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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 3  |  Page : 67-72

Objective assessment of hand hygiene: When we see it, we believe it!


Department of Infection Prevention and Control, KG Hospital and Post Graduate Medical Research Institute, Coimbatore, Tamil Nadu, India

Date of Web Publication4-Mar-2019

Correspondence Address:
Dr. Shikha Ranjan
KG Hospital and Post Graduate Medical Research Institute, No. 5, Government Arts College Road, Coimbatore - 641 018, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_10_18

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  Abstract 


Background: Hand hygiene is the fundamental and leading measure to prevent the spread of antimicrobial resistance and to reduce hospital-acquired infections. Several strategies are recommended to increase the compliance for hand hygiene practice; however, health-care worker (HCW) compliance with optimal practices remains low in most settings.
Aim: This study aims to assess the efficacy of hand hygiene practice in HCWs at our hospital, and to demonstrate objective result of their practices, followed by a questionnaire-based study to assess their attitude towards hand hygiene, and effect of workshop on their hand hygiene practice pattern.
Materials and Methods: Participants were asked to disinfect their hands using a hand rub solution mixed with the fluorescent dye. Photos were taken under an ultraviolet lamp. A self-designed questionnaire was given to all the participants.
Results: A total of 94 HCWs participated in the hand hygiene workshop. Only 11.11% nurses (6/54) and 17.5% doctors (7/40) were able to use disinfectant solution with complete coverage of hand areas. Incomplete coverage of dorsum of hand was more common than that of palms. About 84.21% doctors (32/38) and 80% nurses (36/45) wanted to participate in such hand hygiene workshop in future with majority of them opting for frequent workshop. All the participants admitted that such workshop changed their attitude towards their practice pattern.
Conclusion: It is important to carry out hand hygiene training programmes regularly to achieve increased compliance with hand hygiene practices. This study also emphasises that an objective technique of demonstration has a greater effect in changing professional's attitude towards hand hygiene.

Keywords: Alcohol-based hand rub, fluorescent dye, hand hygiene, hospital acquired infection, multidrug-resistant organisms


How to cite this article:
Ranjan S, Venkatesan D, Devi R. Objective assessment of hand hygiene: When we see it, we believe it!. J Patient Saf Infect Control 2018;6:67-72

How to cite this URL:
Ranjan S, Venkatesan D, Devi R. Objective assessment of hand hygiene: When we see it, we believe it!. J Patient Saf Infect Control [serial online] 2018 [cited 2019 Jul 23];6:67-72. Available from: http://www.jpsiconline.com/text.asp?2018/6/3/67/253382




  Introduction Top


Hospital-acquired infections (HAI) or nosocomial infections are infections which are acquired in a healthcare setting. In the United States, the centres for disease control and prevention estimated roughly 1.7 million hospital-associated infections that contribute to around 99,000 deaths each year.[1] While World Health Organization (WHO) estimates about 7%–12% HAI burden in hospitalized patients globally, the figures from India are alarming, with an incidence rate varying from 11% to 83% for different kinds of HAI.[2] Although it is impossible to eliminate nosocomial infection completely, its incidence, and hence associated hospital cost, morbidity and mortality can be reduced considerably by following recommended guidelines to prevent HAI.[3]

Hand hygiene is the fundamental leading measure to ensure patient safety by reducing HAI and preventing the spread of antimicrobial resistance.[4] The methods used for hand hygiene during patient care include hand washing with plain or antimicrobial soap and hand rubbing with alcohol-based hand rubs (ABHR). However, health-care worker (HCW) compliance with optimal hand hygiene practices remains unacceptably low in most settings of health-care contributing to the transmission of microbes capable of causing avoidable HAIs.[5] Several strategies are recommended for increased compliance; however, the strategy showing the most promising result is the objective demonstration using the fluorescent dye in the ABHR.

Despite many studies being conducted about the hand hygiene compliance in the HCWs, there is paucity of data from the Asian subcontinent. Furthermore, most of these studies are questionnaire based. There are only a very few studies using ABHR and using an objective method. We conducted a study with aim to assess the efficacy of hand hygiene practice in HCWs at our hospital, and also to demonstrate objective result of their practices to them by conducting 'Hand Hygiene Workshop', followed by a questionnaire-based study to assess their attitude towards hand hygiene, and to assess the effect of objective assessment on their approach towards hand hygiene practice pattern.


