Nursing Essays

Free Essays - Free Nursing Essays

Evaluation of Health Promotion Strategies

Health Policy and Health Promotion

Critically evaluate the actual or potential effectiveness of a contemporary health promotion intervention/strategy which has been published at local or national level, taking account of the theoretical concepts which underpin health promotion practice. Option B - areas to include in essay Public Health agenda Assessment of health needs Critical analysis of health promotion models, approaches and strategies Ethical issues in health promotion and evaluation of health promotion strategies.

The particular Health Promotion issue that we shall discuss in this essay will be the issue of cleanliness within the hospital, with specific reference to the current climate of MRSA control and the various initiatives that have been instituted with regard to hand washing, reduction in cross-patient contamination and general levels of cleanliness. We shall particularly consider the issues within the context of the critical care setting.

It is accepted that the media have, to a large extent, hyped up the public awareness of the issues involved. Clearly it can be argued that the public should indeed be aware of the issues, and should be rightly concerned if there are areas which require attention. This is certainly a legitimate function of the media. Most healthcare professionals working within the NHS, whilst agreeing that MRSA does pose a significant problem, would also agree that it is not quite the problem presented to the public by some of the less reputable (but still widely read) newspapers.

It also follows from this, that the public, by being aware, can exert a vicarious pressure on the policy makers - both in the NHS and in the country at large - to ensure that appropriate measures are taken to combat the problems that the MRSA (and other less well publicised infective agents) pose, both within the hospital estate and in the community as a whole.

In a Machiavellian way there is a legitimate argument that the greater the public frenzy over a particular issue (irrespective of its actual importance in the general scheme of things) the more likely it is that some positive action will ensue from a politically inspired agenda.

Public Health Agenda

There is a generally held consensus of opinion that the whole issue of the spread of infection by contamination, within the hospital setting in general and the ICU setting in particular, is a cause of great concern. It has a direct bearing on issues of patient morbidity and certainly in the ICU environment, it has great bearing on the issue of patient mortality as well. The basis of this statement recognises the fact that not only are ICU patients invariably particularly ill and debilitated but also that they are particularly prone to infections because of the likelihood of multiple breaches in the integrity of the skin, either from suffered trauma or from iatrogenic breaches for instrumentation or fluid access etc. An intact layer of skin still represents that best available protection against infection in the otherwise healthy patient.

In order to consider the public health implications of cross contamination one needs to look back about 160 years in history, to the hospital wards of Dr Ignaz Semmelweis who, in 1846 pioneered the groundbreaking work which led to the universal realisation that patient cross-infection by health professionals was at the root cause of the frightening mortality rates from puerperal fever. His work led to the discovery that it was the dirty hands and clothes of the healthcare professionals that transmitted the germs from the dissecting room to the ward and from the ill patient to the healthy one. His pioneering work was built upon by countless others over the intervening years including such medical giants as Sir Joseph Lister who opened up the field of antisepsis and asepsis.

Despite the quantum leaps in our understanding of the problems over the last 160 years and the fact that our knowledge has improved and modern-day tools have expended our horizons beyond the wildest dreams of Semmelweis's day, it is the simple expedient of hand-washing and good personal hygiene between the professional contacts with patients that is still the Gold standard in the measures employed to reduce the toll of cross-patient contamination.

The paradox is that, although this is widely known within both the healthcare community and also by the public in general, this simple expedient is still often overlooked as both an inconvenience and a hindrance when working in a healthcare environment.

The Government has rightly taken the lead in setting the agenda in this area over the last few years. It has been recognised that this is a national problem and locally drafted initiatives are simply neither appropriate nor adequate to deal with it. It is vital to have a national policy that can be adhered to by all concerned parties. In recognition of this fact the Government have launched a number of initiatives in recent years. One of the most significant has been New Guidelines For Cleaner Hospitals in 2004.

Successive Health Ministers have repeatedly set and revised targets to be achieved in the area of hospital cleanliness. One of the most significant pronouncements of recent months was that of John Reid (the current incumbent) who has set the target of achieving a 50% reduction in iatrogenic MRSA contamination by 2008.

