Indicator of Patient Quality and Safety in Nursing

This article discusses the significance of Hospital Acquired Infections (HAIs) as an indicator of patient quality and safety in nursing. It explores the causes, prevention, and monitoring of HAIs, with a specific focus on pneumonia as a key indicator. The role of education and training in reducing HAIs and improving patient outcomes is also examined.

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Individual indicator of patient quality or patient safety
According to the National Safety and Quality Health Service Standards (NSQHS)
proposed by the Australian Commission of Safety and Quality in Health Care (ACSQHC)
(2012), prevention of the Hospital Acquired Infections (HAIs) falls under the standard 3 for
the maintenance of quality and safety in the healthcare service. Thus HAIs is an important
indicator of the patients’ quality and safety in the healthcare system. Rajaram et al. (2015) are
of the opinion that HAIs are common under the healthcare settings and it mainly spreads
through the touch contact that is from the infected or non-sterilised hands of the nursing
professionals who spend majority of the time with the patients. The chances of getting HAIs
are higher among the ICU units. The reason behind this is patients in the ICUs are immune-
compromised, making them vulnerable in getting affected with the HAIs or noscomial
infection. Moreover, the patients’ in the ICU are mainly treated through intravenous
injections or are surgical patients. The surgical cites or site of intravenous injection channel
are regarded as the point of entry of the bacteria into the body of the patients.. The HAIs or
the nosocomial infection is mainly caused by multidrug resistant bacteria that increase the
overall morbidity and mortality of the patients while increasing the cost of care, increased
length of stay at the hospital and decrease in the overall quality of care (Khan, Baig &
Mehboob, 2017). One of the common indicators of the HAIs that help to ascertain the degree
of the patients’ safety in the ICU is pneumonia. The early signs of pneumonia include high
fever, sudden cold and cough, purulent sputum in the cough and abnormal chest auscultatory
findings. The abnormal chest findings are defined by decreased breath sounds along with
crackles or wheezes or labored breathing (Herkel et al., 2016). In order to use pneumonia as
an important indicator of the HAIs in order to measure the overall outcome in the patents’
care, the ICU patients are monitored regularly. The preliminary monitoring is done with the

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help of the pulse oxymetry in order to keep a track of the level of oxygen saturation in the
blood (SpO2), the respiratory rate and pulse rate. Kalil et al. (2016) stated that older adults or
the patients who are admitted under the ICU settings mainly exacerbate signs of decreased
oxygen saturation in the body (less than 90%) as an important indicator for monitoring of the
any possible signs of pneumonia. Monitoring of the chest auscultations, movement of the
diaphragm and measurement of the blood parameters and body temperature is used to detect
any possible signs of infection with the body. If the body temperature is found elevated with
high levels of white blood cells then immediately sputum test is conducted followed by the
measurement of the C-reactive protein (CRP) in the blood in order to confirm the presence of
pneumonia (HAIs) is any. The CRP and WBC count or high fever also act indicator for other
HAIs like blood stream infection (Gadsby et al., 2016).
Literature Review
According to the reports published by the World Health Organization (WHO) (2019),
approximately 15% of the hospitalized patients suffer from hospital-acquired pneumonia
commonly known a ventilator-associated pneumonia. Other important hospital acquired
infections highlighted by WHO (2019) include blood stream infections, surgical site infection
and catheter associated urinary tract infections and central line infection. The main
nosocomial pathogens that are responsible for the spread of the HAIs like ventilator-
associated pneumonia are multi drug resistant bacteria. The review conducted by Rosenthal
(2016) stated that during their stay in the ICU of the hospital, the patients are exposed to
numerous pathogens through different sources environment, along with healthcare
professionals and other infected patients. Tansmissions of these infections or the spread of the
bacteria causing pneumonia must be prevented for the effective prevention of the HAIs
(ventilator-associated pneumonia) and thereby helping to increase the overall safety of the

