Hand-washing Practices in Health Care Workers - medIND

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3) Medical Personnel and 4) Hospital Support Staff. Maximum number of medical and lab personnel practised optimal desirable hand washing practices, ...
Indian Medical Gazette

400

— OCTOBER 2011

Original Study

Hand-washing Practices in Health Care Workers P. M. Prabhu, Assistant Professor — Dept. of PSM, Govt. Medical College, Miraj – 416 410. Abstract The care provided to a patient in a hospital has to be curative as well as preventive. The curative aspect deals with the disease with which the patient was admitted to the hospital; while the preventive aspect deals mainly with prevention of nosocomial infections to the patient. Various bio-safety measures, which prevent disease transmission to health care workers and to the patients as well, are in vogue. The most widely used is the ‘Universal Safety Precautions’ (USP)1. Preventing the transmission of the diseases from Health Care Workers (HCWs) to patient or from patient-to-patient is one of the responsibilities of the Health Care Setup. To achieve this, adherence to universal safety precautions is necessary. The first and foremost principle of USP IS “HANDWASHING”. Even though hand-washing has been recognized as a single most effective measure to prevent the spread of infections since more than 150 years, the present scenario is very bleak. The compliance of hand washing is found to be quite variable and unsatisfactory, even in western countries. The experts in infection control coax, cajole, threaten and plead, but still their colleagues neglect to wash their hands. To assess and rectify, such pathetic attitudes and practices, the present study was conducted to assess the compliance and practice of hand washing in all health care personnel; as the saying “self analysis or introspection is the secret of success” holds good as much as for an institution or a system as for an individual.

Miraj, Maharashtra using pre-tested semi-structured questionnaire. All HCWs who has worked for more than 6 months were included in the study. The study was conducted in Jan-Feb 2003. As the nature of work differs for each group, the opportunities for hand washing are also quite different; hence separate questionnaire proformas were designed for each of these categories. For the purpose of analysis, the hand washing practices were categorized into six different subgroups as, ‘Not desirable’, ‘Minimum desirable’, ‘Fair’, ‘Optimal desirable’, ‘Good’, and ‘Better’. The opportunities for hand washing in each subgroup are as given below. z

Not desirable (negative): hand washing is not done at all

z

Minimum desirable: Done before starting OR after examining all patients/ completion of duty hours

z

Fair: Done before starting AND after examining all patients/ completion of duty hours

z

Optimal desirable: Done after examining/ touching more than 1 patient OR after any contamination

z

Good: Done after examining/ touching every patient OR after removing gloves OR after every work.

z

Better (positive): (3) + (5)

Materials and Methods A cross sectional study was carried out in all HCWs (n=307) i.e. doctors, nurses, lab personnel and hospital support staff of Government Medical College Hospital,

Results The HCWs included in the study were as follows: Medical personnel (98), Nurses (52), Lab personnel (82)

Address for correspondence: Dr P. M. Prabhu, Assistant Professor, Dept. of PSM, Govt. Medical College, Miraj – 416 410, Dist. Sangli, Maharashtra. E-mail: [email protected]

Indian Medical Gazette

401

— OCTOBER 2011

and Hospital support staff (75). Lab personnel also included doctors performing lab related duties. The proportion of males was more in doctors and hospital support staff, while female dominance was observed in lab personnel and particularly in nurses. The hand washing practices of health care personnel are shown in Table 1. As the above table indicates, hand washing is practised at one or the other juncture by all (100%) health care providers. The hand-washing practices of around 59% HCWs were above optimal desirable level. But only around 28% of medical personnel, lab personnel and hospital support staff practiced ‘Good’ and ‘Better’ hand-washing practices; while more than 50% of nursing staff was doing the same. The hand-washing practices in descending order of betterment were recorded in 1) Nurses, 2) Lab Personnel, 3) Medical Personnel and 4) Hospital Support Staff. Maximum number of medical and lab personnel practised optimal desirable hand washing practices, maximum nurses practised good hand-washing practices, while maximum hospital support staff followed minimum desirable handwashing practices.

It was found that the commonest material used for hand washing was water and soap (73.6%), followed by water and disinfectants (19.8%). Only plain water was used by (5.2%) of HCWs; mainly hospital support staff (18.6%) and medical personnel (2.04%). 4 nurses (7.6%) working in OT answered that every time they washed their hands along with scrubbing. When soap and water is used primarily for washing hands, the time for which the hand washing is done becomes important. As per the guidelines the hand washing should be performed at least for 10 seconds 1. The approximate time period for which each hand-washing is performed by health care providers is summarizes in Table 2. Majority of medical personnel and laboratory personnel washed their hands for 10 to 30 seconds and majority of nurses and hospital support staff washed their hands for 30 to 60 seconds. Nearly 16% of HCWs did not wash their hands for 10 seconds. In this category, majority were doctors. An interesting finding was that all hospital support staff washed their hands for more than 10 seconds. The mean time for hand wash as reported by health care providers was 37±23 seconds which was minimum in doctors (25.6±12.49 sec) and was maximum in Hospital support staff (46.3±21.01sec).

