Lithuanian University of Health Sciences
Faculty of Medicine
Department of Paediatrics
Title of Master’s Thesis:
HAND HYGIENE COMPLIANCE, KNOWLEDGE AND PRACTICES AMONG PAEDIATRIC PATIENTS IN A HOSPITAL SETTING
A Dissertation Submitted in
Partial Fulfillment of the
Requirements for the Degree
Master of Medicine
Lithuanian University of Health Sciences
Author:
Shaden Zuhairy
Supervisor:
Dr. Vaidotas Gurskis
TABLE OF CONTENTS
SUMMARY………...3 ACKNOWLEDGEMENTS………...4 CONFLICTS OF INTEREST………....5 ABBREVIATIONS ………..5 CHAPTER 1: INTRODUCTION ………...6CHAPTER 2: AIMS AND OBJECTIVES………....8
CHAPTER 3: LITERATURE REVIEW ………..9
3.1 Multimodal Vs Unimodal………10
3.2 Hand Hygiene for Children in a Health Care Setting………..16
3.3 Parents and children’s educational role in hand hygiene………….16
3.4 Hand Hygiene Techniques………...17
CHAPTER 4: RESEARCH METHODOLOGY AND METHODS ………..22
CHAPTER 5: RESULTS………..23
CHAPTER 6: DISCUSSION OF THE RESULTS………..24
CHAPTER 7: CONCLUSIONS………...25
CHAPTER 8: PRACTICAL RECOMMENDATIONS………...26
SUMMARY
Author name: Shaden Zuhairy
Research title: Hand Hygiene Compliance, Knowledge and Practices Among Paediatric Patients in a Hospital Setting
Aim: To analyse and review hand hygiene compliance, knowledge and practices used for paediatric patients
Objectives:
1. To assess educational practices of hand hygiene of parents, children and medical staff 2. To assess efficacious results comparing soap vs. alcohol based hand-scrubs
3. To assess compliance rates associated with multimodal hand hygiene techniques
Methodology: This was a Systematic Literature review where searches were conducted using several databases: Medline (PubMed), Paediatric publications, science direct publications and UpToDate. All articles published from 2011 were included in the searches with no more than 5 years search criteria used. The search terms used were: ‘hand hygiene paediatrics’, ‘compliance hand washing’, ‘paediatric hand washing’, ‘hand washing techniques’, ‘compliance and hand hygiene paediatrics’. Keywords were matched to database indexing terms. In PubMed, the related articles were also retrieved and added to this review.
Compliance Rates Results: There was a significant increase in overall compliance rates post-intervention among health care workers. The studies reviewed showed that there were better compliance rates among health care workers from between 74-84%, and a review of soap and water vs. alcohol- based hand hygiene showed that soap and water were more effective and commonly used (63.6%) compared to alcohol- based rub (36.6%). While reviewing prior patient contact in comparison to after patient contact following the five moments of hand hygiene, we can see that compliance rates were better after patient contact (68.1%) than before patient contact (43.2%) with a baseline compliance rate across all settings of 40%.
Conclusions: Educating patients, families and medical staff about the benefits of proper hand hygiene is an important factor in reducing the spread of infections, as well as increasing their knowledge. Use of soap and water for visibly soiled hands was more effective and commonly used among health care workers, compared to alcohol-based hand hygiene which should be routinely used for non-visibly soiled hands. A focused hand hygiene initiative is effective in increasing compliance. Improving physician compliance with proper hand hygiene is achievable and a first step in decreasing health care–associated infections. Additionally, we noted the importance of continuous intervention in maintaining high compliance rates. Implementation of certain guided interventions such as effective education, training of medical staff, reminders and
ACKNOWLEDGMENTS
I dedicate this thesis to my beloved mother, father and sister for their constant encouragement and unwavering faith in me. I would like to say a special thank you to my father Dr.Hamed Zuhairy for his enormous support, always inspiring me to follow my dreams. This journey would not have been possible without the support of my family, friends, professors and university staff .
Finally would like to extend my thanks to my supervisor Dr. Vaidotas Gurskis for his guidance throughout this research project.
CONFLICT OF INTEREST
The author reports no conflicts of interest.
ABBREVIATIONS
CHAPTER 1: INTRODUCTION
Hand hygiene is known to be one of the most effective and efficient ways to prevent healthcare-associated infection. The question is that although we understand how crucial hand hygiene is, why is it that compliance in today’s world still remains problematic and inadequate?
Children are notoriously susceptible to infection and act as a huge channel for
transmission[1]. On paediatric wards, viruses are commonly transmitted from patient to patient and healthcare workers to patients by means of direct contact rather than through other routes [2]. Therefore virus transmission can become reduced among healthcare workers and patients if correct hand hygiene techniques are practiced [2].
Many factors play a huge role in low compliance rates and practices used for paediatric patients, such as lack of knowledge and education of staff regarding hand hygiene.
