
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1.1 BACKGOUND
According to Teitelbaum et al., the Board of directors and standards
committee of the American society for parental and enteral nutrition (2005),
enteral feeding refers to the delivery of nutrients through the gastrointestinal
tract via a tube, catheter or stoma. It is used in children with a functional
gastrointestinal tract but unable to ingest through oral cavity. Indications of
enteral feeding in children include gastrointestinal disorders, neuromuscular
disorders, cardiopulmonary disorders, metabolic disorders, prematurity and
failure to thrive (Axelrod et al., 2006). Nasogastric tube feeding and
gastrostomy tube feeding are two of the most common ways of enteral feeding.
Nasogastric tube passes through the nostril, down the esophagus into the
stomach while gastrostomy tube is inserted through a small incision in the
abdomen wall into the stomach. Enteral feeding is now widely used and it is
preferable than parental nutrition as it is an easier, safer and more cost
effective method to deliver nutritional support (Marion & Rupp, 2000).
However, poor handling of enteral feeding may lead to bacterial
contamination. Several studies show high rate of bacterial contamination in the
administration sets. According to Matlow et al. (2003), 78% of enteral feeding
administration sets in a paediatric institution had bacterial contamination and
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Matlow et al. (2006), 59% of the enteral feeding administration sets grew
numerous nosocomial pathogens. Roy et al. (2005) have done a prospective
study on the incidence of bacterial contamination in enteral feeding
administration sets in a paediatric hospital and showed that 35% and 57% of
the enteral feeding administration sets had bacterial contamination in two
separate study periods respectively.
Moreover, studies showed that open enteral feeding system have a higher
rate of bacterial contamination than closed enteral feeding system. According
to Teitelbaum et al., the Board of directors and standards committee of the
American society for parental and enteral nutrition (2005), open enteral
feeding system refers to the enteral feeding system that requires caregiver to
decant formula into the enteral container or bag and closed enteral feeding
system refers to sterile liquid formula pre-filled in a closed enteral container or
bag by the manufacturer and considered ready to administer. Herlick et al.
(2000) have done a research to compare the open enteral feeding system and
closed enteral feeding system of intermittent enteral feeding. It showed that
the bacterial contamination rate of the open enteral feeding system was 78%
while that of the closed enteral feeding system was 39%. McKinlay et al.
(2001) have done another study with similar outcome. The bacterial
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contamination rate of the open enteral feeding system was 21% while that of
the closed feeding system was 12%. A quality improvement study also showed
that the incidence of bacterial contamination in a closed enteral feeding system
decreased when compared to an open enteral feeding system (Vanek, 2000).
Two studies suggested that the risk of bacterial contamination in a closed
enteral feeding system was very low in room temperature (Lafourcade et al.,
2002) and even at a high ambient temperature (Hsu et al., 2000).
Furthermore, rate of contamination is associated with the enteral feeding
hang time and frequent manipulations of the enteral feeding system.
According to Teitelbaum et al., the Board of directors and standards
committee of the American society (2005), for parental and enteral nutrition,
hang time refers to the length of time an enteral formula is considered to be
safe for delivery to patient. Mathus-Vliegen, Bredius & de Haan (2000) have
done a study showed that increased hang time of enteral feeding resulted in
increased bacterial contamination of the enteral feeding system. Frequent
manipulations of the enteral feeding system such as repeatedly adding the
formula into the enteral feeding administration sets increase the risk of
introducing bacteria into the feeding system and hence increase the rate of
bacterial contamination (Padula et al., 2004; Patchell et al., 1998; Roberts &
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Lyman, 2008).
Severe consequences related to enteral feeding include necrotizing
enterocolitis, abdominal distention and gastrointestinal intolerance and other
nosocomial infections such as gastroenteritis, pneumonia and septicaemia
especially in paediatric patients (Best, 2008).
Nosocomial infection refers to the late onset infection, that is 48 hours
after birth or admission (Borghesi & Stronati, 2008). Premature babies are
more at risk because of their immaturity of the immune system (Berthelot et
al., 2001). Common pathogens of nosocomial infection include Clostridium
difficile (Bliss, 1998; O’Keefe, 2010), gram positive organisms such as
Coagulase-negative staphylococci, Staphylococcus aureus and Enterococcus
(Borghesi & Stronati, 2008; Bott et al., 2001; Carvalho et al., 2000) and gram
negative organisms such as Escherichia coli, Klebsiella, Pseudomonas and
Enterobacter (Borghesi & Stronati, 2008; Bott et al., 2001; Carvalho et al.,
2000). These organisms colonized on the skin of patients and can be
transmitted through the hands of health care workers.
Mehall et al. (2002) have done a prospective study to show the
relationship between the incidence and complications of bacterial
contamination in neonates. It showed that bacterial contamination of enteral
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feeding can cause abdominal distention, gastrointestinal intolerance and may
contribute to necrotizing enterocolitis (NEC). Cuabilla-Barron et al. (2007)
indicated that the outbreak of necrotizing enterocolitis (NEC) occurred in a
neonatal intensive care unit (NICU) in France in 1994 was related to enteral
feeding.
Enteral feeding is related to nosocomial infection (Matsuoka, 2004) and
enteral solutions or administration sets have frequently been reported as
sources of nosocomial infection (Herlick et al., 2000; Hurrell et al., 2009;
Mehall et al., 2002). McErlean et al. (2005) have done a study on the
relationship between enteral feeding and gastroenteritis showed that 37% of
nosocomial gastroenteritis was related to enteral feeding. Moreover,
hospitalized enteral feeding patients are more prone to develop nosocomial
gastroenteritis. 9% of hospitalized enteral feeding patients had nosocomial
gastroenteritis while only 1% of hospitalized non enteral feeding patients had
nosocomial gastroenteritis (Bliss, 1998).
1.2 AFFIRMING THE NEED
Nosocomial infections account for 11.9% in paediatric intensive care unit
(Grohskopf et al., 2002) and 11.4% in neonatal intensive care unit (Sohn et al.,
2001). In Hong Kong, the prevalence of nosocomial infections in paediatric is
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8.9-11.5% (French, Cheng & Farrington, 1987; French, et al., 1989) of which
nosocomial gastroenteritis accounts for 13.4% (Lam et al., 1989), nosocomial
pneumonia accounts for 33% (Ko, 2007) and nosocomial septicaemia accounts
for 30-33.3% (French et al., 1990; Cheng et al., 1991).
Nosocomial infections increase the mortality and morbidity rate in
neonates (Borghesi & Stronati, 2008; Gill et al., 2011; Matsuoka et al., 2004;
Mathus-Vliegen, Bredius & Binnekade, 2006; Rahim & Barnett, 2009).
According to Bullock et al. (2004), the mortality rate of nosocomial
pneumonia in patients with enteral feeding is higher than those without enteral
feeding despite similar underlying medical condition. The mortality rate of
nosocomial pneumonia in patients with enteral feeding was 33% while the
mortality rate of nosocomial pneumonia in patients without enteral feeding
was 17%. The mortality rate in neonatal intensive care unit is 7% in which
18% is contributed by nosocomial infections (Stoll et al., 2002). Morbidity is
determined by the site of infections. For instance, meningitis can lead to visual
and hearing impairment, seizure, learning disability, cerebral palsy or even
mental retardation (Bedford et al., 2001; Klinger et al., 2000). Moreover,
nosocomial infections increase the length of hospital and intensive care unit
stay (Gill et al., 2011; Mathus-Vliegen, Binnekade & de Haan, 2000; Rahim &
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Barnett, 2009; Trabal et al., 2008; Vanek, 2009). The length of hospital stay for
patients with nosocomial infections was 14.1 days while that for patients
without nosocomial infections was 5.1 days (Cavalcante et al., 2006). The
length of stay in neonatal intensive care unit also greatly increased from a
median hospital stay of 32 days to 88 days for infants with nosocomial
infections (Sohn et al., 2001). Furthermore, nosocomial infections increase the
costs of healthcare system (Gill et al., 2011; Trabal et al., 2008). The overall
costs by nosocomial infections increase $3.5 millions annually in United
States (Correa & Pittet, 2000).
Nosocomial infections are spread by health care workers (Caglar, Yıldız
& Savaser, 2010). Clostridium difficile, gram positive and negative organisms
can be transmitted through the hands of healthcare workers (Berthelot et al.,
2001). Previous studies showed that the compliance rate of hand washing and
the appropriate technique and duration was relatively low. In Hong Kong,
Chau et al. (2011) have done a research and showed that 75% compliance with
hand hygiene, 72% compliance with glove use. Although, we have a relatively
high compliance rate in Hong Kong, the technique and duration of hand
hygiene still need to be improved. There are three ways to decrease
nosocomial infections including the use of non sterile gloves, proper hand
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hygiene and education programs. According to Chau et al. (2011), 28.6% of
healthcare workers did not wear gloves which can help spreading infectious
pathogens. Moreover, proper hand hygiene is one the of most important
interventions to prevent nosocomial infections as the organisms can be spread
by hands of health care workers (Best, 2008; Blaney et al., 2011; Caglar,
Yıldız & Savaser, 2010; Chau et al., 2011; Cohen et al., 2003; Gill et al., 2011;
Rahim & Barnett, 2009). Furthermore, education programs help to increase the
overall hand hygiene performance. A study by Saint et al. (2009) showed that
the overall head hygiene and hand hygiene adherence in Italy increased from
31.5% to 47.4% and 33.7% to 47.9% respectively (Saint, et al, 2009). In Hong
Kong, a study conducted in the neonatal intensive care unit of Queen Mary
Hospital also showed that education program in hand hygiene helped to
improve the hand hygiene compliance from 40% to 53% and 39% to 59%
before and after patient contact respectively and the nosocomial infection rate
decreased from 11.3 to 6.2 per 1000 patient-days (Lam, Lee & Lau, 2004).
However, a study showed that the policy on infection control practice was
ambiguous and inconsistent (Labeau, 2009). Moreover, there are enormous of
variation among enteral feeding, for instance hand hygiene, there are different
policy about hand washing disinfectants in different hospitals (Morritt et al.,
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2006).
There are few ready-to-use close system formulae for children as they
usually require specific nutrient demand or restriction. They may need to have
additives such as polycal, thicken up, fibreprotein, minerals and vitamins. This
enteral feeding is usually individualized and tailor made to meet their nutrient
needs and prone to change according to their growth. Since the addictives need
to be prepared immediately before use by the health care workers, this will
increase the chance of bacterial contamination. In the past, our usual practice
of enteral feeding was changing the administration sets once a week. The
administration sets were then rinsed by water and disinfectant after each
feeding. However, the disinfectant used for feeding equipment faded out.
Therefore, our paediatric department changed the enteral feeding practice. We
change the administration sets every day, use boiled water to rinse the
administration sets between each feeding. However, the residual water
remained inside the administration sets becomes a reservoir for bacterial
growth.
Most of the researches related to enteral feeding were done in western
countries. There are no empirical studies and guidelines can be search via
libraries and electronic resources about the interventions on preventing
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nosocomial infections related to enteral feeding among paediatric patients in
Hong Kong. Moreover, an updated guideline of enteral feeding for paediatric
patient is not available in local settings. Therefore, a more consistent guideline
is needed and the development of a clinical guideline to prevent nosocomial
infection in infants with enteral feeding is highly recommended and affirmed.
1.3 FORMULATING THE REVIEW OBJECTICES
AND THE RESEARCH QUESTION
1.3.1 Review objectives
The first objective is to review the published primary studies to determine
the effects of nursing care in preventing nosocomial infection in terms of
proper hand hygiene, optimal frequency of changing feeding sets and optimal
hang time. The second objective is to analyze and synthesize the reviewed
study and provide basis for developing an evidence-based guideline.
1.3.2 Research question
In infants with enteral feeding, how effective is the improved infection
control measures on optimal hang time and proper hand hygiene in preventing
nosocomial infection?
1.3.3 Significant of the study
An evidence-based guideline in enteral feeding can benefit patients,
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health care workers and hospital. For the patients, proper nursing care in
enteral feeding can prevent bacterial contaminations and nosocomial
infections, reduce the mortality and morbidity rate and the length of hospital
stay. For the nurses, a clear and consistent guideline can help us to make
critical decision, reduce our confusion and minimize variations in order to
decide the best care in enteral feeding practice for our patients (Labeau, 2009).
For the hospital, the nosocomial infection will reduce the healthcare costs
including the medications, intensive care, and extended hospitalization (Gill et
al., 2011; Trabal et al., 2008).
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CHAPTER TWO
CRITICAL APPRAISAL
2.1 SEARCH AND APPRAISAL STRATEGIES
2.1.1 Search strategy
The literatures were searched via the e-Journals of the University of Hong
Kong library and Electronic Knowledge Gate (eKG) of the Hospital Authority
(HA) from May 2011 to August 2011. Moreover, reference and citation lists
from papers meeting inclusion criteria were also searched. Electronic
databases included Ovid MEDLINE(R) (1948 to August Week 3 2011),
CINAHL Plus EBSCO Host (1982 to August 2011) and Cochrane library
(1999 to August 2011). Numerous keywords used included “gastrostomy
feeding”, “tube feeding”, “enteral nutrition”, “food contamination”,
“equipment contamination”, “bacterial contamination”, “Gram-negative
bacteria”, “bacterial infections”, “cross infection”, “staphylococcal infections”,
“hospital acquired infection”, “staphylococcus aureus”, “infection control”,
“bacteria”, “nosocomial infection”, “Klebsiella”, “Klebsiells infections”,
“Klebsiella pneumoniae”, “Clostridium” and “Clostridium difficile”. The
search strategy is attached to appendix 1.
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Initially, the titles and abstracts were screened through literature search
and full texts were obtained for those that were relevant. Studies that met the
inclusion criteria were selected and studies that met one of the exclusion
criteria were excluded.
2.1.2 Criteria for selecting studies for review
Inclusion criteria included primary studies, written in English or Chinese,
paediatric participants, studies involved feeding system, hang time and hand
hygiene and nosocomial infection as an outcome while exclusion criteria
included studies that only involved medical decision, studies that are not in
clinical settings, adult or elderly participants, intervention related to home care
and unpublished studies.
2.1.3 Methodology of the review
A total of sixteen out of one hundred and three papers were chosen in
Ovid MEDLINE(R) (1948 to August Week 3 2011), a total of seven out of
forty papers were chosen in CINAHL Plus EBSCO Host (1982 to August
2011) and 31 papers were reviewed in Cochrane library (1999 to August 2011).
Finally, nine studies were identified and included as some of the papers were
double searched. No additional eligible studies were found through the
reference and citation lists.
