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How Yellow Tape Can Improve Healthcare Facility Resources and Healthcare Worker
Efficiency for Contact and Contact-Enteric Precaution Patients
by
Tanya Staton
B.S., Clemson University, 2005
Applied Research Project Paper
Submitted in Partial Fulfillment
of the Requirements for the Degree of
Master in Public Health
Concordia University, Nebraska
April 2015
ii
Abstract
Contact and contact-enteric precautions are healthcare isolation protocols that reduce the
chance that germs will spread to hospital staff and patients. Patient care can decrease when
patients are placed on isolation precautions because hospital staff generally finds the required
personal protective equipment (PPE) a burden, so they do not observe or communicate with their
patient as often as a non-isolated patient. Creating safe zones for patients on contact and contact-
enteric precautions improves the utilization of the healthcare facility resources and healthcare
worker efficiency through improved communication and observation with patients, decreased
PPE cost and does not increase infection rates. A 2-month study was conducted at AnMed Health
Medical Center in South Carolina to determine if safe zones would indeed be beneficial in
improving patient care. An experimental unit did not have to wear PPE if they never crossed the
yellow tape trialed for the safe zones, and a control unit continued precaution protocols as before
implementation. During the trial, surveys where given to staff members in the experimental unit
to determine satisfaction scores since implementation. Both units were also evaluated to see if
there was a decrease or increase in infection rates since implementation. Costs were examined to
see how much money could be saved with safe zone use. The results revealed that PPE costs in
the experimental unit were reduced since extra PPE did not have to be purchased. Staff was in
favor of safe zones and 80% wanted the practice to continue on their unit. Finally, there was no
change in infection rates from the experimental unit compared with the control unit. Safe zones
are helpful in improving patient care, while also keeping infection rates and costs down. These
results suggest that safe zones should be considered for widespread use in a healthcare setting.
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Table of Contents
List of Figures.....................................................................................................................vi
Chapter 1: Introduction to the Applied Research Project....................................................1
Background of Applied Research Project......................................................................2
Thesis Statement............................................................................................................4
Purpose of the Study......................................................................................................4
Research Questions and Hypotheses.............................................................................5
Theoretical Base.............................................................................................................6
Definition of Terms........................................................................................................7
Assumptions...................................................................................................................9
Limitations.....................................................................................................................9
Delimitations................................................................................................................10
Significance of the Study.............................................................................................10
Summary of Chapter 1.................................................................................................11
Chapter 2: Literature Review.............................................................................................12
Introduction..................................................................................................................12
Body of Review...........................................................................................................13
Increased Observation and Communication between Patient and Staff…………13
Improving Healthcare Worker Resources………………………………………..15
Improves HCW Efficiency and Satisfaction……………………………………..17
Limitations noted………………………………………………………………...19
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Summary......................................................................................................................20
Chapter 3: Research Method Introduction.........................................................................22
Setting ………………………………………………………………………………..23
Participants...................................................................................................................24
Intervention..................................................................................................................24
Materials and Instrumentation.....................................................................................25
Procedure.....................................................................................................................25
Data Analysis...............................................................................................................25
Ethical Considerations.................................................................................................26
Chapter 4: Results..............................................................................................................28
Introduction..................................................................................................................28
Data Results.................................................................................................................28
Comparing PPE Costs:…………………………………………………………...29
HCW Surveys:…………………………………………………………………...30
Hospital Acquired Infection Rates:………………………………………………36
Summary......................................................................................................................37
Chapter 5: Discussion, Conclusions, and Recommendations............................................39
Introduction..................................................................................................................39
Interpretation of Findings............................................................................................40
Limitations...................................................................................................................41
Summary......................................................................................................................42
Recommendations for Action......................................................................................42
Recommendations for Further Study...........................................................................43
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Appendices.........................................................................................................................46
Appendix A..................................................................................................................46
Appendix B..................................................................................................................47
References..........................................................................................................................48
vi
List of Figures
Figure 1. AnMed Health’s Safe Zone.............................................................................. ...3
Figure 2. Trinity Regional’s Red Box.......................................................................…….14
Figure 3. December PPE Data……………………………………………………………29
Figure 4. Communication Change………………………………………………………..31
Figure 5. Observe Patient More…………………………………………………………..31
Figure 6. Hand Hygiene…………………………………………………………………..32
Figure 7. Time Savings…………………………………………………………………...33
Figure 8. PPE Comfort……………………………………………………………………33
Figure 9. Safe Zone Compliance…………………………………………………………..34
Figure 10. Safe Zone Continuation………………………………………………………..35
Figure 11. Number of Admissions………………………………………………………...36
Figure 12. Number of HAIs……………………………………………………………….37
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Chapter 1: Introduction to the Applied Research Project
Antimicrobial resistance or resistance to bacteria is evolving not only in acute-care
settings, like hospitals, but also within the community. Resistance to bacteria can lead to
community and healthcare associated infections (HAIs) that are difficult to treat. These
superbugs are emerging everywhere. One in three people are colonized with Staphylococcus
aureus in their nasal cavity, and Methicillin-Resistant Staphylococcus aureus (MRSA) is present
in about two out of 100 patients (CDC, 2013). MRSA can lead to bloodstream infections,
surgical site infections and pneumonia (CDC, 2013). Clostridium difficile (C. diff) is another
leading bacterium that causes HAIs, and roughly 14,000 people die annually from the diarrhea
associated with the bacteria (CDC, 2011). These organisms are becoming more widespread and
are resulting in longer hospital stays and additional healthcare costs to the patient.
AnMed Health Medical Center, a Magnet status hospital in Anderson, South Carolina, is
no exception when it comes to diagnosing and treating MRSA or C. diff patients. From January
2014 through September 2014, the healthcare facility reported 36 cases of MRSA and 43 cases
of C. diff that were hospital acquired (Midas, 2014). If a multi-drug resistant organism (MDRO)
or a positive C. diff is suspected or confirmed the patient is placed on isolation precautions to
help prevent further spreading of the infection to staff and other patients. Contact precautions are
ordered for MDRO patients and contact-enteric precautions are ordered for C. diff patients.
There are specific guidelines to which healthcare facilities must adhere to when a patient
meets protocol to be put on contact and contact-enteric precautions. According to the Center for
Disease Control and Prevention (2007), all clinical and non-clinical staff must wear gloves and
an isolation gown when entering a contact and contact-enteric precaution room to prevent the
spread of the infectious agent to other staff and patients in the healthcare facility. Contact-enteric
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precautions are slightly different because bleach wipes are recommended to wipe down
equipment and staff must use soap and water upon exiting a patient’s room to ensure C. diff
spores have been killed. The established precautions are in place to help decrease the spread of
infection rates to protect other patients and health providers. Unfortunately, patient care
decreases when patients are on contact precautions due to the barrier of having to don (put on) a
gown and gloves before even entering the patient’s room (Kirkland & Weinstein, 1999).
Healthcare workers (HCWs) are less likely to round (examine a patient) on contact and contact-
enteric precaution patients because of donning (putting on) and doffing (taking off) personal
protective equipment (PPE).
A prospective cohort study done at two university-affiliated medical centers concluded
that patient care has a tendency to decrease for patients who are on precaution protocols. In the
study, attending physicians only examined their contact precaution patients 35 percent of the
time compared to 73 percent of the time for those not on any contact precaution (Saint et al.,
2003). Another study that was done at Duke University revealed that HCWs were two times less
likely to enter a patient’s room that was on contact precautions (Kirkland & Weinstein, 1999).
The investigators believed that not only do patients suffer in treatment because they are visited
less frequently, but they might also suffer psychologically from being put in an isolated
condition (Kirkland & Weinstein, 1999).
