- Email: [email protected]
Hand-hygiene behaviour, attitudes and beliefs in first year clinical medical students
Letters to the Editor Hand-hygiene behaviour, attitudes and beliefs in first year clinical medical students Sir, The Chief Medical Officer’s report, ‘Winning ways’, sets out the action that the National Health Service needs to take to reduce healthcare-associated infection and the proliferation of antibiotic-resistant bacteria.1 High levels of hand hygiene are central to the aims of ‘Winning ways’, and the report calls for the Department of Health to work with the Royal Colleges to ensure a strong emphasis on infection control in the undergraduate curricula of medical and other healthcare students. Doctors’ hand-hygiene compliance is frequently as low as 9%.2,3 A recent study of final MB BS (Bachelor of Medicine, Bachelor of Surgery) candidates reported similar compliance, and concluded that hand hygiene should become an educational priority.3 The aims of this study were to explore behaviour, attitudes and beliefs about hand hygiene amongst medical students in their first year of clinical training, in order to guide future educational interventions. Two hundred first year clinical medical students were observed over two days in their endof-year objective structured clinical examination (OSCE) in 2000, as described elsewhere.4 At the clinical station ‘neurological examination of the legs’, the use of Hydrex (Adams Healthcare, Leeds, UK) handrub (glycerol BP 1.0% v/v with chlorhexidine gluconate 0.5% w/v in I.M.S. BP 70% v/v) was observed by investigators (DH, AM) who accompanied the examiner but took no part in the actual examination. Candidates were not prompted to use the handrub by either person, but on Day 2, two prominent A4 signs were on display stating ‘PLEASE WASH YOUR HANDS’. Use of handrub at any point during the 10-min station was documented. On Day 2, a ‘handhandwashing questionnaire’ assessing attitudes and beliefs was provided at the rest station (Table I). All students had, in the course of the year, received three infection control teaching sessions, including demonstrations of hand hygiene with liquid soap and handrub, with use of the ultraviolet glow lamp. Ninety-nine candidates were assessed on Day 1 and 101 on Day 2. Nine (9%) students used the handrub on Day 1, and 27/100 (27%) on Day 2 (ChisquaredZ10.54, df 1, PZ0.0012). Ninety-seven of 101 students (97%) completed the questionnaire (Table I). All students knew that hand hygiene was required between patient contacts, and 20–30%
371 were unclear of the role of hand hygiene in preventing the spread of enteric infections and antimicrobial resistance. Over 40% thought that their compliance was at least 80%, and one-third thought that it was 60–80%. The three most frequently perceived barriers to hand hygiene were ‘lack of time’ (56%), ‘lack of sinks’ (47%) and ‘nobody else does it’ (25%). The failure of healthcare workers to decontaminate their hands reflects fundamentals of attitudes, beliefs and behaviours.5 Poor compliance may have its roots in a failure to learn this behaviour at medical college, where the influence of consultants and other role models may be critical. The OSCE reflects learnt behaviours and attitudes of medical students ‘absorbed’ from role models within their training. The low compliance reported in this study of first year clinical students is similar to that of doctors2,3 and final year students,4 suggesting that education to remedy this should begin early. ‘Winning ways’ clearly mandates this, and the low compliance observed in this study reflects the failure of current teaching processes. Students greatly over-rated their compliance, as in other studies.6 This might be addressed by feedback3 and by the award of hygiene marks as part of all clinical assessments and teaching quality assessments.4 About half of the students cited time pressures and lack of sinks as barriers to hand hygiene. Provision of alcoholic handrub at the bedside may be associated with improved compliance.3 The questionnaire revealed gaps in their knowledge about the clinical effectiveness of hand hygiene in reducing the spread of enteric infection7 or antimicrobial resistance.3 One-quarter of students thought that nobody else washed their hands, suggesting a negative influence of some role models 5 after only a year of clinical education, underlining the importance of good clinical practice by teachers.4 This study is the first to report on the beliefs and attitudes of medical students regarding hand hygiene. The results suggest that future educational approaches should include clear presentation of the evidence of effectiveness of hand hygiene, availability of alcohol–glycerol handrub at the bedside, better practice by senior doctors (role models), feedback from teachers at the bedside, and inclusion of hygiene marks in all clinical teaching. A review of handwashing compliance noted the absence of planning and intervention on the basis of psychological theory,8 and further research may be necessary to develop a theoretically grounded
372 Table I
Letters to the Editor Hand-hygiene questionnaire with percentage of affirmative responses % agreed
Q1
Q2
Q3
Q4
Q5
Is it appropriate to wash your hands: when your hands are visibly dirty? between patient contacts? after contact with an MRSA patient? before and after a procedure? at the beginning and end of a ward round? Is handwashing clinically significant in: preventing spread of infection? preventing spread of infective diarrhoea? preventing spread of antimicrobial resistance? reduction of infection to yourself? How often do you wash your hands? 0–20% of patient contacts 20–40% of patient contacts 40–60% of patient contacts 60–80% of patient contacts 80–100% of patient contacts What factors prevent you from washing your hands? No time No sink No soap No handrub Nobody else does It is not important What do you use to wash/disinfect your hands? Bar of soap and water Dispensed liquid soap and water Medicated liquid soap and water, e.g. chlorhexidine Handrub, e.g. Hydrex
educational approach to the hand-hygiene behaviour of medical students.
