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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 2  |  Issue : 3  |  Page : 42-44

A study of hand hygiene technique in intensive care unit of a tertiary care hospital


1 Department of Anaesthesia, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
2 Department of Nephrology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India

Date of Web Publication25-Feb-2019

Correspondence Address:
Jitesh Jeswani
Department of Nephrology, Mahatma Gandhi Hospital, Sitapura, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sccj.sccj_28_18

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  Abstract 


Introduction: Hand hygiene (HH) has been characterized as the keystone and starting point in all infection control programs, with the hands of health-care faculty being the handler and advocates of infection in critically ill patients. Materials and Methods: This was a cross-sectional observational study using direct observation technique. A single observer collected all HH data. This single-observer study was conducted in the 45-bedded intensive care unit (ICU) of Mahatma Gandhi Hospital. HH compliance was monitored using the hand hygiene observation form developed by the World Health Organization. A nonidentified observer was used for monitoring compliance with HH. Results and Discussion: A total of 900 observations were recorded from health-care personnel in ICU. With respect to the personnel, the nursing department had the highest number of observations as 400 circulating nurses were sampled. There were also 110 senior consultants, 250 resident doctors, and 140 paramedical staffs. Of the total opportunities, nurses had the highest number of contacts (67%), followed by allied health-care workers (82.94%). The average compliance was about 75%, which differed significantly among health-care workers, with higher compliance among the nursing staff (82.9%) followed by allied staff (67%). Of the average overall compliance of 75%, maximum compliance was seen for moment 3, that is, the staffs were very careful after body fluid contact as it was perceived important for self-protection. The HH instances after patient contact (86.29%) also suggested similarly. The nurses' compliance was 64.40% before patient contact and 68.35% after touching surroundings. Conclusion: The observance of HH is still low in our local environment. Handwashing practices in our study show that health-care workers pay attention to HH, when it appears, there is a direct observable threat to their well-being. Educational programs need to be developed to address the issue of poor HH.

Keywords: Hand hygiene, infection control, intensive care unit


How to cite this article:
Vaya S, Jeswani J. A study of hand hygiene technique in intensive care unit of a tertiary care hospital. Saudi Crit Care J 2018;2:42-4

How to cite this URL:
Vaya S, Jeswani J. A study of hand hygiene technique in intensive care unit of a tertiary care hospital. Saudi Crit Care J [serial online] 2018 [cited 2023 Feb 3];2:42-4. Available from: https://www.sccj-sa.org/text.asp?2018/2/3/42/252891




  Introduction Top


Hand hygiene (HH) has been characterized as the keystone and starting point in all infection control programs, with the hands of health-care faculty being the handler and advocates of infection in critically ill patients. HH has been distinguished as the conducting intervention strategy that will suppress the cross-transmission of microorganism in the health-care environment. It has been proven to decline the prevalence of nosocomial infections.[1],[2]

Health-care-associated infections (HAIs) influence 1 in 20 hospitalized patients.[3] Patients in the intensive care units (ICUs) are more prone to infected by multidrug-resistant microorganisms. Most of such type of infections are escalated through the hand of health-care workers. HH is the single most effectual measure to prevent this spread.[4]

The World Health Organization (WHO) has developed an evidence-based measure of HH called the five moments of HH which refer to washing hands before touching a patient, before performing an aseptic or clean procedure, after potentials exposure to body fluids, after touching a patient, and after touching the patient surroundings.[5]

There are varying reports on the rates of contamination of the hand of health-care workers. Some studies report rates as high as 10%–78% among health practitioners, with Staphylococcus aureus being the predominant organism implicated.[6] The data obtained will also be used to develop rational interventional programs for the hospital in achieving best practices with respect to HH and ultimately efficient infection control programs. The aim of this study is to using multimodal technique to improve HH compliance among all health-care staffs for the past 6 months.


  Materials and Methods Top


This was a cross-sectional, observational study using direct observation technique. A single observer collected all HH data. This single-observer study was conducted in the 45-bedded ICU of Mahatma Gandhi Hospital.

Permission from local ethics committee was taken through proper channel.