Background of Applied Research Project
AnMed Health Medical Center wanted to set a professional goal to keep infection rates
low while also improving the patient and staff experience for contact and contact-enteric
precaution patients. They decided to develop “safe zones” based on the “Red Box Strategy” that
was implemented by Trinity Regional Health Center. Trinity Regional Health Center placed red
3
duct tape on the floor to create a red box inside of a contact precaution room (Franck et al.,
2011). HCWs could then communicate with the patient without having to don PPE. AnMed
Health is applying the same concept, but instead of using a “red box” the facility is expanding on
the idea. AnMed Health is placing a piece of yellow frog tape (painters tape) three feet from the
base of the patient’s bed in contact and contact-enteric precaution rooms. By placing the tape
three feet from the base of the bed the HCW will be able to have visual contact with the patient
and a bigger zone to work in. Figure 1 shows a contact precaution room where the safe zone is
being utilized.
Just like the Red Box Strategy that Trinity implemented, staff does not have to don PPE when
they are inside of the safe zone. HCWs are not physically coming in contact with the patients, so
Figure: 1
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there should not be an opportunity to spread MDROs or C. diff organisms. Hospital acquired
infection rates should not increase because of the new initiative.
There has not been ample research if the Red Box Strategy or safe zones are indeed
helpful in contact and contact-enteric precaution rooms. Because of the need for more research,
AnMed Health approved a quasi-experimental research study that would evaluate safe zone
utilization. A two-month trial was conducted at AnMed Health to measure the effectiveness of
safe zones and to determine if they were indeed helpful and would not interfere in patient care.
An experimental unit implemented safe zones (4 Center) and a control unit (7 South) was
established to see if patient observation and communication, costs and infection rates were
different between the units. The principal investigator followed infection rates for both the
control and experimental unit, developed surveys for staff members and looked at monthly PPE
costs for the two units being studied.
Thesis Statement
Creating safe zones for patients on contact and contact-enteric precautions improves the
utilization of the healthcare facility resources and healthcare worker efficiency through improved
communication and observation with patients, decreased PPE costs and does not lead to an
increase in hospital acquired infection rates.
Purpose of the Study
The purpose of the Safe Zone Research Project was to see if safe zones would save time
and money while also not increasing nosocomial infections at AnMed Health. The study also
explored the benefits of HCW satisfaction and compliance with utilizing the safe zones. There
has been very little research in the past on safe zones and if they actually increase or decrease
HAI rates. In 2009, Medicare quit covering the costs for any preventable health condition;
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Medicare will not pay for any infection that is acquired during a hospital stay (Medical News
Today, 2007). This has given AnMed Health and other healthcare facilities an even bigger push
to focus on keeping their patients safe from nosocomial infections. While AnMed Health realizes
it is important to protect these patients that are on contact and contact-enteric precautions, the
organization also realizes that it is imperative for the patient’s psychological state and treatment
that HCWs round on these patients as often if not more than if they were not on contact or
contact-enteric precautions.
The AnMed Health Safe Zone Research Project was developed to determine if safe zones
could increase communication between staff and patient, while keeping infection rates at bay.
The principal investigator chose to include only contact and contact-enteric precaution patients in
this research trial and did not study droplet or airborne precaution patients. The principal
investigator believed that patients who are placed on droplet or airborne precautions for
respiratory illnesses have no established safe zone; those precaution patients were not included
as participants during the research trial. In the future, the principal investigator hopes to establish
ways to increase patient care for these precaution patients as well, but for now the focus is only
on contact and contact-enteric precaution patients.
Research Questions and Hypotheses
The purpose of the Safe Zone Research Project was to determine if safe zones could
improve patient care for contact and contact-enteric precaution patients, while still keeping
infection rates down. Although annual savings on PPE was to be determined, the main goal of
the research project was to evaluate and prove that safe zones increased HCW and patient
observation and interaction. In addition, the research project sought to gauge the staff’s level of
acceptance of these zones, while also evaluating if there was an increase or decrease in infection
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rates. In order to secure that purpose the following research questions were explored. How does
quality of care differ between control and experimental groups when safe zones are employed?
Will PPE costs vary between the control and experimental unit? What is the relationship
between HCWs attitude toward safe zones? Does the HCW find the safe zones beneficial when
they are observing or communicating with their patients? Is there an increase in HAIs with safe
zone implementation? The principal investigator sought the answer to these research questions
by designing a quasi-experimental study based on the Diffusion of Innovations Theory, while
using mixed methods to evaluate the data.
Theoretical Base
The Safe Zone Research Project is based on the Diffusion of Innovations Theory. The
basis behind this theory is that people are more likely to adopt a new innovation if they observe
others experience a positive outcome (DiClemente, Salazar & Crosby, 2013). This theory shows
how new innovations, like safe zones for contact and contact-enteric rooms, diffuse and can be
used to promote helpful innovations (DiClemente et al., 2013). The Diffusion Theory has four
main elements: innovation, communication channels, time and social system (DiClemente et al.,
2013). The Safe Zone Research Project is using ordinary yellow tape to develop a new way of
caring for precaution patients, thus making it an innovative strategy. Safe zones are a relatively
new concept, and there are currently very few healthcare facilities utilizing this practice. Before
the safe zones were implemented in Four Center the principal investigator communicated
thoroughly about the zones and their use. Awareness knowledge informed the HCWs that the
new innovation existed. The third element of the Diffusion Theory is time (DiClemente et al.,
2013). AnMed Health’s staff adopted the new innovation quickly, because the safe zone was not
complicated, and the staff had more to gain than lose. Finally, the social structure at AnMed
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Health help diffused the idea. Physicians and nursing staff, not on the experimental unit, were
excited about the safe zones, and would ask the infection preventionists when it would be
coming to their unit.
The methodology for the research project on safe zones will be mixed methods. Mixed
methods involve combining both qualitative and quantitative research approaches to allow for a
clearer interpretation than just one single method alone (Bui, 2014). The principal investigator
applied qualitative practices because the project did not start out with a hypothesis, but instead
sought to find support that safe zones were actually helpful in a healthcare setting (Bui, 2014).
The principal investigator collected non-numerical data from staff surveys from Four Center (the
experimental unit) and from Seven South (the control unit). The results were then compared to
see if satisfaction and safe zone perception varied between the units. Quantitative and qualitative
methods were applied to the safe zone research project. The principal investigator oversaw the
application of the yellow tape (independent variable) to contact and contact-enteric rooms for the
experimental unit, then examined to see if infection rates (dependent variable) increased or
decreased. The percentage of infection rates for both the experimental unit and control unit were
recorded.
Definition of Terms
Clostridium difficile (C. diff): A spore-forming, Gram-positive anaerobic bacillus that
produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated
diarrhea (AAD) (CDC, 2010).
Contact Precautions: Apply to patients who have MRSA or an MDRO. HCW must wear
PPE when entering the patient’s room, and adhere to hand hygiene practices (CDC, 2011).
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Contact-Enteric Precautions: Apply to patients who have C. diff. HCW must wear PPE
when entering the patient’s room, adhere to hand hygiene practices and room must be cleaned
with bleach to kill C. diff spores (CDC, 2011).
Don: To put on personal protective equipment.
Doff: To take off personal protective equipment.
Healthcare Associated Infection (HAI): Is any infection by any pathogen that is acquired
as a consequence of a healthcare intervention or which is acquired by a HCW (The Free
Dictionary, 2014)
Healthcare Worker (HCW): Any nursing, medical or supportive staff that help take care
of patients in a healthcare setting.
Institutional Review Board (IRB): A board committee that is designed to approve
proposed non-exempt research before involvement of human subjects can begin (HHS, n.d).
Isolation Precautions: Refer to Contact Precautions
Methicillin-Resistant Staphylococcus aureus (MRSA): A type of staph bacteria that is
resistant to many antibiotics. The organism is usually spread by direct contact from an infected
wound or from contaminated hands (CDC, 2013).