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All nine eligible studies were read through carefully. Data were extracted
from the studies and summarized in a table of evidence. The quality
assessments of the eligible studies were performed by the appraisal tool
developed by the Scottish Intercollegiate Guidelines Network (SIGN). Each
table of evidence consists of the study design and evidence level, subject
characteristics, intervention and comparison, length of follow up of the studies,
outcome measures and results. The nine tables of evidence are attached in
Appendix 2 and the checklists for critical appraisal used in the nine eligible
studies are attached to the Appendix 3.
2.2 RESULTS AND APPRAISAL OF STUDIES
All the nine eligible studies were published between 1999 and 2011 with
three cohort studies, four case control studies and two time series studies. The
interventions and results components of the nine eligible studies were attached
to Appendix 4.
Neely et al. (2006) conducted a cohort study to determine whether it was
safe to extend the hang time enteral feeding from four hours to eight hours.
The study was conducted in an urban hospital in United State of America. It
studied the relationship between the enteral feeding hang time and bacterial
contamination, nosocomial rate and cost. This study was divided into two
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phases. The first phase was a trial experiment to determine the microbial load
after hanging for eight hours. Twenty samples were done in this phase. As the
microbial loads after hanging for eight hours were within the acceptable level,
it went on to the second phase. The second phase took place in a paediatric
burn unit. Thirty eight children under the age of eighteen who were receiving
enteral feeding with custom made formula were included. Custom made
formula referred to milk formula with addictives. The results showed that the
microbial loads did not increase with extended hang time. The microbial load
at the beginning of administration was 1.21 +/- 0.52 cfu/ml while that after
eight hours was 1.13 +/- 0.47 cfu/ml. Also, the extended enteral feeding hang
time did not increase the nosocomial infection rate. The nosocomial rate
before and after the extension of enteral feeding hang time was 3.81% and
4.09% respectively. Moreover, the extended enteral feeding hang time helped
to reduce the cost of enteral feeding. The cost used in enteral feeding
administration set after the hang time was extended was $8029.5 when
compared with $19119.3 before the hang time was extended. The results
indicated that it is safe to extend the enteral feeding hang time to eight hours
when using custom made formula.
Lyman et al. (2011) conducted a cohort study to determine whether it was
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safe to extend the hang time of enteral feeding to twelve hours. The study was
conducted in an urban hospital in United State of America. It studied the
relationship between the enteral feeding hang time and bacterial contamination.
The study took place in a children hospital. Thirty children under the age of
eighteen with a mean age of 6.4 who were receiving continuous enteral
feeding with decanted or ready-to-feed formula were included. It determined
the occurrence of bacterial contaminations of decanted or ready-to-feed
formula after extending the enteral feeding hang time to twelve hours. One
hundred and eleven cultures were taken and the result showed that 90% of the
cultures had not grown any bacteria, 5% of the cultures were negative by the
United States food and drug administration (FDA) guidelines and 5% of the
cultures were positive by the United States food and drug administration (FDA)
guidelines. The results indicated that it is safe to extend the enteral feeding
hang time to twelve hours when using decanted or ready-to-feed formula.
Beattie & Anderson (2001) conducted an experimental case control study
to determine the bacterial contamination rate when the enteral feeding system
was handled with disposable gloves, contaminated hands or faulty handling
procedures. The study was conducted in England. It evaluated the four enteral
feeding systems that used in children with aged one to six years. In this study,
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two open enteral feeding systems and two closed enteral feeding systems were
used. Twelve samples were handled with either contaminated hands or faulty
handling procedures while eight samples were handled with disposable gloves.
The result showed that none of the closed enteral feeding systems were
contaminated when handled with disposable gloves and contaminated hands
(p<0.05). The bacterial contamination in one closed enteral feeding systems
was within acceptable levels when handled with faulty handling procedures
while the other closed enteral feeding systems did not have bacterial
contamination even when handled with faulty handling procedures (p<0.05).
However, there were significant bacterial contaminations in open enteral
feeding system when handled with disposable gloves, contaminated hands and
faulty handling procedures (p<0.05). The results indicated that closed enteral
feeding system is better than open enteral feeding system and had a lower risk
of bacterial contamination.
Beattie & Anderson (1999) conducted an experimental case control study
to determine the bacterial contamination rate of the closed enteral feeding
system when the feeding system was handled faulty handling procedures. The
study was conducted in England. Twenty feeding systems were handled with
faulty handling procedures while twenty feeding systems were handled with
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sterile gloves The result showed that there were bacterial contaminations in
both the feed samples, tops of the enteral feeding system container and
connectors of the enteral feeding system pump set (p<0.05). The results
indicated that there were still chances of bacterial contamination in closed
enteral feeding system even when the enteral feeding systems were handled
with faulty handling procedures.
Ng et al. (2004) conducted a retrospective observational case study to
determine the effectiveness of hand hygiene in terms of the use of gloves,
alcohol hand rub and conventional hand washing. The study was conducted in
an acute hospital in Hong Kong. Three hundred and thirty seven very low birth
weight infants that admitted to the neonatal intensive care unit of the Prince of
Wales hospital were included. One hundred and seventy six very low birth
weight infants were included in alcohol hand rub (Hexol lotion, i.e. 1%
chlorhexidine in isopropyl alcohol and ethyl alcohol) and gloves regimen
while One hundred and sixty one very low birth weight infants were included
in conventional hand washing program (Hibiscrub, i.e. Chlorhexidine
gluconate 4%). The result showed that the incident of infection rate had a
2.8-fold reduction from 89.4% to 36.9% and the incident of necrotizing
enterocolitis (NEC) in very low birth weight (VLBW) infants decreased from
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25.5% to 6.8% when the new alcohol hand rub and gloves regimen introduced.
The infants without ever being infected was 47% in conventional hand wash
and that in new alcohol hand rub and gloves regimen was 69%. The results
indicated that the use of alcohol hand rub and gloves can reduce the incidence
of infections in neonatal intensive care unit.
Helder et al. (2010) conducted an observational time series study to
determine the effectiveness of a hand hygiene education program. The study
was conducted in an urban hospital in Netherlands. It studied the relationship
between hand hygiene compliance and nosocomial infections. One thousand
two hundred and one structured observations including five hundred and
twelve pre-intervention observations and six hundred and eighty nine
post-intervention observations were done on one hundred and thirty seven
health care workers in neonatal intensive care unit. The pre-intervention period
lasted for thirty months. A 30-minute education program on hand hygiene with
both theoretical and practical orientation was given to health care workers
after the pre-intervention period and followed by an 18-month
post-intervention period. The hand hygiene program provided the brief
overview of the background of infection prevention, information on the
incidence of nosocomial infections, their consequences and the poor
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compliance to hand hygiene, instructions for optimal hand hygiene procedures
include timing, techniques and completeness of hand hygiene, return
demonstrations and performance feedback. The result showed that both the
compliance with hand rubbing before and after patient contact were increased
from 68.8% to 86.9% and 68.9% to 84%, respectively (p<0.001) after the hand
hygiene education program. Moreover, the nosocomial bloodstream infections
and the rate of nosocomial infections decreased after the implementation of the
hand hygiene education program from 44.5% to 36.1% and 17.3 to 13.5 per
one thousand patient-days, respectively (P=0.03). The results indicated that
hand hygiene education program is effective in sustaining compliance of hand
hygiene and significantly reduces the nosocomial infections.
Larson et al. (2005) conducted a clinical trial case control study to
determine the effectiveness of hand hygiene in terms of the use of alcohol
sanitizer and traditional antiseptic hand washing. The study was conducted in
an urban hospital in the United States of America. Two thousand nine hundred
and thirty two neonates and one hundred and nineteen nurses working in two
neonatal intensive care units were included and each of the hand hygiene
products was randomly used for eleven consecutive months. One thousand
five hundred and sixteen neonates were enrolled in the group using alcohol
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hand sanitizer (61% ethanol and emollients) while one thousand four hundred
and sixteen neonates were enrolled in the group using traditional antiseptic
hand washing (2% chlorhexidine gluconate). The result showed that the
compliance of hand washing increased while the rate of nosocomial infection
decreased. The results indicated that proper hand hygiene practice can reduce
the incidence of nosocomial infections in neonatal intensive care unit.
Capretti et al. (2008) conducted a prospective case control study to
determine the relationship between hand hygiene program and the rate of
nosocomial infections. The study was conducted in an urban hospital in Italy.
It compared the use of antimicrobial soap with plain fluid detergent. One
hundred and sixty five very low birth weight (VLBW) infants with body
weight less than 1500g admitted to neonatal intensive care unit were included.
Eighty neonates were enrolled in hand washing group using antimicrobial soap
(4% chlorhexidine gluconate) or alcohol-based hand rubs while eighty five
neonates were enrolled in hand washing group using a plain fluid detergent
(0.5% triclosan). The use of plain fluid detergent period lasted for seventeen
months followed by another seventeen months period using the antimicrobial
soap. The result showed that the nosocomial infection rate greatly reduced
from 18.8% to 6.2% (p=0.015) and the length of stay in very low birth weight
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(VLBW) infants with nosocomial infections was 7.7 days longer than those
without nosocomial infections (p=0.016) after the implementation of the use of
antimicrobial soap. The length of hospital stay in infected infant and non
infected infant were more or less the same in both hand hygiene program when
using plain detergent (p=0.003) and antimicrobial agent (p=0.001). The results
indicated that the use of antimicrobial soap program significantly reduces the
rate of nosocomial infection and a standardized hand hygiene program which
focus on the timing, techniques and completeness of hand hygiene can reduce
the length of hospital stay.
Peesoa-Silva et al. (2007) conducted an observational time series study to
determine the effectiveness of a multifaceted hand hygiene education program.
The study was conducted in an urban hospital in Switzerland. It studied the
relationship between hand hygiene compliance and nosocomial infections.
One thousand one hundred and fourteen neonates and one hundred and one
health care workers in neonatal intensive care unit were recruited in three
phases. Phase one was a 9-month baseline phase which enrolled two hundred
and sixty four neonates, phase two was an 18-month intervention phase which
enrolled five hundred and fifty four neonates and phase three was a 9-month
follow up phase which enrolled two hundred and ninety six neonates. The
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result showed that the compliance of hand hygiene increased from 42% in
phase one to 45% in phase two and to 55% in phase three. The compliance
rate in phase two is higher than phase one (p=0.025) while that in phase three
is higher than phase two (p=0.037). The rate of nosocomial infections in very
low birth weight (VLBW) neonates decreased from 15.5 infections per one
thousand patients-day in phase one to 10.7 infections per one thousand
patients-day in phase two and further decreased to 8.8 infections per one
thousand patients-day in phase three. Moreover, the length of hospital stay in
very low birth weight (VLBW) neonates was significantly longer in phase one
when compared with phase two and phase three (p=0.05). The results
indicated that hand hygiene education program include the education on hand
hygiene indications, technique and performance feedback is effective in
sustaining compliance of hand hygiene and significantly reduces the
nosocomial infections and length of hospital stay.
2.3 SUMMARY AND SYNTHESIS OF DATA
2.3.1 Research problem and purpose
Most of the review studies were related to infants younger than three
years old. Five of them were done in neonatal intensive care unit, two of them
were done in general Paediatric unit and one of them was focused on the
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paediatric feeding system. Three of the studies were done in the United States
of America, two of them in England and one from Hong Kong, Netherlands,
Italy and Switzerland. All of the studies clearly stated the research purpose or
objective. Two studies assessed the optimal enteral feeding hang time, two
studies assessed the design of enteral feeding system and five studies assessed
the hand hygiene. Most of them examined the effects of intervention on
preventing bacterial contamination and nosocomial infection among children.
2.3.2 Study type and level of evidence
Among the three cohort studies, four case control studies and two time
series studies, the level of evidence are ranged from 2++ to 3 according to the
hierarchy of evidence developed by the Scottish Intercollegiate Guidelines
Network (SIGN). There are two in level 2++, four in level 2+ and three in
level 3.
2.3.3 Intervention
Two studies assessed the optimal enteral feeding hang time. One of them
focused on the optimal enteral feeding hang time for custom made modular
formula, the microbial load after extending the enteral feeding hang time to
eight hours. The other one focused on the optimal enteral feeding hang time
for decanted or ready-to-feed formula, the bacterial contamination after
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extending the enteral feeding hang time to twelve hours. Two studies assessed
the design of feeding system. One of them included both open and closed
enteral feeding system in the study and examined the bacterial contamination
when the enteral feeding system was handled with diposable gloves,
contaminated hands and faulty handling procedures. The other one included
closed enteral feeding system only and examined the bacterial contamination
when the enteral feeding system was handled with faulty handling procedures.
Five studies assessed the hand hygiene. Two of them focused on hand hygiene
education program and evaluated the importance of proper hand hygiene in
preventing nosocomial infections. The other three of them focused on
disinfectant for hand hygiene. They examined the efficacy of different
disinfectant for hand hygiene.
2.3.4 Internal validity
In the two cohort studies, the two cohort groups were compared before
implementation of intervention and there was no significant difference in the
two population groups. In the other case control studies, the case and control
groups were also compared and found no significant difference. Most of the
studies have a sample size greater than one hundred and fifty. The confounders
were addressed in all of the studies, for example the nurse-to-patient ratio and
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the compliance and skill of staff. The outcome measures were consistent in the
reviewed studies as all of them assessed the incidence of bacterial
contamination and nosocomial infection. Moreover, some of them assessed the
secondary outcome measures included compliance rate and length of hospital
stay.
2.3.5 Synthesis of findings
The finding of this integrated review suggested the increase in the enteral
feeding hang time did not appear to increase the rate of bacterial
contamination in both custom made formula and decanted or ready-to-feed
formula (Neely et al., 2006; Lyman et al., 2011). Moreover, the risk of
bacterial contamination in closed enteral feeding system was lower than open
enteral feeding system; however, there was still a risk of bacterial
contamination when the closed enteral feeding system was handled with faulty
handling procedures (Beattie & Anderson, 2001; Beattie & Anderson, 1999).
Proper hand hygiene before enteral feeding is highly recommended. The
use of chlorhexidine gluconate or alcohol hand rub can significantly reduce the
rate of nosocomial infections (Ng et al., 2003; Larson et al., 2005; Carpretti et
al., 2008). An education program in hand hygiene is effective in sustaining
compliance of hand hygiene and significantly reduces the nosocomial
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infections (Helder et al., 2010; Pessoa-Saliva et al., 2007).
In conclusion, closed enteral feeding system has lower risk of bacterial
contamination and health care professionals should change to closed feeding
system whenever available. The optimal hang time for decanted or
ready-to-feed formula and formula with additives (prepared in milk kitchen
and refrigerated until use) should be reduced to twelve hours and eight hours
respectively. Moreover, proper hand hygiene with the use of chlorhexidine
gluconate or alcohol-based hand rub and education program are highly
recommended as they can effectively reduce nosocomial infections.