Acknowledgements We thank Dr Robin Fox for ensuring near-maximal participation in the study on the two days of the examination.
References 1. Chief Medical Officer. Winning ways: working together to reduce healthcare associated infection in England. London: Department of Health; 2003. 2. Tibballs J. Teaching hospital medical staff to handwash. Med J Aust 1996;164:395—398. 3. Pittet D, Huggonet S, Harbath S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307—1312. 4. Feather A, Stone SP, Wessier A, et al. Now please wash your hands: the hand washing behaviour of final MBBS candidates. J Hosp Infect 2000;45:62—64.
96 99 95 96 85 99 80 65 81 3 6 14 32 42 56 47 16 18 25 2 5 65 75 60
5. Handwashing Liaison Group. Handwashing: a modest measure with big effects. BMJ 1999;318:686. 6. Pratt RJ, Pellowe C, Loveday HP, et al. The EPIC project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase 1: guidelines for preventing hospital-acquired infections. J Hosp Infect 2001; 47(Suppl.):S3—S82. 7. Stone SP, Teare L, Cookson BJ. Guiding hands of our teachers. Hand-hygiene Liaison Group. Lancet 2001;357: 479—480. 8. Larson E, Kretzer EK. Compliance with handwashing and barrier precautions. J Hosp Infect 1995;30:S88—S106.
D.C.E. Hunta, A. Mohammudallya, S.P. Stonea,*, J. Dacreb a Academic Department of Geriatric Medicine, Royal Free Campus, The Royal Free and University College Medical School, London NW3 2PG, UK b Centre for Health Informatics and Multiprofessional Education, University College London Medical School, Whittington Hospital Campus, London N19 5NF, UK E-mail address: [email protected] *Corresponding author. Address: Barnet General Hospital, Care
Letters to the Editor of the Elderly, 25 Peal Gardens, Ealing, London W13 0BA, UK. Tel.: C44 7885 101065 Q 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2004.09.002
The epic project: updating the evidence base for national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. A report with recommendations Sir, National evidence-based guidelines for preventing healthcare-associated infections (HAI) in National Health Service (NHS) hospitals in England were commissioned by the Department of Health (DH) and developed during 1998–2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were published in January 2001.1 These guidelines describe the precautions that healthcare workers should take in three areas: standard principles for preventing HAI, which include hospital environmental hygiene, hand hygiene, the use of personal protective equipment, and the safe use and disposal of sharps; and preventing infections associated with the insertion and maintenance of short-term indwelling urethral catheters and central venous catheters (CVCs). The evidence underpinning infection prevention and control guidelines requires updating at regular intervals as advances in technology and new research findings may influence guideline recommendations. The evidence base for these guidelines has recently been updated using systematic review methods. A critical assessment of the updated evidence indicates that the current guidelines remain robust, relevant and appropriate, but that adjustments need to be made to some guideline recommendations. A full report on the methodology and new evidence has now been published.2 New evidence suggests that recommendations for hospital environmental hygiene need to include assessment and regular monitoring of cleaning and hygiene standards within all clinical areas, especially in high-risk areas such as intensive care units and environments where patients with multiresistant micro-organisms have been placed. The current guidance does not take account of the new evidence in the field of hand hygiene practice, and requires updating to emphasize the use of alcohol
373 hand rub between all clinical care activities that do not result in gross contamination. The recommendations on the use of gloves need amending in two areas. First, they need to be strengthened with regard to handwashing following the removal of gloves. Second, the revised standards on the quality of single-use gloves need to be reflected in the guidelines. The guidelines for preventing infections associated with the use of short-term indwelling urethral catheters continue to reflect current evidence. However, they should now include the appropriate use of silver alloy catheters and the need to develop individual care regimens if it is anticipated that catheterization may be required beyond a few days. The majority of the current guideline recommendations on preventing infections using CVCs are congruent with the updated Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines3 and with new evidence. However, adjustments will be needed in some intervention categories. Our review identified increasing evidence of efficacy for antimicrobial-/antiseptic-coated or impregnated catheters to prevent catheter-related bloodstream infection (CRBSI) in well-defined patient populations, which reinforces our current recommendations for their use. New guidelines will need to refer to National Institute for Clinical Excellence (NICE) guidance on using ultrasound for placement of CVCs. As subclavian vein insertion is associated with the least risk of CRBSI but is also associated with more mechanical complications than internal jugular or femoral insertion sites, the use of ultrasound locating devices may increase the utilization of the subclavian vein site. The use of 2% chlorhexidine gluconate for skin antisepsis prior to catheter insertion and for catheter site care should be explicitly emphasized in the guidelines. HICPAC is now recommending an alcoholic solution of chlorhexidine gluconate 2% as this combines the benefits of rapid action and excellent residual activity. Finally, the theoretical benefit of using low-dose intermittent heparin flushes for preventing infection is outweighed by potential adverse effects of unnecessary exposure to heparin. The guidelines should recommend the routine use of normal saline flushes, and reserve heparin flushes for specific implanted ports or open-ended catheter lumens or for those catheters that are infrequently accessed. The appraisal of new evidence (and in one or two instances, a re-appraisal of previous evidence) confirmed that although the original guidelines were generally robust and still applicable, a few recommendations require adjustment or change.