  Materials and Methods Top


This two-step cross-sectional study was conducted at KG hospital and Postgraduate Research Institute, Coimbatore, India. The study population included both nursing as well as medical staffs. Nursing group included a mixed population of trainees and trained nurses posted in intensive care units and various departments, while medical group included consultants and postgraduate doctors. All nurses and doctors who participated in either first or both steps of study were included. Those who were not willing to participate in the study were excluded from the study.

This study was conducted in two steps. In first step, a workshop was organized for qualitative assessment as well as objective demonstration of the efficacy of hand hygiene practices among HCWs with separate sessions for medical and nursing staffs. Participants were asked to disinfect their hands using a hand rub solution, Sterillium (Bode Chemie Hamburg) mixed with the fluorescent dye Visirub (Bode Chemie Hamburg) in the manufacturer's recommended ratio (10 ml of visirub in 500 ml of Sterillium)[6] [Figure 1]. The disinfection procedure was supposed to achieve a complete coverage of all the areas of the hand. For qualitative assessment of efficacy of hand hygiene practice,[7] photos of air-dried palms and backs of the hands in upright position were taken under an ultraviolet (UV) lamp with a standardised camera setting.
Figure 1: The Sterillium and Visirub used for the objective demonstration of hand hygiene technique

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In second step, a self-designed questionnaire was given to all participants who attended the workshop to assess their knowledge and attitude towards hand hygiene practices [Figure 2]. The questionnaire contained 10 items with both 'Yes' or 'No' questions and multiple choices, where the option to select on a 0–4-point scale between not effective and very effective or no effort and big effort were given. For nursing staffs, questionnaire was translated into Tamil language, while English questionnaire was used for doctors. They were asked to fill out this short questionnaire, and to return the filled questionnaire to the department of microbiology within a week period.
Figure 2: The questionnaire used for the study

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For data collection in the first step of study, photographs collected using UV lamp was used for qualitative analysis. For every participant, total four photographs (palms and dorsa of both hands) were analysed. An untreated skin area was defined as a gap of fluorescent dye on the hands [Figure 3]a and [Figure 3]b. The result was shown to each participant and was used to demonstrate them that how efficacious was their hand hygiene practice using ABHR. For the second step of the study, questionnaire responses of participants returned to the department of microbiology, within a week period, were analysed. GraphPadInstat software was used for all data analyses. Descriptive statistics was used to calculate the percentage for the results of first and second step of the study. Comparative analysis was done to compare the difference in results between nursing and medical staffs.
Figure 3: (a) The photographs showing fluorescent gaps indicating missed areas in the dorsa of hand following hand disinfection by alcohol-based hand rubs. (b) The photographs showing fluorescent gaps indicating missed areas in the palm of hand following hand disinfection by alcohol-based hand rubs

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  Results Top


A total of 94 HCWs, including 54 nurses (24 trained and 30 trainees), and 40 doctors (15 consultants and 25 postgraduates), participated in the first step of study i.e., hand hygiene workshop. Only 11.11% nurses (6/54) and 17.5% doctors (7/40) were able to use disinfectant solution with complete coverage of hand areas. In the nursing group, 4 trained nurses (16.67%) could correctly apply the sterilising solution compared to 2 trainee nurses (6.67%). In the medical group, 3 consultants (20%) and 4 postgraduates (16%) could apply disinfectant solution with complete coverage of their hands.

In both nursing as well as medical groups, incomplete coverage of dorsum of hand was more common than that of palms. In the nursing group, 47.91% nurses (23/48) were recorded with incomplete coverage in dorsum of the hand, 33.33% (16/48) with incomplete coverage of both dorsum as well as palm, and 18.75% (9/48) with incomplete coverage of only palm. Similarly, in medical group, 36.36% doctors (12/33) were noted with incomplete coverage of dorsum of the hand, 33.33% (11/33) with incomplete coverage of both dorsum as well as palm, and 30.30% (10/33) with incomplete coverage of palm only. With incompletely covered dorsa, the most commonly missed area was nail-beds followed by distal part of back of hand in both nursing as well medical group. Similarly, with incompletely covered palm, the most commonly missed area was creases of palms and fingers in both nursing as well as medical groups.

The analysis of data collected from response to questionnaire was used to assess the HCWs' attitude towards hand hygiene practice. Although the questionnaire was distributed to all 94 participants in the workshop, the completely filled questionnaire was returned to the department of microbiology by 83 participants including 45 nurses and 38 doctors. Results have been summarised in [Table 1].
Table 1: Results summarised from questionnaire response of healthcare workers

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Majority of HCWs 63.16% doctors (24/38) and 66.67% nurses (30/45) did not receive any education regarding hand hygiene practice and its importance during the past 1 year. However, most of the staffs said that they are routinely using an alcohol-based sterilising solution for hand hygiene.