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CHAPTER THREE
IMPLEMENTATION POTENTIAL
In this chapter, the implementation potential of the proposed evidenced
based guideline is assessed in terms of transferability, feasibility and cost
benefits ratio. The target audience and setting, the philosophy of care and the
implementation and evaluation time will be discussed in the transferability of
the findings. The autonomy to carry out innovation, the interference with
current practice, the administration and organization support, the consensus
among staffs and administrators, the skills and training time, the availability of
equipments and facilities, the potential frictions and the clinical evaluation
tools will be discussed in the feasibility of the proposed evidence based
guideline. The potential benefits to both the patients, nursing staffs and
organization, the potential risks and the cost of innovation will be discussed in
the cost benefits ratio.
3.1 TRANSFERABILITY
3.1.1 Target audience and setting
The new evidence based guideline will be implemented in a paediatric
unit of an acute hospital in the Kowloon Central Cluster. The paediatric unit
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consists of a total of seven paediatric wards including neonatal special care
baby unit (SCBU), neonatal intensive care unit (NICU), paediatric intensive
care unit (PICU), general infant ward, general child and adolescent ward,
paediatric oncology ward and paediatric isolation ward, providing one hundred
and ninety five beds for children under the age of three. There are two hundred
and ten nursing staffs in the paediatric unit to provide care for children under
three years old with enteral feeding including both Ryle’s tube and
gastrostomy feeding.
The target population and setting are similar in both the reviewed
evidence and current proposed setting. The target population in the nine
reviewed evidence was children with enteral feeding with five of them focused
on children under age of three while the target population in the current
proposed setting is children under three with enteral feeding. Two of the
reviewed evidence took place in paediatric hospitals and five of them took
place in neonatal intensive care units while the proposed setting is a paediatiric
unit.
3.1.2 Sufficient number of clients can be benefited from the
new innovation
According to the statistic which was done by our paediatric unit from
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July 2010 to Jun 2011, the average occupancy rate of our paediatric wards was
80% and forty children under the age of three have enteral feeding each day
which accounted for 25% of the daily occupancy. 10% of the children with
enteral feeding got nosocomial infection, that is, 2.5% of nosocomial infection
were children with enteral feeding and 50% of them required intensive care.
Although the number of children with enteral feeding being infected is
relatively small, the consequences of nosocomial infection in these children
cannot be overlooked or under estimated. Nosocomial infection in children
with enteral feeding increases the lengths of hospital stay, the mortality and
morbidity rate and the medical costs which cause serious problems to both the
organization, the nursing staffs, the children and their parents. Therefore, there
is a need to develop an evidence based guideline to minimize the rate
nosocomial infection.
3.1.3 Philosophy of care
The goals of the Hospital Authority include providing people centre care
and professional service, improving and assuring the hospital quality standards
and quality of care to patients by promoting proper infection control measures
in order to minimize the risk of infection and provide safe and cost effective
practice to patients and knowledge based information to nursing staffs. The
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aims of the proposed paediatric setting are consistent with the philosophy of
care of the Hospital Authority. According to our departmental orientation
program to newcomers, the aims of the proposed paediatric setting are
improving quality of life, reducing the medical costs and nosocomial infection
rate and providing evidence based guidelines for nursing staffs.
3.1.4 Implementation and evaluation time
The innovations will be delivered to all the nursing staffs through a
45-minute training session. The training session consists of two parts including
theory input and hand hygiene training workshop. An education program with
both theoretical and practical orientation is effective to enhance the
compliance and reduce nosocomial infection (Helder et al., 2010). There are
fifty Advanced Practice Nurses (APN) and one hundred and sixty Registered
Nurses (RN) in our paediatric unit. The training sessions will be provided for
the Advanced Practice Nurses (APN) in the first two weeks. Then the
Advanced Practice Nurses (APN) will train the Registered Nurses (RN) in the
following two weeks. There will be three to four nurses in each training
session. The whole training session will take around forty five minutes.
Introduction, background information and objectives of guideline will be
given in the first fice minutes, followed by a ten minutes practical
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demonstration of enteral feeding and hand washing technique. Then, there will
be a 15- to 20-minute of return demonstration by each participant and last ten
minutes will be used for discussion and feedback. The whole training session
for the implementation will be completed in four weeks.
The evaluation will be assessed at three stages including the impact
evaluation, the process evaluation and the outcome evaluation. The impact
evaluation will be done immediately after the training session to assess the
changes in awareness, attitudes, knowledge, skills and behaviour of the
nursing staffs. This can be assessed through discussion and return
demonstration. The process evaluation will be done by regular audit and ward
meeting to assess the compliance of the guideline. Regular audit will be
arranged one month after the completion of training sessions and will be done
monthly while regular ward meeting will be held every two to three months.
The nursing staffs can express their opinions and obtain the audit report during
regular ward meeting. The outcome evaluation will be done by half yearly
review on the rate of nosocomial infection to assess the long term effect, that
is, whether the implementation can reduce the rate of nosocomial infection
effectively.
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3.2 FEASIBILITY
3.2.1 Nurse related factors
3.2.1.1 Freedom to carry out and terminate the innovation
In our current practice, nursing staffs are responsible for providing enteral
feeding to children. Therefore, nursing staffs have the autonomy to terminate
any undesirable practice, make arrangement and carry out new innovations
according to evidence.
3.2.1.2 Interference with current staff function
The implementation will not cause interference with our current practice.
In current practice, the enteral administration feeding set is used for one day.
Nursing staffs need to wash the administration feeding sets after each feeding
and put back to the bedside box of each child and supporting staffs need to
refill the supply of enteral administration sets to bedside once every afternoon.
In the new innovation, although we need to change the enteral feeding
administration set two to three times per day, the whole enteral feeding
procedure is the same. Supporting staffs refill the necessary number of enteral
feeding administration sets in bedside as usual. Nursing staffs still need to
gather the enteral feeding equipments from bedside and prime the enteral
feeding administration set before each enteral feeding. Moreover, hand
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hygiene is essential in both current practice and the implementation of
innovation. The only difference is using anti microbial soap chlorhexidine
gluconate or alcohol based handrub in the innovation rather than plain
detergent in current practice. Therefore, the nursing staffs will not have extra
workload in new practice. However, it may have some confusion to staff as
different children have different changing time. This can be solved by putting
a tag in bedside stating the time of changing enteral feeding administration
sets.
3.2.1.3 Training and skills
Nursing staffs are familiar with the enteral feeding procedure and hand
hygiene. We have orientation program for new staffs and our current staffs are
familiar with the enteral feeding procedure. However, no regular training
sessions on hand hygiene are provided. The main purposes of providing
training sessions for all the nursing staffs are to increase their awareness and
promote the new guideline and motivate to apply the innovations into practices.
Moreover, training sessions can be done in neonate and paediatric enhance
programs which is compulsory to all nursing staffs. Since the training program
will be hold by the Advanced Practice Nurses (APN), one to two training
sessions can be hold in each ward per day. There are usually four to five
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nursing staffs in general wards and eight to nine staff in intensive care units
each shift. Two nursing staffs can be spared after medical round to attend the
training session and those who have attended the training session out of
working hours can receive time compensation later after the training period.
This may slightly increase the workload of other staffs, however, time
compensation will be granted if the ward is less busy and only one staff will be
granted each time to minimize the inconvenience caused and the increase in
workload.
3.2.2 Organization related aspects
3.2.2.1 Support from administration and organization
The administration supports the implementation of innovation and the
organization climate is conductive to the utilization of the evidence based
guideline. In our paediatric unit, we have regular risk alert conferences and
neonate and paediatric enhance programs. Nursing staffs are welcomed to
raise any medical concerns, share different views on medical issues and
discuss current nursing practices in order to provide better care for children
and develop evidence based practice. The aims of Hospital Authority are to
improve the hospital quality standard. They enhance nursing knowledge and
skills by putting a lot of resources and efforts to develop safe and cost
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effective evidence based practices for nursing staffs for years in order to
minimize the risk of infection. Moreover, there is a Hospital Accreditation
Scheme in our hospital which supports the implementation of evidence based
practices and guidelines.
3.2.2.2 Consensus among staff and administrators
There is a fair degree of consensus among both the staffs and
administrators to implement and evaluate the innovation. There are two major
outbreaks in our peadiatric unit within four months. They are the Rotavirus
outbreak in August 2011 and the Norovirus outbreak in mid November 2011.
The nursing staffs and the administrators started to review the possibility of
spreading the virus via enteral feeding administration set and inadequate hand
hygiene. They started to realize the relationship between enteral feeding and
nosocomial infection and eager to find ways to change the current practice and
prevent further outbreaks and nosocomial infection.
3.2.2.3 Equipments and facilities
The enteral feeding administration sets are available in each ward.
However, milk pump will be required in the implementation of innovation.
This can be solved and no extra costs for milk pump is needed as the enteral
feeding set company will provide the milk pump for us if we buy the enteral
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feeding administration sets regularly. Moreover, the training sessions will be
hold in ward, the enteral administration sets, the chlorhexidine hand washing
solution and the alcohol based hand rub can be obtained easily. Furthermore,
the washing basins are available in each ward for hand hygiene training.
3.2.3 Potential friction
There will be potential friction when new innovation is implemented
even though the new practice does not have much difference when compared
with the current practice. Some staffs maybe reluctant to change the current
practice that they have been used for many years. As different nursing staffs
have different level of motivation, acceptance and beliefs towards the change
process, the training sessions should not only provide theoretical and practical
input but also promote evidence based practice and encourage them to change.
Moreover, the whole guideline should be kept in each ward for quick reference
so that nursing staffs can easily find and refer to it when they encounter any
problems.
3.2.4 Measuring tools
Appropriate measuring tools are available for clinical evaluation of the
innovation. The hand hygiene audit and evaluation form are currently
available in each ward. However, different wards have different audit and
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evaluation form and regular audit on hand hygiene is performed on nursing
staffs working in paedaitric isolation ward only. Therefore the hand hygiene
audit and evaluation form need to be standardized and done regularly after the
implementation of the innovation. Moreover, enteral feeding technique audit is
currently available, however, the audit need to be updated to match the
implementation of the innovation. Furthermore, infection control team
members have regular audit on the compliance of hand hygiene.
3.3 COST BENEFITS RATIO OF THE
INNOVATION
3.3.1 Potential benefits to children
From the reviewed evidence, the implementation of innovation has
potential benefits to children. It can decrease the nosocomial infection rate, the
incident of necrotising enterocolitis and life threatening consequences and
hence improve the quality of life in children (Ng et al., 2003; Helder et al.,
2010; Larson et al., 2005; Capretti et al., 2008; Pessoa-Silva et al., 2007).
3.3.2 Potential benefits to nursing staffs
The implementation of innovation has potential benefits to nursing staffs.
Evidence based practice can enhance our nursing authority and autonomy and
hence improve our morale and develop our nursing professionalism. Moreover,
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evidence based guideline can enhance nursing knowledge and confidence in
caring children with enteral feeding.
3.3.3 Potential benefits to the organization
From the reviewed evidence, the implementation of innovation has
potential benefits to the organization. It can reduce the rate of nosocomial
infection (Ng et al., 2003; Helder et al., 2010; Larson et al., 2005; Capretti et
al., 2008; Pessoa-Silva et al., 2007) and the lengths of stay in intensive care
unit (Capretti et al., 2008). Moreover, the improved hospital health care
standard, quality of life of children and the reduced rate of nosocomial
infection, mortality and morbidity can enhance organization image.
3.3.4 Costs of innovation
There is an average of forty children receiving seven enteral feeding each
day, twenty seven of them use ready to feed formula while thirteen of them
use formula with additives which are prepared by milk kitchen. Forty gravity
enteral feeding administration sets are used each day in current practice while
the enteral feeding administration sets will be increased to ninety three pumps
enteral feeding administration sets per day after the implementation of
innovation. From the latest quotation, the costs of gravity enteral
administration sets and pump enteral administration sets are $6 and $9
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respectively. The expenses used on enteral feeding administration sets in one
year are $87600 in current practice and $305500 after the implementation of
innovation. The material costs increased by $217900 after the implementation
of innovation. However, the material costs can be counterbalanced by the non
material costs.
Reviewed evidenced showed that the innovation can reduce the lengths of
stay in intensive care unit by 7.7 days (Capretti et al., 2008) and one study
done in Hong Kong showed that the nosocomial infection rate can be reduced
by 5.1 incidents per one thousand patient days after the implementation of
innovation (Lam, Lee & Lau, 2004). According to the statistic done by our
department, the average lengths of hospital stay of each children was fourteen
days. Using the average daily occupancy rate of 80%, we can reduce two
hundred and ninety incidents of nosocomial infection annually and at least
three children with enteral feeding can be prevented from acquiring
nosocomial infection and require intensive care. According to the Finance
Division of the Hospital Authority, the average inpatient cost per patient day
in paediatric intensive care unit in our cluster in 2010 was $14251. Therefore,
the medical cost saved in these 3 children is $329200. Other non material costs
include the extra isolation costs due to nosocomial infection as the use of
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disposable personal protective equipment and anti-mocrobial soap are
increased, the maintenance cost of isolation facilities and the potential non
material benefits such as reduced mortality and morbidity rate and parent
anxiety and improved quality of life in children, staff morale and organization
image.
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CHAPTER FOUR
EVIDENCE BASED PRACTICE GUIDELINE
4.1 CONCEPTUAL PRINCIPLE OF THE
GUIDELINE
This clinical guideline is designed for paediatric nurses to care children
age under three with enteral feeding. This guideline focuses on the enteral
feeding system, the optimal hang time of enteral feeding and proper hand
hygiene. The aims of this guideline is to provide evidence base care practice
for paediatric nurses and improve their knowledge and technique in order to
prevent bacterial contamination of enteral feeding administration sets and
minimize the rate of nosocomial infection. This guideline is generated after
reviewing our current practice and various literatures and it will be reviewed
and modified regularly in order to provide the most updated evidence based
practice for children with enteral feeding.
4.2 PRESENTATION OF THE GUIDELINE
This guideline targets all paediatric nurses who provide enteral feeding
for children under three years old. The recommendations will be presented in a
simple and clear way (Appendix 5). They will be listed in point form under
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two categories including enteral feeding system and optimal hang time and
hand hygiene, followed by the supporting evidence and rationale. The
definitions of the grading of recommendations used in this guideline are
originated from Scottish Intercollegiate Guidelines Network (SIGN) (2009)
(Appendix 6).
4.3 EVIDENCE BASED ENTERAL FEEDING
GUIDELINE IN INFANTS
4.3.1 Hang time
Objective: To promote a proper enteral feeding system and optimal hang time
to prevent bacterial contamination.