Multi-Drug Resistant Organisms (MDRO): Common bacteria that have developed
resistance to multiple antibiotics. Examples include MRSA, Vancomycin Resistant
Enterococcus, Extended Spectrum Beta Lactamase and Klebsiella Pneumoniae Carbapenemase
Producer (Children’s Hospital of Minnesota, n.d).
Nosocomial Infection: Originating or taking place in a hospital, acquired in a hospital
(Medicine Net, 2013).
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Personal Protective Equipment (PPE): Equipment that is worn to protect workers from
specific threats of exposure. PPE includes gown, gloves and masks for HCW (CDC, 2012).
Red Box Strategy: Red tape that is placed in a 3 feet square from the door of a patient’s
room. In the tapped zone HCW do not have to adhere to contact precautions and can observe and
communicate with their patient without having to wear PPE (Franck et al, 2011).
Round (Rounding): When a HCW visits a patient for routine or immediate care to address
the needs of a patient.
Safe Zones: Similar to the Red Box, but a yellow piece of painters tape is placed on the
floor 3 feet from the patients bed inside a contact or contact-enteric precaution room. HCWs do
not have to don PPE if they do not leave the safe zone area.
Assumptions
One assumption in the Safe Zone Research Project was that all surveys were answered
honestly, and participants did not deviate from the truth. It was also anticipated that HCWs want
to observe and communicate with their patients more. Since it is AnMed’s policy it was assumed
that hand hygiene was performed upon entering and exiting the safe zones every time. Finally,
the principal investigator assumed that the safe zones were communicated effectively to the staff
about their use, and staff comprehended what the safe zones intended to accomplish.
Limitations
Like all research studies conducted, there can be limitations. The safe zone study that was
conducted at AnMed Health had a relatively small sample size. On average, Four Center only
has 30 occupied beds, two-four of which belong to contact and contact-enteric precaution patient
weekly. The control unit, Seven South, has 37 beds and was also occupied by two-four contact or
contact-enteric patients weekly. The study also was relatively short in comparison to other
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research projects. The investigator made no observations on how the staff was adhering to the
safe zones due to denied approval from Concordia University’s Institutional Review Board
(IRB). Although the staff was fully informed regarding safe zones and the purpose these zones
serve, staff may not have adhered to the safe zone policy that was in place since they were not
monitored. Finally, safe zones were not permitted for patients on droplet or airborne precautions,
so no data was collected on these types of precaution patients.
Delimitations
The principal investigator was able to choose what units at AnMed Health to use as the
experimental and control unit. The investigator chose Four Center and Seven South because
these two units generally have high compliance rates in practicing hand hygiene. These units also
commonly have contact and contact-enteric patients on the units on any given day. The principal
investigator was able to write the survey questions to be given to the HCW taking care of contact
and contact-enteric patients, and was allowed daily access to MDRO and C. diff infection rates
for the facility.
Significance of the Study
The Safe Zone Research Project will be able to fill a gap in literature because there is
very limited information available on the actual safety and infection rates of utilizing safe zones.
This project will contribute to the domain of public health and health promotion by providing a
new resource that HCWs can utilize to increase patient care. The Safe Zone Research Project
will improve services through clinical effectiveness and efficiency. Safe zones have the potential
to become a new standard in practice in the future for contact and contact-enteric patients that all
healthcare facilities can utilize that is affordable and beneficial for both patient and healthcare
providers.
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Summary of Chapter 1
This research project was conducted and written in favor of safe zones being
implemented for all units at AnMed Health. Safe zones will only improve patient care and
infection rates will not rise if the staff utilizes the safe zones correctly. Having said this, the next
four chapters of this master thesis will discuss how safe zones in contact and contact-enteric
precaution rooms will help not hinder patient care. Chapter two of the Safe Zone Research
Project will include a literature review comparing previous studies that have utilized a similar
safe zone method for contact and contact-enteric precaution patients. The Red Box Strategy that
Trinity Regional Health Center and Fletcher Allen Health Care will be examined using an
analytical approach. Chapter three explains how the research design was conceptualized and
utilized during the research study. Chapter three will also look at the steps the principal
investigator took when presenting the project idea to the Institutional Review Board (IRB) at
AnMed Health Medical Center and Concordia University. The results that AnMed Health
obtained will be examined and evaluated in chapter four, and chapter five will include discussion
and recommendations for improving the Safe Zone Research Project for future implementation.
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Chapter 2: Literature Review
Introduction
There has been very limited research as to whether safe zones or the use of a “red box” in
contact and contact-enteric precaution rooms are actually beneficial and not harmful for the
patients and HCWs. Before the Safe Zone Research Project began at AnMed Health the principal
investigator did a thorough search to examine and compare previous studies that had
implemented a similar innovative strategy for contact isolation patients. Observational studies
that were conducted at Trinity Regional Health Center and at Fletcher Allen Health Care
implemented a Red Box Strategy, which was very similar to AnMed Health’s safe zones for
contact and contact-enteric precaution rooms. The literature review will address four areas
related to the use of safe zones/red boxes for contact and contact-enteric precaution patients. The
first section will examine the effects safe zones have on increased observation and
communication between the patient and staff. The second section will focus on how healthcare
workers resources are improved (e.g. cost associated with PPE) when safe zones are
implemented. The third section will discuss research related to HCW efficiency and satisfaction
when utilizing safe zones. Finally, the fourth section will discuss the limitations found in the
research observational studies.
The literature searched was performed using Google Scholar, PubMed and The American
Journal of Infection Control. The research articles were limited to peer-reviewed primary
research articles published after 2008. Search terms used to generate articles for the literature
review included: “isolation”, “contact precautions”, “cost of isolation”, “PPE costs”, “Red Box
Strategy”, “safe zones”, and “HCW satisfaction”.
13
Body of Review
Increased Observation and Communication between Patient and Staff
Communication and observation are key components in patient care and improving
health outcomes for patients. Increased communication and observation is especially important
for patients who are on contact and contact-enteric precautions to help them avoid the feeling of
being isolated and abandoned. There is a volume of research on the impact that isolation or
contact precautions has on a patient. A study conducted by Kennedy and Hamilton found that
contact precaution patients were found to have higher levels of anxiety (12.8 vs. 8.2, P < .001),
and increased depression rates (12.5 vs 7.3, P < .001) (Morgan et al., 2009). Patients on contact
precautions are also more likely to formally complain about the care they received (8% vs 1%, P
< .001) (Morgan et al., 2009). Gasink interviewed 42 patients on contact precautions and 43
patients not on contact precautions. His findings discovered that contact precaution patients were
less likely to recommend the healthcare facility to a friend (81% vs 95%, P = .08) (Morgan et al,
2009). Patients on isolation precautions had limited interaction with HCW’s and subsequently, a
negative perception of the care received from the health care facility.
The utilization of safe zones increases observation for these patients. This leads to an
increase in communication and interaction between the patient and healthcare provider. Trinity
Regional Health Center and Fletcher Allen Health Care both realized that there is limited
information or strategies available to reduce barriers and increase interactions for patients on
contact precautions. Both facilities conducted observational studies at their facility to see if
utilizing a “red box” that created safe zones in contact and contact-enteric isolation rooms would
improve patient outcomes. Trinity Regional’s observational study lasted for two years (Franck et
14
al., 2011). Fletcher Allen’s observational study lasted six months (Snell, 2013). The intervention
that both facilities utilized was simple and inexpensive. Both healthcare facilities placed red tape
on the floor in contact precaution rooms to form a red box. Why red tape? According to Andrew
Behan (2012), employed at Trinity Regional, red duct tape is a low adhesive tape that is
relatively inexpensive costing around $7 dollars per roll. Figure 2 is an example of the Red Box
Strategy utilized at Trinity Regional Health Center.