Effort taken to practice hand hygiene measures was assessed on a scale of 0–4. Among doctors, 5.26% (2/38) were practicing hand hygiene measures effortlessly-0, 10.53% (4/38) needed big effort-4, while majority needed some amount of effort for hand hygiene practice with 26.32% (10/38)– 1, 26.32% (10/38%)– 2 and 31.58% (12/38)– 3. Among nurses, 100% had to take some effort to maintain hand hygiene practice with scale of 1–6.67% (3/45), 2–46.67% (21/45), 3–26.67% (12/45) and 4–20% (9/45). In medical group, only 31.58% doctors (12/38) were performing hand hygiene practice without needing any form of reminder, while 47.37% (18/38), 5.26% (2/38) and 15.79% (6/38) needed some form of reminder sometimes, often and always respectively at various moments of hand hygiene. Majority of them wanted posters (84.21%) as a routine reminder at various moments of hand hygiene, followed by nurses (21.05%) to remind them about use of hand rub. In nursing group, 53.33% (24/45) were using hand rub solution without any reminder, while 20% (9/45), 6.67% (3/45) and 20% (9/45) needed some form of reminder sometimes, often and always, respectively. For nurses also, poster was the most accepted (80%) reminder tool at various moments of hand hygiene.

Workshop was found very effective by all the staffs, nursing as well as medical (94.74% and 60% respectively) in clearing their concepts about how to perform hand hygiene practice using ABHR. In medical group, 94.74% doctors (36/38) rated the efficacy of this workshop as 4/4, and remaining 5.26% doctors (2/38) rated this workshop as 3/4. In nursing group, 60% (27/45), 33.33% (15/45) and 6.67% (3/45) nurses rated the efficacy of this workshop as 4, 3 and 2 out of 4 respectively.

Majority of staffs showed their interest to participate in a similar workshop if conducted in futures. In medical and nursing groups, 84.21% doctors (32/38) and 80% nurses (36/45) wanted to participate in such hand hygiene workshop with objective demonstration of efficacy of their practices. In medical group, majority of doctors wanted such workshop at least twice in a year with 31.25% doctors (10/32) opted for monthly, bimonthly and half-yearly each, while only 6.25% (2/32) would like to participate in annual workshop. Similarly, all the nurses wanted to be part of such workshop at least twice in a year with 50% (18/36), 25% (9/36) and 25% (9/36) opting for monthly, bimonthly and half-yearly conduction respectively.

In both groups, 100% doctors as well as nurses admitted that the objective demonstration of the efficacy of hand hygiene practice has changed their attitude towards their practice pattern. Majority of doctors (94.74%, 36/38) as well as nurses (86.67%, 39/45) had no problem in revealing the result of the future workshop.


  Discussion Top


Although hand hygiene is the simplest and most cost-effective method to prevent transmission of HAI and multidrug-resistant organisms, it is the most neglected entity. The recommendation on hand hygiene has been updated, and hand washing has been replaced by hand-rub as the standard of care if there is no obvious soiling of hand.[8],[9] ABHR are used worldwide for their rapid antimicrobial effects, broad-spectrum coverage, better tolerability and ease of application.[10] However, the failure to translate awareness of hand hygiene into compliance has been shown to be a major problem among HCWs in various studies.[11],[12] The most common reason for HCWs not performing hand hygiene practice is their belief that clean looking hands cannot cause harm.[13] Another problem in maintaining hand hygiene among those who are compliant for hand-rub practice is their inability to realise whether hand-rub application covers their hand optimally or not.

Recently, a study has validated objective and qualitative assessment of hand hygiene technique using UV dye-based hand rub solution and found that the method indicates correctly disinfected areas with 95.05% sensitivity and 98.01% specificity.[14] Another study has shown that a 45 min standardised peer-teaching training for hand disinfection procedures including surgical scrubbing is sufficient to improve the measurable coverage of hand area and reduce the infection gap by one-third. In this study fluorescence dye mixed disinfectant solution was used to quantify the coverage of hand area with disinfectant solution, and was found that insufficiently covered hand area after the training in intervention group was only 4.99% compared to 7.33% of that in control group.[15]

Similar to previous studies, in our study also dorsa of the hand were more frequently missed as compared to the palms during hand hygiene practice. Other studies using fluorescent dye-based technique also had a similar finding.[15],[16],[17]