Recommendations:
1. Sterile close enteral feeding system can last for 24 hours. (Grade B)
The rate of bacterial contamination does not increase in the first 24 hours
(Beattie & Anderton, 1999) (Level of evidence 2+)
2. Closed enteral feeding system should be used whenever available
(Grade B)
Close enteral feeding system has a lower rate of bacterial contamination
when compared with open enteral feeding system (Beattie & Anderton,
2001) (Level of evidence 2+)
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3. The optimal hang time for decanted or ready-to-feed formula should be
reduced to 12 hours (Grade B)
The rate of bacterial contamination and nosocomial infection do not
increase when the hang time for decanted or ready-to-feed formula is
limited to 12 hours (Neely et al., 2006) (Level of evidence 2+)
4. The optimal hang time for formula with additives (prepared in milk
kitchen and refrigerated until use) should be reduced to 8 hours (Grade B)
The rate of bacterial contamination does not increase when the hang time
for formula with additives (prepared in milk kitchen and refrigerated
until use) is limited to 8 hours (Lyman et al., 2011) (Level of evidence
2+)
4.3.2 Hand hygiene
Objective: To maintain proper hand hygiene in order to decrease the rate of
nosocomial infection.
Recommendations:
5. Proper hand hygiene, either hand washing for at least 15 seconds or using
handrub until thoroughly dry, should be done before enteral feeding
(Grade C)
Proper hand hygiene can reduce nosocomial infection effectively
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(Capretti et al., 2008; Larson et al., 2005; Ng et al., 2003) (Level of
evidence 2++; 2+; 3)
6. Perform hand hygiene by using anti microbial soap chlorhexidine
gluconate or alcohol based handrub rather than plain detergents (Grade B)
The use of chlorhexidine gluconate or alcohol based handrub is more
effective to reduce nosocomial infection when compared with plain
detergent (Capretti et al., 2008) (Level of evidence 2++)
7. Hand hygiene should not be obviated by the use of gloves (Grade C)
No significant data showed that the use of glove alone can reduce
nosocomial infection (Ng et al., 2003) (Level of evidence 3)
8. A 30-minute educational program with both theoretical and practical
orientation on enteral feeding and hand hygiene techniques should be
provided for staff compulsorily and regularly (Grade C)
Educational program can increase the compliance rate of hand hygiene
and hence reduce the nosocomial infection (Helder et al., 2010;
Pessoa-Silva et al., 2007) (Level of evidence 3)
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This evidence based guideline is formulated according to the reviewed
literature (Neely et al., 2006; Lyman et al., 2011; Beattie & Anderton, 2001;
Beattie & Anderton, 1999; Ng et al., 2003; Helder et al., 2010; Larson et al.,
2005; Capretti et al., 2008; Pessoa-Silva et al., 2007). Paediatric nurses will be
guided to care children under age of 3 with enteral feeding by this guideline.
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CHAPTER FIVE
IMPLEMENTATION PLAN
In this chapter, the implementation plan of the new enteral feeding
guidelines will be developed to ensure a smooth and successful adoption of the
innovation. First of all, the stakeholders will be identified and then a
communication plan with different stakeholders will be developed. Moreover,
a pilot test will be designed to test the feasibility of the new enteral feeding
guideline before implementing to whole paediatric unit.
5.1 COMMUNICATION PLAN
A communication plan is essential to effectively implement the
innovation and facilitate a continuous communication. We need to plan
carefully about who and how to communicate. A brief communication plan is
attached in Appendix 7.
5.1.1 Identify the stakeholders
In the communication plan, the initial step is to identify the stakeholders
who have the power to make change, who are actively involved in the change
or whose interests can be affected positively or negatively during the
implementation (Andrew, 2009; Merlnyk, 2005). These stakeholders include
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the Chief of Service (COS), the Department Operative Manager (DOM),
Paediatric doctors, Ward Managers (WM), Nurse Specialists (NS) and
Advanced Practice Nurses (APN) and ward nurses (Registered Nurses (RN)
and Enrolled nurses (EN)). It is necessary and important to communicate with
all identified stakeholders in order to gain their authorization and support.
The Department Operation Manager (DOM) and the Chief of Service
(COS) are key persons for decision making who offer resources and grant
permission to carry out the innovation. The Ward Managers control the
manpower and resources used in the implementation and monitor and facilitate
the whole implementation change.
The Nurse Specialists (NS) and Advanced Practice Nurses (APN) are
those with advanced clinical experiences, knowledge and skills. They are
responsible to facilitate, supervise and review the implementation of new
innovation and provide education and training to all those involved in the
implementation.
Paediatric doctors are another stakeholder as they are responsible to
diagnose suspected nosocomial infections and provide treatment plans.
Therefore, it is important to gain their support in the implementation. The
evidence based guideline should be given to them for reference in order to
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facilitate a better understanding of the new innovation.
Ward nurses including Registered Nurses (RN) and Enrolled Nurses (EN)
are responsible to carry out the new evidence based guideline. Training
sessions will be provided for them and ward meeting will be held regularly in
order to collect feedbacks.
5.1.2 Identify the problem
Initially, we need to identify the problem in our paediatric department,
which is nosocomial infection in infants related to enteral feeding. Then we
can present the problem to the Ward Manager (WM) and Advanced Practice
Nurses (APN) by providing statistics from our paediatiric department on the
nosocomial infection related to enteral feeding in infants. Evidence from the
researches and literature reviews on the need to change our current practice via
a brief presentation should also be provided in order to gain their awareness.
5.1.3 Communication activities
5.1.3.1 Working committee
A working committee will be formed after communicating with the
stakeholders. Two Advanced Practice Nurses (APN), two senior Registered
Nurses and the guideline proposer will be invited to be members of the
working committee. These frontline nurses have enough knowledge and
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experiences to understand the current situation and the problems encountered
and give constructive opinions to the new innovation. They are responsible for
the implementation and evaluation process of the innovation by reviewing the
evidence-based guideline and considering and discussing different points of
views and suggestions about the guideline. The committee members will
receive training from the guideline proposer in order to familiar with the new
enteral feeding guideline and provide training and support to the remaining
paedaitric nurses later.
5.1.3.2 Propose to Ward Manager (WM)
A formal meeting will be arranged with the Ward Manager (WM) to
explain the details of the proposal in order to seek the approval. After that, the
details of implementing the innovation such as the manpower, the material
resources and costs, the training program and the schedule of the
implementation and evaluation will be discussed by the working committee
before proposing the innovation to the Department Operation Manager
(DOM).
5.1.3.3 Propose to Department Operation Manager (DOM)
A formal meeting will be arranged with the Department Operation
Manage (DOM) and Ward Manager (WM) from other paediatric wards. The
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meeting will focus on the background information on the nosocomial infection
related to enteral feeding in infants, the statistic done by our paediatric
department, the evidence from the researches and literature reviews on the
need to change our current practice, the objectives and the flow of new
guideline, the cost benefit ratio, the staff training program and the evaluation
plan. The guideline and the implementation plan will be adjusted and modified
based on the suggestions, feedbacks and comments collected from the
meeting.
5.2 PILOT STUDY
A pilot study is designed to test the feasibility of the proposed
intervention. The preliminary data collected is useful to identify and eliminate
possible problems and minimize unexpected difficulties. Moreover, it helps to
assess time, the adequacy of the training procedures, the appropriateness and
duration of the training workshop, the effectiveness of data collection and
estimate the budget plan. Furthermore, it helps to revise and modify the
innovation before implementing in the whole department. The pilot test will
last for 1 month and evaluated by the perception and satisfaction level of staff.
5.2.1 Objectives
A pilot study is designed to test the feasibility of the proposed
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intervention. The preliminary data collected is useful to identify and eliminate
possible problems and minimize unexpected difficulties. Moreover, it helps to
assess time, the adequacy of the training procedures, the appropriateness and
duration of the training workshop, the effectiveness of data collection and
estimate the budget plan. Furthermore, it helps to revise and modify the
innovation before implementing in the whole department. The pilot test will
last for 1 month and evaluated by the perception and satisfaction level of staff.
5.2.2 Subjects and procedure
The pilot study will be held in two paediatric wards including the
Neonatal Intensive Care Unit (NICU) and general infant ward. Three nurses
from Neonatal Intensive Care Unit (NICU) and three nurses from general
infant ward will be invited to participate in the pilot study. Six patients will be
included in the pilot study. Three of them are from Neonatal Intensive Care
Unit (NICU) and the rest of them are from general infant ward. The inclusion
criteria include paediatric patients under the age of three who are having
enteral feeding. However, those with suspected infection will be excluded.
The guideline proposer will register patients who meet the inclusion
criteria and record their demographic data and the duration of enteral feeding.
All the parents of our paediatric participants will be introduced about the new
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practice. Verbal consent will be obtained from their parents after explaining
the benefits and risks to them. The participating nurses should observe the
general condition of each patient and report any signs and symptoms of
nosocomial infection. The whole observation will be last for a month.
The members of the working committee will monitor and observe the
performance and the progress of the participating nurses and assist the
guideline proposer in implementing and evaluating the process.
5.2.3 Training workshops
A training session will be provided by the guideline proposer for the six
nurses before the pilot study. The training session consists four parts including
introduction, background information and objectives of new enteral feeding
guideline, practical demonstration of enteral feeding and hand washing
technique, return demonstration and discussion and feedback. The training
session provides opportunity for them to express their concerns and opinions.
This also provides opportunity for the guideline proposer to reassure the
nurses for the change and encourage them to comply with the new enteral
feeding guideline in order to provide a better nursing care and evidence based
practice to our paediatric patients. After the training session, the recruited
nurses will deliver enteral feeding according to the guideline in their own ward
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and a prospective evaluation will be done one month after the training.
5.2.4 Evaluation
A post test questionnaire which is anonymous will be given to the
participating nurses to evaluate the perception and satisfaction level of the new
enteral feeding guideline. The questionnaire which is modified according to
the nurses satisfactory survey currently used in our paediatric department is
attached in Appendix 8. A semi-structured interview will be arranged for each
participated nurse with the guideline proposer to explore their satisfaction with
the innovation and the implementation process. The adequacy of the training
session, the comprehensiveness and clarity of the new enteral feeding
guideline, the format and duration of the training session and the timing of the
outcome measures will be evaluated. The enteral feeding guideline will then
be revised or modified and presented to the Department Operation Manager
(DOM) and the Ward Managers (WM) together with the evaluation results for
promoting the new enteral feeding guideline to the whole paediatric
department.
5.3 PROMOTION TO OTHER PAEDIATRIC
WARDS
The members of working committee are responsible to answer the doubts
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about the new enteral feeding guideline. The new enteral feeding guideline
should be kept at the nursing stations or posted in the treatment room to
encourage continue usage and for reference.
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CHAPTER SIX
EVALUATION PLAN
The comprehensive evaluation plan is developed to evaluate the
effectiveness of the new enteral feeding guideline. It is a good indicator for the
stakeholders to determine the feasibility and transferability and the
effectiveness and benefits of the new enteral feeding guideline. Patient
outcomes, healthcare provider outcomes and system outcomes will be
evaluated.
6.1 OUTCOMES TO BE ACHIEVED
6.1.1 Patient outcomes
6.1.1.1 Identification of patient outcomes measure
The aim of the new enteral feeding guideline is to prevent nosocomial
infection in infants with enteral feeding. Nosocomial infection in infants with
enteral feeding increases the lengths of hospital stay, the mortality and
morbidity rate and the medical costs. The primary outcome is the nosocomial
infection rate and the secondary outcome is the length of hospital stay.
6.1.1.2 Nature and number of patients involved
The inclusion and exclusion criteria for this study are the same as the
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pilot study. Paediatric patients aged under three who are having enteral
feeding are included while those with suspected nosocomial infection related
to enteral feeding will be excluded. The number of patients is based on the
primary outcome, the study design and the method of analysis. The estimated
sample size is forty seven when using Z-test for one proportion with the level
of significant set to be 0.5, the effect size set to be 0.3 as most of the previous
literature reviews had a relatively effect size ranged from 0.1 to 0.5 (Neely et
al., 2006; Ng et al., 2004; Helder et al., 2010; Larson etal., 2005; Carpretti et
al., 2008; Peesoa-Silva et al., 2007) and the power set to be 80% by an online
program (Lenth, 2006-2009).
According to statistic done in July 2010 to Jun 2011 in our hospital, 25%
of paediatric patients under the age of three receiving enteral feeding in which
25% are very low birth weight (VLBW), 25% are neonates and 50% are
infants. According to the statistic, around ninety VLBW can be admitted
annually to our paediatric department of which around five were receiving
enteral feeding. Around seven hundred neonates and infants can be admitted
annually of which around forty five neonates and ninety infants were receiving
enteral feeding. A total of one hundred and forty children under the age of
three requiring enteral feeding can be admitted annually. Additionally, the
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attrition rate of the literature reviews is around 6-10%. Taking the attrition rate
as 10%, the estimated sample size is around fifty three which can usually be
recruited in four to six months.
6.1.1.3 Outcomes measure – nosocomial infection rate
The primary outcome is the nosocomial infection rate. All subjects
received the intervention from new enteral feeding guideline are observed for
any evidence of nosocomial infection such as fever and one or more of the
following signs such as milk intolerance, chest infection or positive result
from blood cultures or stool specimens. The evaluation objective is to
determine if the nosocomial infection rate is changed since the implementation
of the innovation. The data will be analyzed by Z-test for one proportion and
collected in a 6-month basis.
6.1.1.4 Outcomes measure – length of hospital stay
The secondary outcome is the length of hospital stay. All subjects
received the intervention from new enteral feeding guideline are observed for
the length of stay in hospital and intensive care unit (ICU). The evaluation
objective is to determine if the length of hospital stay is changed since the
implementation of the innovation. The data will be analyzed by Z-test for one
proportion and collected in a 6-month basis.
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6.1.2 Health care provider outcomes
6.1.2.1 Identification of health care provider outcomes measure
The frontline nursing staff is the one of the stakeholders in the innovation.
It is necessary to address their level of satisfaction and confidence level and
the enteral feeding technique and compliance rate.
6.1.2.2 Outcomes measure – satisfaction and confidence level
A staff evaluation questionnaire with a self-rating scale (1-5) is used for
all participated nurses to assesss their satisfaction and confidence level. The
enteral feeding satisfaction questionnaire is attached in Appendix 9. This
questionnaire is modified according to the nurses satisfactory survey currently
used in our paediatric department. It is a self-administered questionnaire and
need to send back to the guideline proposer in a sealed envelop. The data will
be analyzed by McNemar test and collected in a 3-month basis.