Assessment of Health Needs

In any project of this size (or indeed it can be argued of any size), it is important to clarify the rationale, the evidence and the reasons for pursuing a particular goal. The public purse needs to be assured that money committed is for good and valid reasons and the public themselves need reassurance that the goals to be achieved are both sound and in their best interest.

The rationale for this particular initiative can be assessed on several different levels. The main raison d'Aatre is, and should be, patient well-being. Hippocrates said that if you were to aspire to be a doctor that you should first do no harm. His implication was clearly that, as health professionals in your attempts to cure or aid a patient you should not embark on any treatment which could finish up by causing him harm. There is no merit in saving a patient from serious multiple trauma by admitting him to an ICU if he thereby contracts MRSA and dies from septicaemia. This is clearly the worst case scenario but it serves to delineate the problem faced by modern hospitals.

Beyond this, there is the financial implication. A recent DOH study analysed the current situation and showed that healthcare associated infection (HCAI's) were currently responsible for over 8% of all acute admissions to our hospitals nationally. It is clear that the presence of such infections will inevitably cause complications and delay potential patient discharge thereby having a direct financial implication to the NHS and therefore the taxpayer. The study concluded that For the NHS in England this represents 3.6 million bed days lost, with a projected cost of 1 billion a year. This is an enormous financial burden by any evaluation and a major incentive to reduce the total burden of cross-contamination by any means possible. The report also concluded that implementation of all the measures suggested by the NPSA would release 147 million and save about 450 lives per year once target compliance rates have been met.

A recent paper by Garrouste-Orgeas (2001) specifically looked at the morbidity and mortality of ICU patients who had contracted the MRSA. It is a complicated paper with several significant findings. In the context of this piece its major conclusion was that an MRSA control programme is warranted if only to decrease vancomycin use and to limit glycopeptide resistance in gram-positive cocci. This puts a rather unexpected slant on the arguments advanced thus far. We have argued that the main rationale for MRSA control is to reduce patient morbidity and mortality. This paper suggests that a more important intermediate goal is appropriate and that is, by reducing the incidence of MRSA cross-contamination, one can reduce the need for MRSA-controlling substances and thereby reduce the possible incidence of further resistance.

A paper by Ibelings (1998) looked at the wider picture of MRSA acquisition in ICUs. The conclusions drawn were that patients in an ICU were at high risk of becoming infected with MRSA and that the risk increased with the longer length of stay in the unit. He also found that patients who had contracted the MRSA were less likely to survive than those who either did not contract it or who contracted MSSA.

Critical Analysis of Health Promotion Models, Approaches and Strategies

In any implementation of a significant health promotion initiative there is a demonstrable need to have a clear strategy of introduction in place to facilitate the optimum uptake of the strategy and therefore, hopefully, the maximal uptake of the strategy.

In the specific case of MRSA in ICU there is a very relevant study by Guiguet (1990) (9) which illustrates the point very well. It firstly demonstrates the need for change by analysing an outbreak of MRSA in an ICU (in a 400 bed cancer centre) which was traced back to one index case. Having been identified, the paper then outlines the various methods of infection control including strong reinforcement of handwashing procedures resulted in a sharp decrease in the rate of colonisation by MRSA. Interestingly the study found that the index case had been admitted from another hospital and was ultimately responsible for 17 new cases in the ICU. Other risk factors were also identified as being the length of stay in hospital and the number of invasive procedures done to the patients. Guiguet points out that even simple measures, when stringently applied, can control outbreaks of MRSA even in severely immunocompromised cancer patients.

It may be all very well in pointing out that these simple measures are very effective in the control of such infections, but one should be prepared for opposition when they are enforced. It is sadly a reflection of the current pressure of work that many healthcare professionals, although fully cogniscent of the risks of cross-contamination of patients, simply find that handwashing and other barrier measures are both annoying and time consuming. This observation underlines the need for a broad based strategy to implement such a programme. Generally speaking, when implementing new strategy coercion is better than confrontation and education is better than ignorance.

Useful strategies might include a programme of seminars and educational lectures for all healthcare staff. These could be specifically targeted at senior staff who were opinion formers in the unit. Reference to peer-reviewed articles is often a particularly convincing ploy and can often be used to advantage to sway waverers.

