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OJHAS: Vol. 5, Issue
4: (2006 Oct-Dec) |
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Hand washing Compliance - Is It A Reality? |
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Suchitra JB
Laboratory Head, Freedom Foundation, Bangalore
Lakshmidevi N
Senior lecturer Microbiology, Manasagangothri, Mysore University |
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Address For Correspondence |
Laboratory Head, Freedom Foundation
1091, 2nd block, BEL
layout
Vidyaranyapura, Bangalore-560097,
Karnataka, INDIA
E-mail:
suchitra_preetham@yahoo.com |
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Suchitra JB, Lakshmidevi N. Hand washing Compliance - Is It A Reality?
Online J Health Allied Scs.2006;4:2 |
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Submitted: Dec 22,
2006; Suggested Revision Feb 13, 2007;
Revised paper resubmitted Feb 14, 2007; Accepted: Mar 20,
2007; Published: Mar 26, 2007 |
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| Abstract: |
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Background: Transmission of microorganisms from the hands of health care
workers is the main source of cross-infection in hospitals and can be prevented
by hand washing. The aim of this study was to identify
predictors of noncompliance with hand washing during
routine patient care.
Materials And Methods: This is an observational
study. The participants in the study were Health Care Workers (HCWs). Doctors, nurses and ward aides working in different
wards of the hospital who were observed for compliance with hand washing.
Results: In 270 observed opportunities for hand washing,
average compliance was 63.3%. Noncompliance was highest among doctors followed
by nurses. Ward aides were most compliant.
Conclusions: Compliance with hand washing was
moderate. Variation across the hospital ward and type of HCW suggests that
targeted educational programs may be useful. Noncompliance suggests that
understaffing may decrease quality of patient care.
Key Words:
Hand washing, Compliance |
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Nosocomial infections constitute a major challenge
of modern medicine. On an average, infections complicate 7% to 10% of hospital
admissions.(1) Transmission of microorganisms from the hands of Health Care
Workers (HCWs) is the main cause of nosocomial
infections, and hand washing remains the most
important preventive measure.(2) Unfortunately, compliance with hand washing is low in most institutions.(3-7) Average
compliance is usually below 50%.(3) Many barriers to appropriate hand hygiene
have been reported including: hand hygiene agents cause skin irritation and
dryness, patient care takes priority over hand hygiene, sinks are
inconveniently located or not available, glove use, insufficient time for hand
hygiene, high workload and understaffing, inadequate knowledge of guidelines or
lack of protocols for hand hygiene, lack of a role model from seniors or peers,
lack of recognition of the risk of cross-transmission of microbial pathogens
and scientific information showing a definitive impact of improved hand hygiene
on nosocomial infection rates, or simply
noncompliance.(4-6) Determinates of adequate hand washing
in hospitals are not usually investigated. We undertook the present study to
investigate the factors associated with noncompliance.
This was an observational study. The authors were the observers who randomly
observed the subjects during routine patient care. The study was conducted in
December 2004 and the subjects were health care workers working in different
units and wards of the hospital which included the Intensive care units (ICUs),
general wards and private wards. The observation periods were distributed
randomly during the day as well as the night for 30 days. The subjects were
unaware that they were being observed. Each subject was observed once and the
observation was recorded with the subject number, time of the event, unit or
ward and compliance or failure to comply with hand washing.
The name, age, gender, years of experience in the hospital, category of employment
was obtained by administering an information form to the subject. This also
included probable reasons for noncompliance which were categorized as
individual level, group level and institutional level. The subjects could tick
more than option. Anonymity was preserved for data analysis and no judgment was
passed to the subject about the duration or efficacy of the hand washing
technique. Hand washing facilities were located
throughout the institution. There was also availability of hand washing
soap and towels. Dispensers of hand antiseptic solutions were available at high
risk areas. Individual bottles containing alcohol-based preparation were also
available at every ward. The potential opportunities for actual performance of hand washing were observed. The categories of HCWs were doctors (n=90), nurses (n=90) and ward aides
(n=90). Opportunities of hand washing were all
situations in which hand washing is indicated
according to guidelines.(2,8) Compliance with hand washing was defined as either washing the hands and
wrists with water and plain soap or rubbing with an antiseptic solution. This
was the quick hygienic hand disinfection that is advocated in routine care of
the patients. In high risk areas and aseptic care of infected patients, a
hygienic hand wash was with antiseptic soap and
scrubbing hands and wrists for one minute.(2) Departure from the room after
patient care without hand washing was regarded as
noncompliance. Hand washing was required regardless of
whether gloves were used or changed. Failure to remove gloves after patient
contact or contact between dirty and clean body site on the same patient was
considered noncompliance. Predictors were hospital ward, time of the day,
professional category, and type of patient care. Statistical analysis was made
using Chi-square and Fisher exact test, 95% Confidence
Interval.