6.1.2.3 Outcomes measure – enteral feeding technique and compliance
The enteral feeding technique and compliance rate of new enteral feeding
guideline is evaluated by observation and regular audit. The audit form of
enteral feeding technique and compliance rate is attached in Appendix 10.
This audit form is modified according to the current hand hygiene audit form
used in our paediatric department. The members of working committee will
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act as observers and are responsible for observing and monitor the enteral
feeding technique and compliance rate of new enteral feeding guideline. The
observation and regular audit will be done in a monthly basis.
6.1.3 System outcomes
Material cost, manpower and medical expenses are calculated for
evaluation. The manpower expenses are mainly from the members of the
working committee which caused by regular meeting to discuss and plan the
implementation. Other manpower expenses include additional staff workload
and overtime such as attending the training session. The material cost includes
print-out, equipments for demonstration and practice, the use of treatment
room and conference room and extra expenses used on enteral feeding
administration set. The medical expenses include the cost used in treating
nosocomial infection, the cost of stay in hospital and intensive care unit (ICU)
and isolation facilities. The expenses will be calculated in a 6-month basis.
6.1.4 Basis for an effective change of practice
The effectiveness of the new enteral feeding guideline is based on the
evaluation of patient outcomes, healthcare provider outcomes and system
outcomes.
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6.1.4.1 Patient outcomes
The primary outcome that is the nosocomial infection rate determines the
effectiveness of the new enteral feeding guideline. According to Neely, et al,
2006, the nosocomial infection rate is more or less the same, however,
according to the data provided from reviewed studies, the nosocomial
infection rate is 1.3-3-fold reduced (Ng et al., 2004; Helder et al., 2010;
Larson et al., 2005; Capretti et al., 2008; Pessoa-Silva et al., 2007). Therefore,
the new enteral feeding guideline is effective when the nosocomial infection
rate has a 1.3-fold reduction since the implementation of the new enteral
feeding guideline.
The secondary outcome that is the length of hospital stay also determines
the effectiveness of the new enteral feeding guideline. According to Capretti,
et al, 2008, the length of stay in hospital and intensive care unit (ICU) caused
by nosocomial infections is reduced by forty and seven days respectively, that
is a reduction of 45% and 8% respectively. Therefore, the new enteral feeding
guideline is effective when the length of stay in hospital is reduced by 45%
and length of stay in intensive care unit (ICU) is reduced by 8%.
6.1.4.2 Healthcare provider outcomes
According to the data provided from reviewed studies, the compliance
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rate is increased by 13-16% (Helder et al., 2010; Pessoa-Silva et al., 2007).
Therefore, the new enteral feeding guideline is effective when over 50% of
participated nurse have an overall rate of three in the staff evaluation
questionnaire and the enteral feeding technique and compliance rate is
increased by 15%.
6.1.4.3 System outcomes
According to Neely et al. (2005), the manpower and material costs are
increased. However, the medical expenses are reduced. Therefore, the new
enteral feeding guideline is effective if the medical expenses can
counterbalance the manpower and material costs.
6.1.5 Dissemination and measure to sustain the change
The proposed implementation time frame is one year. The time frame for
monitoring the process is attached in Appendix 11.
Ongoing communication with the stakeholders is essential to sustain the
change and gain their support to carry out the new enteral feeding guideline.
The guideline will be reviewed and modified in regular basis according to the
comments and feedbacks from stakeholders and the evidence from updated
literature reviews.
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The evaluation report of the implementation of the new enteral feeding
guideline will be included in the formal report and distributed to the
management team including the Chief of Service (COS), Department
Operation Manager (DOM) and Ward Managers (WM). The evaluation result
will be distributed and the achievements of the development of the evidence
based guideline will be shared with all nursing staff during ward meetings.
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CHAPTER SEVEN
CONCLUSION
Enteral feeding is essential to maintain the nutrition status in children
who are unable to eat. However, nosocomial infection is one of the major
concerns in enteral feeding in paediatric units and nurses have the
responsibility to prevent nosocomial infections among the children. A
literature review revealed that nosocomial infection related to enteral feeding
can be reduced significantly by proper nursing care including optimal enteral
feeding hang time and proper hand hygiene. However, the guideline for enteral
feeding in infants was not standardized in the present clinical situation of the
target unit. Therefore, a translational nursing research on evidence based
enteral feeding guideline in infants was proposed. A structured training
program that emphasizes adherence to the recommendations of the enteral
feeding guideline and reinforces previously learned skills is provided. Besides,
the potential benefits and costs of implementing the program were assessed.
The implementation plan including the communication plan, training
workshops and pilot test was developed. The aim of pilot test is to assess the
feasibility of the program. Moreover, an evaluation plan was designed to
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evaluate the patient outcome, health care provider outcome and the system
outcome. The primary outcome of the evaluation is nosocomial infection rate.
The result that could improve clinical practice and enhance the enteral feeding
care t will be disseminated to health care providers and policy makers.
This dissertation translates nursing research into clinical practice and
provides an evidence based guideline to give enteral feeding care to paediatric
patients. This may also help to promote further practice of translational
nursing researches in other aspects of peadiatric nursing in the future.
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Appendix 1 Search strategy
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Keywords Medline CINAHL Plus Cochrane Library
1 Gastrostomy feeding or tube feeding or enteral nutrition 15130 5460 3583 2 Food contamination or equipment contamination or bacterial contamination 92961 5593 1011 3 Gram-negative bacteria or bacterial infections or cross infection or staphylococcal
infections or hospital acquired infection or staphylococcus aureus or infection control or bacteria or nosocomial infection or Klebsiella or Klebsiells infections or Klebsiella pneumoniae or Clostridium or Clostridium difficile
444523 51656 46474
4 1 and 2 187 75 35 5 1 and 3 596 242 581 6 1 and 2 and 3 103 40 31 7 Limit 4 to “All Child (0-18 years)” 32 8 8 Limit 5 to “All Child (0-18 years)” 129 42 9 Limit 6 to “All Child (0-18 years)” 16 7 Final number of studies chosen 10
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Appendix 2 Table of evidence
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Neely, A. N., Mayes, T., Gardner, J., Kagan, R. J. & Gottschlich, M. M. (2006). A microbiologic study of enteral feeding hang time in a burn hospital: can feeding costs be reduced without compromising patient safety? Nutrition in clinical practice, 21(6), 610-616.
Design (Level)
Subject characteristic
Intervention Comparison Length of follow up
Outcome measures Results
Cohort (2+)
38 children under 18 receiving enteral feeding with custom made formula in a paediatric burn hospital
The microbial load after the administration hanged for 8 hours (N=58)
The microbial load at the beginning of enteral feeding(N=58)
Not stated 1. To determine whether the microbial load increases with extended hang time
2. To determine whether the microbial load would increase the nosocomial infection rate
3. To compare the costs for 12 months
1. At the beginning: 1.21 +/- 0.52 After 8 hours: 1.13 +/- 0.47
2. Before change of practice: 12/315 (3.81%) After change of practice: 13/318 (4.09%)
3. Before change of practice: $19119.3 After change of practice: $8029.5
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Lyman, B., Gebhards, S., Hensley, C., Roberts, C. & Pablo, W. S. (2011). Safety of decanted enteral formula hung for 12 hours in a pediatric setting. Nutrition in clinical practice, 26(4), 451-456.
Design (Level)
Subject characteristic
Intervention Comparison Length of follow up
Outcome measures Results
Cohort (2++)
30 children under 18 receiving continuous enteral feeding with decanted or ready-to-feed formula
The bacterial contamination rate after the administration hanged for 4, 8 and 12 hours (N=111)
The bacterial contamination rate at the beginning of enteral feeding(N=111)
22 months To determine the occurrence of bacterial contaminations of decanted or ready-to-feed formula before, during and after 12-hours hang time
No growth: 100/111 (90%) Negative by FDA guidelines: 5/111 (5%) Positive by FDA guidelines: 5/111 (5%)
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Beattie, T. K. & Anderton, A. (2001). Decanting versus sterile pre-filled nutrient containers – the microbiological risks in enteral feeding. International journal of environmental health research, 11(1), 81-93.
Design
(Level)
Subject characteristic Intervention Comparison Length of
follow up
Outcome measures Results
Experimental case
contol
(2+)
4 enteral feeding
systems that used in
children with aged
1-6 years
(2 open system and 2
closed system)
The bacterial
contamination rate
when the feeding
system is handled with
either contaminated
hands or faulty
handling procedures
(N=12)
The bacterial
contamination rate
when the feeding
system is handled with
disposable gloves
(N=8)
Not stated To compare the rate of bacterial
contamination (cfu/ml) after 24 hours
when the feeding system is handled with
disposable gloves, contaminated hands
and faulty handling procedures
Disposable gloves: (p<0.05)
Nutrini bottle system: Nil
Nutrini Pack system: Nil
Nutricia container system: Nil
Ross Flexitainer system: 2 samples
Contaminated hands: (p<0.05)
Nutrini bottle system: Nil
Nutrini Pack system: Nil
Nutricia container system: average 1.8*103
( 27% are contaminated with none >=104)
Ross Flexitainer system: average 9.3*105
(93% are contaminated with 27% >= 104)
Faulty handling procedures: (p<0.05)
Nutrini bottle system: average 1.1*102
(85% contaminated with none >= 104)
Nutrini Pack system: Nil
Nutricia container system: average 1.3*105
(73% contaminated with 20% >= 104)
Ross Flexitainer system: average 1.7*105
(60% contaminated with 20% >= 104)
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Beattie, T. K. & Anderton, A. (1999). Microbiological evaluation of four enteral feeding systems which have been deliberately subjected to faulty handling procedures. Journal of
hospital infection, 42(1), 11-20.
Design
(Level)
Subject
characteristic
Intervention Comparison Length of
follow up
Outcome measures Results
Experimental case control (2+)
4 ready-to-feed enteral feeding systems that commonly used (4 closed system)
The bacterial contamination rate when the feeding system is handled with faulty handling procedures (N=20)
The bacterial contamination rate when the feeding system is handled with sterile gloves (N=20)
Not stated To compare the rate of bacterial contamination after 24 hours when the feeding system is handled with faulty handling procedures
Feed samples: (p<0.05) Dripac-flex: 27% with none >= 104
Easybag: 13% with none >= 104
Osmolite: 87% with 13% >= 104
Steriflo: 80% with 13% >= 104
Agar imprints from container tops: (p<0.05) Dripac-flex: 60% Easybag: 40% Osmolite: 100% Steriflo: 100% Agar imprints from pump set connectors: (p<0.05) Dripac-flex: 10% Easybag: 40% Osmolite: 100% Steriflo: 100%
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Ng, P. C., Wong, H. L., Lyon, D. J., So, K. W., Liu, F., Lam, R. K. Y., Cheng, A. F. B. & Fok, T. F. (2004). Combined use of alcohol hand rub and gloves reduces the incidence of late onset infection in very low birthweight infants. Archives of disease in childhood: fetal & neonatal, 89(4), 336-340.
Design (Level)
Subject characteristic
Intervention Comparison Length of follow up
Outcome measures Results
Retrospective observational case study (3)
337 very low birth weight infants admitted to NICU
Alcohol hand rub (Hexol lotion, i.e. 1% chlorhexidine in isopropyl alcohol and ethyl alcohol) and gloves regimen (HR) (N=176)
Conventional hand washing program (HW)(Hibiscrub, i.e. Chlorhexidine gluconate 4%) (N=161)
6 years To compare the incident of infection rate and necrotizing enterocolitis in very low birth weight infants before and after the implementation of new hand hygiene regimen
Incident of infection rate: HW: 89.4% (13.5 episodes per 1000 patient days) HR: 36.9 (4.8 episodes per 1000 patient days) 2.8-fold reduction Incident of necrotizing enterocolitis: (p<0.0001) HW: 25.5% (3 episodes per 1000 patient days) HR: 6.8% (0.8 episodes per 1000 patient days) 3.75-fold reduction Infants without ever being infected: (p<0.0001) HW: 75/161 (47%) HR: 122/176 (69%)
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Helder, O. K., Brug, J., Looman, C. W. N., van Goudoever, J. B. & Kornelisse, R. F. (2010). The impact of an education program on hand hygiene compliance and nosocomial infection incidence in an urban neonatal intensive care unit: an intervention study with before and after comparison. Internation journal of nursing studies, 47(10), 1245-1252.
Design (Level)
Subject characteristic
Intervention Comparison Length of follow up
Outcome measures Results
Observational time series study (3)
1201 structured observations done on 137 healthcare workers in NICU
A 30-min education program on hand hygiene with both theoretical and practical orientation (N=689)
Usual practice (N=512)
3 years To evaluate the effectiveness of a hand hygiene education program
Compliance with hand rubbing (before patient contact): (p<0.001) Pretest: 352/512 (68.8%) Posttest: 599/689 (86.9%) Compliance with hand rubbing (after patient contact): (p<0.001) Pretest: 327/512 (68.9%) Posttest: 579/689 (84%) Nosocomial bloodstream infections: (p=0.03) Before education program: 191/429 (44.5%) After education program: 99/274 (36.1%) Rate of nosocomial infections: (p=0.03) Before education program: 17.3 per 1000 patient days After education program: 13.5 per 1000 patient days
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Larson, E. L., Cimiotti, J., Haas, J., Parides, M., Nesin, M., Della-Latta, P. & Samian, L. (2005). Effective of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in neonatal intensive care units. Archives of pediatric & adolescence Medicine, 159(4), 377-383.
Design (Level)
Subject characteristic
Intervention Comparison Length of follow up
Outcome measures Results
Clinical trial case control (2+)
2932 neonates and 119 nurses in 2 NICU
Alcohol hand sanitizer (61% ethanol and emollients) (ALC) (N=1516)
Traditional antiseptic hand washing (2% chlorhexidine gluconate) (CHG) (N=1416)
22 months 1. To determine the nosocomial infection
2. To determine nurses’ skin condition (observation assessment)
3. To determine nurses’ skin condition (self-assessment)
4. To determine microbial count on nurses’ hand
1. ALC: 12.1 infections per 1000 days CHG: 9.5 infections per 1000 days
2. ALC: 4.25 score CHG: 4.06 score (p=0.02)
3. ALC: 22.3 score CHG: 21.5 score (p=0.049)
4. ALC: 3.11 CHG: 3.21 (p=0.38)
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Capretti, M. G., Sandri, F., Tridapall, E., Galletti, S., Petracci, E. & Faldella, G. (2008). Impact of a standardized hand hygiene program on the incidence of nosocomial infection in very low birth weight infants. American journal of infection control, 36(6), 430-435.