Plenty of studies and research has been conducted to investigate strategies for better hand hygiene compliance rates among doctors and healthcare workers when with their patients. To be able to develop such strategic and successful interventions, it is necessary to identify the factors which influence such poor compliance.
This systematic literature review will assess and evaluate compliance and knowledge of hand hygiene with regards to following interventions and strategies. Hand hygiene is one area where compliance still needs to be improved. Hand hygiene (i.e. washing hands with soap and water, or using alcohol- based hand rub) is considered the most important preventive measure of hospital acquired infections [2].
Over time, it was through initiating various campaigns, hand hygiene guidelines and the launch of multimodal interventions which have helped doctors and health care workers maintain better compliance rates [3]. Compliance of hand hygiene in healthcare, especially among paediatric patients, is a preventive measure and should be standard practice.
Many strategies have been implemented to help increase compliance in the paediatric setting; increased availability of alcohol-based hand sanitizers, staff training, and parent and patient involvement in hand hygiene [2].
The aim of this thesis is to review hand hygiene compliance, knowledge and follow techniques and commonly used practices for paediatric patients. The first step to improving health care-associated infections is through improvement of physician compliance with proper hand hygiene
[3]. By doing this, you can also help teach and give a better insight to parents on the importance of hand hygiene for prevention of infection.
If more hospitals put emphasis on setting up and implementing multimodal hand hygiene strategy, this would provide more encouragement to all medical staff, parents and children to perform good hand hygiene.
At present, there are just 48 participants in the network of campaigning countries which promote effective hand hygiene compliance [4]. By assessing the effectiveness of an educational practice and adopting a multimodal strategy with regards to hand hygiene compliance (whether guided by WHO or other multimodal strategies), we can expect to find a significant rise in compliance rates among paediatric patients in a hospital setting.
This leads us back to the initial question and aim of this thesis.
Why is hand hygiene compliance, knowledge and practices among paediatric patients poorly maintained despite the massive research conducted? And what can we do to further encourage proper hand hygiene?
CHAPTER 2: AIM AND OBJECTIVES
Aim: To analyse and review hand hygiene compliance, knowledge and practices used for paediatric patients
Objectives:
1. To assess educational practices of hand hygiene of parents, children and medical staff 2. To assess efficacious results comparing soap vs. alcohol based hand-scrubs
CHAPTER 3: LITERATURE REVIEW
Studies and research have been conducted in this field of compliance in hand hygiene. Research revealed that rates of compliance are not as high as they should be, which is critical in helping prevent infections from spreading among paediatric patients.
A major factor of low compliance rates in hospitals is due to a lack of educational practices and programs being implemented in hospitals.
We will assess the first objective, which is by assessing how educational interventions impact the hand hygiene compliance rates of health professionals, parents and children. We will look at observational studies using multimodal techniques to assess the obedience to hand
hygiene practice among health care workers and for monitoring compliance. Infections are easily spread from the hands of health care workers and it is through hand hygiene which prevents this spread, hence the importance of this simple step.
The multimodal strategy consists of five key components to be implemented according to WHO’s multimodal Hand Hygiene Improvement Strategy [5]. Educational practices include training, demonstrations of hand hygiene techniques, awareness in the workplace by placement of posters featuring the five moments of hand hygiene in strategic areas. Continuous feedback and evaluation is important and, finally, keeping alcohol-based hand rub gels easily available in hospitals as well as at the bedside [5].
The second objective we will assess is the comparison of soap vs. alcohol- based hand scrubs. Alcohol-based hand sanitizers is an alternative to traditional hand washing with soap and water. According to WHO guidelines, when hands are visibly dirty or soiled, hands should be washed with soap and water. When there is exposure to outbreaks of bacteria like Clostridium Difficile, washing hands with soap and water is also preferred [6]. The use of alcohol- based hand scrubs is more for routine hand antisepsis [6]. We will compare the efficacy of these two methods in the following review.
Lastly, We will assess compliance rates associated with hand hygiene techniques with regards to the multimodal system.
Multimodal Vs Unimodal:
Despite many interventions, hospitals still continue to battle with lower incidences of hand hygiene compliance rates.
Study one conducted in a Paediatric hospital, compliance rates were shown to be just 68% in a general paediatric unit [7]. A multimodal system was used to increase compliance rates with the implementation of proper hand hygiene and results showed a massive improvement to more than 95%. This method was started by teaching residents before the start of their rotation about proper hand hygiene; data on hand washing was displayed on the residents’ board for encouragement. The main outcome was competent hand washing with the use of an alcohol- based product or hand washing with soap and ensuring the tap was off without the use of fingers or palms. Instead of using a unimodal method.
