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ORIGINAL ARTICLE
Year : 2018  |  Volume : 11  |  Issue : 3  |  Page : 210-214  

Hand hygiene compliance among health-care personnel in intensive care unit of a tertiary care super specialty institute


1 Department of Microbiology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Microbiology, Mayo Institute of Medical Sciences, Barabanki, Uttar Pradesh, India

Date of Web Publication29-Jun-2018

Correspondence Address:
Meenakshi Sharma
Department of Microbiology, Mayo Institute of Medical Sciences, Barabanki - 225 001, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.MJDRDYPU_194_17

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  Abstract 


Introduction: Hospital-acquired infections complicate 7%–10% of hospital admissions. Patients in the Intensive Care Units (ICUs) are more likely to be colonized or infected. Most of these infections are spread by carriage of microorganisms on the health-care workers' (HCW) hands. Hand hygiene (HH) is the single most important measure to prevent this. Despite relative simplicity of HH procedures and recommendations, compliance with HH is still poor. Aim and Objectives: To assess HH compliance among health-care personnel in the ICU of Ram Manohar Lohia Institute of Medical Sciences, Lucknow. Materials and Methods: A prospective cross-sectional observational study using direct observation technique was done. A single observer collected all HH data. A survey was done, before the study, pertaining to perception and knowledge, opportunities, steps, actions, and attitude toward HH. The nursing staff, doctors, and allied health-care personnel were taken as a sample size. The observations were noted for all five moments of HH before and after patient contact. Results: A total of 10 HCW were observed over 50 h of observation period, spread over 1 month, which created 535 HH opportunities. HH actions actually performed by the HCW were 498, and overall compliance of the study group was 93.1%. Conclusion: The average level of compliance with recommended HH techniques among health-care personnel was 93.1% which is appropriate for critical care areas.

Keywords: Hand hygiene compliance, health-care personnel, healthcare-associated infections


How to cite this article:
Sen M, Sharma M, Das A, Singh AK. Hand hygiene compliance among health-care personnel in intensive care unit of a tertiary care super specialty institute. Med J DY Patil Vidyapeeth 2018;11:210-4

How to cite this URL:
Sen M, Sharma M, Das A, Singh AK. Hand hygiene compliance among health-care personnel in intensive care unit of a tertiary care super specialty institute. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2019 Jul 17];11:210-4. Available from: http://www.mjdrdypv.org/text.asp?2018/11/3/210/235558




  Introduction Top


Healthcare-associated infections (HAIs) have been a problem worldwide affecting a significant number of hospitalized patients. World Health Organization (WHO) had estimated that globally, 7%–12% of hospitalized patients will acquire health HAIs.[1] International Nosocomial Infection Control Consortium in 2007 had reported an overall HAI incidence rate of 4.4% corresponding to 9.06 infections per 1000 Intensive Care Units (ICU) days from 7 Indian cities.[2]

Patients in the ICUs are more likely to be colonized or infected during their hospital stay. Most of these infections are transmitted to the patients by carriage of microorganisms on the hands of health-care workers (HCW) while handling patients.[1] Hand hygiene (HH) is one of the most important measures to prevent HAIs.

HH is a general term that applies to handwashing, antiseptic hand wash, alcohol-based hand rub, or surgical HH/antisepsis.[1] While these measures as simple and inexpensive as handwashing with soap and water can be implemented to reduce HAIs and save millions of lives, compliance with it is still low in developing countries.[3],[4] This may be attributed to lack of proper knowledge and recognition of HH opportunities during patient care.[5]

To address this problem, continuous efforts are being made to identify effective and sustainable strategies. One of such efforts is the introduction of an evidence-based concept of “My five moments for HH” by World Health Organization which includes use of HH before touching a patient, before performing aseptic and clean procedures, after being at risk of exposure to body fluids, after touching a patient, and after touching patient surroundings.[6]

In India, technology to monitor adherence may not be available at every hospital setting; direct observation remains the gold standard. With this aim, we attempted to assess HH compliance among HCW in the ICU of a tertiary care super specialty institute in North India by direct observation method.


  Materials and Methods Top


The present study was a cross-sectional observational study. The ICU staff (10 HCW, namely doctors, outsource nursing staff and nursing staff Grade II, and allied health-care personnel) posted in ICU were taken as sample population. All the ICU staff were briefed about the current HH practices and five moments of HH which included use of HH before touching a patient, before performing aseptic and clean procedures, after being at risk of exposure to body fluids, after touching a patient, and after touching patient surroundings as per WHO guidelines before starting the study. A survey was done, before the study, by filling a questionnaire. The questionnaire was to access the perception, knowledge, opportunities, steps, actions, and attitude toward HH.