Table 1 Hand washing practices of 307 hospital personnel Sr. no.

Practices

Medical personnel

Nurses

Lab. Personnel

Hosp. Support Staff

Total

1.

Not desirable (Negative)

0 (-)

0 (-)

0 (-)

0 (-)

0 (-)

2.

Minimum desirable

26 (26.53)

6 (11.54)

15 (18.29)

29 (38.67)

76 (24.76)

3.

Fair

14 (14.28)

7 (13.46)

18 (21.95)

8 (10.67)

47 (15.31)

4.

Optimal desirable

30 (30.61)

7 (13.46)

25 (30.49)

17 (22.66)

79 (25.73)

5.

Good

20 (20.42)

18 (34.62)

17 (20.73)

13 (17.33)

68 (22.15)

6.

Better (Positive)

8 (8.16)

14 (26.92)

7 (8.54)

8 (10.67)

37 (12.05)

98 (31.92)

52 (16.94)

82 (26.71)

75 (24.43)

307 (100.0)

Total

Percentages are calculated group-wise & are shown in parenthesis (χ2 test is applied to Sr. No. (2) to (6)) χ2 =35.9 df=12 p < 0.001 highly significant

Indian Medical Gazette

402

— OCTOBER 2011

Table 2 Approximate time utilized for hand washing by health care personnel Response

Medicos

Nurses

Lab Personnel

Hosp. Support Staff

Total

Up to 10 sec

29 (29.59)

3 (5.77)

18 (21.95)

0 -

50 (16.29)

>10 to 30 sec

37 (37.76)

12 (23.08)

28 (34.15)

19 (25.33)

96 (31.27)

>30 to 60 sec

31 (31.63)

22 (42.31)

14 (17.07)

35 (46.67)

102 (33.22)

> 1 min

1 (1.02)

15 (28.84)

22 (26.83)

21 (28.0)

59 (19.22)

Total

98 (31.92)

52 (16.94)

82 (26.71)

75 (24.43)

307 (100)

(Percentages are calculated group-wise and are shown in parenthesis) Mean score = 36.9 ± 22.9 (i.e.37 ± 23sec) χ2 test applied after pooling the data into 2 groups (Group A = Sr. No. 1 +2 and Group B = Sr. No. 3 +4) df = 3 p < 0.001 highly significant. χ2 = 39.96

The difference observed was found to be statistically significant. (χ2 = 39.96, p < 0.001) Discussion It’s been more than 120 years since 1887 when Ignaaz Semmelweis demonstrated the importance of hand washing in prevention of nosocomial spread of infections (51). Since then various formal guidelines on hand-washing practices in hospitals have been published by CDC, APIC and HICPAC2,3. Lipselt P A4 did a similar observation with significant difference in handwashing practices of all HCWs- physicians (15%), nurses (50%) and support personnel (35%): where the medical personnel were last in order.

duration (>10 sec) is sufficient for proper hand hygiene. As majority of the HCWs washed their hands for >10 sec the hand hygiene was found to be sufficient. With emerging threat of hospital acquired infections with drug resistant micro bacteria, the call of the hour is to give emphasis on the principles of hand-washing; first introduced by Semmelweis. References 1.

NACO: Manual for control of hospital associated infections standard operative procedures. Government of India, 1999.

2.

Centers for Disease Control Update: Universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus and other bloodborne pathogens in health-care settings. MMWR. 37: 377, 1998.

3.

Boyce J.M., Pittet D. et al. — Guideline for Hand Hygiene in health care settings, Recommendations of the health care Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recomm Report. 51 (RR-16) : 1 – 44, 2002.

4.

Lipsett P.A., Swoboda S.M. — Hand-washing compliance depends on professional status. Surg Infect (Larehmt). 2 (3): 241-245, 2001.

5.

Zimakoff J. et al. — A multicenter questionnaire investigation of attitudes towards hand hygiene, assessed by the staff in fifteen hospitals in Denmark and Norway. Am J Infect Control. 20 (2): 58-64, 1992.

Zimakoff J et al 5 in his multi-centric study found that physicians reported significantly fewer instances of hand hygiene per day than the other medical professionals. These finding indicate the need of practical oriented training for doctors and the need to stress the hand-hygiene practices in day-to-day patient care activities. Similarly the hospital support staff should also be trained in proper way of hand washing. Care has to be taken by all HCWs not to miss the indicated hand-washing opportunity. The predominant use of soap might be there due to its easy availability and low cost. Also disinfectants are not universally available in large amounts and have to be used caution. But hand washing with soap and water for optimal