A second outcome was competent hand hygiene before and after contact with the patient. This intervention was set in a paediatric hospital [7]. It was planned very carefully and consisted of an enhanced team of general paediatric team leaders, paediatric chief residents, medical students doing their paediatric rotations, an infectious disease attendee and a quality improvement consultant. Key drivers were drawn to prioritize the interventions as shown in Fig. 1.[7]. Figure 1. Steps taken to improve hand hygiene using different interventions
The intervention was started by providing training for residents and medical students by completing an online training course. This course demonstrated proper hand hygiene practices before and after patient contact, causes of failures by non-adherence to hand washing and a review of staff compliance rates. The chief residents of the paediatrics department were sent monthly emails about proper hand hygiene and discussions were conducted with the entire team at faculty meetings. Many visible reminders were placed on display in the paediatric unit, including signs on the patient’s doors to help promote hand washing for the patients and parents on entering and exiting the room. It also included many imposing pictures to help promote hand washing.
Standardization was implemented by ensuring adequate placement of alcohol gel dispensers and adequate placement of soaps. Alcohol wipes were also placed near computers of various resident teams. ‘Stop signs’ were visibly placed on some patients’ rooms with the diagnosis of Clostridium Difficile to remind team members that before entering the room, relevant hand hygiene techniques must be performed to prevent any spread of infections. A medical student would be designated to intervene with hand washing reminders and provide alcohol gel to team members who did not perform hand hygiene before entering and exiting a patient’s room. Every morning before rounds, a daily reminder would be given to the team. Feedback was given to each team member and presented on a large chart which displayed reports on daily percentage compliance and weekly percentage compliance[7].
Results from this intervention showed that there was a significant improvement in physician compliance with proper hand hygiene over a 6 month period from 68% to more than 95% and these results were maintained for a longer period of time shown below in Fig. 2.[7].
Figure 2. Graph showing results of long-term hand hygiene following steps of intervention.
Finally, the desirable results of more than 95% were obtained, which impacted directly on the delivery of proper health care. These methods greatly improved physician compliance with regards to hand hygiene. Thus, education and training play a huge role as an intervention strategy. Constant feedback, display of educational posters and addition of alcohol dispensers outside each room have proven to prompt parents and residents to follow proper hand hygiene. It is critical to continue to implement these measures to ensure that this multimodal approach remains sustainable. The next step is to spread this intervention throughout the hospital and implement more parent/ patient initiated interventions[7].
Study 2 was conducted in a tertiary Paediatric hospital to evaluate the use of the multimodal intervention to evaluate if it was proven to significantly raise compliance rates. This intervention was carried out among all health care staff, aiming to assess the quality of hand hygiene following all five moments of hand hygiene as per WHO guidelines. Sustainment of proper hand hygiene knowledge and consistent monitoring massively raises compliance rates [8].
This study included strong leadership training sessions for all healthcare workers. The training included many practical sessions with demonstrations of proper hand hygiene
techniques. Posters were presented and displayed in all areas of the hospital as well as alcohol- based hand rub at the point of patient care following guidance based on WHO recommendations
[6].It is through consistent training, feedback and poster display which ensures sufficient
adherence to hand hygiene [5]. This intervention shows that there was a massive increase in hand hygiene compliance from 2006 which was only 23% to 87% in 2011 in a tertiary hospital, which shows that significant improvement has been evident throughout the last 4 years. It is through these programs that we can evaluate the effectiveness of this interventional strategy and improve hand hygiene compliance in hospitals.
Study 3 was carried out in 2014 evaluating the effectiveness of a multimodal hand hygiene campaign which used a ‘before and after’ assessment of medical staff adherence to WHO guidelines [9]. This study showed a massive improvement in hand hygiene adherence among medical staff following the WHO multimodal hand hygiene program. These campaigns are needed in developing countries as health care- associated infections are much higher than in Europe [10]. This study was implemented in three steps: the first step was using baseline evaluation, which involved observations of healthcare workers’ hand hygiene. The second step was the intervention itself which included making soap readily available and alcohol- based hand sanitizer for use while in the hospital. Also implemented were training courses and education for medical staff which focused on the importance of proper hand hygiene for improving the quality of care for patients. Another feature included placing posters throughout the hospital as a visual reminder of the importance of hand hygiene. Lastly, to make the intervention successful, monitoring and feedback were given to the health care workers, which were intended to encourage hand hygiene. The third step included post-intervention evaluation in which
observation was continued to determine if adherence improved following the baseline evaluation. Following implementation of the multimodal hand hygiene strategy, we could observe an
increase in hand hygiene adherence rates from 2.1% at baseline to 12.7%.
Study 4 which was an observational study of hand hygiene compliance in a paediatric ward was conducted in an English hospital using the ‘five moments of hand hygiene’ system shown in fig.3. [11] And posters with hand washing techniques in fig.4.[12].