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patients. Hsopital waste serves as a potential source of pathogens leading to the 20 to 25%
occurrence of the HAIs like ventilator-associated pneumonia. Thus, for the effective control
of nosocomial infection, the nursing professionals and the other healthcare associated staffs
must practice proper infection control programs. This must be associated with keeping a tract
of the usage of the antimicrobial and its simultaneous resistance in adopting the antibiotic
control policy (Murni et al., 2015). Efficient surveillance system also plays an important role
in controlling HAIS. Not only the nursing professionals but also the efforts must be taken by
all the stakeholders in order to prevent and control the nosocomial infection and thereby
increasing the level of patients’ safety (Khan, Baig & Mehboob, 2017).
A 24-month long observation longitudinal survey conducted by the Parisi et al. (2016)
highlighted that one of the important indicator of the ventilator-associated pneumonia (VAP)
is lack of proper training and education among the nursing professionals. There was found
lack of awareness in the domain or proper usage of the hand hygiene and the use of the
personal protective equipments and sterile nasal masks for the patients in the ICU. This lack
of awareness leads to poor professional standards of practice. Moreover, nurses due to lack of
proper education about the pneumonia pathogeneses fail to identify the initial signs of the
spread of infection like fever and cold/cough. This increases the tendency of getting affected
with VAP and at the same time increases the severity of the disease. Observation study
highlighted that proper education of the nursing professionals who are assigned to install the
oxygen through nasal canula can help to reduce the chances of the VAP (Parisi et al., 2016).
Braun (2019) stated that a registered nurses who have underwent a training of one month
about the HAIs and use of the personal protective equipments are more likely to increase the
level of patients’ safety by reducing the chances of HAIs or VAP. Arefian et al. (2016)
argued in favor of the trained nursing professionals as an important parameters for increase in
the overall quality in patients’ care in VAP. Arefian et al. (2016) further indicated that from

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the point of view of the cot-benefit analysis, a trained nursing professionals or the other
healthcare staffs is found to bring more revenue of the hospital as it will help to increase the
level of patients’ satisfaction and thus drawing in more patients in the long run.
Tokmaji et al. (2015) revealed that older adults who are admitted to the ICU are
vulnerable towards getting affected with the VAP during the first 10days of their stay in the
ICU as it is during this stage, they are given mechanical ventilation. Endotracheal tubes
(ETTs) appear to be an independent risk factor for VP. Silver-coated ETT releases the silver
cations slowly. These slow release of the silver-coated ETT appear to generate strong
antimicrobial effect. Due to this antimicrobial effect of the silver ion, the silver-coated ETTS
is regarded as one of the important intervention for preventing VAP in people whose
physiological parameter demands more than 24 hours of constant ventilation. Batra et al.
(2018) stated that use of silver coated ETT decreases the overall bacterial load entering into
the body and thus helping to keep the CRP within the control along with the prevention of
chonic hypersensitivity reaction and thus helping to reduce the chances of VAP and
increasing the level of patients’ safety and quality in health care.
Landelle, Lucet and Pittet (2017) highlighted in their studies that installation of the
nasal canulla through the contaminated hands of the nurses increases the chances of touch
contamination. Hospital nurses are mainly exposed to the multidrug resistance bacteria
(MDR) and thus such touch contamination increases the risk of developing MDR VAP.
Proper use of the hand hygiene protocol is used to decrease the chances of the surface
contamination or touch contamination and thus helping to reduce the chances of occurring of
VAP through HAIs. Pássaro, Harbarth and Landelle (2016) proposed that practice of he
WHO five moments of the hand hygiene protocol can be helpful in reducing the chances of
the HAIs through VAP among the patients in the ICU.

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The review conducted by Batra et al. (2018) over the randomized control trial
highlighted that the use of the non-invasive positive pressure ventilation (NPPV) helps in the
significant reduction in the risks of acquiring the VAP among the critically ill patients in the
ICU who are immune-compromised. The reduction rate is significant in comparison to the
invasive mechanical ventilation (MV). Furthermore, NPPV also helps to improve the gas
exchange thus helping to maintain a standard SpO2 within the body and thereby helping
reducing the threat of developing VAP. It is also associated with fewer complications
(Branson & Hess, 2015). The systematic review of the randomized control trial done by Batra
et al. (2018) also showed that daily weaning trials is a validated strategies that reduce the
requirement of the prolong or constant use of the MV and thus helping to decrease the
chances of occurrence of VAP. The reduced or signs of VAP is indicated by the normal
respiratory rate and proper oxygen saturation within the body as shown in the pulse
oxymetery. In order to maintain a standardized oxygen saturation further and to decrease the
need to the MV, patients must be kept in semirecumbent position or Fowler’s position. Under
this position an angle to 30 to 45 degree is made between the head and the waist line to
prevent aspiration of the gastric contents leading to clogging of the pulmonary arteries and
increasing the chance of VAP (Batra et al., 2018).

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PDSA cycle
Figure: Plan-Do-Check-Act (PDCA) cycle
Source: Created by author
PDSA cycle:
Indicator of the HAIs that endangers the patients’ quality and safety include VAP.
PDSA cycle 1:
Plan: The problem include lack of proper hand hygiene of the healthcare professionals
and lack of proper usage of the personal protective equipments like face masks, disposable
hand gloves and aprons. Lack of observance of the proper hand hygiene and other personal
protective equipments (PPE) increase the risk of the cross contamination to the immune-
compromised patients and this increasing the chance of the HAIs like VAP (Finco et al.,
2018).

