SR ITEMS TITEL AND SYNOPSIS

NO
1 Title:- A Study to Assess the knowledge and Compliance of Hand Hygiene
during Bundle of Care Interventions among staff nurses working in ICU
with a view to develop a self-instructional module at selected a Tertiary
Care Hospital.

INTRODUCTION

Health Care Associated Infections (HCAI) or infections acquired in health-care

settings are a major public health problem for patient safety and its impact can result
in prolonged hospital stay, long-term disability, increased resistance of
microorganisms to antimicrobial agents, a massive additional financial burden for the
health care system, high costs for patients and their families, and increased mortality.
This has become more important in today's changing environment, dealing with the
threats of newly emerging pathogens and the widespread dissemination of old
pathogens. 1

Modern healthcare especially intensive care units, employs many types of invasive
devices and procedures to treat patients and to help them recover. Also our
knowledge and understanding of medical and Clinical Microbiology is constantly
growing and expanding. The bacterial cell in the microbiota, (normal flora)
outnumbers the human cells in the host by 10:1. In the hospital acute care ICU
settings, where vulnerable people are crowded together, the battle between man and
microbe is at its most obvious. Patients are exposed to a variety of microorganisms
during hospitalization and hand hygiene is the most frequent adverse event for
hospitalized patients and is a major global issue for patient’s safety. It refers to
infection associated with health care delivery in any setting. Factors influencing the
development of hand hygiene are severity of infection and existing illness, comorbid
conditions, equipment and environment sanitation, practices and adherence to
recommended guidelines. 2
The more susceptible patients usually require the most intensive care with far more
daily contacts with staffs who act as vectors in the transmission of microbes.
Inanimate reservoir of infection, such as equipment’s, instruments and materials like
fomites, linen used in hospitals often become contaminated with microorganisms
which may subsequently transfer infection to susceptible patients. Pathogenesis of
infectious diseases depends on three main factors: the number and virulence of the
microorganism, and the immune status of the host. The establishment of the infection
is directly proportional to number and virulence characteristic of microbe and
inversely proportional to immune status of the host. The infection may be of
exogenous and endogenous. Endogenous are self-infection where the organisms are
derived from patient’s own skin, GI, upper respiratory flora. Exogenous infections
may be a cross infection when it is acquired from another patient or from hand
hygiene in the hospital or environmental infection when it is acquired through
contaminated item from equipment or environment. 3

Hand washing remain the simplest and most effective methods of preventing
transmission of infectious agents from clinicians to patients and among patients.
Several hospital-based studies demonstrated that improved hand hygiene techniques
significantly reduced infection rates. Hand hygiene is an important indicator of safety
and quality of care delivered in any health-care setting is emphasized in the WHO
Collaborating Centre on Patient Safety Solutions. An alcohol hand rub, correctly
applied to socially clean hands is an acceptable and very effective method of hand
decontamination and is now the preferred method of hygienic hand hygiene in most
clinical situations. Alcohols effectively reduce bacterial counts on the hands.
Typically, log reductions of the release of test bacteria from artificially contaminated
hands average 3.5 log10 after a 30-second application and 4.0–5.0 log10 after a 1-
minute application. Health-care–associated pathogens can be recovered not only from
infected or draining wounds, but also from frequently colonized areas of normal,
intact patient skin. Many studies have documented and proved evidence based the
contamination of HCPs hands with potential health-care–associated pathogens. 4
Outbreak investigations have indicated an association between infections and
understaffing or overcrowding; the association was consistently linked with poor
adherence to hand hygiene. During an outbreak investigation of risk factors after
adjustment for confounding factors, the patient-to-nurse ratio remained an
independent risk factor for bloodstream infection, indicating that nursing staff
reduction below a critical threshold may have contributed to this outbreak by
jeopardizing adequate catheter care. 5

The understaffing of nurses can facilitate the spread of infection in intensive-care

settings through relaxed attention to basic control measures (e.g., hand hygiene).
Hand hygiene technique Amount of hand-hygiene solution and duration of hand-
hygiene procedure should be as per Manufacturer’s instructions. Dispense the
required amount of alcohol hand rub and vigorously rub hands together for 15 - 30
seconds until dry, ensuring that all areas of the hands and wrists are covered as per
the world health organization (WHO) 6
Alcohol hand rubs are only effective when used on socially clean hands and when
allowed to dry. Hand washing A hand washes using a liquid soap may be used as an
alternative to the above method. Soap and water are recommended for visibly soil
hands. Rub hands together applying the soap for at least 30 – 40 seconds, covering all
surfaces, focusing on fingertips and fingernails. Rinse under running water and dry
with disposable towel. Hand drying is an essential part of hand hygiene. Use towel to
turn off the faucet. 7

Steps of hand hygiene

WHO recommends following important steps of hand hygine:
1. Rub palm to palm
2. Right palm over left dorsum and left palm over right dorsum
3. Palm to palm finger interlaced
4. Backs of fingers to opposing palms with fingers interlocked
5. Rotational rubbing of rights thumb clasped in left palm and vice versa
6. Rotational rubbing back and forwards with clasped fingers of right hand in left
palm and vice versa
7. Rub both wrists in a rotating manner. Rinse and dry thoroughly. 8

Hand Hygiene Moments

According to the Centers for Disease Control and Prevention (CDC), hand hygiene
encompasses the cleansing of your hands with soap and water, antiseptic hand
washes, antiseptic hand rubs such as alcohol-based hand sanitizers, foams or gels, or
surgical hand antisepsis. Indications for handwashing include when hands are
visibly soiled, contaminated with blood or other bodily fluids, before eating, and after
restroom use. Hands should be washed if potential there was potential exposure
to Clostridium difficile, Norovirus, or Bacillus anthracis. 9

In 2009, the World Health Organization (WHO) highlighted preset guidelines known
as the "Five Moments for Hand Hygiene."

1. Before touching or coming into contact with a patient

2. Before performing a clean or aseptic procedure

3. After an exposure risk to bodily fluids and glove removal

4. After contact with a patient and their immediate surroundings

 5. After touching an inanimate object in the patient's immediate surroundings
even if no direct patient contact

Alcohol-based hand sanitizers are the recommended product for hand hygiene when
hands are not visibly soiled. Apply alcohol-based products per manufacturer
guidelines on dispensing of the product. Typically, 3 mL to 5 mL in the palm,
rubbing vigorously, ensuring all surfaces on both hands get covered, about 20
seconds is required for all surfaces to dry completely. 10

Patient and facility healthcare professionals are monitored for hand-washing

practices, and they are conforming to hand-hygiene practices. This practice is
becoming increasingly popular as healthcare professionals strive for a safer
environment. 11

BACKGROUND FOR STUDY

Structurally, the skin is made up of an outer, superficial layer known as the stratum
corneum, the epidermis, dermis, and the hypodermis. Healthy skin is colonized with
resident flora that are microorganisms that reside below the stratum corneum and the
skin's surface. This flora has two main functions: microbial antagonism and
competing for nutrients within the ecosystem. Generally, these bacteria are not
pathogenic on intact skin but may cause infections in other areas of the body such as
nonimpact skin, the eyes, or sterile body cavities. 12

Transient microorganisms are often acquired by healthcare workers through direct,

close contact with patients or contaminated inanimate objects or environmental
surfaces. Transient flora colonizes the superficial skin layers It can be removed by
routine handwashing more easily than resident flora. These organisms vary in
number depending upon body location. Healthcare-associated infections are a result
of these transient organisms. 13

The 1980s represented a landmark in the evolution of concepts of hand hygiene in

health care. The first national hand hygiene guidelines were published in the 1980s,
followed by several others in more recent years in different countries. In 1995 and
1996, the CDC/Healthcare Infection Control Practices Advisory Committee
(HICPAC) in the USA recommended that either antimicrobial soap or a waterless
antiseptic agent be used for cleansing hands upon leaving the rooms of patients with
multidrug-resistant pathogens. More recently, the HICPAC guidelines issued in
200258 defined alcohol-based hand rubbing, where available, as the standard of care
for hand hygiene practices in health-care settings, whereas handwashing is reserved
for particular situations only. The present guidelines are based on this previous
document and represent the most extensive review of the evidence related to hand
hygiene in the literature. They aim to expand the scope of recommendations to a
global perspective, foster discussion and expert consultation on controversial issues
related to hand hygiene in health care, and to propose a practical approach for
successful implementation For generations, handwashing with soap and water has
been considered a measure of personal hygiene. 14

The concept of cleansing hands with an antiseptic agent probably emerged in the
early 19th century. As early as 1822, a French pharmacist demonstrated that solutions
containing chlorides of lime or soda could eradicate the foul odors associated with
human corpses and that such solutions could be used as disinfectants and antiseptics.
In a paper published in 1825, this pharmacist stated that physicians and other persons
attending patients with contagious diseases would benefit from moistening their
hands with a liquid chloride solution. In 1846, Ignaz Semmelweis observed that
women whose babies were delivered by students and physicians in the First Clinic at
the General Hospital of Vienna consistently had a higher mortality rate than those
whose babies were delivered by midwives in the Second Clinic. He noted that
physicians who went directly from the autopsy suite to the obstetrics ward had a
disagreeable odor on their hands despite washing their hands with soap and water
upon entering the obstetrics clinic. 15