Figure 3. Picture displaying the ‘five moments of hand hygiene’
Figure 4. Hand washing techniques
Direct observation was conducted and the five moments system was implemented before child contact, before an aseptic task, after bodily fluid exposure risk, after child contact, and after contact with children’s environmental surroundings. All observed data was collected manually from the participants who were doctors, nurses, children or visitors. Results showed an increase in hand hygiene compliance from 74-84% among healthcare workers, 84% for health care professionals, 81% of doctors and 74% for other staff. There were significantly low compliance rates among visitors at 39%. The aim of this study was to observe how much care was put into paediatric clinical areas and to prove how hand hygiene has an impact in reducing hospital acquired infections [13].
The WHO has put emphasis on the importance of observing and monitoring all health care workers’ hand hygiene performance[14]. This ongoing routine monitoring is done in order to assess if health care workers’ quality of hand hygiene has been effective, with the
interventions of the multimodal system. It is through direct observation that one can control and monitor the effectiveness of hand hygiene. This method ensures all doctors, staff and healthcare
workers comply with the hand hygiene guidelines, allowing them to become aware of any factors which decrease hand compliance rates and subsequently take corrective measures. It is through continued training of staff and health care workers which increase hand compliance rates overall.
In Study 5 Hand hygiene compliance of health care workers was shown to be between 5% and 81% [15] and many interventional studies have estimated that there has been a rise in hand hygiene compliance through soap and water or an alcohol- based hand rub. The observation began with recording whether protocols were followed by healthcare professionals and an
addition of posters around the hospital. Afterwards, the health care professionals received feedback about their compliance to hand hygiene techniques and then repetition of the cycle by observation again.
Studies show that compliance rates are hard to keep optimum and it is only through the implementation of interventions that we can expect to keep compliance rates remaining high with at least a full year of audit compared to no non-compliance. Another factor that was identified is that repeating these interventions and not just trying it once can significantly increase compliance rates.
All hospital wards should implement hand hygiene programs using continuous multimodal interventions to keep improving compliance rates in order to decrease the risk of hospital acquired infections.
Study 6 in a Paediatric hospital in Washington, they focused on monitoring and improving the compliance process. Using the ‘five moments’ by WHO they paid most attention to hygiene before and after patient contact. They then reviewed failures and suggested causes for these failures shown in Fig.5.[16].
In spite of the fact that knowledge of hand hygiene has a huge role in health care associated infections, adherence remains poor amongst health care workers in general. A lack of hand hygiene material found around hospitals, as well as a lack of time and large workload are reasons for low compliance, as well as poor knowledge and lack of education of the staff.
Interventions which impose strong leadership, monitoring and availability of alcohol- based hand sanitizers increase hand hygiene in paediatric hospitals. It is clear that all physicians and
healthcare workers should be aware and have a better view of hand hygiene attitudes and techniques to improve hand hygiene compliance. It is also important for senior physicians to encourage younger health care workers and recently graduated medical students to comply with hand hygiene techniques[17].
Hand Hygiene for Children in a Health Care Setting
According to the American Academy of Paediatrics [18] for children below the age of 2 years hand washing with soap and water is the only adequate form of hand hygiene, while for children over the age of 2 years and for adults, visible soil can be removed by running water or a wipe, followed by alcohol- based sanitizer. The Alcohol- based rub is fast acting and kills enough germs present on the skin.
Parents and children’s educational role in hand hygiene:
Hand hygiene is an effective tool in the prevention of hospital acquired infections. It is not only necessary for health care professionals to perform routine hand hygiene, but also for parents who visit their children.
Study 7 was conducted to evaluate the effectiveness of hand washing teaching
programs to assess the educational knowledge of parents [19]. They conducted a video teaching program to inform families and aid them with hand hygiene techniques. They then created a comparison between video vs. illustration of hand techniques through posters to find out if compliance rates were improved. Results of this study showed that through a video- based teaching program, it produced greater compliance but overall both methods led to an increase in compliance and accuracy. From this study, we can say that more teaching programs should be incorporated among adult visitors.
Study 8 comparing soap vs. alcohol- based hand scrubs, it was observed that most hand hygiene techniques used were by performing traditional hand washing with soap (72%)
compared to alcohol based hand scrub (28%). Adherence to hand washing using soap and water was a more popular choice [20].
In the same study, it was clear that health care workers do not wash their hands enough and compliance rates rarely exceed 40%. The fundamental principle of hand washing is removal and not the killing of bacteria [27]. If we take hand washing for instance - which is a method of washing and rubbing the hands vigorously together, followed by rinsing the hands under a stream of water - this method mechanically removes the microorganisms by rinsing with water. On the other hand, hand washing with an alcohol- based rub uses a waterless alcohol- based compound that is used to clean the hands. Microorganisms are killed by the disinfectant and not removed physically like in hand washing. Microorganisms that are not in direct contact with the alcohol will not be affected [21].
Hand hygiene techniques:
Techniques of hand hygiene through hand washing or alcohol- based hand rub are observed when it comes to hand compliance.