The staff of Trinity Regional was able to utilize the Red Box without having to don any
PPE when they adhered to the zone. The box was used specifically for observation and
communication between the patient and the HCW. The same policy of not having to don PPE
when inside of the red box was also implemented at Fletcher Allen (Snell, 2013). After the study
was concluded the staff at both facilities were given surveys to determine the effectiveness of the
Red Box Strategy. Survey questions from Trinity Regional Health Center focused on HCW’s
rate of patient visitation and communication (Franck et al., 2011). The survey was distributed to
Figure: 2
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154 HCWs at Trinity Regional Health Center (Franck et al., 2011). Fletcher Allen Health Care
took a more direct approach with surveying by inquiring whether the red box made a difference
and whether employees wanted to continue using it in their facility (Snell, 2013). However, their
study did not list how many participants were involved in taking their red box survey.
The researchers who analyzed data from both Trinity Regional and Fletcher Allen used
quantitative methods. After the intervention was completed, researchers provided surveys to staff
members and recorded observations. Even though the time span of the two observational studies
varied, the results between facilities produced very similar results. Trinity Regional Health
Center discovered that 79.2 percent of HCWs reported they could assess and communicate with
patients more frequently (Franck et al., 2011). The study also concluded that 67.5 percent of
HCWs reported barriers were lessened when communicating because of the red box, and 73
percent of HCWs checked on their patients more frequently (Franck et al., 2011). Trinity also
found that almost 30 percent of quick communication and assessment was conducted in the red
box/safe zone they had established (Franck et al., 2011).
Fletcher Allen Heath Care concluded that 75 percent of the staff believed the red box
significantly raised their awareness (Snell, 2013). Healthcare staff from Trinity Regional Health
Center and Fletcher Allen Health Care both embraced the safe zones. The Red Box Strategy
proved to be a success in both studies in regards to increased communication and observation
between the staff and patient.
Improving Healthcare Worker Resources
PPE is relatively inexpensive, costing only about $0.76 to don a disposable gown and
gloves (Behan, 2012). However, when PPE is worn multiple times a day substantial annual costs
can be obtained. Contact and contact-enteric precaution rooms also incur costs that are harder to
16
capture. For example, because staff members know they will have to don PPE to enter the room,
they will often grab multiple supplies like extra linens or intravenous kits before entering the
patient’s room. This keeps them from having to doff PPE, perform hand hygiene, gather the
needed supplies and then return to the patient’s room where they will have to rewash and reapply
the PPE before entering. Many items that HCWs bring into the contact precaution room are not
utilized, but since the supplies were in a precaution room they cannot be transported to another
patient’s room. These items, whether actually tainted or not, are then discarded or sent to the
facility’s laundry service even if the items are clean or unused.
A research study done at three Michigan hospitals revealed the average daily cost for
contact isolation was $34.72 per patient (Verlee et al, 2014). This daily average was calculated
by counting the number of gowns used per isolation day. On average 48 gowns and pairs of
gloves were used per patient room (Verlee et al, 2014). The average cost per day was slightly
higher for ICU patients. Trinity Regional compared PPE costs in a similar manner. The
healthcare fcaility evaluated PPE cost by comparing how many times per day PPE would have
been worn had the safe zone not been implemented for 25 contact precaution rooms (Behan,
2012). If the staff did not have to don PPE during those instances they would save $9.88 on
average per day per patient (Franck, 2011). Overall, this could amount to an annual savings of
$90,155 based on 25 isolation patients per day (Franck, 2011).
One conclusion can be made from the results of Trinity Regional and the Michigan
observational studies in regards to PPE cost; it is apparent that any healthcare facility will save
money in PPE costs if they do not have to wear gown and gloves every time a staff member
enters a contact or contact-enteric room. Cost savings overall will vary depending on how many
patients are on contact precautions and the size of the healthcare facility. The utilization of safe
17
zones will decrease PPE use, and supportive staff members will be able to use the box to hand
off supplies to the HCW that is currently treating the patient. This will allow for higher cost
savings for the facility. Safe zones will alleviate the need to bring in extra supplies that could
potentially be wasted, along with saving money from not having to don PPE when working
within the red box.
Improves HCW Efficiency and Satisfaction
To keep patients happy, you must first keep your staff happy (Bowles, 2014). Keeping
staff happy is a challenge for any healthcare facility because there are so many employees and
departments the facility must accommodate. Healthcare organizations are constantly searching
for ways to better suit the needs of their staff while also keeping their patients protected. Bowles
(2014) believes the key to staff happiness is to make them comfortable, and make them feel like
they belong to their surroundings. Although PPE is necessary when directly interacting with a
contact and contact-enteric patient and their environment, Trinity Regional staff did not
understand why it had to be worn when not touching the patient or equipment (Behan, 2012).
One of the biggest complaints Trinity Regional Health Center and Fletcher Allen Health Care
reported was that staff did not adhere to wearing PPE in isolation rooms because the gowns were
too hot or fell off (Behan, 2012). PPE was simply not efficient while they were working. As
stated previously, staff is less likely to be compliant if they are uncomfortable in their work
environment. The Red Box Strategy is an innovative technique that can decrease barriers from
PPE and greatly improve staff’s PPE compliance when outside of the safe zones.
PPE Compliance: Fletcher Regional noted that HCWs had less than 40 percent
compliance with wearing PPE when entering an isolation room (Snell, 2013). Trinity Regional
noted that their compliance with PPE use was around 60 percent for HCWs entering isolation
18
rooms (Behan, 2012). One of Fletcher’s main objectives was to see if utilizing the Red Box
Strategy in their contact precaution rooms would help their staff increase compliance when
wearing PPE outside of the red box. Trinity Regional also reported having compliance issues in
regards to wearing PPE before implementing the Red Box Strategy. Many times their staff would
say “I didn’t touch anything” or “Why do I have to put all this stuff on just to ask the patient if
they need anything?” (Behan, 2012) Both facilities implemented the Red Box Strategy to
evaluate compliance. While Trinity Regional and Fletcher Allen both sought to measure PPE
compliancy outside of the red box, their methods of measurement were different. Trinity
Regional directly observed its staff; Fletcher Allen, on the other hand, used staff surveys.
The results from Trinity Regional Health Center concluded that 30 percent of patient
interactions occurred within the safe zone (Franck, 2011). Trinity Regional also discovered that
PPE compliance rates outside of the red box went from 60 percent before implementation to over
80 percent after the safe zone was implemented (Behan, 2012). Fletcher Allen’s survey revealed
that PPE compliance went from 40 percent before implementation to staff being compliant over
60 percent of the time (Snell, 2013). It is important to note the results that both Trinity Regional
and Fletcher Allen had with PPE compliance after the red box was implemented. Both studies
had increased PPE compliance rates when not inside of the safe zone. Because the staff did not
have to utilize PPE when inside of the red box, they were more willing to don PPE when they
had to come in close contact with the patient.
HCW Time: Another valuable resource that is saved by not having to don or doff PPE
when utilizing the red box is HCW time. Patients are assessed quicker from not having to don
and doff PPE. Trinity Regional timed how long it took to take on and off PPE then times that
number by how many isolation gowns were used daily. They discovered that HCWs could save
19
on average 30 minutes a day if they did not have to wear PPE when utilizing the red box
(Franuck et al, 2011). This is equivalent to 110 hours saved annually per patient or 2742 hours
saved based on 25 isolation patients per day (Franck et al, 2011).
HCW Satisfaction: Both Trinity Regional Health Center and Fletcher Allen Health Care
surveyed their staff to gauge its level of satisfaction since implementing the Red Box Strategy.
Fletcher Allen Health Care reported that 83.3 percent of the staff believed the Red Box Strategy
made a difference and 96.8 percent of those surveyed believed the practice should continue
(Snell, 2013). Trinity Regional Health Center reported its HCWs expressed greater satisfaction
with not needing to don PPE when they were just doing a quick assessment of the patient
(Franck et al., 2011). Trinity also reported that 67.5 percent of those surveyed believed the zones
lessened barriers when trying to communicate with their patient who was on contact precautions
(Franck et al., 2011). Overall, the use of the Red Box Strategy at both facilities led to an increase
in satisfaction with their HCWs, and both groups were in favor of keeping the safe zones facility
wide.