There are other measures to help improve compliance that can be used. Signs on patient's beds and indeed, involving the patients directly are two measures that are often suggested. There is considerable evidence that patient involvement does produce a positive increase in compliance in the healthcare professionals attitude to the various measures taken to prevent cross-contamination. The National Patient Safety Agency (2004) (10) produced an interesting document on the subject. This has been amplified by the a fascinating article by the unlikely body of the Public Accounts Committee (6) who looked at the issue and came to the conclusion that many patients expressed a view in private, that they would confront a healthcare professional if they thought that they had breached the control of infection rules. The same study went on to comment that, in reality, the patients were to reserved to actually do this in the actual situation unless they perceived an element of self-interest. If a healthcare professionals was about to touch them after coming from direct contact with another infected patient then the patient was far more likely to question the healthcare professional's actions

Ethical Issues in Health Promotion

The ethical issues involved in this area are, on the face of it, quite simple. On the one hand you have a situation which, when analysed in the face of the best practices of evidence-based medicine, is a quite straight-forward choice - does one instigate simple measures that have been demonstrated to reduce the spread of MRSA in a hospital setting or not? There are clearly no major ethical issues in this area. On the other hand you have a situation where apparently highly trained healthcare professionals can enter an area of denial where they will ignore (or possibly choose to forget) the fact that simple but irritating and time consuming procedures, can directly lead to improved patient care. This is possibly helped by the fact that there is no direct observed immediate consequence of not handwashing or changing clothes. The patient appears to be the same whether one has washed one's hands or not. The patient will behave in the same way if one doesn't change one's sterile use once only apron.

There are certain individuals who will argue directly in the face of overwhelming evidence that handwashing is not a useful procedure. I refer the reader to a fascinating collection of letters on the subject in the BMJ (11) one of which is entitled Why I don't wash my hands between patient contacts. There is clearly a major ethical issue here and one must make one's own decision on the point.

On a slightly more rational basis we would commend an excellent article by Vincent (2005) (12), in which a discussion is reported after a patient in an ICU dies from septicaemic shock after an MRSA infection due to a catheterisation procedure. The article admits that the next-door patient had MRSA and the barrier procedures were less than adequate. As a result, the patient's family sued the hospital. The article presents the views of four different specialists from different countries and raises many different and fascinating ethical viewpoints.

The real ethical dilemma is faced - as is so often the case in the NHS - when one has to balance the benefits to an individual patient against the cost to the community as a whole. This argument is deepened further by an article by Farr and Bellingan (2004) (13). The authors point out that not only is there an ethical debate over Staff-to-patient spread and patient-to-patient spread of infection, but there is also the case of the patients infecting staff as was the case in the recent SARS epidemic. The article takes the form of a very well structured debate between two experienced clinicians over the need for barrier methods when caring for infected patients and poses a number of difficult ethical problems.

The actual ethical dilemma rests ultimately on the question of what is the evidence to support the argument that barrier procedures are effective in preventing patient morbidity and mortality. The answer lies in the current and commendable trend towards evidence-based medicine. A good definition comes from Sackett in the form of The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. Later he added a supplementary statement - Evidence-based healthcare "takes place when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information". The arguments presented in this piece are based (unless otherwise stated) on peer-reviewed research and therefore represent the best of our knowledge at the present time.

Evaluation of Health Promotion Strategies.

In order to evaluate the actual health promotion strategies involved, we must expand upon the statement in the last section. There is a world of difference between the evidence produced by a properly constructed and delivered, randomly controlled, double-blind trial, and the evidence that a Government department has made a pronouncement. We may all hope that such pronouncements are based on the strongest of evidence, but we would tentatively suggest that this has not always proved to be the case. The difficulty that we may all potentially have with government policy documents is that the statements made within them are seldom attributed to a reputable or peer-reviewed source. We are therefore powerless to make an informed judgement as to the validity of the particular statement in question. In this piece therefore we shall review the evidence for the success or failure of the health promotion targets on the basis of peer-reviewed research only.

Chaix et al. (1999) (16) reviewed the cost-benefit of controlling MRSA. This was done in the USA where the actual financial implications of any measure are probably more carefully scrutinised and transparently costed than under the NHS. It is worth examining the actual figures quoted in some detail. They found that the costs attributable to MRSA infection was, on average, $5885 per patient. The MRSA control programme was costed at an average of about $900 per patient. The resulting reduction in the complications from the isolation exercise proved to be considerably cost effective.