HH compliance was monitored using the hand hygiene observation form developed by the WHO. A nonidentified observer was used for monitoring compliance with HH. The observation was conducted in a discreet manner in order not to let the staffs know that their HH practices were monitored. Daily five random observations were made. The observational period was over a 180-day period from January 2018 to June 2018.

The checklist in the assessment included the presence or absence of handwashing facilities with alcohol-based hand rubs. The nature and frequency of HH were also recorded for analysis. The assessment tools had the following components such as compliance with HH before touching a patient, after contact with the patient surroundings, after performing an invasive procedure, after contact with body fluids, and after the removal of gloves. Confidentiality was maintained as personal identity was not recorded.

The observations were noted for all five moments of HH before and after patient contact. A separate checklist was used for nursing and allied staffs. If an indication for HH was noted, a tick was placed on the checklist next to the relevant guideline, under the column “indication.” If HH occurred, another tick was inserted in the column “occurred.” If it did not occur, no insertion was made. The intensive care team did teachings and awareness on HH on the regular basis in the form of seminars and poster hangings.


  Results Top


A total of 900 observations were recorded from health-care personnel in ICU. With respect to the personnel, the nursing department had the highest number of observations as 400 circulating nurses were sampled. There were also 110 senior consultants, 250 resident doctors, and 140 paramedical staffs [Table 1].
Table 1: Hand hygiene observation made

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Of the total opportunities, nurses had the highest number of contacts (67%), followed by allied health-care workers (82.94%). The average compliance was about 75%, which differed significantly among health-care workers, with higher compliance among the nursing staff (82.9%) followed by allied staff (67%). Of the average overall compliance of 75%, maximum compliance was seen for moment 3, that is, the staffs were very careful after body fluid contact as it was perceived important for self-protection. The HH instances after patient contact (86.29%) also suggested similarly [Table 2]. The nurses' compliance was 64.40% before patient contact and 68.35% after touching surroundings. The nursing staff did better with a fairly equal distribution across all moments. The HH compliance for moment 5, that is, after touching patient surroundings, was poor across all staffs [Table 3]. We noted no difference in compliance rates between day and night times. However, the compliance level decreased when the ICU was busy, especially during acute resuscitation settings or if multiple admissions occurred simultaneously.
Table 2: Compliance of hand hygiene

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Table 3: Observed compliance for nursing staff

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  Discussion Top


The nurses had an overall compliance of 82.9%, that is, comparable to the most other studies.[7],[8],[9],[10] They survive best for the WHO moments 3 and 4, that is, after body fluid exposure risk and patient contact with the compliance of 93% and 91%, respectively. This reflects an urge to protect oneself. They fared the worst for the WHO moment 2, that is, before aseptic procedure (39%). We found that most nurses clubbed moments 1 and 2 together and would not additionally perform HH before suctioning or doing any other clean procedure.

In a study by Marra et al.,[8] comparing the observational method, product use method, and electronic surveillance, the overall rate of HH adherence was found to be 62.3% (there were 2249 opportunities for HH observed and representing 1402 cleansing episodes). However, they did not collect data for individual moments.

The allied staff fared better overall with a compliance of 62%. All opportunities for allied staff were observed during daytime, and most of the patient contact was elective and planned. This could be one reason why they did better at HH adherence. In a study by Randle et al.,[10] a 24-h observational study, it was found that, of the total of 823 HH opportunities (health-care workers, n = 659; patient and visitors, n = 164), the compliance was 47% for doctors, 75% for nurses, 78% for allied health professionals, and 59% for ancillary and other staffs (P < 0.001).

Similarly, in a multicenter study in Poland, 95.6% hospitals had a written protocol for handwashing procedures, but according to the findings of the study, the compliance rates varied from 20% to 80%; although in most institutions, it was between 40% and 60%.[9]

In a study by Mathai et al.,[11] probably the first published Indian article on multimodal interventions, they have emphasized the importance of multimodal technique in improving HH compliance. They observed a large and significant difference pre- and postmultimodal interventions. In another study by Lam et al.,[12] they found that multimodal interventions such as educational sessions, posters, performance feedback, and verbal reminders have improved their HH rates.

