Exploring Clinical Governance and Healthcare Associated Infections

This literature review explores the effectiveness of clinical governance in preventing healthcare-associated infections (HAIs). It critiques three papers using the CASP tool, focusing on infection prevention protocols, the use of chlorhexidine, and the role of personal protective equipment (PPE). The review assesses the impact of interventions like daily chlorhexidine bathing, infection control programs for Vancomycin-resistant enterococci (VRE), and the proper use of PPE. Findings suggest limited evidence supporting the effectiveness of chlorhexidine baths and VRE prevention programs. It highlights the importance of comprehensive training for healthcare professionals in PPE usage to reduce HAIs. The review concludes that improving infection control practices and perceptions among healthcare personnel is crucial for patient safety and antimicrobial stewardship. Desklib offers a range of similar solved assignments and study materials for students.

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Running head: CLINICAL GOVERNANCE
CLINICAL GOVERNANCE
Name of student:
Name of university:
Author note:

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CLINICAL GOVERNANCE
Health care associated infections
Introduction
Clinical governance can be defined as a framework by the help of which heath care
organisations are responsible for improving the quality of the their services and upholding the
highest standards of care. HAIs are one of the key performace indicators of the clinical
governance process. A good clinical governance in a hospital setting would not permit the
occurace of any kinds of infections within the hospital premises.
Health care associated infections are the type of infections that a person gets while in
hospitals, long term facilities, ambulatory care and home care settings. The unanticipated
infection that occurs in patients might result in significant illness in the patients, even causing
death, prolonged hospital stays, additional therapeutic interventions and treatments that
contribute to the cost burden (Lobdell, Stamou & Sanchez, 2012). The major type of
nosocomial infections that can occur in hospitals are catheter-associated urinary tract
infections, central line associated blood stream infection, surgical site infection and some
ventilator associated events. According to Mehta et al., (2014), extensive hand hygiene
techniques, using of the personal protective equipment and use of the antimicrobial agents
and sanitizers have been found to be useful in preventing HAIs to some extent.
Research question: Does infection prevention program and adherence to proper infection
prevention protocol among the health care professonals prevents health care associated
infections in the hospital settings?

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Critiquing of the literature
There are several papers describing the importance of the infection prevention
protocols for the health care proffesionals to prevent HAIs. Three papaers have been chosen
and CASP tool had been chosen for the critical analysis. A paper by Noto et al., (2015), has
evaluated procedures like daily bathing with the antimicrobial agent chlorohexidine in the
patients to prevent health care associated infections. The clinical question of the study was
clearly focused interms of clinical question and the target population. A pragmatic clustered
randomised control trial hasbeen conducted over 9340 patients admitted in 5 adult intensive
care units of a tertiary medical care centre in Nashville, Tennessee, from July 2012 through
July 2013. The research design of this study is appropriate and the sample size is also large ,
as RCTs are the most rigorous way to determine the cause and effect relationship between the
treatment and the outcome and large sample size reduces the rate of response bias and
increases the credibility of the paper. It generally reduces the bias while the testing of the
interventions. The number of participants were enough for finding significant results. The
interventions involved bathing of all the patients with diposabe cloths impregnated with 2%
of cholorohexidine as the control. The interventions was contined for a 10 weeks period
followed by a 2 weeks washout period when the patients were bathed with nonantimicrobial
disposable cloth. All the test were 2-tailed with a significant threshold of about P<0.05,
effective for these kinds of studies. However, as per the findings there was no significant
reduction in the primary outcomes after the intermentions.
A systematic review and a metaanalysis has been covered by De Angelis et al.,
(2014), where 549 studies and 9 studies with 30949 participants have been included in the
study. The main aim was to measure whether the nfection control and the prevention program