The ICU staff was observed for HH compliance by a single observer for 2 h/working day for 1 month. The observations were noted for all five moments of HH as opportunity utilized or missed in a checklist where a tick was placed if the HH practice was adhered to by the HCW when the opportunity for the same is there. The kind of HH practice (hand wash, hand rub, or wearing gloves) which was practised by the HCW was also noted. To reduce Hawthorne effect, the observer visits ICU randomly with no fixed schedule.

Statistical analysis

The data were recorded and analyzed in Microsoft Office Excel Sheet 2013. Data have been represented as frequencies and percentages.


  Results Top


During the study, a total of 10 HCW were observed over 50 h of observation period, spread over 1 month, which created 535 HH opportunities [Figure 1]. The HCW comprised of one non-PG resident, five nursing staff Grade II, three outsource nursing staff members, and one housekeeping staff posted in the ICU.
Figure 1: Hand hygiene opportunities (n=535)

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Total HH opportunities during the study period were 535 (242 [45.2%] from the outsource nursing staff, 226 [42.2%] from the hospital nursing staff Grade II, 21 [3.9%] from resident doctor, and 46 [8.5%] from housekeeping staffs). HH actions actually performed by the HCW were 498 and overall compliance of the study group was estimated as 93.1%.

Maximum hand-hygiene compliance among health care staff was seen after fluid exposure which is moment 3 of HH moments. Analysis of the survey showed that 100% of the health-care staff had knowledge about HH methods. However, only 90% of HCW had knowledge about the correct method of performing HH. Only 50% had knowledge about the timing of performing hand wash and hand rub. Thirty percent of HCW were found wearing jewelry and wrist watches while washing hands.

Except for before aseptic procedure and after fluid exposure for all the other opportunities, hand rub was the most common HH practice. Before aseptic procedure, wearing gloves was the most common practice.


  Discussion Top


Proper HH is the single most important, simplest, and least expensive means of reducing the prevalence of HAIs and the spread of antimicrobial resistance.[7],[8] Several studies have demonstrated that handwashing virtually eradicates the carriage of MRSA which invariably occurs on the hands of HCW working in ICUs.[9] In most health-care institutions, adherence to recommend handwashing practices remains unacceptably low, rarely exceeding 40 percent of situations in which HH is indicated.[10],[11] Patients in the ICUs are more likely to be colonized or infected by harmful and multidrug-resistance microorganisms carried on the HCW hands.

Total 535 HH opportunities were observed during the study period. HH actions actually performed by the HCW were 498, and overall compliance of the study group was estimated as 93.1% [Table 1], [Table 2], [Table 3], [Table 4]. Which is higher as compared to other studies in India.[12],[13],[14],[15]
Table 1: Observed compliance for nursing staff Grade II

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Table 2: Observed compliance of outsource nursing staff

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Table 3: Observed compliance for resident

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Table 4: Observed compliance for housekeeping staff

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Compliance rate was lower in outsource nursing staff and housekeeping staff as compared to hospital nursing staff Grade II and doctor for all the opportunities. This result is consistent with study done by Sharma et al. which observed compliance of 43.2%, and it was more in doctors (50.8%) than nurses (41.3%).[12] In contrary, Pittet et al. observed compliance of 48% and nurses had the highest handwashing adherence rates (52%), while physicians were the worst offenders (23%).[11]

Maximum compliance was seen after body fluid exposure, that is, the staffs were very careful after body fluid contact as it was perceived important for self-protection. Statistically significant (P < 0.05) difference was seen in HH compliance before patient contact and after patient contact.

Almost all the HCW included in the study perceived HH as useful measure to prevent hospital-acquired infections; yet, the knowledge was not converted to actions. In response to the questionnaire, 100% of the health-care staff claimed to have knowledge about HH methods. However, only 50% had knowledge about the correct timing of performing hand wash and hand rub. About 30% of HCWs were found wearing jewelry and wrist watches while washing hands.

Hand rub was the most common HH practice (significant difference: P <0.001) followed by the participants for most of the opportunities except before aseptic procedure and after fluid exposure for which the participants preferred washing hands over using hand rub. Wearing gloves was the most common practice (significant difference: P <0.001) before aseptic procedure as it is considered safe and less time-consuming by the participants.

Less time in emergency situations, lack of knowledge, and allergy to soap/hand rub were the most common reasons given by the participants for lack of compliance.

Limitations

Direct observations have limitations; they are time-consuming, workforce intensive, and do not allow continuous monitoring. They probably provide information about a very low percentage of all HH opportunities. If staff is aware, direct observation may affect health-care personnel behavior (Hawthorne effect). We have tried to limit these difficulties by engaging a single trained observer. However, there could be opportunities that were missed. The sample size in our study was very low which may have affected the overall results.


  Conclusion Top


The average level of compliance with recommended HH techniques among health-care personnel was 93.1% which is appropriate for critical care areas. Routine observation of HCW can also help in evaluation of HH technique and can check compliance rates among different health-care personnels.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Hand Hygiene Knowledge Questionnaire

S.no Date Time Department

  1. Junior resident/Senior resident/Faculty/Nursing staff/Other health-care worker
  2. Knowledge about hand hygiene recommendations: Yes/No
  3. Hand hygiene refers to


    1. Handwashing using soap
    2. Handwashing using alcohol hand rub
    3. Decontaminating using 4% chlorhexidine
    4. All the above.