Design (Level)
Subject characteristic
Intervention Comparison Length of follow up
Outcome measures Results
Prospective case control study (2++)
165 very low birth weight infants with body weight <1500g admitted to NICU
Hand washing using antimicrobial soap (4% chlorhexidine gluconate) or alcohol-based hand rubs (N=80)
Hand washing using a plain fluid detergent (0.5% triclosan) (N=85)
34 months 1. To determine the nosocomial infection
2. To compare the length of hospital stay
1. Plain detergent: 16/85 (18.8%) Antimicrobial agent: 5/80 (6.2%) (p=0.015)
2. Length of hospital stay in infected infant Plain detergent: 87 +/- 45 days (p=0.003) Antimicrobial agent: 89 +/- 34 days (p=0.001)
3. Length of hospital stay in non infected infant Plain detergent: 46 +/- 26 days (p=0.003) Antimicrobial agent: 49 +/- 25 days (p=0.001)
4. Length of stay in very low birth weight infants with nosocomial infection is 7.7 days longer (p=0.016)
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Pessoa-Silva, C. L., Hugonnet, S., Pfister, R., Touveneau, S., Dharan, S., Posfay-Barbe, K. & Pittet, D. (2007). Reduction of health care associated infection risk in neonates by successful hand hygiene promotion. Pediatrics, 12(2), 382-390.
Design (Level)
Subject characteristic
Intervention Comparison Length of follow up
Outcome measures Results
Observational time series study (3)
1127 neonates and 101 healthcare workers in a neonate unit
A multifacetedhand hygiene education program (Phase 2: 554) (Phase 3: 296)
Usual practice (Phase 1: 264)
3 years 1. To determine the compliance with hand hygiene
2. To compare the overall rate of nosocomial infections
3. To compare the rate of nosocomial infections in very low birth weight neonates
1. Phase 1: 42% Phase 2: 45% Phase 3: 55% Phase 3>Phase 2 (p=0.037) Phase 2>Phase 1 (p=0.025)
2. Phase 1: 11.1 infections per 1000 patient days Phase 2: 7.9 infections per 1000 patient days Phase 3: 8.2 infections per 1000 patient days
3. Phase 1: 15.5 infections per 1000 patient days Phase 2: 10.7 infections per 1000 patient days Phase 3: 8.8 infections per 1000 patient days
P.92
Appendix 3 Critical appraisal
P.93
S I G N
Methodology Checklist 3: Cohort studies
Study identification: Neely, A. N., Mayes, T., Gardner, J., Kagan, R. J. & Gottschlich, M. M. (2006). A
microbiologic study of enteral feeding hang time in a burn hospital: can feeding costs be reduced
without compromising patient safety? Nutrition in clinical practice, 21(6), 610-616.
SECTION 1: INTERNAL VALIDITY
In a well conducted cohort study: In this study the criterion is:
1.1 The study addresses an appropriate and clearly
focused question.
Adequately addressed
SELECTION OF SUBJECTS
1.2 The two groups being studied are selected from
source populations that are comparable in all
respects other than the factor under
investigation.
Not applicable
1.3 The study indicates how many of the people
asked to take part did so, in each of the groups
being studied.
Poorly addressed
1.4 The likelihood that some eligible subjects might
have the outcome at the time of enrolment is
assessed and taken into account in the
analysis.
Adequately addressed
1.5 What percentage of individuals or clusters
recruited into each arm of the study dropped out
before the study was completed.
Nil drop out
1.6 Comparison is made between full participants
and those lost to follow up, by exposure status.
Not applicable
ASSESSMENT
1.7 The outcomes are clearly defined. Well covered
P.94
1.8 The assessment of outcome is made blind to
exposure status.
Not applicable
1.9 Where blinding was not possible, there is some
recognition that knowledge of exposure status
could have influenced the assessment of
outcome.
Adequately addressed
1.10 The measure of assessment of exposure is
reliable.
Adequately addressed
1.11 Evidence from other sources is used to
demonstrate that the method of outcome
assessment is valid and reliable.
Adequately addressed
1.12 Exposure level or prognostic factor is assessed
more than once.
Not addressed
CONFOUNDING
1.13 The main potential confounders are identified
and taken into account in the design and
analysis.
Adequately addressed
STATISTICAL ANALYSIS
1.14 Have confidence intervals been provided? No
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise the
risk of bias or confounding, and to establish a
causal relationship between exposure and
effect?
Code ++, +, or −
+
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
exposure being investigated?
Yes
P.95
2.3 Are the results of this study directly applicable
to the patient group targeted in this guideline?
Yes
SECTION 3: DESCRIPTION OF THE STUDY (Note: The following information is required for
evidence tables to facilitate cross-study comparisons. Please complete all sections for
which information is available).
PLEASE PRINT CLEARLY
3.1 Do we know who the study was funded by? No
3.2 How many centres are patients recruited from? One
3.3 From which countries are patients selected?
(Select all those involved. Note additional
countries after “Other”)
USA
3.4 What is the social setting (ie type of
environment in which they live) of patients in the
study?
Urban
3.5 What criteria are used to decide who should be
INCLUDED in the study? Paediatric patients who have enteral
feeding with custom made formula
3.6 What criteria are used to decide who should be
EXCLUDED from the study?
Paediatric patients who have enteral
feeding with ready made formula
3.7 What intervention or risk factor is investigated in
the study? (Include dosage where appropriate)The microbial load after the administration
hanged for 8 hours
3.8 What comparisons are made in the study (ie
what alternative treatments are used to
compare the intervention/exposure with).
Include dosage where appropriate.
The microbial load at the beginning of
enteral feeding
3.9 What methods were used to randomize
patients, blind patients or investigators, and to
conceal the randomization process from
investigators?
Nil randomization, all the patients are
included in the control and intervention
group
3.10 How long did the active phase of the study last?
Not stated
P.96
3.11 How long were patients followed-up for, during
and after the study?
1 year
3.12 List the key characteristics of the patient
population. Note if there are any significant
differences between different arms of the trial.
Children receiving enteral feeding with
custom made formula in a paediatric burn
hospital
3.13 Record the basic data for each arm of the study.
To determine whether the
microbial load increases with
extended hang time
To determine whether the
microbial load would increase
the nosocomial infection rate
To compare the costs
for 12 months
3.14 Record the basic data for each IMPORTANT outcome in the study.
At the beginning: 1.21 +/- 0.52
After 8 hours: 1.13 +/- 0.47
Before change of practice:
12/315 (3.81%)
After change of practice: 13/318
(4.09%)
Before change of
practice: $19119.3
After change of
practice: $8029.5
P.97
S I G N
Methodology Checklist 3: Cohort studies
Lyman, B., Gebhards, S., Hensley, C., Roberts, C. & Pablo, W. S. (2011). Safety of decanted enteral
formula hung for 12 hours in a pediatric setting. Nutrition in clinical practice, 26(4), 451-456.
SECTION 1: INTERNAL VALIDITY
In a well conducted cohort study: In this study the criterion is:
1.1 The study addresses an appropriate and clearly
focused question.
Adequately addressed
SELECTION OF SUBJECTS
1.2 The two groups being studied are selected from
source populations that are comparable in all
respects other than the factor under
investigation.
Not applicable
1.3 The study indicates how many of the people
asked to take part did so, in each of the groups
being studied.
Well addressed
1.4 The likelihood that some eligible subjects might
have the outcome at the time of enrolment is
assessed and taken into account in the
analysis.
Adequately addressed
1.5 What percentage of individuals or clusters
recruited into each arm of the study dropped out
before the study was completed.
1 patient dropped out (3.33%) because of
suspected retrograde infection
1.6 Comparison is made between full participants
and those lost to follow up, by exposure status.
Not applicable
ASSESSMENT
1.7 The outcomes are clearly defined. Well covered
P.98
1.8 The assessment of outcome is made blind to
exposure status.
Not applicable
1.9 Where blinding was not possible, there is some
recognition that knowledge of exposure status
could have influenced the assessment of
outcome.
Adequately addressed
1.10 The measure of assessment of exposure is
reliable.
Adequately addressed
1.11 Evidence from other sources is used to
demonstrate that the method of outcome
assessment is valid and reliable.
Adequately addressed
1.12 Exposure level or prognostic factor is assessed
more than once.
Not addressed
CONFOUNDING
1.13 The main potential confounders are identified
and taken into account in the design and
analysis.
Adequately addressed
STATISTICAL ANALYSIS
1.14 Have confidence intervals been provided? Yes
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise the
risk of bias or confounding, and to establish a
causal relationship between exposure and
effect?
Code ++, +, or −
++
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
exposure being investigated?
Yes
P.99
2.3 Are the results of this study directly applicable
to the patient group targeted in this guideline?
Yes
SECTION 3: DESCRIPTION OF THE STUDY (Note: The following information is required for
evidence tables to facilitate cross-study comparisons. Please complete all sections for
which information is available).
PLEASE PRINT CLEARLY
3.1 Do we know who the study was funded by? No
3.2 How many centres are patients recruited from? One
3.3 From which countries are patients selected?
(Select all those involved. Note additional
countries after “Other”)
USA
3.4 What is the social setting (ie type of
environment in which they live) of patients in the
study?
Urban
3.5 What criteria are used to decide who should be
INCLUDED in the study? Hospitalized infant or child who required
12-hour continuous-drip enteral feeding
using sterile ready-to-feed non-diluted
formulas
3.6 What criteria are used to decide who should be
EXCLUDED from the study?
Not stated
3.7 What intervention or risk factor is investigated in
the study? (Include dosage where appropriate)The microbial load after the administration
hanged for 4, 8 and 12 hours
3.8 What comparisons are made in the study (ie
what alternative treatments are used to
compare the intervention/exposure with).
Include dosage where appropriate.
The microbial load at the beginning of
enteral feeding
3.9 What methods were used to randomize
patients, blind patients or investigators, and to
conceal the randomization process from
investigators?
Nil randomization, all the patients are
included in the control and intervention
group
3.10 How long did the active phase of the study last? 22 months
P.100
3.11 How long were patients followed-up for, during
and after the study?
Not stated
3.12 List the key characteristics of the patient
population. Note if there are any significant
differences between different arms of the trial.
Children receiving continuous enteral
feeding with decanted or ready-to-feed
formula
3.13 Record the basic data for each arm of the study.
To determine the occurrence of bacterial contaminations of decanted or ready-to-feed
formula before, during and after 12-hours hang time
3.14 Record the basic data for each IMPORTANT outcome in the study.
No growth: 100/111 (90%)
Negative by FDA guidelines: 5/111 (5%)
Positive by FDA guidelines: 5/111 (5%)
P.101
S I G N
Methodology Checklist 4: Case-control studies
Study identification: Beattie, T. K. & Anderton, A. (2001). Decanting versus sterile pre-filled nutrient
containers – the microbiological risks in enteral feeding. International journal of environmental health
research, 11(1), 81-93.
SECTION 1: INTERNAL VALIDITY
In an well conducted case control study: In this study the criterion is:
1.1 The study addresses an appropriate and
clearly focused question
Adequately addressed
SELECTION OF SUBJECTS
1.2 The cases and controls are taken from
comparable populations
Adequately addressed
1.3 The same exclusion criteria are used for both
cases and controls
Not addressed
1.4 What percentage of each group (cases and
controls) participated in the study?
Cases: 12
Controls: 8
1.5 Comparison is made between participants and
non-participants to establish their similarities or
differences
Adequately addressed
1.6 Cases are clearly defined and differentiated
from controls
Adequately addressed
1.7 It is clearly established that controls are
non-cases
Adequately addressed
ASSESSMENT
1.8 Measures will have been taken to prevent
knowledge of primary exposure influencing
case ascertainment
Not addressed
P.102
1.9 Exposure status is measured in a standard,
valid and reliable way
Adequately addressed
CONFOUNDING
1.10 The main potential confounders are identified
and taken into account in the design and
analysis
Adequately addressed
STATISTICAL ANALYSIS
1.11 Confidence intervals are provided No
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise the
risk of bias or confounding?
Code ++, +, or −
+
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
exposure being investigated?
Yes
2.3 Are the results of this study directly applicable
to the patient group targeted by this guideline?
Yes
SECTION 3: DESCRIPTION OF THE STUDY (Note: The following information is required for
evidence tables to facilitate cross-study comparisons. Please complete all sections for
which information is available).
PLEASE PRINT CLEARLY
3.1 Do we know who the study was funded by? No
3.2 How many centres are patients recruited
from? ---
3.3 From which countries are patients selected?
(Select all those involved. Note additional
countries after “Other”)
England
P.103
3.4 What is the social setting (ie type of
environment in which they live) of patients in
the study?
---
3.5 What criteria are used to decide who should
cases? The feeding systems that are handled with
either contaminated hands or faulty
handling procedures
3.6 What criteria are used to decide who should
be controls?
The feeding systems that are handled with
disposable gloves
3.7 What exposure or risk factor is investigated in
the study? (Include dosage where
appropriate)
The rate of bacterial contamination (cfu/ml)
after 24 hours when the feeding system is
handled with disposable gloves,
contaminated hands and faulty handling
procedures
3.8 How long were patients followed-up for? Not stated
3.9 List the key characteristics of the patient
population. Note if there are any significant
differences between different arms of the trial.
Four enteral feeding systems that used in
children with aged 1-6 years
(2 open system and 2 closed system)
3.10 Record the basic data for each arm of the study. If there are more than four arms, note data
for subsequent arms at the bottom of the page.
To compare the rate of
bacterial contamination
(cfu/ml) after 24 hours when
the feeding system is handled
with disposable gloves
Nutrini bottle system: Nil
Nutrini Pack system: Nil
Nutricia container system: Nil
To compare the rate of
bacterial contamination
(cfu/ml) after 24 hours when
the feeding system is handled
with contaminated hands
Nutrini bottle system: Nil
Nutrini Pack system: Nil
Nutricia container system:
average 1.8*103 ( 27% are
To compare the rate of
bacterial contamination
(cfu/ml) after 24 hours
when the feeding system
is handled with faulty
handling procedures
Nutrini bottle system:
average 1.1*102 (85%
contaminated with none
>= 104)
Nutrini Pack system: Nil
Nutricia container system:
average 1.3*105 (73%
P.104
Ross Flexitainer system: 2
samples
(p<0.05)
contaminated with none
>=104)
Ross Flexitainer system:
average 9.3*105 (93% are
contaminated with 27% >=
104)
(p<0.05)
contaminated with 20% >=
104)
Ross Flexitainer system:
average 1.7*105 (60%
contaminated with 20% >=
104)
(p<0.05)
P.105
S I G N
Methodology Checklist 4: Case-control studies
Study identification: Beattie, T. K. & Anderton, A. (1999). Microbiological evaluation of four enteral
feeding systems which have been deliberately subjected to faulty handling procedures. Journal of
hospital infection, 42(1), 11-20.