In 1961, the U. S. Public Health Service produced a training film that demonstrated
handwashing techniques recommended for use by health-care workers (HCWs) At
the time, recommendations directed that personnel wash their hands with soap and
water for 1–2 minutes before and after patient contact. Rinsing hands with an
antiseptic agent was believed to be less effective than handwashing and was
recommended only in emergencies or in areas where sinks were unavailable. In 1975
and 1985, formal written guidelines on handwashing practices in hospitals were
published by CDC. These guidelines recommended handwashing with non-
antimicrobial soap between the majority of patient contacts and washing with
antimicrobial soap before and after performing invasive procedures or caring for
patients at high risk. Use of waterless antiseptic agents (e.g., alcohol-based solutions)
was recommended only in situations where sinks were not available 16

As far as the implementation of recommendations on hand hygiene improvement is

concerned, very significant progress has been achieved since the introduction and
validation of the concept that promotional strategies must be multimodal to achieve
any degree of success. According to the Centers for Disease Control and Prevention
(CDC), incidence on established guidelines recommend that agents used for surgical
hand scrubs should reduce microorganisms on intact skin in a substantial manner,
contain a nonirritating antimicrobial preparation, have broad-spectrum activity, and
be fast-acting and persistent. Studies have demonstrated that formulations containing
60% to 95% alcohol alone or 50% to 95% in combination with other products lower
bacterial counts on the skin immediately post-scrub more effectively than other
agents 17

NEED FOR STUDY

Healthcare workers' hands are the most common vehicle for the transmission of
healthcare-associated pathogens from patient to patient and within the healthcare
environment. Hand hygiene is the leading measure for preventing the spread
of antimicrobial resistance and reducing healthcare-associated infections (HCAIs),
but healthcare worker compliance with optimal practices remains low in most
settings. This paper reviews factors influencing hand hygiene compliance, the impact
of hand hygiene promotion on healthcare-associated pathogen cross-transmission and
infection rates, and challenging issues related to the universal adoption of alcohol-
based hand rub as a critical system change for successful promotion. Available
evidence highlights the fact that multimodal intervention strategies lead to improved
hand hygiene and a reduction in healthcare-associated infections (HCAIs) However,
further research is needed to evaluate the relative efficacy of each strategy
component and to identify the most successful interventions, particularly in settings
with limited resources. The main objective of the First Global Patient
Safety Challenge, launched by the World Health Organization (WHO), is to achieve
an improvement in hand hygiene practices worldwide with the ultimate goal of
promoting a strong patient safety culture. We also report considerations and solutions
resulting from the implementation of the multimodal strategy proposed in the WHO
Guidelines on Hand Hygiene in Health Care. 18

C Clancy and T Delungahawatta et.al 2021 conduct a comprehensive systematic

study review on Hand-hygiene-related clinical trials reported between 2014 and
2020. Comprehensive systematic review provides an up-to-date compilation of
clinical trials, reported between 2014 and 2020, assessing hand hygiene interventions
in order to inform healthcare leaders and practitioners regarding approaches to reduce
healthcare-associated infections using hand hygiene. compliance among healthcare
workers. In total, 332 papers were identified from these searches, of which 57 studies
met the inclusion criteria. Forty-five of the 57 studies (79%) included in this review
were conducted in Asia, Europe and the USA. The large majority of these clinical
trials were conducted in acute care facilities, including hospital wards and intensive
care facilities. Nurses represented the largest group of healthcare workers studied (44
studies, 77%), followed by physicians (41 studies, 72%). Thirty-six studies (63%)
adopted the World Health Organization's multi-modal framework or a variation of
this framework, and many of them recorded hand hygiene opportunities at each of the
'Five Moments'. However, recording of hand hygiene technique was not common.
Both single intervention and multi-modal hand hygiene strategies can achieve
modest-to-moderate improvements in hand hygiene compliance among healthcare
workers. 19

Hand hygiene practices are paramount in reducing cross-transmission of

microorganisms, hospital-acquired infections and the risk of occupational exposure to
infectious diseases. Mortality and morbidity increase in the presence of hospital-
acquired infections, thus diligent hand hygiene is essential to providing safe, cost-
efficient, quality care to our patients. Based on this evidence and the demonstration
of its effectiveness, optimal hand hygiene behavior is considered the cornerstone of
healthcare-associated infection (HCAI) prevention. Furthermore, not only is it a key
element of standard and isolation precautions, but its importance is emphasized also
in the most modern ‘bundle’ approaches for the prevention of specific site infections
such as catheter-related bloodstream infection (CRBSI), catheter-related urinary tract
infection (CRUTI), surgical site infection (SSI), and ventilator-associated pneumonia
(VAP). 20

The purpose of routine handwashing in patient care is to remove dirt and organic
material as well as microbial contamination acquired by contact with patients or the
environment. While water is often called a “universal solvent”, it cannot directly
remove hydrophobic substances such as fats and oils often present on soiled hands.
Proper handwashing therefore requires the use of soaps or detergents to dissolve fatty
materials and facilitate their subsequent flushing with water. To ensure proper hand
hygiene, soap or detergent must be rubbed on all surfaces of both hands followed by
thorough rinsing and drying. Thus, water alone is not suitable for cleaning soiled
hands; soap or detergent must be applied as well as water Washing hands with soap
and water is the best way to get rid of germs in most situations. If soap and water are
not readily available, you can use an alcohol-based hand sanitizer that contains at
least 60% alcohol instead. Sanitizers can quickly reduce the number of germs on
 hands in many situations; however, sanitizers do not get rid of all types of germs.21

Health-care institutions in many parts of the developing world may not have piped-in
tap water, or it may be available only intermittently. An intermittent water supply
system often has higher levels of microbial contamination because of the seepage of
contamination occurring while the pipes are supplied with treated water. On-site
storage of sufficient water is often the only option in sites without a reliable supply.
However, such water is known to be prone to microbial contamination unless stored
and used properly and may require point-of-use treatment and/ or on-site
disinfection.251 Containers for on-site storage of water should be emptied and
cleaned252 as frequently as possible and, when possible, inverted to dry. Putting
hands and contaminated objects into stored water should be avoided at all times.
Storage containers should ideally be narrow-necked to facilitate proper coverage,
with a conveniently located tap/faucet for ease of water collection. 22

Kathryn Ann Lambe et.al 2020 conduct A Systematic Review on Hand Hygiene
Compliance in the ICU, English-language, peer-reviewed studies measuring hand
hygiene compliance by healthcare workers in an ICU setting using direct observation
guided by the World Health Organization's "Five Moments for Hand Hygiene,"
published since 2009, were included. Information was extracted on study location,
research design, type of ICU, healthcare workers, measurement procedures, and
compliance levels. Sixty-one studies were included. Most were conducted in high-
income countries (60.7%) and in adult ICUs (85.2%). Mean hand hygiene
compliance was 59.6%. Compliance levels appeared to differ by geographic region
(high-income countries 64.5%, low-income countries 9.1%), type of ICU (neonatal
67.0%, pediatric 41.2%, adult 58.2%), and type of healthcare worker (nursing staff
43.4%, physicians 32.6%, other staff 53.8%). Mean hand hygiene compliance
appears notably lower than international targets. The data collated may offer useful
indicators for those evaluating, and seeking to improve, hand hygiene compliance in
ICUs internationally. 23

primary research Does there is any effect of hand hygiene during bundle of care intervention among
question:- nurses working in ICU of a tertiary care hospital

HYPOTHESES:
primary
hypothesis:- H0: There is no a significant difference in the pre-test and post-test Knowledge and
level of compliance of hand hygiene during bundle of care interventions among staff
nurses working in the ICU

H1: There is a significant difference in the pre-test and post-test Knowledge and
level of compliance of hand hygiene during bundle of care interventions among staff
nurses working in the ICU

ASSUMPTIONS  Staff nurses may have basic Knowledge and compliance of hand hygiene during
bundle of VAP interventions among staff nurses working in the ICU.