  4. When to perform hand hygiene:


    1. Before touching a patient
    2. Immediately after a risk of body fluid exposure
    3. After exposure to the immediate surroundings of a patient
    4. Immediately before a clean/aseptic procedure.


  5. Knowledge about technique of hand hygiene: Yes/No
  6. Duration of hand hygiene:


    1. 5 s
    2. 10 s
    3. 15 s
    4. 60 s.


  7. Hand hygiene performed


    1. Before patient contact Yes/No
    2. Before aseptic procedure Yes/No
    3. After body fluid exposure Yes/No
    4. After patient contact Yes/No
    5. After contact with patient surroundings Yes/No


  8. Which type of hand hygiene method is required in the following situations?


    1. Before palpation of the abdomen


      • Rubbing/Washing/None


    2. Before giving an injection


      • Rubbing/Washing/None


      • After emptying a bedpan


        • Rubbing/Washing/None


      • After removing examination gloves


        • Rubbing/Washing/None


      • After making a patient's bed


        • Rubbing/Washing/None


      • After visible exposure to blood


        • Rubbing/Washing/None


  9. Wearing jewellery or wrist watch while washing hands: Yes/No
  10. Which of the following should be avoided, as associated with increased likelihood of colonization of hands with harmful germs?


    1. Wearing jewellery
    2. Damaged skin
    3. Artificial fingernails
    4. Regular use of a hand cream.




 
  References Top

1.
Dayanand M, Rao S. Prevention of hospital acquired infections: A practical guide. Med J Armed Forces India 2004;60:312.  Back to cited text no. 1
    
2.
Mehta A, Rosenthal VD, Mehta Y, Chakravarthy M, Todi SK, Sen N, et al. Device-associated nosocomial infection rates in Intensive Care Units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC). J Hosp Infect 2007;67:168-74.  Back to cited text no. 2
    
3.
Asare A, Enweronu-Laryea CC, Newman MJ. Hand hygiene practices in a neonatal Intensive Care Unit in Ghana. J Infect Dev Ctries 2009;3:352-6.  Back to cited text no. 3
    
4.
Karaaslan A, Kepenekli Kadayifci E, Atıcı S, Sili U, Soysal A, Çulha G, et al. Compliance of healthcare workers with hand hygiene practices in neonatal and pediatric Intensive Care Units: Overt observation. Interdiscip Perspect Infect Dis 2014;2014:306478.  Back to cited text no. 4
    
5.
Anargh V, Singh H, Kulkarni A, Kotwal A, Mahen A. Hand hygiene practices among health care workers (HCWs) in a tertiary care facility in Pune. Med J Armed Forces India 2013;69:54-6.  Back to cited text no. 5
    
6.
World Health Organization. WHO Guidelines on Hand Hygiene in Health Care: A Summary; 2005. Available from: http://www.who.int/patientsafety/events/05/HH_en.pdf. [Last accessed on 2018 Jan 24].  Back to cited text no. 6
    
7.
Guide to Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy. Available from: http://www.who.int/patientsafety/en/. [Last accessed on 2018 Jan 24].  Back to cited text no. 7
    
8.
Smith SM. A review of hand-washing techniques in primary care and community settings. J Clin Nurs 2009;18:786-90.  Back to cited text no. 8
    
9.
Mathur P. Hand hygiene: Back to the basics of infection control. Indian J Med Res 2011;134:611-20.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Trampuz A, Widmer AF. Hand hygiene: A frequently missed lifesaving opportunity during patient care. Mayo Clin Proc 2004;79:109-16.  Back to cited text no. 10
    
11.
Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Infection control program. Ann Intern Med 1999;130:126-30.  Back to cited text no. 11
    
12.
Sharma S, Sharma S, Puri S, Whig J. Hand hygiene compliance in the Intensive Care Units of a tertiary care hospital. Indian J Community Med 2011;36:217-21.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Sharma R, Sharma M, Koushal V. Hand washing compliance among healthcare staff in Intensive Care Unit (ICU) of a multispecialty hospital of North India. J Hosp Adm 2012;1:27-33.  Back to cited text no. 13
    
14.
Ramasubramanian V, Iyer V, Sewlikar S, Desai A. Epidemiology of healthcare acquired infection – An Indian perspective on surgical site infection and catheter related blood stream infection. Indian J Basic App Med Res 2014;3:46-63.  Back to cited text no. 14
    
15.
Chavali S, Menon V, Shukla U. Hand hygiene compliance among healthcare workers in an accredited tertiary care hospital. Indian J Crit Care Med 2014;18:689-93.  Back to cited text no. 15
[PUBMED]  [Full text]  


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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