Monitoring Protocol Adherence and
Documentation of Skin Reactions
Two documents were created and maintained
throughout the study period to assess and report
nurses’ adherence to the PHHP.
1. Nurse documentation of protocol adherence:
a daily report in the electronic medical record of the
frequency of nurse documentation of yes, no, and
provided comments to the PHHP.
2. Nurse adherence audit: a biweekly audit completed
by a nurse on the study team observing frequency
and timeliness of nurses’ completion of the
PHHP. Report results were compared biweekly to
measure nurses’ adherence to the protocol (Figure 2).
Protocol adherence was defined as washing the
patient’s hands at 8 AM, 2 PM, and 8 PM. A 1-hour
grace period for the nurse to wash the patient’s hands
was established. Nurses were prompted with a timesensitive
reminder in the electronic medical record to
document all 3 patient hand hygiene episodes, as
well as assess the patient’s hands for cracking, fissures,
scales, redness, and dryness during hand hygiene. The
repeated use of CHG had the potential to remove
protective substances on the surface of the hands,
making the hands more pliable with greater risk for
cracks and fissures.19 Skin assessment criteria originally
developed by Frosch and Kligman20 to study
skin reactions to soaps were adapted for the study to
evaluate skin reactions to CHG use (Table 1). If skin