Limitations noted
Unfortunately, all research studies have limitations. Dirty gowns were counted when
calculating costs associated with PPE usage. Dirty gowns could have been worn by the patients
friends or family members, thus the average daily use for HCWs could be wrong (Verlee et al,
2014). The Trinity Regional Health Center and Fletcher Allen Health Care studies did not utilize
any form of control unit when they were tracking the safe zone progress. Fletcher Allen also
reported that the tape was not put down in all of their contact precaution rooms, and the support
staff needed to be better trained on when and how to apply the tape (Snell, 2013). For the red box
to be effective the tape needs to be applied so the staff can utilize it. Although Fletcher Allen
20
Health Care reported that infection rates decreased on several units, it failed to mention how this
data was captured. Trinity Regional Health Center did not even mention infection rates in their
study. The whole purpose of safe zones in contact precaution rooms is to increase
communication and decrease PPE costs while ensuring that the chance to spread infection
remains low.
Summary
Unfortunately, research in this area is lacking. There were only a few studies on safe zone
use for contact and contact-enteric precaution rooms that the principal investigator could
evaluate. That being said, the preceding literature review was presented in an analytical format
that compared the results from implementing safe zones from two different studies. The literature
review also examined other various research studies to help provide support and documentation
for why implementing safe zones would be beneficial in a healthcare setting. The analysis was
done by identifying the relevant variables and locating relevant research before the analysis
began (Bordens & Abbott, 2014). The analysis studied the impact that safe zones had on
communication, efficiency, resources and HCW satisfaction for contact and contact-enteric
precaution rooms.
The literature presented suggests that the utilization of a red box or safe zones in contact
and contact-enteric precaution rooms can be beneficial for the patient and HCW. In fact, all the
articles presented safe zones as being positive for patient care and not harmful. Communication
between the patient and HCW increased, while also providing cost savings to the facility because
the staff no longer had to don PPE when inside the safe zone. The findings from the two research
studies provided minimal information on whether safe zones had an effect on hospital acquired
infection rates, thus more research is needed in this area. These studies might appear
21
insignificant and subtle on an individual level, but safe zones have the potential to change how
we interact and care for contact and contact-enteric precaution patients overall. Finding
innovative ways to treat and care for patients who are on precaution protocols will prove
challenging. The addition of red tape to the floor of a patient’s room is one way to decrease
barriers while keeping costs down for the healthcare facility.
22
Chapter 3: Research Method Introduction
There is a gap in literature due to limited information available on safe zone use. More
studies need to be completed to address whether or not safe zone utilization is appropriate in a
healthcare setting for contact and contact-enteric precaution patients. AnMed Health wanted to
establish more research on safe zones while also evaluating if the zones would be beneficial for
their facility. More importantly, AnMed wanted to ensure that infection rates would not increase
due to the safe zones before the zones would be implemented facility wide. Creating safe zones
for patients on contact and contact-enteric precautions improves the utilization of facility
resources and healthcare worker efficiency through improved communication and observation
with patients. The purpose of the Safe Zone Research Project was to determine if safe zones
helped patient care for contact and contact-enteric precaution patients, while still keeping
infection rates down. The principal investigator sought to answer the following research
questions. How does quality of care differ between control and experimental groups when safe
zones are employed? Will PPE costs vary between the control and experimental unit? What is
the relationship between HCWs attitude toward safe zones? Does the HCW find the safe zones
beneficial when they are observing or communicating with their patients? Is there an increase in
HAIs with safe zone implementation?
Safe zones were established in an experimental unit, and the effects that the zones had on
HCWs perception was measured through a survey. The narrative data was then transcribed,
coded and evaluated regarding the research questions. A cost analysis was conducted to compare
PPE pricing from the safe zone unit versus a unit that did not have safe zones implemented.
HAIs were tracked during the two-month trial to look for trends in infection rates.
23
Setting
The Safe Zone Research Study took place at AnMed Health Medical Center, a Magnet
status hospital in Anderson, South Carolina. The Magnet Recognition Program recognizes
healthcare organizations for quality patient care, nursing excellence and nursing innovations
(ANCC, 2014). Worldwide there are only 402 hospitals that have achieved this award (ANCC,
2014). The Safe Zone Research Project was implemented on Four Center and Seven South was
established as the control unit. Four Center at AnMed Health is a medical/surgical unit devoted
to caring for cancer and dialysis patients, and Seven South is a medical unit that is designed to
care for neuroscience patients. Even though the units differ in the type of patients they treat, both
units have similar census in the amount of contact and contact-enteric patients they have on the
unit during a given week.
The intervention occurred only in Four Center for contact and contact-enteric precaution
patients. Since there is not a specific patient room that is designated for precaution patients, the
room the contact or contact-enteric patient was admitted to would become the intervention room
requiring the yellow tape to create the safe zone. Unfortunately, patient rooms are not
standardized at AnMed Health and rooms vary in size. Because of this the principal investigator
decided to place the yellow safe zone tape three feet (roughly 2 and half ceiling tiles) from the
patients bed for patients on contact and contact-enteric precautions. Yellow frog tape (painters
tape) was utilized because it did not leave marks on the floor tiling, and was relatively easy for
Environmental Services (EVS) to clean and remove after the patient had been discharged. Once
the principal investigator educated the staff in Four Center on safe zones and their purpose, the
nursing staff was then allowed to place the tape when they received a patient that had a MDRO
or was C. diff positive.
24
Participants
The principal investigator had no control over what unit patients were admitted to, or
what HCWs would be involved in the intervention. However, the sampling for this research
project was a purposive sample. The sample population enrolled in the Safe Zone Research
Project was a representative sample, because they all met a certain criteria to be in the research
study (Bui, 2014). The intervention only occurred in rooms on Four Center for patients that met
criteria to be on contact and contact-enteric precaution protocols (i.e. had a MDRO or C. diff).
That being said the patients’ reasons for being in isolation varied. During the study Four Center
had 19 patients on contact precautions because they had a MDRO, and 11 patients were on
contact-enteric precautions because they were C. diff positive. The control unit had 12 patients
that had a MDRO isoalted, and 7 patients that were C. diff positive. The principal investigator
surveyed HCWs from Four Center that had interacted with contact and contact-enteric patients
and utilized the safe zones during the research trial.
Intervention
The Safe Zone Research Project intervention was a simple yet innovative technique.
When a contact or contact-enteric precaution patient was admitted or an MDRO organism was
identified in Four Center, yellow tape was placed on the floor three feet from the isolated
patient’s bed to create a safe zone that staff could utilize. The yellow tape or safe zone was
considered the independent variable, and the principal investigator measured changes that
occurred after placing the tape. The component of placing the yellow tape was intended to
increase staff observation and communication, increase staff satisfaction in the work
environment and decrease PPE costs while also keeping HAIs down. The dependent variables
25
measured were results from a survey on safe zones that examined how satisfied staff were with
the zones, PPE costs for both units and tracking HAIs for the experimental and control unit.
Materials and Instrumentation
The materials used in the Safe Zone Research Project included an information sheet that
was handed out to staff before the zones were implemented (see Appendix A). The information
sheet explained when the safe zones could be utilized, how to properly apply the yellow frog
tape and why AnMed Health wanted to implement the zones. The principal investigator analyzed
responses the staff submitted during the safe zone survey, examined PPE budget and tracked
HAI rates for the two units. The staff survey was only given to the experimental unit where the
safe zones had been implemented. An example of a survey question asked was “Do you feel like
you communicated with your patient more, because of the safe zones” (Appendix B)?