Study 9 which was conducted in relation to ‘compliance of healthcare workers with hand hygiene practices in neonatal and paediatric units’ showed that health care workers are more prone to using soap and water (63.6%) compared to using just alcohol-based hand sanitizer (36.6%) [22].
The Consistency of hand hygiene practice and use of alcohol- based hand rub was found to be quite low. It is through educational and training programs that improve the effectiveness of hand hygiene. WHO guidelines recommend the use of soap and water to wash hands when visibly dirty, while alcohol- based hand rub is used for most other occasions [23]. The use of alcohol- based disinfectants and simple soap and water hand washing technique have equal efficacy [24]. Following a study conducted in a research paediatric hospital, the results were as follows with respect to the five moments for hand hygiene: compliance prior to patient contact was 43.2%, prior to a procedure was 8.5%, after bodily fluid exposure was 18.1%, after patient
Nonetheless, Health care workers’ preferred method of hand washing was with soap and water. Doctors and health care workers are more likely to use soap and water (63.6%) compared to alcohol based hand hygiene (36.3%). Results are shown below in Table 1 [24]. Overall compliance rates to hand hygiene was higher in nurses (41.4%) compared to doctors (31.9%). Nurses’ preferred method of hand hygiene technique was to wash their hands with soap and water compared to waterless alcohol- based hand hygiene. According to the five moments for hand hygiene, results showed that health care workers used hand hygiene more after patient contact or contact with the patient’s environment.
Table 1: Compliance and technique of hand hygiene among nurses and doctors.
Total, (%) Nurses, (%) Doctors, (%)
P value, OR (95% CI) Hand washing with soap and water Hand hygiene with disinfectant Hand washing with soap and water Hand hygiene with disinfectant Hand washing with soap and water Hand hygiene with disinfectant Hand washing with soap and water and with disinfectant Prior to patient contact 33 (20.4%) 37 (22.8%) 24 (21.0%) 26 (22.8%) 9 (21.9%) 11 (26.8%) 0.719, 0.820 (0.401–1.678) Prior to a clean or aseptic procedure 4 (3.4%) 6 (5.1%) 2 (2.3%) 4 (4.7%) 2 (6.2%) 2 (6.2%) 0.458, 0.532 (0.140–2.023) After contact with body fluids 12 (12.1%) 6 (6.1%) 8 (10.3%) 5 (6.4%) 4 (18.1%) 1 (4.5%) 0.540, 0.691 (0.216–2.207)
After patient contact 46 (52.3%) 14 (15.9%) 41 (61.1%) 9 (13.4%) 5 (27.7%) 5 (27.7%) 0.199, 2.353 (0.799–6.931) After contact with the patient environment 71 (29.8%) 32 (13.5%) 56 (45.5%) 18 (14.6%) 10 (11.9%) 14 (16.6%) 0.001, 3.776 (2.082–6.847)
Total hand hygiene compliance among nurses and doctors
0.02,
1.504
(1.058–2.137)
The best way to improve health care practice is found through official assessment. As has been discussed, hand hygiene still remains difficult when it comes to achieving optimum compliance rates. Implementation of multimodal programs, continuous education and awareness of the importance of clean and proper hand hygiene is a key feature in the success of this
program by use of audit and feedback to promote the best possible practice [25].
In literature, the best hand hygiene practice was WHO’s ‘five moments for hand hygiene’ [11]. which is an evidence-based approach on the importance of educating health care workers on hand hygiene during their daily care of patients. Effectiveness of this research was through following certain hand hygiene principles [26].
Effective hand washing should be conducted before and after each contact with patients Alcohol- based sanitizers should be routinely used provided that hands are not visibly soiled. For visibly soiled hands, soap and water hand washing should be used.
Study 10 in which a project conducted described three phases for audit. Firstly, to observe and form a baseline audit with strategies that were followed to promote better hand hygiene practice. This included education and training sessions held for paediatric doctors and staff, putting up posters and distributing brochures as a reminder and motivation for health care workers for when and how to use hand hygiene. Lastly, distributing sufficient hand hygiene
completion of this audit, a follow-up audit was conducted a few weeks later and results are shown below comparing pre and post audit (table 2 and table 3) [25].
The post-audit strategy showed an improvement in hand hygiene practices in the paediatric wards. An increase in compliance rates was over 40% for all criteria. Despite this project, there is still a need for further strategies to be implemented to enable the best possible hand hygiene practice.