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Do: Tested potential solution includes use of the WHO five moments of the hand
hygiene among the healthcare professionals along with the use of the PPE. In order to
increase the adherence the healthcare professionals must be educated about the importance of
hand hygiene and PPE along with an increase in the bed side hospital resources like hand
sanitizers, hand gloves and face masks (WHO, 2018).
Figure: WHOs’ Five Moments of Hand Hygiene
(Source: WHO, 2018)
Check: Several systematic reviews of the randomised control trials have highlighted
that use of the PPE and WHOs five moments of hand hygiene helps to reduce HAIs like
reducing VAP and improving patients’ safety (Finco et al., 2018)
Act: The interventions will be implemented across the ICU settings and must be use
every time the healthcare professional is going to care of the patients and after the completion
of the care process.

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PDSA cycle 2
Plan: Ensuring proper oxygenation with the body and decreasing the requirement of
the MV in order to reduce the chances of VAP through MV
Do: Testing will be done by maintaining the patients in the semirecumbent position or
Fowler’s position and using during few intervals of the non-invasive positive pressure
ventilation (NPPV) (Batra et al., 2018)
Study: Study the chances of occurrence of the VAP within the first 10 days of the ICU
admission when the requirement for the MV is high (Batra et al., 2018)
Act: Making it mandatory for the older adults or patients who are admitted to the ICU
with pulmonary or cardiovascular complications and with low SpO2 as maintained in
semirecumbent position and use of non-invasive positive pressure ventilation in certain
interventions. However, HH must be followed while position the patient in semirecumbent
position or removing the MV (Batra et al., 2018)
PDSA Cycle 3
Plan: Use of Silver-coated ETT for giving MV in order to reduce the chance of sepsis
occurring as a result of the transmission of the nosocomial MDR bacteria. This will in turn
help to prevent bacterial colonization in the pulmonary cavity and preventing the decreasing
of the oxygen saturation sputum accumulation of development of VAI (Weiser, Ferreira,
Paton, 2018).
Do: Implement this intervention in one of the ICU unit of the hospitals that cares for
elderly patients as they are more vulnerable in getting affected with VAP. Required funding
must be availed form the hospital or the NGOs in order erect the setup for one month. Study:

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Study: The data (cases of the VAP) will be compared with the baseline after one
month of trial
Act: If positive change found then it will be implemented in the ICU settings with
proper funding extracted through the grant proposal for the installation of the Silver-coated
ETT
The evaluation of the quality improvement program
The evaluation of the quality improvement program will be done based on the
perception of the nursing professionals about the HAIs with the special mention to the VAPs.
Zingg et al. (2015) stated in their study that nurses are the main source behind the increased
incidence of the hospital-acquired infection under the healthcare settings. The reason behind
this is, nurses are spent majority of the duty hours with the patients and they hold the prime
duty to procure care for the patients. The main tasks done by the nursing professionals for
patients’ care, is checking the body temperature by thermometer, adjusting the nasal canula,
helping patients to take meal and giving patients medication either intravenously or orally
(Teshager, Engeda & Worku, 2015). All these activities require direct contact with the
patients and thus have chance of developing HAIs like VAP. Khan, Baig and Mehboob
(2017) stated that the education of the nursing professionals in the HAIs and like proper use
of the HH and PPE along with information regarding placing the patient in the fowler’s
position or semirecumbent position and periodic use of the non-invasive positive pressure
ventilation (NPPV) will help to decrease the chances of occurrence of VAP. The training of
the nursing professionals must be given under the health care settings by the use of the
power-point presentations. Iedema et al. (2015) stated that power-point presentation based
training increase provision for the interactive sessions and thus improving the depth of
knowledge and increase in the level of interest of the learners. Hands on training will be

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given in the presence of doctors regarding how to the patients must be kept in semirecumbent
position and procedure for conducting non-invasive positive pressure ventilation (NPPV).
The presence doctors will help to increase the overall efficiency of the training process (Kaye
et al., 2015; Asadollahi et al., 2015).
The evaluation of the training program will be done by taking test with the multiple
choice questions among the nurses in order to test their dept in knowledge about maintenance
of standard 3 of National Safety and Quality Health Service Standards (NSQHS) proposed by
the Australian Commission of Safety and Quality in Health Care (ACSQHC) (2012). The
trained nurses who will pass in the test will be appointed in the ICU sections and baseline
data of HAIs will be compared with the data that will be extracted after one month of trained
nurses serving the ICU.

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