SECTION 1: INTERNAL VALIDITY
In an well conducted case control study: In this study the criterion is:
1.1 The study addresses an appropriate and
clearly focused question
Adequately addressed
SELECTION OF SUBJECTS
1.2 The cases and controls are taken from
comparable populations
Adequately addressed
1.3 The same exclusion criteria are used for both
cases and controls
Not addressed
1.4 What percentage of each group (cases and
controls) participated in the study?
Cases: 20
Controls: 20
1.5 Comparison is made between participants and
non-participants to establish their similarities or
differences
Adequately addressed
1.6 Cases are clearly defined and differentiated
from controls
Adequately addressed
1.7 It is clearly established that controls are
non-cases
Adequately addressed
ASSESSMENT
1.8 Measures will have been taken to prevent
knowledge of primary exposure influencing
case ascertainment
Not addressed
P.106
1.9 Exposure status is measured in a standard,
valid and reliable way
Adequately addressed
CONFOUNDING
1.10 The main potential confounders are identified
and taken into account in the design and
analysis
Adequately addressed
STATISTICAL ANALYSIS
1.11 Confidence intervals are provided No
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise the
risk of bias or confounding?
Code ++, +, or −
+
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
exposure being investigated?
Yes
2.3 Are the results of this study directly applicable
to the patient group targeted by this guideline?
Yes
SECTION 3: DESCRIPTION OF THE STUDY (Note: The following information is required for
evidence tables to facilitate cross-study comparisons. Please complete all sections for
which information is available).
PLEASE PRINT CLEARLY
3.1 Do we know who the study was funded by? No
3.2 How many centres are patients recruited
from? ---
3.3 From which countries are patients selected?
(Select all those involved. Note additional
countries after “Other”)
England
P.107
3.4 What is the social setting (ie type of
environment in which they live) of patients in
the study?
---
3.5 What criteria are used to decide who should
cases? The feeding systems that are handled with
faulty handling procedures
3.6 What criteria are used to decide who should
be controls?
The feeding systems that are handled with
sterile gloves
3.7 What exposure or risk factor is investigated in
the study? (Include dosage where
appropriate)
The rate of bacterial contamination after 24
hours when the feeding system is handled
with faulty handling procedures
3.8 How long were patients followed-up for? Not stated
3.9 List the key characteristics of the patient
population. Note if there are any significant
differences between different arms of the trial.
Four ready-to-feed enteral feeding
systems that commonly used
(4 closed system)
3.10 Record the basic data for each arm of the study. If there are more than four arms, note data
for subsequent arms at the bottom of the page.
The rate of bacterial contamination
on feed samples after 24 hours
when the feeding system is handled
with faulty handling procedures
Dripac-flex: 27% with none >= 104
Easybag: 13% with none >= 104
Osmolite: 87% with 13% >= 104
Steriflo: 80% with 13% >= 104
(p<0.05)
The Agar imprints from
container tops after 24
hours when the feeding
system is handled with
faulty handling
procedures
Dripac-flex: 60%
Easybag: 40%
Osmolite: 100%
Steriflo: 100%
(p<0.05)
The Agar imprints from
pump set connectors after
24 hours when the feeding
system is handled with
faulty handling procedures
Dripac-flex: 10%
Easybag: 40%
Osmolite: 100%
Steriflo: 100%
(p<0.05)
P.108
S I G N
Methodology Checklist 4: Case-control studies
Study identification: Ng, P. C., Wong, H. L., Lyon, D. J., So, K. W., Liu, F., Lam, R. K. Y., Cheng, A. F.
B. & Fok, T. F. (2004). Combined use of alcohol hand rub and gloves reduces the incidence of late
onset infection in very low birthweight infants. Archives of disease in childhood: fetal & neonatal,
89(4), 336-340.
SECTION 1: INTERNAL VALIDITY
In an well conducted case control study: In this study the criterion is:
1.1 The study addresses an appropriate and
clearly focused question
Adequately addressed
SELECTION OF SUBJECTS
1.2 The cases and controls are taken from
comparable populations
Adequately addressed
1.3 The same exclusion criteria are used for both
cases and controls
Not addressed
1.4 What percentage of each group (cases and
controls) participated in the study?
Cases: 176
Controls: 161
1.5 Comparison is made between participants and
non-participants to establish their similarities or
differences
Adequately addressed
1.6 Cases are clearly defined and differentiated
from controls
Adequately addressed
1.7 It is clearly established that controls are
non-cases
Adequately addressed
ASSESSMENT
1.8 Measures will have been taken to prevent
knowledge of primary exposure influencing
case ascertainment
Not addressed
P.109
1.9 Exposure status is measured in a standard,
valid and reliable way
Adequately addressed
CONFOUNDING
1.10 The main potential confounders are identified
and taken into account in the design and
analysis
Adequately addressed
STATISTICAL ANALYSIS
1.11 Confidence intervals are provided No
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise the
risk of bias or confounding?
Code ++, +, or −
+
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
exposure being investigated?
Yes
2.3 Are the results of this study directly applicable
to the patient group targeted by this guideline?
Yes
SECTION 3: DESCRIPTION OF THE STUDY (Note: The following information is required for
evidence tables to facilitate cross-study comparisons. Please complete all sections for
which information is available).
PLEASE PRINT CLEARLY
3.1 Do we know who the study was funded by? No
3.2 How many centres are patients recruited
from? One
3.3 From which countries are patients selected?
(Select all those involved. Note additional
countries after “Other”)
Hong Kong
P.110
3.4 What is the social setting (ie type of
environment in which they live) of patients in
the study?
Urban
3.5 What criteria are used to decide who should
cases? Very low birth weight (VLBW) infants
admitted to the NICU between December
1993 to November 1996 that the
conventional hand washing program (HW)
(Hibiscrub, i.e. Chlorhexidine gluconate
4%) are being used
3.6 What criteria are used to decide who should
be controls?
Very low birth weight (VLBW) infants
admitted to the NICU between December
1996 to November 1999 that alcohol hand
rub (Hexol lotion, i.e. 1% chlorhexidine in
isopropyl alcohol and ethyl alcohol) and
gloves regimen (HR) are being used
3.7 What exposure or risk factor is investigated in
the study? (Include dosage where
appropriate)
The incident of infection rate and
necrotizing enterocolitis in very low birth
weight infants before and after the
implementation of new hand hygiene
regimen
3.8 How long were patients followed-up for? 6 years
3.9 List the key characteristics of the patient
population. Note if there are any significant
differences between different arms of the trial.
Very low birth weight infants admitted to
NICU
P.111
3.10 Record the basic data for each arm of the study. If there are more than four arms, note data
for subsequent arms at the bottom of the page.
Incident of infection rate:
HW: 89.4% (13.5 episodes per
1000 patient days)
HR: 36.9 (4.8 episodes per 1000
patient days)
2.8-fold reduction
Incident of necrotizing
enterocolitis:
HW: 25.5% (3 episodes per
1000 patient days)
HR: 6.8% (0.8 episodes per
1000 patient days)
3.75-fold reduction
(p<0.0001)
Infants without ever
being infected:
HW: 75/161 (47%)
HR: 122/176 (69%)
(p<0.0001)
P.112
S I G N
Methodology Checklist 4: Case-control studies
Study identification: Helder, O. K., Brug, J., Looman, C. W. N., van Goudoever, J. B. & Kornelisse, R.
F. (2010). The impact of an education program on hand hygiene compliance and nosocomial infection
incidence in an urban neonatal intensive care unit: an intervention study with before and after
comparison. Internation journal of nursing studies, 47(10), 1245-1252.
SECTION 1: INTERNAL VALIDITY
In an well conducted case control study: In this study the criterion is:
1.1 The study addresses an appropriate and
clearly focused question
Adequately addressed
SELECTION OF SUBJECTS
1.2 The cases and controls are taken from
comparable populations
Adequately addressed
1.3 The same exclusion criteria are used for both
cases and controls
Not addressed
1.4 What percentage of each group (cases and
controls) participated in the study?
Cases: 689
Controls: 512
1.5 Comparison is made between participants and
non-participants to establish their similarities or
differences
Adequately addressed
1.6 Cases are clearly defined and differentiated
from controls
Adequately addressed
1.7 It is clearly established that controls are
non-cases
Adequately addressed
ASSESSMENT
1.8 Measures will have been taken to prevent
knowledge of primary exposure influencing
case ascertainment
Not addressed
P.113
1.9 Exposure status is measured in a standard,
valid and reliable way
Adequately addressed
CONFOUNDING
1.10 The main potential confounders are identified
and taken into account in the design and
analysis
Adequately addressed
STATISTICAL ANALYSIS
1.11 Confidence intervals are provided No
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise the
risk of bias or confounding?
Code ++, +, or −
+
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
exposure being investigated?
Yes
2.3 Are the results of this study directly applicable
to the patient group targeted by this guideline?
Yes
SECTION 3: DESCRIPTION OF THE STUDY (Note: The following information is required for
evidence tables to facilitate cross-study comparisons. Please complete all sections for
which information is available).
PLEASE PRINT CLEARLY
3.1 Do we know who the study was funded by? No
3.2 How many centres are patients recruited
from? One
3.3 From which countries are patients selected?
(Select all those involved. Note additional
countries after “Other”)
Netherlands
P.114
3.4 What is the social setting (ie type of
environment in which they live) of patients in
the study?
Urban
3.5 What criteria are used to decide who should
cases? Hand hygiene of health care professionals
after implementation of education program
3.6 What criteria are used to decide who should
be controls?
Hand hygiene of health care professionals
before implementation of education
program
3.7 What exposure or risk factor is investigated in
the study? (Include dosage where
appropriate)
A 30-min education program on hand
hygiene with both theoretical and practical
orientation
3.8 How long were patients followed-up for? 3 years
3.9 List the key characteristics of the patient
population. Note if there are any significant
differences between different arms of the trial.
1201 structured observations done on 137
healthcare workers in NICU
3.10 Record the basic data for each arm of the study. If there are more than four arms, note data
for subsequent arms at the bottom of the page.
Compliance with
hand rubbing
(before patient
contact):
Pretest: 352/512
(68.8%)
Posttest: 599/689
(86.9%)
(p<0.001)
Compliance with hand
rubbing (after patient
contact):
Pretest: 327/512
(68.9%)
Posttest: 579/689
(84%)
(p<0.001)
Nosocomial
bloodstream
infections:
Before education
program: 191/429
(44.5%)
After education
program: 99/274
(36.1%)
(p=0.03)
Rate of nosocomial
infections:
Before education
program: 17.3 per
1000 patient days
After education
program: 13.5 per
1000 patient days
(p=0.03)
P.115
S I G N
Methodology Checklist 4: Case-control studies
Study identification: Larson, E. L., Cimiotti, J., Haas, J., Parides, M., Nesin, M., Della-Latta, P. &
Samian, L. (2005). Effective of antiseptic handwashing vs alcohol sanitizer on health care-associated
infections in neonatal intensive care units. Archives of pediatric & adolescence Medicine, 159(4),
377-383.
SECTION 1: INTERNAL VALIDITY
In an well conducted case control study: In this study the criterion is:
1.1 The study addresses an appropriate and
clearly focused question
Adequately addressed
SELECTION OF SUBJECTS
1.2 The cases and controls are taken from
comparable populations
Adequately addressed
1.3 The same exclusion criteria are used for both
cases and controls
Adequately addressed
1.4 What percentage of each group (cases and
controls) participated in the study?
Cases: 1516
Controls: 1416
1.5 Comparison is made between participants and
non-participants to establish their similarities or
differences
Adequately addressed
1.6 Cases are clearly defined and differentiated
from controls
Not addressed
1.7 It is clearly established that controls are
non-cases
Adequately addressed
ASSESSMENT
1.8 Measures will have been taken to prevent
knowledge of primary exposure influencing
case ascertainment
Adequately addressed
P.116
1.9 Exposure status is measured in a standard,
valid and reliable way
Adequately addressed
CONFOUNDING
1.10 The main potential confounders are identified
and taken into account in the design and
analysis
Adequately addressed
STATISTICAL ANALYSIS
1.11 Confidence intervals are provided No
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise the
risk of bias or confounding?
Code ++, +, or −
+
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
exposure being investigated?
Yes
2.3 Are the results of this study directly applicable
to the patient group targeted by this guideline?
Yes
SECTION 3: DESCRIPTION OF THE STUDY (Note: The following information is required for
evidence tables to facilitate cross-study comparisons. Please complete all sections for
which information is available).
PLEASE PRINT CLEARLY
3.1 Do we know who the study was funded by? No
3.2 How many centres are patients recruited
from? Two
3.3 From which countries are patients selected?
(Select all those involved. Note additional
countries after “Other”)
USA
P.117
3.4 What is the social setting (ie type of
environment in which they live) of patients in
the study?
Urban
3.5 What criteria are used to decide who should
cases? The use of alcohol hand sanitizer (61%
ethanol and emollients) (ALC)
3.6 What criteria are used to decide who should
be controls?
The use of traditional antiseptic hand
washing (2% chlorhexidine gluconate)
(CHG)
3.7 What exposure or risk factor is investigated in
the study? (Include dosage where
appropriate)
The nosocomial infection, nurses’ skin
condition (observation assessment),
nurses’ skin condition (self-assessment)
and the microbial count on nurses’ hand
3.8 How long were patients followed-up for? 22 months
3.9 List the key characteristics of the patient
population. Note if there are any significant
differences between different arms of the trial.
2932 neonates and 119 nurses in 2 NICU
3.10 Record the basic data for each arm of the study. If there are more than four arms, note data
for subsequent arms at the bottom of the page.
The nosocomial
infection
ALC: 12.1 infections
per 1000 days
CHG: 9.5 infections
per 1000 days
Nurses’ skin
condition
(observation
assessment)
ALC: 4.25 score
CHG: 4.06 score
(p=0.02)
Nurses’ skin condition
(self-assessment)
ALC: 22.3 score
CHG: 21.5 score
(p=0.049)
The microbial
count on nurses’
hand
ALC: 3.11
CHG: 3.21
(p=0.38)
P.118
S I G N
Methodology Checklist 4: Case-control studies
Study identification: Capretti, M. G., Sandri, F., Tridapall, E., Galletti, S., Petracci, E. & Faldella, G.
(2008). Impact of a standardized hand hygiene program on the incidence of nosocomial infection in
very low birth weight infants. American journal of infection control, 36(6), 430-435.