Procedure
The principal investigator collected data through surveys, analyzing PPE budgets and
tracking HAIs. The safe zone survey was administered to staff on the experimental unit (see
Appendix B). When the survey was given out it was noted to the staff that it was voluntary. The
surveys were entered into Survey Monkey and analyzed upon completion. The principal
investigator collected before and after PPE budget sheets from the control and experimental unit
to examine cost savings. Most importantly, the principal investigator looked for shifts in HAIs
daily for the experimental unit. This was done with the use of Midas computer system. Midas
Care Management includes integrated discipline-specific case management, quality management,
risk management, and infection control subsystems that allow infection preventionists to monitor
disease surveillance (Midas, 2014).
Data Analysis
26
The collected data from the surveys was categorized and analyzed. Descriptive statistics
and inferential statistics were used to quantitate the data collected. The results of the staff survey
were analyzed descriptively; the HCWs had the option to answer with three responses that were
then coded for analysis of the dependent variable: less often (1), same as before implementation
(2) and more often (3). The completed surveys were then entered into an online survey company
called Survey Monkey, where the results were analyzed and graphed according to their response.
The principal investigator organized the data depending on the response. PPE budgets were
collected from the nurse managers from both the experimental and control unit. A cost
comparison was conducted and the data was graphed comparing the two units. Nosocomial
infection rates were measured with the use of Midas.
When a patient has a MDRO or is C. diff positive, contact or contact-enteric orders are
put into the electronic medical record. This populates a list in Midas where an infection
preventionist will review the case to see if the infection was community or hospital acquired. If a
patient is C. diff positive or an MDRO is collected and cultured less than three days from day of
admittance the organism is considered community acquired. A positive result greater than three
days is considered hospital acquired. The principal investigator kept separate line lists for each
unit during the length of the study to examine how many contact and contact-enteric precaution
patients were community versus hospital acquired to look for shifts or trends in infection rates on
these units.
Ethical Considerations
The Safe Zone Research Project was submitted to AnMed Health’s Medical Center
Institutional Review Board (IRB) and to Concordia University’s IRB. No patients under the age
of 18 were enrolled in the Safe Zone Research Project. Younger patients that need to be on
27
contact and contact-enteric precautions are admitted to AnMed Health’s Women and Children’s
North Campus and do not stay at the main medical center where the research project took place.
There was no manipulation of human subjects or their environment, only the recording of survey
data from the HCWs. The HCWs that were providing care to the contact and contact-enteric
patients during the study were fully aware there was a research project being conducted, and they
had the option to fill out a survey. The principal investigator informed the staff that completion
of the surveys implied consent when handing out the surveys to the HCWs. This stipulation was
also listed on the survey itself. Informed consent documents were not submitted to AnMed
Health’s IRB at any time during the project for two reasons: implementation posed no risk to the
patient and only HCWs were being observed and surveyed. The research project was approved
by AnMed Health’s IRB and Concordia University’s IRB because there was no departure from
the established standard of care and the research study did not present any significant risk to the
patient or HCW.
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Chapter 4: Results
Introduction
This research project was designed to explore the effectiveness of the use of safe zones
for patients on contact and contact-enteric precautions. The project sought to improve the
utilization of the healthcare facility resources and healthcare worker efficiency through improved
communication and observation with patients. Furthermore, the goal was to determine the impact
of safe zone use on hospital acquired infection rates. The objective of the Safe Zone Research
Project was to gather research from existing data collected through a literature review, and to
look at new data collected through AnMed Health to determine the relevance of the thesis
statement. The principal investigator sought to answer the following research questions through
the use of surveys, observations and the Midas computer system to track HAIs; Do HCWs
interact with their patients more because of the safe zones? Will PPE costs vary between the
control and experimental unit? What is the relationship between HCWs attitude toward safe
zones? Does the HCW find the safe zones beneficial when they are observing or communicating
with their patients? Finally, will safe zones increase hospital acquired infection rates?
The collected data from the surveys was categorized and analyzed using descriptive
statistics. Surveys were used to gauge HCW satisfaction and compliance when utilizing safe
zones. The Midas computer system was used to track HAIs, and the principal investigator
confirmed that these patients had indeed acquired a nosocomial infection from the control or
experimental unit before these cases were captured. The succeeding sections of this chapter will
examine the results that AnMed Health occurred during their Safe Zone Research Project trial
period.
Data Results
29
Data collected consisted of PPE costs from the experimental and control unit, surveys
from the HCWs on the experimental unit and nosocomial information that the Midas computer
system provided from the control and experimental unit.
Comparing PPE Costs:
Before implementing safe zones, costs for gowns and masks were averaging $496 a
month for the experimental unit (4C). After the safe zone initiative was put in place costs
dropped. The biggest savings came from not having to wear the disposable gown while in the
safe zone. The cost for disposable gloves was excluded from the cost comparison because gloves
are worn in every patient’s room, not just contact or contact-enteric patients. Both the
experimental unit and control unit provided PPE totals for the month of December and January.
The control (7S) unit’s total costs for gowns and masks for December was $510.72, while the
experimental (4C) unit’s costs for gowns and masks for December was $181.60. This was a
64.4% decrease in PPE costs between the units (Figure 3).
December PPE (gowns & masks) Costs
4C $181.60
7S $510.72
Figure: 3
The January PPE costs for 7S ended up being $562.48. The PPE costs for 4C ended up being
$543.06 for January. The experimental unit costs for January was up compared to Decembers
30
PPE costs because total isolations were higher, and many patients were on droplet precautions
for Influenza. PPE had to be worn at all times for droplet precaution patients. However, droplet
precaution patients were not included in the Safe Zone Research Project. Even though the
experimental unit had more patients on contact and contact-enteric precautions than the control
unit their PPE costs were considerably lower because of not donning PPE while staying in the
safe zone. If all units at AnMed Health switched to safe zones, annual PPE costs could be greatly
reduced for the facility.
HCW Surveys:
After receiving approval from AnMed Health’s Intuitional Review Board (IRB) and
Concordia University’s IRB a survey was administered to HCWs that had utilized the safe zone
on 4 Center. The survey (see Appendix B) was placed on the unit, and staff had the opportunity
to complete the survey if they desired. This was a voluntary survey, and completion implied
consent. No identifying information was present on the survey, other than staff category, which
included registered nurse, nursing assistant, physician or other. During the two month study the
experimental unit had 19 patients on contact precautions and 11 patients on contact-enteric
precautions. Survey results were entered into Survey Monkey, the world’s leading provider of
web-based survey solutions (Survey Monkey, 2009). The questions asked were sorted and
graphed according to the response that had been given.
Communication and Observation with Safe Zones: The analysis of the survey
questions revealed that no one believed that patients were observed less often or communication
had decreased since the implementation of safe zones. In fact, the staff was split down the middle
on whether or not they communicated more with their patients. Figure 4 shows that 50 percent
believed they communicated the same as before the implementation of safe zones, and 50
31
percent believed they communicated more often. Since starting safe zones for contact and
contact-enteric patients 40 percent of the survey respondents believed they checked on their
patients more often (Figure 5). The survey also revealed that half of the respondents felt their
patients’ needs were being met more often since the utilization of safe zones.
Figure: 4
32
Figure: 5
Hand Hygiene Compliance: Figure 6 shows 70 percent of staff performed hand hygiene
the same as before implementation with the safe zones in place, while 20 percent felt it was
performed more often and 10 percent were unsure. Hand hygiene compliance was one survey
result that was not anticipated to change very much since utilizing safe zones. AnMed Health has
a very strict policy on hand hygiene, requiring staff the wash or sanitize their hands every time
when entering and exiting a patient’s room. Even before implementing safe zones the
experimental unit had great hand hygiene compliance rates. For the year 2014, the experimental
unit hand hygiene rates that were close to 80 percent (Midas, 2014). This included over 668
observations from secret observers.