Table 2 P r e - A u d i t
Criteria Sample Measurement of compliance Baseline Follow-up
Alcohol-based hand-rub is routinely used to clean hands unless hands are visibly soiled. WHO HH moments 1 and 2
Hands decontaminated immediately before each episode of direct patient contact or care, and/or all inanimate objects. WHO HH moments 1 and 2
Hands decontaminated immediately after contact with each individual patient and/or all inanimate objects. WHO HH moments 3, 4, and 5
Hands decontaminated with an alcohol-based hand-rub (unless visibly soiled) between different care activities for same patient. WHO HH moments 1, 2 and 5
Hands washed using an effective hand washing technique involving 3 stages. WHO HH moments 1, 2, 3, 4 and 5
Hands that are visibly soiled, or potentially grossly contaminated with dirt or organic material, are washed with liquid soap and water. WHO HH moments 1, 2, 3, 4 and 5
Members of staff have received education about hand hygiene. 95 hand hygiene opportunities 95 hand hygiene opportunities 75 hand hygiene opportunities 95 hand hygiene opportunities 80 hand hygiene opportunities 40 hand hygiene opportunities 18 HCWs 95 hand hygiene opportunities 94 hand hygiene opportunities 75 hand hygiene opportunities 95 hand hygiene opportunities 84 hand hygiene opportunities 40 hand hygiene opportunities 20 HCWs
Direct observation. Compliance rate (%) ¼ no. hand hygiene opportunities correctly performed/no. hand hygiene opportunities over 2-week period. As above. As above. As above. As above. As above. Questionnaire. Compliance if HCW received training in last 12 months.
Table 3 - P o s t - A u d i t
Audit criteria Baseline audit Follow-up audit % Change in compliance
Alcohol-based hand-rub are routinely used for hand hygiene unless hands are visibly soiled
Hands are decontaminated immediately after contact with individual patient contact and/or all inanimate objects including equipment
Hands are decontaminated immediately before each and every episode of direct patient contract or care and/or all inanimate objects including equipment
Hands are decontaminated with an alcohol-based hand-rub unless hands are visibly soiled between different care activities for the same patient
Hands are washed using an effective hand washing technique involving three stages
Hands that are visibly soiled or potentially grossly contaminated with dirt or organic material are washed with liquid soap and water
Staff have received education about hand hygiene
19% (18 yes, 77 no, total 95) 8 % (6 yes, 69 no, total 75) 16% (15 yes, 67 no, 13 NA, total 95) 5% (5 yes, 87 no, 3 NA, total 95) 15% (12 yes, 68 no, total 80) 13% (5 yes, 35 no, total 40) 56% (10 yes, 8 no, total 18) 62% (59 yes, 30 no, NA 6, total 95) 67% (50 yes, 23 no, 2 NA, total 75) 73% (69 yes, 25 no, 1 NA, total 94) 74% (70 yes, 20 no, 5 NA, total 95) 71% (60 yes, 24 no, total 84) 55% (22 yes, 26 no, NA 2, total 40) 100% (20 yes, 0 no, total 20) 43% 59% 57% 69% 56% 42% 44%
Table 4 - Getting Research into Practice Results
Barrier Strategy Resources Outcomes
Workload and overcrowding Staff attitude and lack of
education/knowledge Insufficient hand hygiene
equipment/resource limitations
Limitations on number of visitors
Increase staff to patient ratio Staff sensitization/reminders,
e.g. through posters/ distribution of materials Education/awareness raising
about best practice hand hygiene and risk of infection. Provision of infection control
materials, e.g. hand gel, additional liquid soap and paper towels
Additional staff/personal Staff time
Venue for training Training materials Pamphlets and poster
materials Alcohol hand gel Liquid soap
Disposable paper towels for drying the hands
Reduce crowding and reduced contamination in ward.
More time to allocate to hand hygiene among workers.
Increased awareness about the danger of not washing hands and poor hand hygiene practice among workers
Increased compliance with hand hygiene practice
Increased use of soap and alcohol due to availability and hence greater compliance with best practice hand hygiene and in turn reduction in HAIs
In Table 4, it is through the knowledge and use of evidence-based audit and feedback that can improve hand hygiene care in hospitals. It is necessary to supply adequate equipment, to raise awareness and provide education to help facilitate good hand hygiene. From all the data gathered, we can clearly say that evidence-based audit and feedback is a powerful tool in shaping up the health care practice and through significant research we can see a substantial change and
CHAPTER 4: RESEARCH METHODOLOGY AND METHODS
Methodology: This was a Systematic Literature review where searches were conducted using several databases: Medline (PubMed), Paediatric publications, science direct publications and Up To Date. All articles published from 2011 were included in the searches with no more than 5 years search criteria used. The search terms used were: ‘hand hygiene paediatrics’, ‘compliance hand washing’, ‘paediatric hand washing’, ‘hand washing techniques’, ‘compliance and hand hygiene paediatrics’. Keywords were matched to database indexing terms. In PubMed, the related articles were also retrieved and added to this review. Keywords were matched to database indexing terms.
Selection Criteria: This review was conducted to investigate how hand hygiene guidelines were followed by health care workers in regards to compliance to hand hygiene. Compliance was defined as acceptable hand hygiene before and after contact with the patient or care environment. Measurement of hand hygiene was performed through observation made during routine patient care and through follow-up of healthcare workers after post-intervention of paediatric patients. Empirical studies were included; samples were taken from countries all around the world and strategies to improve hand hygiene compliance were tested through multiple interventions.