SECTION 1: INTERNAL VALIDITY
In an well conducted case control study: In this study the criterion is:
1.1 The study addresses an appropriate and
clearly focused question
Adequately addressed
SELECTION OF SUBJECTS
1.2 The cases and controls are taken from
comparable populations
Adequately addressed
1.3 The same exclusion criteria are used for both
cases and controls
Adequately addressed
1.4 What percentage of each group (cases and
controls) participated in the study?
Cases: 80
Controls: 85
1.5 Comparison is made between participants and
non-participants to establish their similarities or
differences
Adequately addressed
1.6 Cases are clearly defined and differentiated
from controls
Adequately addressed
1.7 It is clearly established that controls are
non-cases
Adequately addressed
ASSESSMENT
1.8 Measures will have been taken to prevent
knowledge of primary exposure influencing
case ascertainment
Adequately addressed
P.119
1.9 Exposure status is measured in a standard,
valid and reliable way
Adequately addressed
CONFOUNDING
1.10 The main potential confounders are identified
and taken into account in the design and
analysis
Adequately addressed
STATISTICAL ANALYSIS
1.11 Confidence intervals are provided Yes
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise the
risk of bias or confounding?
Code ++, +, or −
+
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
exposure being investigated?
Yes
2.3 Are the results of this study directly applicable
to the patient group targeted by this guideline?
Yes
SECTION 3: DESCRIPTION OF THE STUDY (Note: The following information is required for
evidence tables to facilitate cross-study comparisons. Please complete all sections for
which information is available).
PLEASE PRINT CLEARLY
3.1 Do we know who the study was funded by? No
3.2 How many centres are patients recruited
from? One
3.3 From which countries are patients selected?
(Select all those involved. Note additional
countries after “Other”)
Italy
P.120
3.4 What is the social setting (ie type of
environment in which they live) of patients in
the study?
Urban
3.5 What criteria are used to decide who should
cases? Hand washing using antimicrobial soap
(4% chlorhexidine gluconate) or
alcohol-based hand rubs
3.6 What criteria are used to decide who should
be controls?
Hand washing using a plain fluid detergent
(0.5% triclosan)
3.7 What exposure or risk factor is investigated in
the study? (Include dosage where
appropriate)
The nosocomial infection and the length of
hospital stay
3.8 How long were patients followed-up for? 34 months
3.9 List the key characteristics of the patient
population. Note if there are any significant
differences between different arms of the trial.
Very low birth weight infants with body
weight <1500g admitted to NICU
3.10 Record the basic data for each arm of the study. If there are more than four arms, note data
for subsequent arms at the bottom of the page.
The nosocomial
infection
Plain detergent:
16/85 (18.8%)
Antimicrobial agent:
5/80 (6.2%)
(p=0.015)
Length of hospital
stay in infected infant
Plain detergent: 87
+/- 45 days
(p=0.003)
Antimicrobial agent:
89 +/- 34 days
(p=0.001)
Length of hospital
stay in non infected
infant
Plain detergent: 46
+/- 26 days
(p=0.003)
Antimicrobial agent:
49 +/- 25 days
(p=0.001)
Length of stay in
very low birth
weight infants with
nosocomial
infection is 7.7 days
longer
(p=0.016)
P.121
S I G N
Methodology Checklist 4: Case-control studies
Study identification: Pessoa-Silva, C. L., Hugonnet, S., Pfister, R., Touveneau, S., Dharan, S.,
Posfay-Barbe, K. & Pittet, D. (2007). Reduction of health care associated infection risk in neonates by
successful hand hygiene promotion. Pediatrics, 12(2), 382-390.
SECTION 1: INTERNAL VALIDITY
In an well conducted case control study: In this study the criterion is:
1.1 The study addresses an appropriate and
clearly focused question
Adequately addressed
SELECTION OF SUBJECTS
1.2 The cases and controls are taken from
comparable populations
Adequately addressed
1.3 The same exclusion criteria are used for both
cases and controls
Not addressed
1.4 What percentage of each group (cases and
controls) participated in the study?
Phase 1: 264
Phase 2: 554
Phase 3: 296
1.5 Comparison is made between participants and
non-participants to establish their similarities or
differences
Adequately addressed
1.6 Cases are clearly defined and differentiated
from controls
Adequately addressed
1.7 It is clearly established that controls are
non-cases
Adequately addressed
ASSESSMENT
1.8 Measures will have been taken to prevent
knowledge of primary exposure influencing
case ascertainment
Not addressed
P.122
1.9 Exposure status is measured in a standard,
valid and reliable way
Adequately addressed
CONFOUNDING
1.10 The main potential confounders are identified
and taken into account in the design and
analysis
Well covered
STATISTICAL ANALYSIS
1.11 Confidence intervals are provided Yes
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise the
risk of bias or confounding?
Code ++, +, or −
+
2.2 Taking into account clinical considerations,
your evaluation of the methodology used, and
the statistical power of the study, are you
certain that the overall effect is due to the
exposure being investigated?
Yes
2.3 Are the results of this study directly applicable
to the patient group targeted by this guideline?
Yes
SECTION 3: DESCRIPTION OF THE STUDY (Note: The following information is required for
evidence tables to facilitate cross-study comparisons. Please complete all sections for
which information is available).
PLEASE PRINT CLEARLY
3.1 Do we know who the study was funded by? No
3.2 How many centres are patients recruited
from? One
3.3 From which countries are patients selected?
(Select all those involved. Note additional
countries after “Other”)
Switzerland
3.4 What is the social setting (ie type of Urban
P.123
environment in which they live) of patients in
the study?
3.5 What criteria are used to decide who should
cases? Hand hygiene of health care professionals
after implementation of education program
3.6 What criteria are used to decide who should
be controls?
Hand hygiene of health care professionals
before implementation of education
program
3.7 What exposure or risk factor is investigated in
the study? (Include dosage where
appropriate)
A multifaceted hand hygiene education
program
3.8 How long were patients followed-up for? 36 months
3.9 List the key characteristics of the patient
population. Note if there are any significant
differences between different arms of the trial.
5325 hand hygiene observation done on
101 healthcare workers in NICU
3.10 Record the basic data for each arm of the study. If there are more than four arms, note data
for subsequent arms at the bottom of the page.
The compliance with hand
hygiene
Phase 1: 42%
Phase 2: 45%
Phase 3: 55%
Phase 3>Phase 2
(p=0.037)
Phase 2>Phase 1
(p=0.025)
The overall rate of nosocomial infections
Phase 1: 11.1 infections per
1000 patient days
Phase 2: 7.9 infections per
1000 patient days
Phase 3: 8.2 infections per
1000 patient days
The rate of nosocomial
infections in very low birth
weight neonates
Phase 1: 15.5 infections per
1000 patient days
Phase 2: 10.7 infections per
1000 patient days
Phase 3: 8.8 infections per
1000 patient days
P.124
Appendix 4 Intervention and result
components
P.125
Neely, et al
(2006)
Lyman, et al
(2011)
Beattie &
Anderton
(2001)
Beattie &
Anderton
(1999)
Ng, et al
(2003)
Helder, et al
(2010)
Larson, et al
(2005)
Capretti, et al
(2008)
Pessoa-Silva,
et al (2007)
Design Cohort Cohort Esperimetnal
case control
Esperimetnal
case control
Retrospective
observational
case study
Observational
time series
study
Clinical trial
case control
Prospective
case control
study
Observational
time series
study
Patients’ characteristics Children
receiving
enteral
feeding with
custom
made
formula in a
paediatric
burn
hospital
Children
receiving
continuous
enteral feeding
with decanted
or
ready-to-feed
formula
Four enteral
feeding
systems that
used in
children with
aged 1-6 years
(2 open system
and 2 closed
system)
Four
ready-to-feed
enteral feeding
systems that
commonly
used
(4 closed
system)
Very low birth
weight infants
admitted to
NICU
1201
structured
observations
done on 137
healthcare
workers in
NICU
2932
neonates and
119 nurses
in 2 NICU
Very low birth
weight infants
with body
weight <1500g
admitted to
NICU
5325 hand
hygiene
observation
done on 101
healthcare
workers in
NICU
P.126
Neely, et al
(2006)
Lyman, et al
(2011)
Beattie &
Anderton
(2001)
Beattie &
Anderton
(1999)
Ng, et al
(2003)
Helder, et al
(2010)
Larson, et al
(2005)
Capretti, et al
(2008)
Pessoa-Silva,
et al (2007)
Interventions
Feeding hang time
Feeding system
Hand washing
Glove
Gown
Plain detergent
Chlorhexidine
gluconate
Alcohol- based
rub
Hand
hygiene
Education
program
P.127
Neely, et al
(2006)
Lyman, et al
(2011)
Beattie &
Anderton
(2001)
Beattie &
Anderton
(1999)
Ng, et al
(2003)
Helder, et al
(2010)
Larson, et al
(2005)
Capretti, et al
(2008)
Pessoa-Silva,
et al (2007)
Results
Bacterial contamination — — Glove:
Closed: —
Open: —
Contaminated
hands:
Closed: —
Open: ┼
Faculty
handling
Closed: —
Open: ┼
Faulty
handling: ┼
Nosocomial rate — ↓ ↓ ↓ ↓
Cost ↓
Infection rate ↓
Incident of NEC ↓
Infants without infection ↓
Hand washing compliance ↑ ↑
Length of stay ↓
Level of evidence 2+ 2++ 2+ 2+ 3 3 2+ 2++ 3
P.128
Appendix 5 Evidence based
enteral feeding guideline
P.129
Evidence based guideline on enteral feeding for children under 3 years old
Enteral feeding system and optimal hang time
Recommendations Grades
1. Sterile close enteral feeding system can last for 24 hours B
2. Closed enteral feeding system should be used whenever available B
3. The optimal hang time for decanted or ready-to-feed formula should
be reduced to 12 hours
B
4. The optimal hang time for formula with additives (prepared in milk
kitchen and refrigerated until use) should be reduced to 8 hours
B
Hand hygiene
Recommendations Grades
5. Proper hand hygiene, either hand washing for at least 15 seconds or
using handrub until thoroughly dry, should be done before enteral
feeding
C
6. Perform hand hygiene by using anti microbial soap chlorhexidine
gluconate or alcohol based handrub instead of plain detergents
B
7. Hand hygiene should not be obviated by the use of gloves C
8. A 30 minutes educational program with both theoretical and
practical orientation on enteral feeding and hand hygiene techniques
should be provided for staff compulsorily and regularly
C
P.130
Appendix 6 Grading of
recommendations
P.131
Grades of recommendations
At least one meta-analysis, systematic review, or RCT rated as 1++, and
directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly
applicable to the target population, and demonstrating overall consistency of
results
A body of evidence including studies rated as 2++, directly applicable to the
target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
A body of evidence including studies rated as 2+, directly applicable to the
target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
P.132
Appendix 7 Communication plan
P.133
P.134
Appendix 8 Questionnaire of
pilot test evaluation
P.135
Questionnaire of pilot test evaluation Thank you for your participation in the pilot test of proposing the enteral feeding guideline. Your feedback will enable us to improve the innovation. Please let us have your opinion on the following: Questionnaire of pilot test evaluation 1. Does the proposed innovation well organized?
No comment Yes No
Reason_____________________________________________________ 2. Does the enteral feeding guideline useful?
Very useful Somewhat useful Not useful
Reason_____________________________________________________ 3. Does the promotion of the innovation enough?
No comment Yes No
Reason_____________________________________________________ 4. Did the content of the training workshop appropriate?
No comment Appropriate Too less Too much
What would you prefer? ___________________________________________________________
5. Did the duration of the training workshop adequate? No comment Appropriate Too short Too long
How long would you prefer? ___________________________________________________________
P.136
6. Did the working committee provide enough support to you? No comment Yes No
Reason_____________________________________________________ 7. Did you know who can be referred to when you have difficulties?
Yes No
Reason_____________________________________________________ 8. Do you satisfied with this innovation?
No comment Yes No
Reason_____________________________________________________ 9. Do you think that the proposed innovation should be implemented in
future? No comment Yes No
Reason_____________________________________________________ 10. Could you give us some suggestions?
___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
The end Thank you very much!
P.137
Appendix 9 Enteral feeding
satisfaction questionnaire
P.138
Enteral feeding satisfaction questionnaire We hope that the enteral feeding guideline has provided you with useful information on caring the infants with enteral feeding. Your feedback is important to us. Please circle as appropriate: Stronly
disagreeDisagree Neutral Agree Strongly
agree 1. The proposed innovation is well
organized. 1 2 3 4 5
2. The enteral feeding guideline is useful.
1 2 3 4 5
3. The proposed innovation is cost effective.
1 2 3 4 5
4. The content of the training workshop is appropriate.
1 2 3 4 5
5. The duration of the training workshop is adequate.
1 2 3 4 5
6. I have gained a better understanding about enteral feeding.
1 2 3 4 5
7. I feel more confident in delivering enteral feeding.
1 2 3 4 5
8. The objectives of this innovation are achieved.
1 2 3 4 5
9. Overall, I am satisfied with this innovation.
1 2 3 4 5
10. The proposed innovation should be implemented in future.
1 2 3 4 5
The end Thank you very much!
P.139
Appendix 10 Enteral feeding technique
and compliance audit
P.140
Enteral feeding technique and compliance audit
Enteral feeding technique Pass Fail Remarks * Hand hygiene before priming the enteral feeding system * Hand hygiene before manipulating the enteral feeding system * Change the whole enteral feeding system according to optimal hang time Hand hygiene technique and compliance Pass Fail Remarks Remove all the accessories No watch No bracelet No ring Hand washing with anti microbial soap chlorhexidine gluconate Hands are wet under running water Anti microbial soap chlorhexidine gluconate is applied to all surfaces * Hands are rubbed vigorously, covering all surfaces, for at least 15 seconds Rubbing palm to palm Rubbing palm over dorsum Rubbing fingers interlaced Rubbing back of fingers Rotational rubbing of thumbs Rubbing wrist Rubbing forearm Hands are rinsed thoroughly under running water Keep hands upper than elbows while rinsing Hands are dried well with paper towel Wipe hands in fingertip to wrist direction Turn off water without contamination Discard used paper in a garbage bin Hand rub with alcohol based handrub All surfaces of hands are covered with recommended volume of alcohol Rubbing palm to palm Rubbing palm over dorsum Rubbing fingers interlaced Rubbing back of fingers Rotational rubbing of thumbs Rubbing wrist Rubbing forearm * Hands are rubbed thoroughly till dry
P.141
Appendix 11 Time frame
P.142
Task 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52
Identification of
stakeholders
Identification of the
problem
Formation of
working committee
Proposal to decision
makers (WM)
Committee further
discussion for
resources and
implementation plan
Proposal to DOM
Pilot study
Data analysis and
refining the guideline
of implementation
Actual stu dy
Data analysis of
actual study
Report findin gs
Evaluation
P.143
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