In the present study we observed 270 hand washing
opportunities. The categories of staff were doctors, nurses and ward aides. The
total compliance was 63.3%. Hand washing was done by
soap in 41 opportunities (71.9%). The remaining 16 (28.0%) opportunities were
by use of hand disinfection. Compliance for hand washing
differed among the different categories of HCWs. The
demographic characteristics of the study population was doctors (n=90), mean
age 29.6 years, average years of experience 5.4 years; nurses (n=90), mean age
32.9 years, average years of experience 11.3 years and ward aides
(n=90), mean age 34.2 years, average years of experience 12.7 years. Ward
aides were significantly compliant with a compliance level of 76.7% (95%
CI=63.38-81.38) followed by nurses 66.7% (95% CI=56.42-75.55). Doctors showed
least compliance of 46.7% (95% CI=36.71-56.90). Compliance differed in
different wards. There was 54.3% compliance in the general wards as compared to
45.6% in the intensive care units. Females were more 68.4% compliant as
compared to males who were 31.5% compliant. Compliance was better during
the night 59.6% when compared to 40.3% during the day. The observed risks for
noncompliance with hand hygiene are found in Table 1.
Table 1: Risk Factors For Noncompliance To Hand
Hygiene
| Being a doctor |
| Male sex |
| Working in intensive care units |
| Working in the morning shift |
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Self reported reasons for noncompliance are given in Table 2. The reasons
were classified into individual level, group level and institutional level.
Table 2: Reasons For Noncompliance To Handwashing
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Individual Level
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Doctors |
Nurses |
Ward
Aides |
| Lack of education |
80.0% |
40.0% |
30.0% |
| Lack of experience |
10.0% |
20.0% |
10.0% |
| Being a doctor |
80.0% |
- |
- |
| Male sex |
40.0% |
- |
40.0% |
| Lack of knowledge of
guidelines |
70.0% |
60.0% |
40.0% |
| Being refectory
non-complier |
30.0% |
10.0% |
20.0% |
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Group Level
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Doctors |
Nurses |
Ward
Aides |
| Lack of education |
50.0% |
80.0% |
100.0% |
| Working in critical care |
50.0% |
60.0% |
60.0% |
| High work load |
80.0% |
90% |
90.0% |
| Downsizing/understaffing |
70.0% |
90.0% |
90.0% |
| Lack of encouragement |
80.0% |
70.0% |
80.0% |
| Lack role model from senior
staff |
60.0% |
70.0% |
80.0% |
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Institutional Level
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Doctors |
Nurses |
Ward
Aides |
| Lack of written guidelines |
100.0% |
100.0% |
100.0% |
| Lack of suitable hand
hygiene agents |
100.0% |
100.0% |
100.0% |
| Lack of tradition of
compliance |
100.0% |
100.0% |
100.0% |
| No suitable rewards |
100.0% |
100.0% |
100.0% |
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Our study confirms that the primary problem with handwashing
is the laxity of practice.(3-7) During routine patient care, HCWs disinfected or washed their hands in about half the
indicated instances. Studies previously conducted on compliance showed a
variation in compliance among the different categories of HCWs.(3) The present study indicated that ward aides complied by 76.7% which is
significant. A probable reason for the significant compliance level among ward
aides could be because they are under constant scrutiny. Doctors on the other
hand showed low compliance levels of 46.7%. There has also been some concern
about the substitution of glove use for handwashing.(9,10) This could contribute to the numbers of Nosocomial
infections. Studies have shown that high demand for handwashing
which reflects high workload was associated with low compliance.(11) Opportunities
for handwashing were much more frequent during busier
times of the day and during critically ill patient care. The results confirm
reports by HCWs that busyness substantially reduces handwashing.(6,9,12) Understaffing
of hospital wards decreases compliance and therefore increases the risk of nosocomial infections.(13,14)
Voss A et al., 1997 studied the time taken by HCW to walk to the sink, wash
their hands and return to the patient took about a minute.(15) If 40
opportunities to wash hands occur per hour of care, the total time spent
washing hands becomes prohibitive. In such cases ‘no time for handwashing’ is more a reality than an excuse. Therefore it
becomes necessary to advocate bedside hand sepsis in areas of high risk.(16)
Noncompliance with handwashing is a substantial
problem in a hospital setting. From the responses indicated by the HCWs, it becomes evident that a behavioral change is
warranted. It involves a combination of education, motivation and system
change. The factors necessary for change include dissatisfaction with the
current situation, the perception of alternatives and the recognition, both at
the individual and institutional level, of individual’s ability and potential
to change. While the institutional level of involvement includes education and
motivation, the individual level and group level necessitate primarily a system
change. This suggests that interventions aimed at improving handwashing
practices may be more effective if they are focused on selective wards,
categories of HCWs, or patient care situations.
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AC, Mallison GF. Handwashing
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