The WHO has recommended guidelines for HH and its central theme is to wash hands with soap and water when it is visibly dirty or soiled with blood or other body fluids or after toilet use. The guidelines recommend washing with water and soap or an alcohol-based hand rub. Studies on the efficiency of alcohol-based hand rubs show that they have good efficacy. This concentration of alcohol ranges from 62% to 95%, thus ensuring that they are rapidly bactericidal.[13],[14]

Promoting the use of alcohol-based hand rubs in hospitals in the developing countries such as ours will also help drive down the rates of HAI as running water is not always available after patient contact or the performance of invasive procedures. Such alcohol-based hand rubs can be reconstituted in our local pharmacies and made available on a regular basis for hospital use.


  Conclusion Top


The observance of HH is still low in our local environment. Handwashing practices in our study show that health-care workers pay attention to HH, when it appears, there is a direct observable threat to their well-being. Educational programs need to be developed to address the issue of poor HH.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Scheithauer S, Kamerseder V, Petersen P, Brokmann JC, Lopez-Gonzalez LA, Mach C, et al. Improving hand hygiene compliance in the emergency department: Getting to the point. BMC Infect Dis 2013;13:367.  Back to cited text no. 1
    
2.
Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection control programme. Lancet 2000;356:1307-12.  Back to cited text no. 2
    
3.
Klevens RM, Edwards JR, Richards CL Jr., Horan TC, Gaynes RP, Pollock DA, et al. Estimating health care-associated infections and deaths in U.S. Hospitals, 2002. Public Health Rep 2007;122:160-6.  Back to cited text no. 3
    
4.
World Health Organization. Guidelines on Hand Hygiene in Health Care, 2009. World Health Organization; 11 September, 2014. Available from: http://www.whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf. [Last assesed on 2018 Dec 19].  Back to cited text no. 4
    
5.
Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D, et al. ‘My five moments for hand hygiene’: A user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 2007;67:9-21.  Back to cited text no. 5
    
6.
Kampf G, Kramer A. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clin Microbiol Rev 2004;17:863-93.  Back to cited text no. 6
    
7.
Stewardson A, Pittet D. Quicker, easier, and cheaper? The promise of automated hand hygiene monitoring. Infect Control Hosp Epidemiol 2011;32:1029-31.  Back to cited text no. 7
    
8.
Marra AR, Moura DF Jr., Paes AT, dos Santos OF, Edmond MB. Measuring rates of hand hygiene adherence in the intensive care setting: A comparative study of direct observation, product usage, and electronic counting devices. Infect Control Hosp Epidemiol 2010;31:796-801.  Back to cited text no. 8
    
9.
Heczko PB, Kleszcz P. Handwashing practices in polish hospitals: Results of a survey conducted by polish society of hospital infection. J Hosp Infect 2001;48 Suppl A: S47-9.  Back to cited text no. 9
    
10.
Randle J, Arthur A, Vaughan N. Twenty-four-hour observational study of hospital hand hygiene compliance. J Hosp Infect 2010;76:252-5.  Back to cited text no. 10
    
11.
Mathai AS, George SE, Abraham J. Efficacy of a multimodal intervention strategy in improving hand hygiene compliance in a tertiary level intensive care unit. Indian J Crit Care Med 2011;15:6-15.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Lam BC, Lee J, Lau YL. Hand hygiene practices in a neonatal intensive care unit: A multimodal intervention and impact on nosocomial infection. Pediatrics 2004;114:e565-71.  Back to cited text no. 12
    
13.
World Health Organization. World Health Organization Guidelines on Hand Hygiene in Health Care. Geneva: World Health Organization; 2009.  Back to cited text no. 13
    
14.
Zaragoza M, Sallés M, Gomez J, Bayas JM, Trilla A. Handwashing with soap or alcoholic solutions? A randomized clinical trial of its effectiveness. Am J Infect Control 1999;27:258-61.  Back to cited text no. 14
    



 
 
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  [Table 1], [Table 2], [Table 3]



 

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