 Self-Instructional Module may increase the Knowledge and level of compliance

of hand hygiene during bundle of VAP interventions among staff nurses working
in the ICU.

review of ligature Literature of review in this study is organized under following headings

 Study related to handwashing in hospitals

(Maria Lazo-Porras et.al 2021) conduct study on A Medical Health intervention to

promote hand-washing and cell phone cleaning in medical residents of a public
hospital in Peru. We explore the limitations to adherence of hand-washing and
evaluate the impact of a mHealth intervention for hand hygiene in residents. We
explore resident's perspectives about Hospital-acquired infections (HAI) and hand
washing. In baseline, participants completed socio-demographic characteristics and
hand-washing habits survey. The intervention consisted of sending SMS three times a
week for two months about hand hygiene and "five moments" for hand washing. The
cultures of hands and cell phones were analyzed at baseline, 2 months and 4 months.
We used chi-square and adjusted Generalized Estimating Equations. Five physicians
were interviewed and 33 participants were included for quantitative analysis. Critical
barriers that hinder hand washing were identified. The proportion of Staphylococcus
aureus in hands was 54.5% at baseline and was significantly reduced at 2 months
follow-up (p = 0.009), but, benefit was lost when the intervention was discontinued;
Escherichia coli and Klebsiella sp. were observed in 22.2% of hands, no changes
were noted with intervention. In cell phones, there was a tendency to lower values of
bacterial colonization after intervention for Staphylococcus aureus growth. High
prevalence of contamination in hands and phones in medical residents were found.
Serious barriers to compliance with hand washing must be overcome. It is possible
that prolonged or continuous interventions could be necessary to optimize hand
washing and reduce hand and cell phones contamination.

(C Clancy 2021) conduct study on a comprehensive systematic review Hand-

hygiene-related clinical trials reported between 2014 and 2020 This comprehensive
systematic review provides an up-to-date compilation of clinical trials, reported
between 2014 and 2020, assessing hand hygiene interventions in order to inform
healthcare leaders and practitioners regarding approaches to reduce healthcare-
associated infections using hand hygiene. CINAHL, Cochrane, EMbase, Medline,
PubMed and Web of Science databases were searched for clinical trials published
between March 2014 and December 2020 on the topic of hand hygiene compliance
among healthcare workers. In total, 332 papers were identified from these searches,
of which 57 studies met the inclusion criteria. Forty-five of the 57 studies (79%)
included in this review were conducted in Asia, Europe and the USA. The large
majority of these clinical trials were conducted in acute care facilities, including
hospital wards and intensive care facilities. Nurses represented the largest group of
healthcare workers studied (44 studies, 77%), followed by physicians (41 studies,
72%). Thirty-six studies (63%) adopted the World Health Organization's multi-modal
framework or a variation of this framework, and many of them recorded hand
hygiene opportunities at each of the 'Five Moments'. However, recording of hand
hygiene technique was not common. Both single intervention and multi-modal hand
hygiene strategies can achieve modest-to-moderate improvements in hand hygiene
compliance among healthcare workers.

(Helena Ojanperä 2020) conduct study on Hand-hygiene compliance by hospital

staff and incidence of health-care-associated infections, Finland We conducted an
internal audit survey in a tertiary-care hospital in Finland from 2013 to 2018.
Infection-control link nurses observed hand-hygiene practices based on the World
Health Organization's strategy for hand hygiene. We calculated hand-hygiene
compliance as the number of observations where necessary hand-hygiene was
practice divided by the total number of observations where hand hygiene was needed.
We determined the incidence of health-care-associated infections using a semi-
automated electronic incidence surveillance program. We calculated the Pearson
correlation coefficient (r) to evaluate the relationship between the incidence of
health-care-associated infections and compliance with hand hygiene. The link nurses
made 52 115 hand-hygiene observations between 2013 and 2018. Annual hand-
hygiene compliance increased significantly from 76.4% (2762/3617) in 2013 to
88.5% (9034/10 211) in 2018 (P < 0.0001). Over the same time, the number of
health-care-associated infections decreased from 2012 to 1831, and their incidence
per 1000 patient-days fell from 14.0 to 11.7 (P < 0.0001). We found a weak but
statistically significant negative correlation between the monthly incidence of health-
care-associated infections and hand-hygiene compliance (r = -0.48; P < 0.001). The
compliance of doctors and nurses with hand-hygiene practices improved with direct
observation and feedback, and this change was associated with a decrease in the
incidence of health-care-associated infections. Further studies are needed to evaluate
the contribution of hand hygiene to reducing health-care-associated infections.

(Clara MacLeod 2023) conduct study on a scoping review of current international

guidelines Recommendations for hand hygiene in community settings Hand hygiene
is an important measure to prevent disease transmission. We identified 51 guidelines
containing 923 recommendations published between 1999 and 2021 by multilateral
agencies and international non-governmental organizations. Handwashing with soap
is consistently recommended as the preferred method for hand hygiene across all
community settings. Most guidelines specifically recommend handwashing with
plain soap and running water for at least 20 s; single-use paper towels for hand
drying; and alcohol-based hand rub (ABHR) as a complement or alternative to
handwashing. There are inconsistent and discordant recommendations for water
quality for handwashing, affordable and effective alternatives to soap and ABHR,
and the design of handwashing stations. There are gaps in recommendations on soap
and water quantity, behaviour change approaches and government measures required
for effective hand hygiene. Less than 10% of recommendations are supported by any
cited evidence. While current international guidelines consistently recommend
handwashing with soap across community settings, there remain gaps in
recommendations where clear evidence-based guidance might support more effective
policy and investment.
  Studies related to bundle of care intervention after handwashing
among hospitals

(Julie Rivera 2020) conduct study on Implementing a Pressure Injury Prevention

Bundle to Decrease Hospital-Acquired Pressure Injuries in an Adult Critical Care
Unit: An Evidence-Based, Pilot Initiative patients in critical care units (CCUs) are at
risk of the development of hospital-acquired pressure injuries (HAPIs). Research
supports the use of a pressure injury prevention (PIP) bundle to standardize PIP
strategies and reduce the incidence of HAPIs. This evidence-based practice initiative
was undertaken to implement a PIP bundle to decrease HAPIs in an adult patient
CCU. A literature review was conducted during the first month of the
implementation of the initiative to identify best PIP and bundle implementation
practices. Wound, ostomy, and continence nurses conducted educational sessions and
mentored registered nurses who became PIP bundle resource nurses. Adoption of the
bundle was validated using an audit tool and PIP rounds. The pre- and post-
implementation HAPI indices, pressure injuries / patient care days × 1000, were
compared. Implementation of the PIP bundle resulted in a notable decrease in HAPIs
on the unit. During the pre-intervention period, January 2017 to January 2018, there
were 9 HAPIs (HAPI index 3.4). During the 10-month post-intervention period, 1
HAPI developed (HAPI index 0.48). An evidence-based PIP bundle initiative was
implemented in an adult patient CCU to standardize the process for HAPI prevention
and reduce the number of HAPIs. Staff involvement and leadership support were
vital to the success of the initiative. Integration of the bundle into practice resulted in
a notable decrease in HAPIs.

(Stéphanie Bierlaire 2021) conduct study on How to minimize central line-

associated bloodstream infections in a neonatal intensive care unit: a quality
improvement intervention based on a retrospective analysis and the adoption of an
evidence-based bundle Central line-associated bloodstream infection (CLABSI) is a
significant cause of morbidity and mortality in neonatal intensive care units (NICUs).
A "bundle" is defined as a combination of evidence-based interventions that provided
they are followed collectively and reliably, are proven to improve patient outcomes.
The aim of this quasi-experimental study was to assess the impact of new central line
insertion, dressing, and maintenance "bundles" on the rate of CLABSI and catheter-
related complications. We performed a quality improvement (QI), prospective,
before-after study. In the first 9-month period, the old "bundles" and pre-existing
materials were used/applied. An intervention period then occurred with changes
made to materials used and the implementation of new "bundles" related to various
aspects of central lines care. A second 6-month period was then assessed and the
CLABSI rates were measured in the NICU pre- and post-intervention period. The QI
measures were the rate of CLABSI and catheter-related complications. Data are still
being collected after the study to verify sustainability. The implementation of the
new "bundles" and the change of certain materials resulted in a significantly
decreased rate of CLABSI (8.4 to 1.8 infections per 1000 central venous catheter
(CVC) days, p = 0.02,) as well as decreased catheter-related complications (47 to 10,
p < 0.007).Conclusions: The analysis of pre-existing "bundles" and the
implementation of updated central line "bundles" based on best practice
recommendations are crucial for reducing the rate of CLABSI in the NICU. The
implementation of the new evidence-based central line "bundles" was associated with
a significant reduction in CLABSI rate in our unit soon after implementation. What is
Known: • Central line-associated bloodstream infection (CLABSI) is a major cause
of morbidity and mortality in the neonatal population. • The implementation of
evidence-based "bundles" in the NICU is associated with a reduction in the incidence
of CLABSI. What is New: • For the improvement in quality care in the NICU, audits
are necessary to assess the existing systems. • The "Plan-Do-Study-Act cycle" is an
effective tool to use when tackling challenges in an existing system. Using this tool
assisted in the approach to reducing CLABSI in our NICU.