371 were unclear of the role of hand hygiene in preventing the spread of enteric infections and antimicrobial resistance. Over 40% thought that their compliance was at least 80%, and one-third thought that it was 60–80%. The three most frequently perceived barriers to hand hygiene were ‘lack of time’ (56%), ‘lack of sinks’ (47%) and ‘nobody else does it’ (25%). The failure of healthcare workers to decontaminate their hands reflects fundamentals of attitudes, beliefs and behaviours.5 Poor compliance may have its roots in a failure to learn this behaviour at medical college, where the influence of consultants and other role models may be critical. The OSCE reflects learnt behaviours and attitudes of medical students ‘absorbed’ from role models within their training. The low compliance reported in this study of first year clinical students is similar to that of doctors2,3 and final year students,4 suggesting that education to remedy this should begin early. ‘Winning ways’ clearly mandates this, and the low compliance observed in this study reflects the failure of current teaching processes. Students greatly over-rated their compliance, as in other studies.6 This might be addressed by feedback3 and by the award of hygiene marks as part of all clinical assessments and teaching quality assessments.4 About half of the students cited time pressures and lack of sinks as barriers to hand hygiene. Provision of alcoholic handrub at the bedside may be associated with improved compliance.3 The questionnaire revealed gaps in their knowledge about the clinical effectiveness of hand hygiene in reducing the spread of enteric infection7 or antimicrobial resistance.3 One-quarter of students thought that nobody else washed their hands, suggesting a negative influence of some role models 5 after only a year of clinical education, underlining the importance of good clinical practice by teachers.4 This study is the first to report on the beliefs and attitudes of medical students regarding hand hygiene. The results suggest that future educational approaches should include clear presentation of the evidence of effectiveness of hand hygiene, availability of alcohol–glycerol handrub at the bedside, better practice by senior doctors (role models), feedback from teachers at the bedside, and inclusion of hygiene marks in all clinical teaching. A review of handwashing compliance noted the absence of planning and intervention on the basis of psychological theory,8 and further research may be necessary to develop a theoretically grounded
372 Table I
Letters to the Editor Hand-hygiene questionnaire with percentage of affirmative responses % agreed
Q1
Q2
Q3
Q4
Q5
Is it appropriate to wash your hands: when your hands are visibly dirty? between patient contacts? after contact with an MRSA patient? before and after a procedure? at the beginning and end of a ward round? Is handwashing clinically significant in: preventing spread of infection? preventing spread of infective diarrhoea? preventing spread of antimicrobial resistance? reduction of infection to yourself? How often do you wash your hands? 0–20% of patient contacts 20–40% of patient contacts 40–60% of patient contacts 60–80% of patient contacts 80–100% of patient contacts What factors prevent you from washing your hands? No time No sink No soap No handrub Nobody else does It is not important What do you use to wash/disinfect your hands? Bar of soap and water Dispensed liquid soap and water Medicated liquid soap and water, e.g. chlorhexidine Handrub, e.g. Hydrex
educational approach to the hand-hygiene behaviour of medical students.
Acknowledgements We thank Dr Robin Fox for ensuring near-maximal participation in the study on the two days of the examination.
References 1. Chief Medical Officer. Winning ways: working together to reduce healthcare associated infection in England. London: Department of Health; 2003. 2. Tibballs J. Teaching hospital medical staff to handwash. Med J Aust 1996;164:395—398. 3. Pittet D, Huggonet S, Harbath S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307—1312. 4. Feather A, Stone SP, Wessier A, et al. Now please wash your hands: the hand washing behaviour of final MBBS candidates. J Hosp Infect 2000;45:62—64.