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is effective to reduce the spread of the hospital acquired Vancomycin-resistant enterococci
(VRE) infection. Hence , the review addressed a clearly focussed question. A proper
systematic review requires a correct searching of the databases using correct search startegies
for searching relevant papers. MEDLINE, EMBASE and CINAHL databases were used for
finding the studies. The level of evidence of the studies were low as only 1 randomised
clinical tria had been used for the study. RCTs are generally placed at the highest level of
evidences as it has got less probability of bias and systematic errors. The risk of bias has
been assessed with the help of Cochrane Effective Practice and Organisation of Care (EPOC)
group. Assessment of the heterogeneity of the studies had been rightfully done.All the
papaers that has been included were not relevant. There was a lack of rigor of the studies that
might have affected the results. The primary outcomes that has been considered are the VRE
acquisition rate, the efficacy of the contact precautions in the prevention for preventing the
VRE acquisition, the effectiveness of antibiotic formulary in preventing the VRE acquisition ,
efficiency in screening cultures in preventing the acquisition of the VRE. As the number of
studies chosen were less in number the metaanalysis could not been applied for the
surveillance screening.
Personal protective equipments play an important role in controlling the health care
associated infections. They are specialised clothing or equipment that protect the health
professionals from harmful pathogens on exposure to body fluids, blood and other potential
infectious materials (Aguwa et al., 2016). Although each and the every clinical settings are
accountable to follow specific guidelines for the use of the personal protective equipment, but
it is questionable as of whether the health care workers or the nurses are properly trained for
using the personal protective equipment. John et al., (2016), had conducted a survey in the

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Cleveland Veterans Medical centre with the physicians, nurses and the allied health
professionals in order to understand their perception regarding the PPE training that was
given to the new employees. Education about PPE donning and doffing was provided to the
health care professionals. According to the recent studies, most health professionals use
incorrect techniques of donning PPE, increasing the risks of contamination. The paper has
suggested that sub optimal education for the correct donning of the PPE. As per the survey it
was found that among the physicians, nurses and the health care workers, the nurses are
likely to done gloves. Most of the nurses and the health care workers have admitted that there
is a lack of proper training programs regarding the use of the PPE and the even if it is done,
they are not done at the basic levels such as ways of wearing the basic protective equipment .
There had been some recent cases of the Ebola virus acquisition that proves that despite of
the use of the PPE, there is a need of improving the knowledge for developing more effective
training strategies for the correct use of PPE (Fischer et al., 2013).
Findings
The results by Noto et al., (2015), are precise enough for making the decision as a non
significant reduction in the hospital mortality was found (P=0.07)and hence made it easy to
conclude the result. all the important outcomes has been considered, such as occurance of
central line associated bloodstream infection , CAUTI, ventilator-associated pneumonia , or C
difficile infection. The findings of the trial by Noto et al., (2015) demonstrated that daily
bathing by chlorohexidine necessarily does not reduce the incidence of the health care
associated infections like C. diffile, CLABSI or CAUTI. As per the findings of De Angelis et
al., (2014), there were less evidences of ICP measures for reducing the VRE spread of
infections. The paper by John et al., (2016), displays some limitations. The survey consisted

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of personnel from a single centre. Taking a larger sample size might have given a
comprehensive picture regarding the experiences and the opinions. The findings of this paper
can be supported by a paper by Aguwa et al., (2016), that have admitted that despite of the
importance of the PPE in the disease prevention, no deliberate efforts are made by the health
care authority to educate their workers on their use. Another factor that has been pointed out
is the unavailability of the appropriate personal protective equipments (Pincock et al., 2012).
However from the two papers it can be stated that there are quite less evidences
regarding the effectiveness of prevention programs and practices such as chlorohexidine
bath . From the paper by John et al., (2016), It can be proved that there is a lck of proper
trainng procedures for the nurses to prevent HAIs.
Conclusion
Health care associated infections are common in most of the developing countries
with patients and the health care workers often dying from the infections. All the three papers
have described the probable ways of preventing HAIs, the perception of the health personnel
about the use and also suggests that there is a lack of comprehensive training procedures and
it can be found that there is a need for the improvement in the practice and the perception of
the infection control measures among the health care personnel, both for their own safety and
the safety of the patient. The health care professionals will be able to uphold the systems and
the strategies for the prevention of the infection and to limit the developments of the
antimicrobial resistance by the prudent utilisation of the antimicrobials.