33
Figure: 6
HCW Efficiency: HCW were also asked to determine if time was saved, or work became
more efficient with safe zone implementation. Figure 7 shows that 100 percent agreed their time
was saved because they did not have to don PPE when utilizing the safe zones. Ninety percent of
the survey participants also reported they were more comfortable because they did not have to
wear PPE when they were just observing or communicating with their contact or contact-enteric
patient (Figure 8).
34
Figure: 7
Figure: 8
HCWs Perception of Safe Zones: The question, “do you think staff are adhering
to the safe zone the way it was intended to be used” provided a mixed response. Forty
percent said yes, 40 percent said no and 20 percent responded they were unsure. This
35
research question shows the need for further education on safe zones and their utilization
before implementing to other units. One thing for certain, the survey revealed that 80
percent of staff believed the safe zone initiative should continue on their unit (Figure 10).
A registered nurse even provided a separate comment that she “loved it.”
Figure: 9
Figure: 10
36
Hospital Acquired Infection Rates:
Data was collected regarding HAIs with the use of the Midas Care Management
computer system. Multiple variables were looked at regarding HAIs for both the control and
experimental unit. The number of patients on contact and contact-enteric precautions was looked
at regarding HAIs for both the control and experimental unit. The number of patients admitted to
the control unit the month of December and January totaled 348 patients, 19 patients were placed
on isolation. Out of the 19 isolated patients, 12 were placed on contact precautions for a MDRO
and seven were placed on contact-enteric precautions for C. difficile (Midas, 2014). The number
of patients admitted to the experimental unit during the research trial was 410. Out of the 410
patients 30 qualified for the Safe Zone Research Project. There were 19 patients who trialed the
tape due to being on contact precautions, and 11 patients who trialed the tape for contact-enteric
precautions (Midas, 2014). Figure 11 is a graph representing the number of admits the two units
had during the trial period. The experimental unit not only had more admissions during the two
month trial, but also had more patients on isolation for MDROs or C. difficile.
Figure 11
37
According to the Center for Disease Control and prevention (2015), HAIs for MDROs
and C. difficile are defined as any specimen collected greater than three days after the admission
to the facility. The study concluded that HAIs decreased from utilizing safe zones for the
experimental unit compared to previous months before implementation. However, when the
experimental unit was compared with the control unit, the control unit reported one less hospital
acquired case. In the month of December the experimental unit reported one hospital acquired
MRSA (Midas, 2014). The control unit did not report any nosocomial infections in December.
Both the experimental and control unit reported two hospital acquired cases each in January. The
control unit reported one C. difficle case and one MRSA casse, and the experimental unit also
reported one C. difficle case and one MRSA that met the definition for hospital acquired. Figure
12 is a graph comparing the two units HAI rates. November was included to illustrate rates
before the utilization of safe zones.
Figure 12
Summary
Although the results of the Safe Zone Research Project were encouraging, there is a clear
need for more information and data on this new innovative technique for contact and contact-
38
enteric precaution patients. It is evident that staff needs more education on the purpose of the
safe zones because many staff members are unsure if the zones are being utilized correctly.
While the survey did not produce any statistically significant trends in regards to increased
observation and communication between HCW and patients, it did show that time is saved
through the use of safe zones. It is evident that the majority of staff believes the safe zone should
continue on the experimental unit. In order to obtain survey results that would have more of an
impact, the Safe Zone Research Project needs to be expanded to other units. This would allow
for a more statistically significant result.
The Safe Zone Research Project validates existing literature provided by Trinity Regional
Health Center and Fletcher Allen Health Care in support of utilizing safe zones or the red box
strategy for inpatient contact and contact-enteric precaution patients. Fletcher Allen Health Care
reported that 96.8 percent of those surveyed believed the safe zone practice should continue
(Snell, 2013). The survey conducted on the experimental unit at AnMed also corroborates
previous findings that time is saved because of not having to don PPE when just observing or
communicating with a precaution patient. The Safe Zone Research Project differs from and
enhances existing literature because it also captures HAI rates from a unit that has implemented
safe zones compared to a unit that does not currently execute the new precaution practice.
39
Chapter 5: Discussion, Conclusions, and Recommendations
Introduction
Due to minimal amounts of published research, there is limited understanding of the
impact of safe zone use on healthcare associated infections. AnMed Health wanted to establish
more research on safe zones, while also evaluating if the zones would be beneficial for their
facility. The Safe Zone Research Project sought to evaluate how a piece of yellow tape could
improve the utilization of the healthcare facility resources and healthcare worker efficiency
through improved communication and observation with patients. Data related to hospital-
acquired infection rates were also captured to see if infection rates would change due to
implementation of the safe zone concept. The project began by examining similar studies
conducted by Trinity Regional Health Center and Fletcher Allen Health Care that involved the
use of a red box for contact and contact-enteric precaution patients. The Safe Zone Research
Project implemented a similar initiative like the “Red Box” strategy, except AnMed Health chose
to place yellow tape on the floor in contact and contact-enteric rooms three feet from the
patient’s bed to establish a safe zone. This allowed for the safe zone to be slightly bigger so
HCWs could engage in eye contact with the patient.
The goal of this study was to determine if quality of care differed between the control and
experimental groups when safe zones were employed and whether PPE costs varied between
units. The study also hoped to capture data on HCW’s attitudes toward safe zones and whether or
not those workers found the safe zones beneficial when they were observing or communicating
with patients. Lastly, this study hoped to discover if there would be an increase in HAIs with the
utilization of safe zones. AnMed Health wanted to ensure that infection rates would not increase
due to the safe zones before the zones would be implemented facility-wide.
40
Interpretation of Findings
The Safe Zone Research Project was designed to assess the effects that yellow tape has
on contact and contact-enteric precaution patients in regards to healthcare worker efficiency and
healthcare facility resources. Information from the literature review, the HCW survey and PPE
costs collected at AnMed Health Medical Center concluded that safe zones can improve
healthcare worker efficiency and healthcare facility resources when utilized correctly. Compared
to previous months, PPE cost savings was significant after safe zone implementation. The cost
savings is attributed to not having to don PPE when inside of the safe zone. AnMed Health has
the potential to save thousands of dollars annually in PPE costs. The extra funds that would be
saved could be used for other areas of research to improve patient outcomes for isolation
precaution patients.
Unfortunately, the survey participation results were relatively low. During the two-month
study the experimental unit had 19 patients on contact precautions and 11 patients on contact-
enteric precautions. HCWs were instructed to complete the survey only if they had utilized the
safe zones during the trial. The sample size for the HCW survey ended up being small, and the
response rate could be higher if there was more time and resources (e.g. safe zones on other
units) where available to also compare. That being said, the surveys that HCWs did complete
were consistent. Of the HCWs surveyed, 100 percent felt time was saved from not having to don
PPE, and 90 percent felt more comfortable because they did not have to wear PPE when inside of
the safe zone. In fact, 80 percent of respondents would like the safe zone practice for contact and
contact-enteric precaution patients to continue on their unit.
41
As anticipated, HAI rates did not increase because of safe zone utilization. In fact, the
experimental unit had less HAIs during the two-month trial than during the single month prior to
implementing safe zones. The control unit rates were slightly better with one less HAI being
reported during the trial than the experimental. That being said, the control unit also had 11 less
patients on contact and contact-enteric precautions and 62 fewer patients admitted. A greater
volume of patients increases the likelihood that a pathogen will be spread. One of the three HAIs
that occurred from the safe zone experimental unit technically was not a “true” hospital acquired
infection. The patient had community acquired C. diff when they were admitted to the intensive
care unit. Upon transfer to 4 Center (experimental unit) another C. diff pcr test was collected and
gave a positive result. Since the specimen was collected after day three of admission, and the
patient had transferred locations this could not be considered a duplicate result, but instead had to
be reported as an HAI even though the organism was present on admission. If that HAI result
had been excluded, then both the experimental and control unit would have had two HAIs each
during the study period. However, since the HAI was included in the results it shows a need for
further studies to be conducted in regards to safe zones and the impact it has on nosocomial rates.