96 99 95 96 85 99 80 65 81 3 6 14 32 42 56 47 16 18 25 2 5 65 75 60
5. Handwashing Liaison Group. Handwashing: a modest measure with big effects. BMJ 1999;318:686. 6. Pratt RJ, Pellowe C, Loveday HP, et al. The EPIC project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase 1: guidelines for preventing hospital-acquired infections. J Hosp Infect 2001; 47(Suppl.):S3—S82. 7. Stone SP, Teare L, Cookson BJ. Guiding hands of our teachers. Hand-hygiene Liaison Group. Lancet 2001;357: 479—480. 8. Larson E, Kretzer EK. Compliance with handwashing and barrier precautions. J Hosp Infect 1995;30:S88—S106.
D.C.E. Hunta, A. Mohammudallya, S.P. Stonea,*, J. Dacreb a Academic Department of Geriatric Medicine, Royal Free Campus, The Royal Free and University College Medical School, London NW3 2PG, UK b Centre for Health Informatics and Multiprofessional Education, University College London Medical School, Whittington Hospital Campus, London N19 5NF, UK E-mail address: [email protected] *Corresponding author. Address: Barnet General Hospital, Care
Letters to the Editor of the Elderly, 25 Peal Gardens, Ealing, London W13 0BA, UK. Tel.: C44 7885 101065 Q 2004 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2004.09.002
The epic project: updating the evidence base for national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. A report with recommendations Sir, National evidence-based guidelines for preventing healthcare-associated infections (HAI) in National Health Service (NHS) hospitals in England were commissioned by the Department of Health (DH) and developed during 1998–2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were published in January 2001.1 These guidelines describe the precautions that healthcare workers should take in three areas: standard principles for preventing HAI, which include hospital environmental hygiene, hand hygiene, the use of personal protective equipment, and the safe use and disposal of sharps; and preventing infections associated with the insertion and maintenance of short-term indwelling urethral catheters and central venous catheters (CVCs). The evidence underpinning infection prevention and control guidelines requires updating at regular intervals as advances in technology and new research findings may influence guideline recommendations. The evidence base for these guidelines has recently been updated using systematic review methods. A critical assessment of the updated evidence indicates that the current guidelines remain robust, relevant and appropriate, but that adjustments need to be made to some guideline recommendations. A full report on the methodology and new evidence has now been published.2 New evidence suggests that recommendations for hospital environmental hygiene need to include assessment and regular monitoring of cleaning and hygiene standards within all clinical areas, especially in high-risk areas such as intensive care units and environments where patients with multiresistant micro-organisms have been placed. The current guidance does not take account of the new evidence in the field of hand hygiene practice, and requires updating to emphasize the use of alcohol
373 hand rub between all clinical care activities that do not result in gross contamination. The recommendations on the use of gloves need amending in two areas. First, they need to be strengthened with regard to handwashing following the removal of gloves. Second, the revised standards on the quality of single-use gloves need to be reflected in the guidelines. The guidelines for preventing infections associated with the use of short-term indwelling urethral catheters continue to reflect current evidence. However, they should now include the appropriate use of silver alloy catheters and the need to develop individual care regimens if it is anticipated that catheterization may be required beyond a few days. The majority of the current guideline recommendations on preventing infections using CVCs are congruent with the updated Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines3 and with new evidence. However, adjustments will be needed in some intervention categories. Our review identified increasing evidence of efficacy for antimicrobial-/antiseptic-coated or impregnated catheters to prevent catheter-related bloodstream infection (CRBSI) in well-defined patient populations, which reinforces our current recommendations for their use. New guidelines will need to refer to National Institute for Clinical Excellence (NICE) guidance on using ultrasound for placement of CVCs. As subclavian vein insertion is associated with the least risk of CRBSI but is also associated with more mechanical complications than internal jugular or femoral insertion sites, the use of ultrasound locating devices may increase the utilization of the subclavian vein site. The use of 2% chlorhexidine gluconate for skin antisepsis prior to catheter insertion and for catheter site care should be explicitly emphasized in the guidelines. HICPAC is now recommending an alcoholic solution of chlorhexidine gluconate 2% as this combines the benefits of rapid action and excellent residual activity. Finally, the theoretical benefit of using low-dose intermittent heparin flushes for preventing infection is outweighed by potential adverse effects of unnecessary exposure to heparin. The guidelines should recommend the routine use of normal saline flushes, and reserve heparin flushes for specific implanted ports or open-ended catheter lumens or for those catheters that are infrequently accessed. The appraisal of new evidence (and in one or two instances, a re-appraisal of previous evidence) confirmed that although the original guidelines were generally robust and still applicable, a few recommendations require adjustment or change.