(Raquel Martinez-Reviejo 2023) conduct study on A systematic review and meta-

analysis Prevention of ventilator-associated pneumonia through care bundles
Ventilator-associated pneumonia (VAP) represents a common hospital-acquired
infection among mechanically ventilated patients. We summarized evidence
concerning ventilator care bundles to prevent VAP. A systematic review and meta-
analysis were performed. Randomized controlled trials and controlled observational
studies of adults undergoing mechanical ventilation (MV) for at least 48 h were
considered for inclusion. Outcomes of interest were the number of VAP episodes,
duration of MV, hospital and intensive care unit (ICU) length of stay, and mortality.
A systematic search was conducted in the MEDLINE, the Cochrane Library, and the
Web of Science between 1985 and 2022. Results are reported as odds ratio (OR) or
mean difference (MD) with 95% confidence intervals (CI). The PROSPERO
registration number is CRD42022341780. Thirty-six studies including 116,873 MV
participants met the inclusion criteria. A total of 84,031 participants underwent care
bundles for VAP prevention. The most reported component of the ventilator bundle
was head-of-bed elevation (n=83,146), followed by oral care (n=80,787). A reduction
in the number of VAP episodes was observed among those receiving ventilator care
bundles, compared with the non-care bundle group (OR=0.42, 95% CI: 0.33, 0.54).
Additionally, the implementation of care bundles decreased the duration of MV
(MD=-0.59, 95% CI: -1.03, -0.15) and hospital length of stay (MD=-1.24, 95% CI: -
2.30, -0.18) in studies where educational activities were part of the bundle. Data
regarding mortality were inconclusive. The implementation of ventilator care bundles
reduced the number of VAP episodes and the duration of MV in adult ICUs. Their
application in combination with educational activities seemed to improve clinical
outcomes.

(Joshua P Vogel 2024) conduct study on a systematic review Effectiveness of care

bundles for prevention and treatment of postpartum hemorrhage We searched
MEDLINE, Embase, Cochrane CENTRAL, Maternity and Infant Care Database, and
Global Index Medicus (inception to June 9, 2023) and ClinicalTrials.gov and the
International Clinical Trials Registry Platform (last 5 years) using a phased search
strategy, combining terms for postpartum hemorrhage and care bundles. Peer-
reviewed studies evaluating postpartum hemorrhage-related care bundles were
included. Care bundles were defined as interventions comprising ≥3 components
implemented collectively, concurrently, or in rapid succession. Randomized and
nonrandomized controlled trials, interrupted time series, and before-after studies
(controlled or uncontrolled) were eligible. Risk of bias was assessed using RoB 2
(randomized trials) and ROBINS-I (nonrandomized studies). For controlled studies,
we reported risk ratios for dichotomous outcomes and mean differences for
continuous outcomes, with certainty of evidence determined using GRADE. For
uncontrolled studies, we used effect direction tables and summarized results
narratively. Twenty-two studies were included for analysis. For prevention-only
bundles (2 studies), low-certainty evidence suggests possible benefits in reducing
blood loss, duration of hospitalization, and intensive care unit stay, and maternal
well-being. For treatment-only bundles (9 studies), high-certainty evidence shows
that the E-MOTIVE intervention reduced risks of composite severe morbidity (risk
ratio, 0.40; 95% confidence interval, 0.32-0.50) and blood transfusion for bleeding,
postpartum hemorrhage, severe postpartum hemorrhage, and mean blood loss. One
nonrandomized trial and 7 uncontrolled studies suggest that other postpartum
hemorrhage treatment bundles might reduce blood loss and severe postpartum
hemorrhage, but this is uncertain. For combined prevention/treatment bundles (11
studies), low-certainty evidence shows that the California Maternal Quality Care
Collaborative care bundle may reduce severe maternal morbidity (risk ratio, 0.64;
95% confidence interval, 0.57-0.72). Ten uncontrolled studies variably showed
possible benefits, no effects, or harms for other bundle types. Nearly all uncontrolled
studies did not use suitable statistical methods for single-group pretest-posttest
comparisons and should thus be interpreted with caution. The E-MOTIVE
intervention improves postpartum hemorrhage-related outcomes among women
delivering vaginally, and the California Maternal Quality Care Collaborative bundle
may reduce severe maternal morbidity. Other bundle designs warrant further
effectiveness research before implementation is contemplated.

(Holly N Shadle 2021) conduct study on A Bundle-Based Approach to Prevent

Catheter-Associated Urinary Tract Infections in the Intensive Care Unit. Catheter-
associated urinary tract infections are the second most common health care-
associated infections, occurring most frequently in intensive care units. These
infections negatively affect patient outcomes and health care costs. The targeted
institution for this improvement project reported 13 catheter-associated urinary tract
infections in 2018, exceeding the hospital's benchmark of 4 or fewer such events
annually. Six of the events occurred in the intensive care unit. Project objectives
included a 30% reduction in reported catheter-associated urinary tract infections,
20% reduction in urinary catheter days, and 75% compliance rating in catheter-
related documentation in the intensive care unit during the intervention phase. This
project used a pre-post design over 2 consecutive 4-month periods. The targeted
population was critically ill patients aged 18 and older who were admitted to the
intensive care unit. A set of bundled interventions was implemented, including staff
education, an electronic daily checklist, and a nurse-driven removal protocol for
indwelling urinary catheters. Data were analyzed using mixed statistics, including
independent samples t tests and Fisher exact tests. No catheter-associated urinary
tract infections were reported during the intervention period, reducing the rate by
1.33 per 1000 catheter days. There was a 10.5% increase in catheter days, which was
not statistically significant (P = .12). Documentation compliance increased
significantly from 50.0% before to 83.3% during the intervention (P = .01). This
bundled approach shows promise for reducing catheter-associated urinary tract
infections in critical care settings. The concept could be adapted for other health care-
associated infections.
(Wendy Chaboyer 2024) conduct A complex intervention systematic review and
meta-analysis The effect of pressure injury prevention care bundles on pressure
injuries in hospital patients The Medical Literature Analysis and Retrieval System
Online (via PubMed), the Cumulative Index to Nursing and Allied Health Literature,
EMBASE, Scopus, the Cochrane Library and two registries were searched (from
2009 to September 2023). Randomised controlled trials and non-randomised studies
with a comparison group published in English after 2008 were included. Studies
reporting on the frequency of pressure injuries where the number of patients was not
the numerator or denominator, or where the denominator was not reported, and single
subgroups of hospitalised patients were excluded. Educational programmes targeting
healthcare professionals and bundles targeting specific types of pressure injuries were
excluded. Bundles with ≥3 components directed towards patients and implemented in
≥2 hospital services were included. Screening, data extraction and risk of bias
assessments were undertaken independently by two researchers. Random effects
meta-analyses were conducted. The certainty of the body of evidence was assessed
using Grading of Recommendations, Assessment, Development and Evaluation. Nine
studies (seven non-randomised with historical controls; two randomised) conducted
in eight countries were included. There were four to eight bundle components; most
were core, and only a few were discretionary. Various strategies were used prior to
(six studies), during (five studies) and after (two studies) implementation to embed
the bundles. The pooled risk ratio for pressure injury prevalence (five non-
randomised studies) was 0.55 (95 % confidence intervals 0.29-1.03), and for
hospital-acquired pressure injury rate (five non-randomised studies) it was 0.31
(95 % confidence intervals 0.12-0.83). All non-randomised studies were at high risk
of bias, with very low certainty of evidence. In the two randomised studies, the care
bundles had non-significant effects on hospital-acquired pressure injury incidence
density, but data could not be pooled. Whilst some studies showed decreases in
pressure injuries, this evidence was very low certainty. The potential benefits of
adding emerging evidence-based components to bundles should be considered.
Future effectiveness studies should include contemporaneous controls and the
development of a comprehensive, theory and evidence-informed implementation
plan.

(Moira E Kendra 2023) conduct study on Impact of a COPD care bundle on

hospital readmission rates Chronic obstructive pulmonary disease (COPD) is one of
the leading causes of mortality worldwide and contributes considerably to morbidity
and health care costs. In October 2014, the Centers for Medicare and Medicaid
Services introduced financial penalties followed by bundled payments for care
improvement initiatives in patients hospitalized with COPD. This study seeks to
evaluate whether an evidence-based inter professional COPD care bundle focused on
inpatient, transitional, and outpatient care would reduce hospital readmission rates. A
pre- and post-intervention analysis comparing readmission rates after a
hospitalization for COPD in subjects who received standard of care versus an inter
professional team-led COPD care bundle was conducted. The primary outcome was
30-day all-cause readmissions; secondary outcomes included 60- and 90-day all-
cause readmissions, escalation of pharmacotherapy, inter professional interventions,
and hospital length of stay. A total of 189 subjects were included in the control arm
and 127 subjects in the COPD care bundle arm. A reduction in 30-day all-cause
readmissions between the control arm and COPD care bundle arm (21.7% vs. 11.8%,
P = 0.017) was seen. Similar outcomes were seen in 60-day (18% vs. 8.7%, P =
0.013) and 90-day all-cause readmissions (19.6% vs. 4.7%, P < 0.001). Pharmacists
consulted with 68.5% of subjects and assisted with access to outpatient medications
in 45.7% of subjects in the COPD care bundle arm. An escalation in maintenance
therapy occurred more often in the COPD care bundle arm (22.2% vs. 44.9%, P <
0.001) than the control arm. An inter professional team-led COPD care bundle
resulted in significant reductions in all-cause hospital readmissions at 30, 60, and 90
days.