A trial which looked at the clinical benefits rather than the cost has been reported by Guiguet et al. (1990) (17). This looked at the effectiveness of simple barrier measures in reducing the incidence of cross-contamination of MRSA in an ICU. The actual study is complex but the overall result shows a dramatic improvement after the stringent application of simple barrier measures, the most effective being handwashing.

Another perspective is offered by Urli et al. (2002) (18). He quotes the surprising fact that the surveillance of nosocomial infections, which we perhaps take as a normal mode of practice in the UK and USA, is unusual in Italy. His paper offers an evaluation of a one year prospective study in an Italian ICU which was done in a way that would be almost impossible in the UK today, because of the control of infection measures that we would regard as standard would preclude such a study being done. Interestingly he is able to conclude that ICU infections are not associated with an increased risk of death. In comment, one could observe that this study was run under different parameters than those that one might expect in the UK. The conclusion should not be taken at face value as careful reading shows that the diagnostic criteria for diagnosis of index infection for patients coming into the ICU are not as rigorous as they might have been. It is doubtful whether such conclusions would have been accepted in (for example) the BMJ.

So far, we have examined the evidence to support the argument that barrier methods of infection control are effective in the ICU environment. There is also another issue when deciding how effective are the Government's health promotion policies and that is how frequently do the healthcare staff actually comply with the 'Best-practice' guidelines?. This seems to be an area where a great deal of research effort has been invested. Pittett et al (2000) (19) produced a definitive article on the issue, looking at the effectiveness of a concerted health promotion initiative across one London hospital. On a wider UK base, Teare et al. (1999) (20) looked at the effect of the Government's initiative across the country. Both groups of researchers came up with the same conclusion that there was an initial increase in compliance rates amongst healthcare professionals but, without constant reinforcement, the compliance rate dropped. This was associated with an increase in patient cross-contamination rates.

The issue of maintaining compliance rates was examined by Kretzer and Larson (1998) (21) and expanded on by Tibballs (1996) (22). Each article underlines the difficulties of imposing a simple measure on a human level. This clearly underlines the importance of implementation strategies in the management of change in a large organisation such as the NHS. An earlier article by Dubbert (1990) (23) Looked at the usefulness of group feedback as a tool to aid compliance. This type of peer pressure has been unashamedly used in other circumstances to good effect. Dubbert documents the effect of this exercise.

Other investigators have investigated the actual methods by which the potential for cross contamination is controlled. Donowitz (1987) (24) looked at the way in which healthcare professionals actually washed their hands - rather than 'if' they washed their hands. And found that there was a significant difference in the degree of bacterial reduction achieved depending on the technique employed.

Graham (1990) (25) and Simmons (1990) (26) looked at the same problem in it's entirety and then analysed the impact on the patient outcome.

Back to: Nursing Essays

Taken Overall

There is therefore considerable amounts of evidence that some of the Government's various health promotion targets are being met. Whether the rather ambitions goal of a 50% reduction in the incidence of MRSA cross-contamination by healthcare professionals by 2008 (27) is achieved, clearly remains to be seen.

References.

Boyce JM Pittet D. (2002) Guidelines for hand hygiene in Healthcare settings

Oct 25 2002 / 51 (RR 16); 1-44

Semmelweis IP. (1861) Die aetiologie, der begriff und die prophylaxis des kindbettfiebers. Pest, Wien und Leipzig: CA Hartleben's Verlags-Expedition 1861.

Birte Twisselmann (2003) The Discovery of the Germ BMJ, Jul 2003; 327: 57.

New guidelines to cleaner hospitals: NHS Directive; HMSO, Tuesday 7 December 2004

Dr John Reid Sec. Of State for Health; Hansard: Dec 10^th 2004

Public Accounts Committee. The management and control of hospital acquired infection in acute NHS Trusts in England (HC 306), House of Commons 2000. ISBN 0102695008

Garrouste-Orgeas M, Timsit JF, Kallel H, Ben Ali A, Dumay MF, Paoli B, Misset B, Carlet J. (2001) Colonization with methicillin-resistant Staphylococcus aureus in ICU patients: morbidity, mortality, and glycopeptide use. Infect Control Hosp Epidemiol. 2001 Nov;22(11):687-92.

