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

v

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

2

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;

5

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

6

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

7

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).

8

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

10

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”.

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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.

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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.

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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.

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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

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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

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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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