(Li-Ping Wang 2023) conduct study on A meta-analysis Effects of bundle-care

interventions on pressure ulcers in patients with stroke We conducted a meta-analysis
to assess the effects of bundle-care interventions on pressure ulcers in patients with
stroke to provide a basis for clinical work. Randomised controlled trials on the effects
of bundle-care interventions in patients with stroke were identified using
computerised searches of the PubMed, Embase, Cochrane Library, Chinese National
Knowledge Infrastructure, VIP and Wanfang databases, from the time of inception of
each database to July 2023, supplemented by manual literature searches. Two
researchers independently retrieved and screened the articles, extracted the data and
evaluated the quality of the included studies. After reaching consensus, meta-analysis
was performed using RevMan 5.4. Twenty-four papers were included, involving
3330 patients of whom 1679 were in the intervention group and 1651 were in the
control group. The results showed that, compared with standard care, bundle-care
interventions significantly reduced the incidence of pressure ulcers (3.28% vs.
14.84%, odds ratio [OR]: 0.19, 95% confidence interval [CI]: 0.14-0.26, p < 0.001),
and aspiration (5.60% vs. 18.84%, OR: 0.25, 95% CI: 0.17-0.39, p < 0.001), and
improved patient satisfaction with nursing care (96.59% vs. 84.43%, OR. 5.45, 95%
CI: 3.76-7.90, p < 0.001). Current evidence suggests that care bundles are
significantly better than conventional nursing measures in preventing pressure ulcers
and aspiration, and improving patient satisfaction with nursing care in patients with
stroke, and are worthy of clinical promotion and application.

(Leire Zarain-Obrador 2021) conduct A Quasi-Experimental Intervention Effect of

a Surgical Care Bundle on the Incidence of Surgical Site Infection in Colorectal
Surgery This study, therefore, sought to assess the effect of a surgical care bundle on
the incidence of SSI in colorectal surgery. We conducted a quasi-experimental
intervention study with reference to the introduction of a surgical care bundle in
2011. Our study population, made up of patients who underwent colorectal surgery,
was divided into the following two periods: 2007-2011 (pre-intervention) and 2012-
2017 (post-intervention). The intervention's effect on SSI incidence was analyzed
using adjusted odds ratios (OR). A total of 1,727 patients were included in the study.
SSI incidence was 13.0% before versus 11.6% after implementation of the care
bundle (OR: 0.88, 95% confidence interval: 0.66-1.17, p = 0.37). Multivariate
analysis showed that cancer, chronic obstructive pulmonary disease, neutropenia, and
emergency surgery were independently associated with SSI. In contrast, laparoscopic
surgery proved to be a protective factor against SSI. Care bundles have proven to be
very important in reducing SSI incidence since the measures that constitute these
protocols are mutually reinforcing. In our study, the implementation of a care bundle
reduced SSI incidence from 13% to 11.6%, though the reduction was not statistically
significant.

(Angel Cobos-Vargas 2025) conduct a before-after study Implementation of a risk-

stratified intervention bundle to prevent pressure injury in intensive care Hospital-
acquired pressure injury is an enduring problem in intensive care. Several intensive
care-specific pressure injury risk assessment tools have been developed, but to date,
only the COMHON Index has been aligned with risk-stratified preventative
interventions. The aim of this study was to evaluate the effectiveness of a risk-
stratified intervention bundle to reduce pressure injury in intensive care and to assess
compliance with bundled interventions. A controlled before-after study was
undertaken. All patients admitted to a single intensive care unit were included.
Standard care was provided in the before phase, and the risk-stratified intervention
bundle was implemented in the after phase. The primary outcome measure was
pressure injury incidence. The sample comprised 761 intensive care admissions. In
the after phase, pressure injury incidence was reduced (2.1% vs 3.9%; 46% relative
risk reduction), injury severity was lower, and there were fewer pressure injuries on
the sacrum, buttocks, and heels. Logistic regression modelling identified three
significant factors associated with pressure injury development: intensive care length
of stay (odds ratio: 1.2); COMHON Index admission score (odds ratio: 1.2), and the
before phase (odds ratio: 4.2). In the after phase, individual intervention compliance
was variable (range: 40%-100%), but the all-or-nothing compliance was poor (33%).
Implementation of bundled preventive measures associated with COMHON Index
risk level reduced pressure injury incidence. Likewise, injury severity decreased, and
the location of pressure injuries changed following the intervention. The results from
this study support the use of risk-stratified interventions to prevent pressure injury in
intensive care. However, further research is needed to examine the effectiveness of
the COMHON Index bundle before it can be recommended for widespread clinical
practice.

 Study related to hand washing among nurses in hospitals

(Chia Yin Chong 2021) conduct study on Patient, staff empowerment and hand
hygiene bundle improved and sustained hand hygiene in hospital wards We piloted a
hand hygiene (HH) project in a ward, focusing on World Health Organization
moments 1 and 4. Our aim was to design highly reliable interventions to
achieve >90% compliance. Baseline HH compliance was 57 and 67% for moments
1, 4, respectively, in 2015. After the pilot ward showed sustained improvement, we
launched the 'HH bundle' throughout the hospital. This included: (i) appointment of
HH champions; (ii) verbal/visual bedside reminders; (iii) patient empowerment; (iv)
hand moisturisers; (v) tagging near-empty handrub (HR) bottles. Other hospital-wide
initiatives included: (vi) Smartphone application for auditing; (vii) 'Speak up for
Patient Safety' Campaign in 2017 for staff empowerment; (viii) making HH a key
performance indicator. Overall HH compliance increased from a baseline median of
79.6-92.6% in end-2019. Moments 1 and 4 improved from 71 to 92.7% and from
77.6 to 93.2%, respectively. Combined HR and hand wash consumption increased
from a baseline median of 82.6 ml/patient day (PD) to 109.2 mL/PD. Health-care-
associated rotavirus infections decreased from a baseline median of 4.5 per 10 000
PDs to 1.5 per 10 000 PDs over time. The 'HH Bundle' of appointing HH champions,
active reminders and feedback, patient education and empowerment, availability of
hand moisturisers, tagging near-empty hand rub bottles together with hospital-wide
initiatives including financial incentives and the 'Speak Up for Patient Safety'
campaign successfully improved the overall HH compliance to >90%. These
interventions were highly reliable, sustained over 4 years and also reduced health-
care-associated rotavirus infection rates.

(Judith Hammerschmidt 2019) conduct study on a cross-sectional mixed-methods

study Nurses' knowledge, behavior and compliance concerning hand hygiene in
nursing homes Effective hand hygiene is one of the most important measures for
protecting nursing home residents from nosocomial infections. Infections with multi-
resistant bacteria's, associated with healthcare, is a known problem. The nursing
home setting differs from other healthcare environments in individual and
organizational factors such as knowledge, behavior, and attitude to improve hand
hygiene and it is therefore difficult to research the influential factors to improve hand
hygiene. Studies have shown that increasing knowledge, behavior and attitudes could
enhance hand hygiene compliance in nursing homes. Therefore, it may be important
to examine individual and organizational factors that foster improvement of these
factors in hand hygiene. We aim to explore these influences of individual and
organizational factors of hand hygiene in nursing home staff, with a particular focus
on the function of role modelling by nursing managers. We conducted a mixed-
methods study surveying 165 nurses and interviewing 27 nursing managers from
nursing homes in Germany. Most nurses and nursing managers held the knowledge
of effective hand hygiene procedures. Hygiene standards and equipment were all
generally available but compliance to standards also depended upon availability in
the immediate work area and role modelling. Despite a general awareness of the
impact of leadership on staff behavior, not all nursing managers fully appreciated the
impact of their own consistent role modelling regarding hand hygiene behaviors.
These results suggest that improving hand hygiene should focus on strategies that
facilitate the provision of hand disinfectant materials in the immediate work area of
nurses. In addition, nursing managers should be made aware of the impact of their
role model function and they should implement this in daily practice.

