Evidence-Based Practice for Nurses

Apply What You Have Learned

It has been 6 months since the hand hygiene policy was implemented throughout your facility.
Now it is time to evaluate whether the desired outcomes have been met. You invite the chair of
the Quality Assurance Committee to attend the next meeting of the EBP committee. You
ask the chair to report on the monthly hand hygiene compliance rates for the past 6 months
and rates prior to when the policy was implemented. This will allow EBP committee members
to compare compliance rates before and after implementation of the policy. Review the chair’s
report within this text’s digital resources. What conclusions can you draw about the effectiveness
of the policy?

Quality Assurance Committee Hand Hygiene (HH) Compliance Report

Baseline

Percentage

of HH

Compliance

Rate

Percentage of Hand Hygiene Compliance

Rates After Policy Change

Units Total Jan Feb Mar April May June Total

Critical Care 50.75 84.25 86.5 84.75 83.75 84.75 84.5 84.75

  CCU 50 88 86 80 78 85 83 83.33

  ICU 44 80 85 83 80 79 80 81.17

  ER 39 78 80 81 81 80 83 80.5

1. Which of the following behaviors is unethical? (Select all that apply.)
   a. Ensuring patients enrolled in a protocol meet criteria
   b. Filling in all missing data at the conclusion of your shift
   c. Refusing to participate in outcome measurement
   d. Continuing to follow protocols after data collection ends

TEST YOUR KNOWLEDGE 18-4

How did you do? 1. b, c

(continued)

18.4 Keeping It Ethical 483