CHAPTER 5: RESULTS
Measurement of compliance rates: All compliance rates were derived from pre and post intervention studies. Compliance was measured using direct observation by trained observer and compliance was defined as a percentage of which health care workers followed and adhered to the hand hygiene guidelines. Compliance was reported in terms of patient contact (before and after patient contact).
Compliance rates results: There was a significant increase in overall compliance rates post-intervention among health care workers. The studies reviewed showed that there were better compliance rates among health care workers from between 74-84%, and a review of soap and water vs. alcohol- based hand hygiene showed that soap and water were more effective and commonly used (63.6%) compared to alcohol-based rub (36.6%). While reviewing prior patient contact in comparison to after patient contact following the five moments of hand hygiene, we can see that compliance rates were better after patient contact (68.1%) than before patient contact (43.2%) with a baseline compliance rate across all settings of 40%.
A multimodal hand hygiene initiative is effective in increasing compliance rates among all categories of hospital workers. We identified a variety of positive factors associated with increased compliance. Improving physician compliance with proper hand hygiene is achievable and a first step in decreasing health care–associated infections.
Additionally, we note the importance of continuous interventions in maintaining high compliance rates. We can conclude that implementation of certain guided interventions, effective education in both paediatric and non-paediatric wards showed greater adherence to hand hygiene compliance rates, thus the multimodal system is effective!
Families, visitors and medical staff need to be informed properly about the effectiveness of proper hand hygiene. Educating patients and families is an important factor in increasing their knowledge and reducing infections.
Use of soap and water compared to alcohol- based hand hygiene was more effective and more commonly used among health care workers, but more hospitals should implement a
CHAPTER 6: DISCUSSION OF THE RESULTS
While conducting a systematic review, it can be concluded that direct observation is necessary for terms of measuring hand hygiene compliance. This method was used in most of the studies reviewed. Despite how commonly used this method has become; it is still unclear of the extent to which international hand hygiene guidelines are followed in paediatric units.
If we take into consideration the Hawthorne effect, which signifies that people would naturally change their behavior if they knew that they were being observed, perhaps if more diligence was placed on observing health care workers complying with a hand hygiene initiative, compliance rates would remain high [27]. However, many studies only mention the term ‘observing compliance’ and don’t specify which particular moments were observed, the actual reported compliance rates based on that and whether that affected the compliance rates reported.
A disadvantage of this observational study is that it relies on the observer to accurately report on hand hygiene compliance rates, the type of method used for obtaining data, and on whether the observers themselves were trained or not. This makes the comparison and explanation of results difficult in terms of reviewing studies related to hand hygiene.
Thus the observation of hand hygiene care allows you to directly link adherence of a hand hygiene initiative despite the limitations of the Hawthorne Effect. Unfortunately, there is no perfect method for measuring hand hygiene adherence and it is important to acknowledge the limitations of the measurement method used when compliance rates are reported.
CHAPTER 7: CONCLUSIONS
In conclusion, hand hygiene is the ideal way of reducing hospital- acquired infections. 1. Families, visitors and medical staff need to be informed properly about the effectiveness of proper hand hygiene. Educating patients and families is an important factor in increasing their knowledge and subsequently reducing the transmission of infections.
2. Use of soap and water compared to alcohol- based hand hygiene techniques was more effective and more commonly used among health care workers, for visibly soiled hands, soap and water hand washing should be used. Alcohol- based sanitizers should be routinely used provided that hands are not visibly soiled.
3. Compliance rates were significantly increased after following focused hand hygiene initiatives. It is important to follow such interventions like education and training of medical staff and health care professionals, to provide audit and feedback, to post reminders and posters around hospitals and investing in sufficient hand hygiene equipment. Good hand hygiene compliance rates by health care professionals after an educational program have a satisfactory effect in preventing healthcare infections.
CHAPTER 8: PRACTICAL RECOMMENDATIONS
According to the results of this literature review, it is recommended to carry out more practical and theoretical training of medical personnel. Medical staff should have more emphasis on the importance of hand hygiene in their workplace. Ensure availability of hand washing equipment at all cornerstones of the workplace.
LITERATURE LIST
1. Why Are Clean Hands Important For Children [Internet]. Hpb.gov.sg. 2016 [cited 14 October 2016]. Available from: http://www.hpb.gov.sg/HOPPortal/health-article/7054
2. Dixit D, Hagtvedt R, Reay T, Ballermann M, Forgie S. Attitudes and beliefs about hand hygiene among paediatric residents: a qualitative study. BMJ Open. 2012;2(6):e002188.
3. White C, Statile A, Conway P, Schoettker P, Solan L, Unaka N et al. Utilizing Improvement Science Methods to Improve Physician Compliance With Proper Hand Hygiene.
PEDIATRICS. 2012;129(4):e1042-e1050.