(Monica Nzanga 2022) conduct study on Adherence to Hand Hygiene among

Nurses and Clinicians at Chiradzulu District Hospital, Southern Malawi Healthcare
associated infections (HAIs) are a burden in many countries especially low-income
countries due to poor hand hygiene practices in the healthcare settings. Proper hand
hygiene in the healthcare setting is an effective way of preventing and reducing
HAIs, and is an integral component of infection prevention and control. The
objective of this study was to determine adherence to hand hygiene guidelines and
associated factors among nurses and clinicians. A quantitative cross-sectional study
was conducted at Chiradzulu District Hospital (Malawi) where stratified random
sampling was used to obtain the sample of 75 nurses and clinicians. Data were
collected using self-administered questionnaires (n = 75), observation checklists (n =
7) and structured observations (n = 566). The study findings confirmed low
adherence to hand hygiene practice among healthcare workers (HCWs) in Malawi.
Overall, higher hand hygiene practices were reported than observed among nurses
and clinicians in all the World Health Organization's (WHO) five critical moments of
hand hygiene. This calls on the need for a combination of infrastructure, consumables
(e.g., soap) and theory driven behavior change interventions to influence adoption of
the recommended hand hygiene behaviors. However, such interventions should not
include demographic factors (i.e., age, profession and ward) as they have been
proven not to influence hand hygiene performance.

(Sarah Al-Anazi 2022) conduct study on Compliance with hand hygiene practices
among nursing staff in secondary healthcare hospitals in Kuwait A cross-sectional
study was conducted on nursing staff in all six secondary care hospitals in Kuwait.
Data on knowledge of, attitudes towards, and self-reported CwHH were collected
through a self-administered questionnaire that was developed based on WHO's
questionnaire, while the data on actual compliance were objectively collected through
direct observation of nurses during routine care by two independent observers using
WHO's observation form. Of 829 nurses approached, 765 (92.2%) responded and
participated. Of all participants, 524 (68.5%) were able to list "My Five Moments for
Hand Hygiene" fully and appropriately. However, several misconceptions (e.g. air
circulation in hospital is the main route of infection) about HH were found among the
nurses. CwHH was (25.0%) by direct observation while self-reported compliance
was (69.5%) each varied significantly (p < 0.001) between different hospitals.
Female nurses compared to male nurses and non-Arab compared to Arab
nationalities were more likely to report CwHH in multivariable analysis. Several
items on knowledge of and attitudes towards HH were also associated with self-
reported CwHH. Observed CwHH among nursing staff in secondary care hospitals in
Kuwait was low, which highlights the need to make more efforts to improve HH
practices. Interventions that have been used elsewhere and found to be effective may
be tested in Kuwait. Despite the good overall knowledge on HH among nurses, there
are several misconceptions that need to be corrected.

(N V Torchinskii 2021) conduct the specially designed questionnaire Nurses'

Attitude Towards Various Hand Hygiene Products. Soap vs Antiseptics According to
the latest recommendations of WHO, in most situations requiring hands treatment,
alcohol-based skin antiseptics should be used. This study is aimed to determine the
awareness and preferences of nurses in the city of Moscow regarding the choice of
methods regarding hand hygiene treatment and the factors influencing this choice.
Using the specially designed questionnaire, 184 nurses working in Moscow hospitals
were interviewed to find out the attitude of nurses to various methods of hand
hygiene. The questionnaire was developed on the basis of WHO Recommendations
and Russian Recommendations. The survey was conducted from May 2017 to July
2017. To confirm the statistical significance of the identified associations a chi-
square test was used. To find the 95% confidence interval to the relative values the
Clopper-Pearson method was used. Only 3 (1.63%) of respondents indicated that
they use antiseptic as the most frequently used hand hygiene product, 27 (14.67%)
use liquid soap more often, 153 (83.15%) indicated that they use soap and antiseptic
with equal frequency. In none of the standard situations we examined the use of
antiseptic was the most frequent choice. Only in three cases antiseptic was chosen
more often than soap - before and after manipulations with wounds and catheters
(36.96%) or before performing invasive procedures (36.41%) and after contact with
biological material (29.35%). At the same time nurses with more than 15 years of
experience have preferred antiseptic. Based on the study it can be assumed that
despite the implementation of the Russian guidelines on hand hygiene developed
according to WHO recommendations, nurses prefer the traditional method of
washing hands with soap. This suggests that in the current conditions additional
measures are needed to train nurses and to monitor their work.

(Mete Kagan Karaoglu 2018) conduct A Nonrandomized Quasi-Experimental

Design Effectiveness of Hygienic Hand Washing Training on Hand Washing
Practices and Knowledge Nurses undertake important responsibilities in patient care
and the prevention of hospital-acquired infections. However, adherence to hand
hygiene practices among nurses has been reported to be low. This study aims to
evaluate the effectiveness of hygienic hand washing training on hand washing
practices and knowledge. The study design was a nonrandomized, quasi-
experimental study, with pretest-posttest for one group. Pre- and post-observations
were also conducted using an observation form on any 5 workdays to evaluate the
effectiveness of hygienic hand washing training on hand washing practices. The
study was conducted with 63 nurses working at a hospital in Istanbul. Hand Hygiene
Knowledge Form scores after hygienic hand washing training were higher than the
pre-training scores. The number of the nurses' hand hygiene actions after hand
hygiene training increased significantly compared with that before training. The
results indicate that training in proper hand washing techniques and hygienic hand
washing practices positively affects the knowledge level of nurses and their hand
washing behavior

(Georgios Manomenidis 2019) conduct study on Job Burnout Reduces Hand

Hygiene Compliance Among Nursing Staff Health professional burnout has been
associated with suboptimal care and reduced patient safety. However, the extent to
which burnout influences hand hygiene compliance among health professionals has
yet to be explored. The aim of the study was to examine whether job burnout reduces
hand washing compliance among nursing staff.

A diary study was conducted. Forty registered nurses working in a general city
hospital in Thessaloniki, Greece, completed a questionnaire, while they were
monitored for hand hygiene compliance following the World Health Organization
protocol for hand hygiene assessment. Burnout was measured using validated items
from the Maslach Burnout Inventory. Data were collected from September to
October 2015. Multiple regression analysis showed that controlling for years in
practice, burnout was negatively associated with hand hygiene compliance (R =
0.322, F(3,36) = 5.704, P < 0.01). Nurses reporting higher levels of burnout were less
likely to comply with hand hygiene opportunities (b = - 3.72, 95% confidence
interval = -5.94 to -1.51). This study showed that burnout contributes to suboptimal
care by reducing compliance to hand hygiene among nurses. Given the crucial role of
hand hygiene compliance for the prevention of in-hospital infections, this study
highlights the need for interventions targeting the prevention of burnout among
nursing staff.

(Jorun Saetre Sundal 2017) conduct study on The hand hygiene compliance of
student nurses during clinical placements Hand hygiene is the single most important
measure to prevent healthcare-associated infections. However, research has shown
low compliance among healthcare workers. During clinical placements, student
nurses perform various nursing tasks and procedures to a large number of patients,
requiring extensive patient contact. It is crucial that they practice correct hand
hygiene to prevent healthcare-associated infections. Open, standardized and
nonparticipating observations Twenty-nine student nurses were observed three times
for 20 ± 10 min during clinical placement in a Norwegian university hospital. To
measure compliance, we used WHO's Hand Hygiene Observation tool, based on the
model "My five moments for hand hygiene". Overall hand hygiene compliance in the
student group was 83.5%. Highest moment-specific compliance was after touching
patient surroundings, after touching patients and after body fluid exposure risk.
Lowest moment-specific compliance was recorded before touching patients or patient
surroundings, and before clean/aseptic procedures. Nurse education needs to be
improved both theoretically and during clinical placements in order to advance and
sustain compliance among student nurses. Increasing healthcare workers' compliance
with hand hygiene guidelines remains a challenge to the clinical community. In order
to reduce healthcare-associated infections, it is important to educate student nurses to
comply with the guidelines during clinical placements. Identifying student nurses'
hand hygiene performance is the first step towards developing teaching methods to
improve and sustain their overall and moment-specific compliance. As a measure to
ensure student compliance during clinical placements, mentors should be aware of
their influence on students' performance, act as hand hygiene ambassadors,
encourage students to comply with established guidelines and provide regular
feedback.

study related to self-instructional model

R. Herrera and L. Peirano conducted a retrospective interventional study at Hospital

Carlos Van Buren, Valparaiso, Chile, to evaluate the effectiveness of an infection
control program in reducing bacteremia (BAC) associated with central venous
catheters (CVCs) in an adult ICU​ . The study, conducted between 1994 and 2002,
involved monitoring infection rates, implementing strict supervision, and educating
healthcare personnel. A total of 1,799 patients with CVCs were observed, and
infection rates significantly declined from 7.0 cases per 1,000 CVC days (1994–
1997) to 3.5 cases per 1,000 CVC days (1998–2002). The findings highlight that
adherence to infection control protocols, proper catheter care, and continuous training
of healthcare workers play a crucial role in minimizing CVC-associated bloodstream
infections.

S. Joisy Varghese and Shobha Naidu conducted a pre-experimental one-group pretest-

posttest study to assess the effectiveness of a self-instruction module on knowledge,
attitude, and practice regarding the prevention of complications among diabetic patients in
selected hospitals in Pune. A sample of 60 diabetic patients was selected using a convenient
sampling method. The study used a structured tool comprising demographic data, multiple-
choice questions, a rating scale, and a checklist. After obtaining informed consent, a pretest
was conducted, followed by the administration of the self-instruction module, and a
posttest was performed to evaluate changes. The study concluded that diabetes is a
growing global concern, particularly in developing nations, and that self-instruction modules
serve as an effective, simple, and accessible method to enhance patient knowledge and
preventive practices.