In our study, hand hygiene compliance was slightly higher in nursing group as compared to the medical group. Various other studies have also concluded that the hand hygiene knowledge, attitude and practices are significantly higher among nursing group as compared to medical group.[18],[19]

In our study, only 34.93% (29/83) HCW had received formal training in the last year. This low number could be due to old staffs being absent during previous training program or due to newly recruited staffs. In a study conducted by Nabavi et al., only 16.4% (42/256) had received formal training in hand hygiene.[20] The number of HCW with formal training about hand hygiene practice can be increased by conducting training program on regular basis. Various studies have described the essential role of regular training program on hand hygiene to increase the compliance.[20] Kampf et al. conducted a UV dye-based study in which the procedure was repeated several times and as a result, the participants knew the exact gaps in their personal treatment.[16] In our study also, majority of the participants in both the medical and nursing groups opted for monthly, bimonthly and half yearly training as compared to annual training, highlighting the need for regular as well as frequent training programmes Another UV dye-based study by Fichtner et al. concluded that the visualisation of the disinfection results using a UV lamp strongly contributed to realisation among the participants about the importance of an optimum practice of hygienic disinfection process.[15] They also demonstrated that such training is useful even for the senior medical professionals.[15] Similarly, in our study, 94.74% of the doctors and 60% of the nurses rated the visualisation technique of hand hygiene using UV dye-based ABHR and UV lamp as 4/4. Furthermore, all the participants of our study admitted that the objective demonstration of the efficacy of hand hygiene practice has changed their attitude towards their practice pattern.


  Conclusion Top


This study makes HCW realise how their suboptimal practice pattern of hand hygiene, either due to their lack of knowledge or lack of attitude, contribute to HAI and associated morbidity and mortality. It emphasises the importance of regular and frequent hand hygiene training programmes to improve the compliance among HCW. This study also emphasises the role of the technique of objective demonstration resulting in greater effect in changing professional's attitude towards hand hygiene practice pattern as once we see it, we believe it.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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. 1
    
2.
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 Appl Med Res 2014;3:46-63.  Back to cited text no. 2
    
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World Health Organization. WHO Guidelines on Hand Hygiene in Health Care. Geneva, Switzerland: WHO Press; 2009. Available from: http://www.whqlibdoc.who.int/hq/2009/WHO_IER_PS P_2 009.07_eng.pdf. [Last accessed on 2017 Jun 14].  Back to cited text no. 8
    
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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. 9
    
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Al Kadi A, Salati SA. Hand hygiene practices among medical students. Interdiscip Perspect Infect Dis 2012;2012:679129.  Back to cited text no. 11
    
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Han K, Dou FM, Zhang LJ, Zhu BP. Compliance on hand-hygiene among healthcare providers working at secondary and tertiary general hospitals in Chengdu. Zhonghua Liu Xing Bing Xue Za Zhi 2011;32:1139-42.  Back to cited text no. 12
    
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Chatterjee S, Mondal TK, Sarkar K, Shahbabu B, Sarkar I, Barik G, et al. Assessment of hand hygiene knowledge among medical students at a teaching hospital of India. Sch J App Med Sci 2015;3:2334-9.  Back to cited text no. 13
    
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Lehotsky Á, Szilágyi L, Bánsághi S, Szerémy P, Wéber G, Haidegger T, et al. Towards objective hand hygiene technique assessment: Validation of the ultraviolet-dye-based hand-rubbing quality assessment procedure. J Hosp Infect 2017;97:26-9.  Back to cited text no. 14
    
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Fichtner A, Haupt E, Karwath T, Wullenk K, Pöhlmann C, Jatzwauk L, et al. Asingle standardized practical training for surgical scrubbing according to EN1500: Effect quantification, value of the standardized method and comparison with clinical reference groups. GMS Z Med Ausbild 2013;30:Doc24.  Back to cited text no. 15
    
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Nair SS, Hanumantappa R, Hiremath SG, Siraj MA, Raghunath P. Knowledge, attitude, and practice of hand hygiene among medical and nursing students at a tertiary health care centre in Raichur, India. ISRN Prev Med 2014;2014:608927.  Back to cited text no. 18
    
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20.
Nabavi M, Alavi-Moghaddam M, Gachkar L, Moeinian M. Knowledge, attitudes, and practices study on hand hygiene among imam hossein hospital's residents in 2013. Iran Red Crescent Med J 2015;17:e19606.  Back to cited text no. 20
    


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