Ibelings MM, Bruining HA. (1998) Methicillin-resistant Staphylococcus aureus: acquisition and risk of death in patients in the intensive care unit. Eur J Surg. 1998 Jun;164(6):411-8.

Guiguet M, Rekacewicz C, Leclercq B, Brun Y, Escudier B, Andremont A. (1990) Effectiveness of simple measures to control an outbreak of nosocomial methicillin-resistant Staphylococcus aureus infections in an intensive care unit. Infect Control Hosp Epidemiol. 1990 Jan;11(1):23-6.

Department of Health Study: National Patient Safety Agency (NPSA) 2004

Andrew Weeks, Rachel Sen, Maeve Keaney, Ann Trail, Carol Howard, Paul Chadwick, S Kesavan, C Richard B Welbourn, Steve M Jones, Paul M Hateley, P A Jurnaa, Robert MacDermott, D Varghese, H Patel, and A Majid Katme (1999) Hand washing BMJ, Aug 1999; 319: 518.

Vincent JL, Brun-Buisson C, Niederman M, Haenni C, Harbarth S, Sprumont D, Valencia M, Torres A (2005) Ethics roundtable debate: A patient dies from an ICU-acquired ijnfection related to MRSA - how do you defend your case and your team? Critical Care 2005, 9:5-9 (15 December 2004)

Farr BM, Bellingan G. (2004)

Pro/con clinical debate: isolation precautions for all intensive care unit patients with methicillin-resistant Staphylococcus aureus colonization are essential. Crit Care. 2004 Jun;8(3):153-6. Epub 2004 Feb 19.

Sackett, (1996). Doing the Right Thing Right: Is Evidence-Based Medicine the Answer? Ann Intern Med, Jul 1996; 127: 91 - 94.

Source: University of Hertfordshire, 2001. No attributed author

Chaix C, Durand-Zaleski I, Alberti C, Brun-Buisson C. (1999) Control of endemic methicillin-resistant Staphylococcus aureus: a cost-benefit analysis in an intensive care unit. JAMA. 1999 Nov 10;282(18):1745-51.

Guiguet M, Rekacewicz C, Leclercq B, Brun Y, Escudier B, Andremont A. (1990) Effectiveness of simple measures to control an outbreak of nosocomial methicillin-resistant Staphylococcus aureus infections in an intensive care unit. Infect Control Hosp Epidemiol. 1990 Jan;11(1):23-6.

Urli T, Perone G, Acquarolo A, Zappa S, Antonini B, Ciani A.(2002) Surveillance of infections acquired in intensive care: usefulness in clinical practice. J Hosp Infect. 2002 Oct;52(2):130-5.

Pittet D, Huggonet S, Harbath S, Mouroga P Sauvan V, Touveneau et al. (2000) Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000; 356: 1307-12.

Teare EL, Cookson B, French GL, et al. (1999) UK handwashing initiative. J Hosp Infect 1999; 43:1--3.

Kretzer EK, Larson EL. (1998) Behavioural interventions to improve infection control practices. Am J Infect Control 1998; 26:245--53.

Tibballs J. (1996) Teaching hospital medical staff to handwash. Med J Aust 1996; 164:395--8.

Dubbert PM, Dolce J, Richter W, Miller M, Chapman SW. (1990) Increasing ICU staff handwashing: effects of education and group feedback. Infect Control Hosp Epidemiol 1990; 11:191--3.

Donowitz LG. (1987) Handwashing technique in a paediatric intensive care unit. Am J Dis Child 1987; 141:683--5. Graham M. (1990) Frequency and duration of handwashing in an intensive care unit. Am J Infect Control 1990; 18:77--80.

Simmons B, Bryant J, Neiman K, Spencer L, Arheart K. (1990) The role of handwashing in prevention of endemic intensive care unit infections. Infect Control Hosp Epidemiol 1990; 11:589--94.

Please note: The above essyas were written by students and then submitted to us to display and help others. Thanks to all the students who have submitted their work to us.