Nandaprakash P., Lingaraju M., and B. S. Shakuntala conducted a quasi-

experimental study to evaluate the effectiveness of a self-instructional module (SIM)
on knowledge regarding evidence-based nursing practice among staff nurses in
selected hospitals in Mysore. The study involved 80 staff nurses, with 40 in the
experimental group from K.R. Hospital and 40 in the control group from
Cheluvamba and PKTB Hospital. A pre-test assessed baseline knowledge, followed
by the administration of SIM to the experimental group. After two weeks, a post-test
was conducted, revealing a significant improvement in the experimental group’s
mean score (11.3) compared to the control group (5.97), with a statistically
significant 't' value of 9.07 (p < 0.05). The study concluded that SIM is an effective
tool for enhancing nurses' knowledge of evidence-based nursing practice
primary A) Assess the knowledge and level of Compliance of Hand Hygiene
objectives during Bundle of Care Interventions among nurses working in ICU with
a view to develop a self-instructional module

1. To determine the knowledge and level of compliance of hand

hygiene during bundle of care interventions among staff nurses
working in the ICU.
2. To identify the associated factors with bundle of care interventions
among staff nurses working in the ICU.
3. To assess the effectiveness of Self-Instructional Module on
knowledge and level of compliance of hand hygiene during bundle
of care interventions among Staff Nurses by comparing the pre
and post-test score
1. To find the association between post-test knowledge scores with their

selected demographic Variables of Staff Nurses.

other objectives
(any):-
methodology RESEAR RESEARCH DESIGN
pre-experimental (one group pre-test and post-test) design was adapted in
the present study

Pre Test Intervention Post Test

O1 X O2

O1 – Assessment level of compliance on hand hygiene during bundle of care

intervention among nurses working in ICU.

X- Administration of structured teaching program and Self-administered

questionnaires on hand hygiene during bundle of care intervention among nurses
working in ICU

O2 - Assessment of post-test knowledge level effectiveness of hand hygiene during

bundle of care intervention among nurses working in ICU
VARIABLES UNDER STUDY

Dependent variables: In this study Knowledge and compliance of hand hygiene

during bundle of care interventions among staff nurses.

Independent variable: In this study Self-Instructional Module regarding improve

the level of compliance of hand hygiene during bundle of care interventions among
staff nurses.

RESEARCH APPROACH

A Quantitative evaluative research approach was used.

POPULATION

Target population: In this study, target population consists of all staff nurses of
selected Hospitals

SAMPLE
In this study the sample consisted of staff nurses of selected Hospitals,
SAMPLE SIZE

The total sample size of the study consists of 100 nurses working in ICU of a tertiary
care hospital

Cochran formula for sample size = n

n = Zα2p(1-q)
_________
E2

n = 1.962(0.6) (0.4)
_____________
(0.1)2

n = 3.8416×0.24
0.01
 n= 0.921984
0.01

n = 92.19 n=100
Where:
n = sample size.
Z 2 = value for the selected alpha level (1.96 at 95% confidence level)
d = desired level of precision ( 5%)
p = estimated proportion of an attribute that is present in the population 60%)
q = 1-p
q = 1-0.6
q = 0.4
SAMPLING TECHNIQUE
In this study, Purposive sampling technique was adopted.

CRITERIA FOR SELECTION OF SAMPLING

The criteria for sample selection are mainly depicted under two headings, which
includes the Inclusion and the Exclusion Criteria.
Inclusion Criteria
Inclusion Criteria
 The healthcare professionals Working in ICU.
 Who have a Degree or Diploma in Nursing.

Exclusion Criteria
 The staff nurses having less than 6 months of experience.
 Who were not willing to participate.

OPERAATIONAL DEFINITION
ASSESS
According to oxford student dictionary ‘assess’ means to evaluate or estimate the
quality, quantity, or extent of something. In various contexts

In this the study are assessing the attitude and compliance on hand hygiene during
bundle of care intervention among nurses working in ICU
ATTITUDE
According to oxford student dictionary ‘attitude’ means Attitude refers to a person's
feelings, beliefs, and disposition towards something, such as an idea, object, event, or
behavior. It encompasses the emotional, cognitive, and behavioral aspects of an
individual's response to a particular stimulus
In this study the attitude and compliance on hand hygiene during bundle of care
intervention
HAND HYGIENE
According to oxford student dictionary ‘hand hygiene’ means Hand hygiene refers to
the practices and procedures used to clean and disinfect hands to prevent the spread
of infections and illnesses. It involves the use of soap, water, and/or hand sanitizers
to remove dirt, microorganisms, and other contaminants from the hands.
In this study assess hand hygiene during bundle of care intervention among nurses
working in ICU of a tertiary care hospital

BUNDLE OF CARE INTERVENTION

According to oxford student dictionary ‘bundle of care intervention’ means A bundle
of care intervention refers to a comprehensive package of evidence-based practices,
interventions, and treatments that are combined and implemented together to improve
patient outcomes, quality of care, and safety.
In this study bundle of care intervention assessed for nurses working in ICU

NURSES WORKING IN ICU

According to oxford student dictionary ‘nurses working in ICU’ means Nurses
working in ICU (Intensive Care Unit) refers to registered nurses (RNs) and other
nursing professionals who provide specialized care to critically ill patients in an
Intensive Care Unit.
In this study assess the attitude and compliance on hand hygiene during bundle of
care intervention among nurses working in ICU of a tertiary care hospital

SCORING INTERPRETATION
In the points discussed was basic question on general information about A study to
assess the attitude and compliance on hand hygiene during bundle of care
intervention among nurses working in ICU of a tertiary care hospital and the score
was assess as below:
PROCEDURE OF DATA COLLECTION
 Permission will be obtained from Ethical committee.
 Prior to data collection, permission will be obtained from the concerned
authorities.
 Subjects will be selected according to the selection criteria of the study.
 Consent will be obtained from the participant
 The investigator will assess the a cross sectional survey

DATA MANAGEMENT AND ANALYSIS PROCEDURE:

 Tool validity will be obtained from experts
 Pilot study will be conducted before proceeding for main study.
 Data will be collected.
 Anonymity and Confidentiality will be maintained throughout the study.
 Assessment on attitude and compliance on hand hygiene during bundle of care
intervention among nurses working in ICU of a tertiary care hospital
 Numbering, Coding will be done.
 Master sheet will be prepared for data management and analysis.

DATA ANALYSIS

SR DATA METHOD REMARKS

NO ANALYSIS

1 Descriptive Frequency To describe the distribution of

statistics & demographic variables.
percentage

Mean, To compare the attitude and compliance on

Median, hand hygiene during bundle of care
Standard intervention among nurses working in ICU

Deviation

2 Inferential Chi square There will be association between Pretest

statistics
Score and post test score with their
selected demographic variable

.
Reference
1) Aboumatar H, Ristaino P, Davis RO, et al. 2012. Infection Prevention
Promotion Program Based on the PRECEDE Model: Improving Hand
Hygiene Behaviors among Healthcare Personnel. Infection Control &
Hospital Epidemiology 33(2): 144–151.
2) Alberta Health Services. 2021. Hand Hygiene Toolkit Helping leaders
achieve success. Retrieved from Allegranzi B, Gayet-Ageron A, Damani, N,
et al. 2013. Global implementation of WHO's multimodal strategy for
improvement of hand hygiene: a quasi-experimental study. The Lancet
Infectious Diseases 13(10): 843–851.
3) Baek EH, Kim SE, Kim DH, et al. 2020. The difference in hand hygiene
compliance rate between unit-based observers and trained observers for
World Health Organization checklist and optimal hand hygiene. Int J Infect
Dis 90: 197–200.
4) Electronic monitoring in combination with direct observation as a means to
significantly improve hand hygiene compliance. American Journal of
Infection Control 45(5): 528–535.
5) Boyce J. 2021. Hand Hygiene, an Update. Infectious Disease Clinics of North
America 35(3): 553–573.
6) Brocket J and Shaban RZ. 2015. Characteristics of a successful hospital hand
hygiene program: an Australian perspective. Healthcare infection 20(3): 101–
107.
7) Cawthorne K and Cooke R. 2021. A survey of commercially available
electronic hand hygiene monitoring systems and their impact on reducing
healthcare-associated infections. Journal of Hospital Infection 111: 40–46.
8) Cherry MG, Brown JM, Bethell GS, et al. 2012. Features of educational
interventions that lead to compliance with hand hygiene in healthcare
professionals within a hospital care setting. A BEME systematic review:
BEME Guide No. 22. Medical Teacher 34(6): e406–e420.
9) Clancy C, Delungahawatta T and Dunne CP. 2021. Hand-hygiene-related
clinical trials reported between 2014 and 2020: a comprehensive systematic
review. Journal of Hospital Infection 111: 6–26.
10) Kraker M, Tartari E, Tomczyk S, et al. 2022. Implementation of hand hygiene
in healthcare facilities: results from the WHO Hand Hygiene Self-Assessment
Framework global survey 2019. The Lancet Infectious Diseases 22(6): 835–
844.
 11) Ellingson K, Haas JP, Aiello AE, et al. 2014. Strategies to Prevent
Healthcare-Associated Infections through Hand Hygiene. Infection Control &
Hospital Epidemiology 35(8): 937–960.
12) Gould D, Creedon S, Jeanes A, et al. 2017. Impact of observing hand hygiene
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13) Gould D, Moralejo D, Drey N, et al. 2018. Interventions to improve hand
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Annexures LIST OF ANNEXURES
ANNEXURE No. 1 : Demographic variables
ANNEXURE No 2. [A]. Participants consent form in English.
ANNEXURE No 2. [B]. Participants consent form Marathi
ANNEXURE. No. 3 Permission letter
ANNEXURE. No 4 Certificate of English editing
ANNEXURE. No 5 Certificate of Marathi editing
ANNEXURE. No 6 Letter seeking experts’ opinion for content validity
ANNEXURE. No. 7 Timeline/Gantt Chart :-
 ANNEXURE No 2. Participants consent form in English.
A. Participants consent form in English.