Limitations
The HCWs found the Safe Zone Research Project beneficial. Most hope that it will
continue on their respective unit. However, this doesn’t mean that the study was without
limitations. The first limitation was the length of the study. This study was a pilot program.
Therefore, the two- month timeframe was not long enough to engage a large enough sample from
contact and contact-enteric areas of the facility to produce statistically significant results. Only
30 patients utilized safe zones during the two- month trial. Because safe zones are only being
trialed in contact and contact-enteric precaution rooms for one unit, extending the study would
42
provide more data from more patients. A second limitation was only having one unit implement
safe zones, thereby causing survey response to be low. Survey participation was limited to those
staff working in the safe zone region. The small sample size was contingent upon limited time
and resources, thereby minimizing the response rate. If the researcher were allowed to implement
safe zones in multiple units, survey participation could have been larger and therefore more
representative of AnMed Health’s HCWs and their perspectives on utilizing safe zones in the
facility.
Other limitations were associated to the implementation of the intervention. The safe
zone information sheet (see Appendix A) was given to staff members prior to implementation.
However, the survey revealed that some workers were still unsure of whether or not they utilized
the zones correctly. Yellow tape was placed in a few of the droplet precaution rooms, even
though they were not approved for this type of isolation patient. This warrants the need for
further discussion to the staff about the safe zones and their use before implementation. Placing
and removing the yellow tape was also noted to be a limitation of the study. Because room size is
not standard the staff was unsure where to place the tape. Environmental Services workers were
instructed to remove the tape upon discharge of the contact and contact-enteric patient. In a few
cases the tape was never removed and a new patient was admitted to that room with the tape on
the floor. These type of procedural errors led staff to be confused as to which patients were to
receive the intervention.
Summary
Recommendations for Action
The findings of this study suggest that the staff at AnMed Health utilizing safe zones is in
favor of the new initiative staying on their unit, and continued use for contact and contact-enteric
43
precaution patients. HCW satisfaction scores from AnMed Health are comparable to results that
Trinity Regional Health Center and Fletcher Allen Health Care both obtained. New initiatives,
like safe zones, have the ability to change how HCWs interact with contact and contact-enteric
precaution patients. The zones will allow for greater patient interaction and allow patients to feel
less isolated. However, these new practices will only be beneficial from a public health
perspective if HAIs do not increase in the process of implementation. Even though HAIs
decreased for the experimental unit at AnMed Health the control unit still had better HAI rates
during the study period. The Safe Zone Research Project proves that the need for more research
in this area is vital. There is a gap in literature regarding the impact safe zones or red boxes have
on nosocomial infections.
Recommendations for Further Study
The results of this experimental inquiry support recommendations for further study.
First, some of the limitations could be avoided if there was more education on where to place and
purchase the yellow tape (zones) before implementation. The principal investigator could add an
observation protocol to ensure compliance with tape placement. An observation checklist could
be utilized to measure staff compliance with placing the yellow tape in the correct location,
wearing PPE when outside of safe zones and continuing to practice hand hygiene when entering
and exiting a patient’s room. The addition of observations can increase the validity (accuracy
and credibility) of the study by using a data collection method called data triangulation. Data
Triangulation is “when multiple methods of data collection are used to study one phenomenon
(Bui, 2014). Observations will also ensure that the zones are being utilized correctly, and staff
is adhering to wearing PPE when not inside of the safe zone.
44
The survey results showed that HCWs, on the experimental unit, wanted to keep the safe
zones in place for contact and contact-enteric precaution patients. However, no data was
collected on how the patient felt about the zones and whether or not they felt communication and
observation increased because of the zones. A second recommendation for future studies is to
include the perspective of patients by giving them a survey to fill out on safe zones. Including the
patient perspective will not only provide another sampling population, but will also solidify the
public health domain for continued health improvement and health protection. Patient’s input on
safe zones will help establish a new standard of practice for care for these contact and contact-
enteric patients if they are in favor of the zones as much as HCWs were.
Unfortunately, there is little information in the literature review on safe zones or “red
boxes” and its impact on HAIs. Even though The Safe Zone Research Project conducted at
AnMed Health showed an improvement of HAIs for the experimental unit, it did not produce
better results than the control unit that did not utilize safe zones. Because of the inconclusive
data further studies are warranted on the correlation between safe zones and whether or not HAIs
increase or decrease. The zones need to be expanded to other units and the research trial needs to
be extended to produce more concrete results.
Something as simple as yellow tape can do so much for HCWs, their patients and the
hospitals in which they work. Although more research may need to be completed in regards to
safe zones, the results of this study should be more than enough reason for AnMed Health
Medical Center and other healthcare organizations to seriously consider the implementation of
safe zones. More and more patients are being put on contact precautions due to antimicrobial
resistance problems, or contact-enteric precautions because of increased C. difficile cases. A low-
cost response to this increase in the form of new initiatives that encourage more interaction with
45
these patients while minimizing risk to HCWs is of the utmost importance in the future. It is hard
to put a price tag on what this inexpensive tape does for the patients; not only does it increase
interaction, but it is proven to increase HCW satisfaction. More data should still be collected in
regards to whether or not safe zones increase HAIs, but these zones are proven to be effective
and HCWs are in favor of them. Safe zones save time, save money and allow organizations to
better treat their contact and contact-enteric precaution patients.
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AppendicesAppendix A
The Safe ZoneWhat is the Safe Zone?
Safe Zones are to be used for Contact and Contact-Enteric isolation rooms only.
Area sectioned off by yellow tape three feet from the patient’s bed/environment (bedside chairs).
Area is for staff to use when COMMUNICATION or OBSERVATION of patients is necessary without physical contact (examples: Reassessing pain medication response, Simple communication with patient, find out patient needs prior to entering room).
Hand Hygiene is still required per policy (when entering/exiting patient rooms).
If ANY contact with the patient or environment is necessary, appropriate PPE must be worn.
Any time staff needs to cross yellow line (safe zone) the appropriate PPE must be worn.
EVS has already trialed tape in their department to ensure tape will be able to be cleaned properly and work well with AnMed’s flooring.
How to use?
When hanging patient isolation caddy, place a piece of yellow tape 3 feet (roughly 2 ½ ceiling tiles) from patient bed/environment on Contact and Contact-Enteric isolation rooms.
Patient Education
Important to educate patients and their family about the safe zone if being used
Inform patients and visitors what the safe zone is, and its utilization. Inform them that PPE will be worn if any treatments/patient contact is
necessary.
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Appendix B
Staff Survey for Safe Zones (yellow taped placed in contact and contact-enteric precaution rooms) Implemented on 4 Center: This is a voluntary survey, and answering the survey implies consent. Please circle best response
Position: RN NA MD Other
1) How has communication changed between you and your patient since implementing safe zones? Do you communicate….Less often Same as before implementation More often
2) With the safe zone in place how often do you check on your patient?Less often Same as before implementation More often
3) Do you feel like your patients’ needs are being met because of the safe zone?Less often Same as before implementation More often
4) How often does staff perform hand hygiene upon entering and exiting a patient’s room since the safe zones were implemented?Less often Same as before implementation More often
5) Is staff wearing PPE when outside of safe zonesLess often Same as before implementation More often
6) Do you feel like time is saved because you do not have to don PPE when inside the safe zone?Yes No Other: (please explain)____________________________________________
7) Are you more comfortable because PPE does not have to be worn when you are just communicating/observing the patient?Yes No Other: (please explain)____________________________________________
8) Do safe zones provide less of a barrier in caring for precaution patients?Yes No Other: (please explain)____________________________________________
9) Do you think all staff is adhering to the safe zone the way it was intended to be used?Yes No Other: (please explain)____________________________________________
10) Should safe zones continue on this unit?Yes No Other: (please explain)____________________________________________
Additional Comments: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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