4. WHO | Countries or areas running hand hygiene campaigns [Internet]. Who.int. 2016 [cited 14 October 2016]. Available from:
http://www.who.int/gpsc/national_campaigns/country_list/en/index1.html
5. Shukla U, Chavali S, Menon V. Hand hygiene compliance among healthcare workers in an accredited tertiary care hospital. Indian Journal of Critical Care Medicine. 2014;18(10):689.
6. http://www.who.int/gpsc/5may/tools/who_guidelines-handhygiene_summary.pdf
7. White C, Statile A, Conway P, Schoettker P, Solan L, Unaka N et al. Utilizing Improvement Science Methods to Improve Physician Compliance With Proper Hand Hygiene.
PEDIATRICS. 2012;129(4):e1042-e1050.
8. Jamal A, O'Grady G, Harnett E, Dalton D, Andresen D. Improving hand hygiene in a paediatric hospital: a multimodal quality improvement approach. BMJ Qual Saf. 2012;21(2):171-176.
9. Schmitz K, Kempker R, Tenna A, Stenehjem E, Abebe E, Tadesse L et al. Effectiveness of a multimodal hand hygiene campaign and obstacles to success in Addis Ababa, Ethiopia. Antimicrob Resist Infect Control. 2014;3(1):8.
10. Allegranzi B, Bagheri Nejad S, Combescure C, Graafmans W, Attar H, Donaldson L, Pittet D: Burden of endemic health-care-associated infection in developing countries: systematic
11. WHO | About SAVE LIVES: Clean Your Hands [Internet]. Who.int. 2016 [cited 16 October 2016]. Available from: http://www.who.int/gpsc/5may/background/5moments/en/
12. WHO | Clean hands protect against infection [Internet]. Who.int. 2016 [cited 16 October 2016]. Available from: http://www.who.int/gpsc/clean_hands_protection/en/
13. Randle J, Firth J, Vaughan N. An observational study of hand hygiene compliance in paediatric wards. Journal of Clinical Nursing. 2012;22(17-18):2586-2592.
14. Impact of observing hand hygiene in practice and research: a methodological
reconsideration. D.J. Goulda, ,S. Creedonb, A. Jeanesc, N.S. Dreyd, J. Chudleighe, D. Moralejof.
15. .Nteli C, Galanis P, Koumpagioti D, Poursanidis G, Panagiotopoulou E, Matziou V.
Assessing the Effectiveness of an Educational Program on Compliance with Hand Hygiene in a Pediatric Intensive Care Unit. Advances in Nursing. 2014;2014:1-4.
16. Song X, Stockwell D, Floyd T, Short B, Singh N. Improving hand hygiene compliance in health care workers: Strategies and impact on patient outcomes. American Journal of Infection Control. 2013;41(10):e101-e105.
17. Dixit D, Hagtvedt R, Reay T, Ballermann M, Forgie S. Attitudes and beliefs about hand hygiene among paediatric residents: a qualitative study. BMJ Open. 2012;2(6):e002188.
18. American Academy of Pediatrics
http://www.ecels-healthychildcarepa.org/.../218_aa3d746556093a0ec3f5e3d03f8e2bdf
19. Chen Y, Chiang L. Effectiveness of hand-washing teaching programs for families of children in paediatric intensive care units. Journal of Clinical Nursing. 2007;16(6):1173-1179.
20. Hussein R, Khakoo R, Hobbs G. Hand hygiene practices in adult versus pediatric intensive care units at a university hospital before and after intervention. Scandinavian Journal of Infectious Diseases. 2007;39(6-7):566-570.
21. Widmer A, Conzelmann M, Tomic M, Frei R, Stranden A. Introducing Alcohol‐Based Hand Rub for Hand Hygiene: The Critical Need for Training •. Infection Control and Hospital Epidemiology. 2007;28(1):50-54.
22. 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. Interdisciplinary Perspectives on Infectious Diseases.
2014;2014:1-5.
23. World Health Organization, Guidelines on Hand Hygiene in Health Care. First Global Patient Safety Challenge Clean Care is Safer Care, WHO, 2009,
http://whqlibdoc.who.int/publications/2009/9789241597906 eng.pdf.
24. 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. Interdisciplinary Perspectives on Infectious Diseases.
2014;2014:1-5.
25. Muhumuza C, Gomersall J, Fredrick M, Atuyambe L, Okiira C, Mukose A et al. Health care worker hand hygiene in the pediatric special care unit at Mulago National Referral Hospital in Uganda. International Journal of Evidence-Based Healthcare. 2015;13(1):19-27.
26. Boyce JM, Pittet D. Guideline for hand hygiene in healthcare settings: recommendations of the Healthcare Infection, Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Am J Infect Control 2002; 30: S1– 46.
27. Maury E, Moussa N, Lakermi C, Barbut F, Offenstadt G. Compliance of health care workers to hand hygiene: awareness of being observed is important. Intensive Care Med 2006.