INFORMED CONSENT

NAME

AGE /SEX

ADDRESS

Hereby give my informed consent to participate in A study to assess the attitude and compliance on hand
hygiene during bundle of care intervention among nurses working in ICU of a tertiary care hospital
If I agree to participate in the study, I will be interviewed. The interview may be recorded and will take
place in privacy. No identifying information will be included when the interview is transcribed. I understand
that there are no risks associated with this study. I realize that the knowledge gained from this study may
help either me or other people in the future. I understand that all study data will be kept confidential.
However, this information may be used in nursing publication or presentations. If I need to, I can contact
M.Sc. (N) student of ------------------------------any time during the study. The study has been
explained to me. I have read and understood this consent form, all of my questions have been answered, and
I agree to participate. I understand that I will be given a copy of this signed consent form. There is no
compulsion on me to participate in this project and I am giving my free consent for it. I am ready and
willing to undergo all tests and treatments in the present project. I have read and I have been explained the
general information and purpose of the present project. I understand that there are no risks associated with
this study. I understand that all study data will be kept confidential. I know that I can withdraw from present
project at any time.

Any data or analysis of this project will be purely used for scientific purpose and my name will be kept
confidential except when required for any legal purpose.

Signature of participant Signature of Principal

 परिशिष क्रमा 3. . सहभरगी सम्ती फॉ्् इम ग्ी्ीमध.

सहभरगी सम्ती फॉ्् इम ग्ी्ीमध.

सूशित सम्ती

वम/लिमग

पतर

मरदरिध “A study to assess the attitude and compliance on hand hygiene during bundle of care

intervention among nurses working in ICU of a tertiary care hospital ’’ ्ि ्ी अभमरसरत सहभरगी होणमरस

सह्ती दििी, ति ्ी ्ुिरखत घधतिी ्रईि. ्ुिरखत िध ाॉर् ाध िी ्रऊ िातध आशि गोपनीमतधत होईि. ्ुिरखत शिपममतरित ाध लमरवि

ाोितीही ओळख ्रशहती स्रशवष ाध िी ्रिरि नरही. ्िर स््तध ाी मर अभमरसरिी समबमशित ाोितधही िोाध नरहीत. ्िर ्रिवतध

ाी मर अभमरसरतून श्ळरिधिध जरन ्िर काम वर इति िोारमनर भशवषमरत ्ित ार िातध. ्िर स््तध ाी सव् अभमरस रधटर गोपनीम

ठध विर ्रईि. तथरशप, ही ्रशहती नरससग पारिन काम वर सरििीाििरम्ीमध वरपििी ्रऊ िातध. ्िर आवशमा असलमरस, ्ी M.Sc.

िी समपा् सरिू िातो. (N) अभमरसरििरमरन ािीही ------------------------------ िर शवदरथा. अभमरस ्िर स््रवून सरमशगतिर आहध.

्ी हर सम्ती फॉ्् वरििर आशि स््िर आहध, ्रझमर सव् प्रमिी उतिध दििी गधिी आहधत आशि ्ी सहभरगी होणमरस सह्त आहध.

्िर स््तध ाी ्िर मर सवरािी ाध िधलमर सम्ती फॉ््िी एा पत दििी ्रईि. मर पालपरत सहभरगी होणमरसरठी ्रझमरवि ाोितीही

सकी नरही आशि तमरसरठी ्ी ्रझी शवनर्ूलम सम्ती िधत ​ ​ आहध. ्ी सीमरामर पालपरतीि सव् िरिणमर आशि उपिरिरमसरठी

तमरि आहध आशि तमरि आहध. ्ी वरििध आहध आशि ्िर सीमरामर पालपरिी सर्रनम ्रशहती आशि उदधि सपष ािणमरत आिर आहध.

्िर स््तध ाी मर अभमरसरिी समबमशित ाोितधही िोाध नरहीत. ्िर स््तध ाी सव् अभमरस रधटर गोपनीम ठध विर ्रईि. ्िर ्रशहत

आहध ाी ्ी सीमरामर पालपरतून ािीही ्रघरि घधऊ िातो.

मर पालपरिर ाोितरही रधटर काम वर शवशधलि पूि्पिध वैजरशना हधतूसरठी वरपििर ्रईि आशि ाोितमरही ारमिधिीि हधतूसरठी आवशमा

असलमरशिवरम ्रझध नरव गोपनीम ठध विध ्रईि.

्ुखम अनवधलारिी सहभरगी सवरािी

 ANNEXURE. No. 4. Permission letter

To,

Subject: Letter for seeking permission to conduct the study.

Respected Sir/madam,

This is to introduce…………………………………………... M.Sc. Nursing Student of

---------------. in he requires submitting the research “A study to assess the attitude and compliance on
hand hygiene during bundle of care intervention among nurses working in ICU of a tertiary care
hospital ”. to MaharashtraUniversity of Health Sciences (MUHS), Nashik, in the partial fulfillment for the
M.Sc. Nursing degree. The topic undertaken for the study in he needs your esteemed help and permission to
conduct the study May, I therefore request you to kindly extend cooperation to her work on the proposed
study at your esteemed area.

The student will finish further information in this regard, sir required personally

Thanking you
 ANNEXURE No. 6

CERTIFICATE OF ENGLISH EDITING

TO WHOMSOEVER IT MAY CONCERN

This is to certify that the dissertation work “A study to assess the attitude and compliance

on hand hygiene during bundle of care intervention among nurses working in

ICU of a tertiary care hospital ”. done by first year,

M.Sc. (Nursing) student of------------------------------------------------------------------------------.

Is edited for english language appropriateness by .

Date :

Registration No with Seal Signature

 ANNEXURE.No. 7

CERTIFICATE OF MARATHI EDITING

TO WHOMSOEVER IT MAY CONCERN

This is to certify that the dissertation work “A study to assess the attitude and compliance

on hand hygiene during bundle of care intervention among nurses

working in ICU of a tertiary care hospital ”. done by first year, M.Sc. (Nursing) student of --.

Is edited for Marathi language appropriateness by .

Date :

Registration No with Seal Signature

 LETTER SEEKING EXPERTS’ OPINION FOR

CONTENT VALIDITY

From,

M.Sc. (Nursing) I Year,

To,

Respected sir /madam,

I am a first year M.Sc. (Nursing) student of --.

under the Maharashtra University of Health Science.I would like to “A study to assess the

attitude and compliance on hand hygiene during bundle of care intervention

among nurses working in ICU of a tertiary care hospital ”.

Herewith I am sending the developed tool for content validity and your expert opinion and possible
suggestions. I would be most obliged if you can do the needful and return it to the undersigned.

Thanking you!

Yours faithfully,

Enclosed:

❖ Certificate of content validity

❖ Synopsis
❖ Description of the tool for content validity
❖ Remark sheet for demographic variables and questionnaire
Annexure No. 7 Timeline/Gantt Chart :-
Research Activity Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Apr

1 Research
Methodology Workshop 3
Days
2 Literature Review &Topic
Selection 3
Week
3 Problem Selection &
Presentation 2
Week

4 Synopsis Development
&Presentation for
Ethical Clearance
3
Week

5 Total Validity Relaibility,

Pilot Study 4
Week
6 Pilot Study,Presentation
&Data Collection 4
Week
7 Data Analysis & Presentation
4
Weeks
8 Dissertation & Presentation
4
Weeks

9 MUHS
Dissertation &
Presentation
4
week