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Reference
Aguwa, E. N., Arinze-Onyia, S. U., & Ndu, A. (2016). Use of Personal Protective Equipment
among Health Workers in a Tertiary Health Institution, South East Nigeria: Pre-Ebola
Period. International Journal of Health Sciences and Research (IJHSR), 6(8), 12-18.
De Angelis, G., Cataldo, M. A., De Waure, C., Venturiello, S., La Torre, G., Cauda, R., ... &
Tacconelli, E. (2014). Infection control and prevention measures to reduce the spread
of vancomycin-resistant enterococci in hospitalized patients: a systematic review and
meta-analysis. Journal of Antimicrobial Chemotherapy, 69(5), 1185-1192.
Fischer, W. A., Hynes, N. A., & Perl, T. M. (2014). Protecting health care workers from
Ebola: personal protective equipment is critical but is not enough. Annals of internal
medicine, 161(10), 753-754.
John, A., Tomas, M. E., Cadnum, J. L., Mana, T. S., Jencson, A., Shaikh, A., ... & Donskey,
C. J. (2016). Are health care personnel trained in correct use of personal protective
equipment?. American journal of infection control, 44(7), 840-842.
Lobdell, K. W., Stamou, S., & Sanchez, J. A. (2012). Hospital-acquired infections. Surgical
Clinics, 92(1), 65-77.
Mehta, Y., Gupta, A., Todi, S., Myatra, S., Samaddar, D. P., Patil, V., Bhattacharya, P. K., …
Ramasubban, S. (2014). Guidelines for prevention of hospital acquired
infections. Indian journal of critical care medicine : peer-reviewed, official
publication of Indian Society of Critical Care Medicine, 18(3), 149-63.

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Noto, M. J., Domenico, H. J., Byrne, D. W., Talbot, T., Rice, T. W., Bernard, G. R., &
Wheeler, A. P. (2015). Chlorhexidine bathing and health care–associated infections: a
randomized clinical trial. Jama, 313(4), 369-378. doi:10.1001/jama.2014.18400
Pincock, T., Bernstein, P., Warthman, S., & Holst, E. (2012). Bundling hand hygiene
interventions and measurement to decrease health care–associated infections. American
journal of infection control, 40(4), S18-S27.
https://www.taylorfrancis.com/books/e/9781498793575/chapters/10.1201%2F9781315
375687-2

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Running head: CLINICAL GOVERNANCE
Author/s (year)
Country
Aims
or
Purpose
Sample/ setting
or
Key stake-holders
and their roles
Design/ methods
or
Type of paper
Main findings
or
Primary argument
Strengths and
limitations of the
paper
Article 1 (Noto et al., 2015)
U.S
. To determine whether
regular bathing by
chlorohexidine
reduces he rate of
HAIs.
9,340 patients
admitted to five adult
intensive care units of
a tertiary medical
center in Nashville,
Tennessee were
included for the study
A pragmatic cluster-
randomized control
study
In this trial, no such
evidences of reduction
in the HAI was found
on daily bathing with
cholorohexidine.
Strengths- The
multiple cros over
event permitted the
assessment of the
interventions.
Furthermore the
interventions focused
n several patient
centered outcomes and
evaluated the
effectiveness of
cholorohexidine.
Limitations- Inability
to blind the staff
administering the

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interventions.
Article 2 De Angelis et
al., (2014)
USA
To determine the most
effective infection control
and prevention program
for reducing the
transmission of the HAIs
prompt good HH
behaviour.
549 studies and 9
studies with 30949
participants have been
included.
MEDLINE, Cochrane
databases, CINAHL
until June 2012 was
searched.
Systematic review and
meta-analysis.
Handwashing has
been found to be an
important intervention,
cholrohexidine hand
rub or gel has been
found to be associated
with decrease in the
VRE incidence.
Contact precautions
has also been found to
be effective.
Limitations- Self
reported rate of the
compliance exceeded
the observed value.
Lack of a control
group limited the
conclusion.furthermor
e he study quality was
poor.
Article 3
John et al.,
(2016)
America
To determine the
methods used for the
PPE training and the
perception of the
health professionals
about their
The Cleveland
Veterans Affairs
Medical
Center .ersonnel from
5 medical wards and
one surgical ward
Qualitative study post
an infection prevention
training program
Findings states the
training programs
provided to the nurses
are not sufficient.
Personnel from only
one centre was taken
for the survey that
might not represent the
scenario of other care

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effectiveness. were considered for
the survey.
centres.
Secondly, focus group
interviews were not
carrie out.