Overall the organization is ready able and willing to

patient care and nurse satisfaction. Overall, the organization is ready, able and willing to improve
practice standards through EBP.
Section B: Problem Description
PICOT
Will the staff and Baylor Emergency Medical Center in Burleson, Texas improve hand
hygiene compliance using multi-modal interventions for proper hand hygiene compared to current
practices and thereby reduce the risk of HAIs in patients over a twelve-week period.
Purpose and Objectives
The purpose of this EBP is to introduce a multimodal hand hygiene intervention (MHHI)
into BEMC to improve compliance and reduce the risk of HAIs to patients. Literature supports a
multimodal approach hand hygiene compliance improvement among healthcare professionals.
Staff members at BEMC have expressed their willingness to participate in this initiative.
Objectives are aimed at improving and maintaining hand hygiene practices in order to
improve compliance and reduce the risk of HAIs. The MHHI includes five components retrieved
from the WHO-5 (2018): visual cues, education, feedback, leadership and accountability, and
adequate hand hygiene products. The objectives included:

9
Running Head: EVIDENCE-BASED PRACTICE PROPOSAL
 Identifying current knowledge and perception of hand hygiene and HAI transmission at
BEMC;
 Identifying barriers and facilitators to hand hygiene practices at BEMC;
 Modifying the hand hygiene data collection process to provide a better representation of
practices at BEMC;
 Implementing a practice change aimed at improving hand hygiene compliance at BEMC.
According to the Association for Professionals in Infection Control and Epidemiology (2015),
a multimodal approach is the best strategy to implement and sustain a hand hygiene improvement
initiative. Hand hygiene compliance will be gathered and measured through direct observation for
two moments of hand hygiene:
1. Washing-in before entering a patient room; and
2. Washing-out before exiting a patient room, as well as the use of alcohol-based hand rub
(ABHR) use.
Initially, the goal was set to 100% improvement in hand hygiene compliance, however, this was
not a realistic goal. A more realistic goal of 80% was later set and used for this project. A second
goal was also set to improve BEMC’s process for collecting data by direct observation in order to
provide a better picture of hand hygiene practices.
Identify Stakeholders/Change Agents
Key stakeholders at BEMC include patients, family members of patients, physicians,
advanced practice providers (nurse practitioners and physicians assistants), nurses, ancillary staff
(medics, lab techs, radiology techs, nurse aides, respiratory therapists, pharmacists, registration
personnel, and environmental services) and administrative staff. Patients are the most important of
the stakeholders as HAIs impact their health outcome. Administrative personnel of BEMC are also
important stakeholders, as their support is essential for change to be successful.

10
Running Head: EVIDENCE-BASED PRACTICE PROPOSAL
Supportive Rationale
For decades, hand hygiene has been the single most important way of reducing HAIs. HAIs