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The impact of hand hygiene awareness programme on health care professionals' compliance with hand hygiene in a tertiary care hospital: A clinical audit
JPSIC-33; No. of Pages 4 journal of patient safety & infection control xxx (2015) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/jpsic
Original Article
The impact of hand hygiene awareness programme on health care professionals' compliance with hand hygiene in a tertiary care hospital: A clinical audit Elpreda M. Victor a,*, Evangelin M. Vasanth a, Mary Thankappan a, Srinithya Raghavan a, Amit Dadhich a, Poonam Joshi b, Rakesh Lodha c, Sanjay Arya d, Arti Kapil e a
Hospital Infection Control Nurse, Department of Nursing Services, AIIMS, New Delhi, India College of Nursing, AIIMS, New Delhi, India c Department of Paediatrics, AIIMS, New Delhi, India d Department of Hospital Administration, AIIMS, New Delhi, India e Department of Microbiology, AIIMS, New Delhi, India b
article info
abstract
Article history:
Background: Hand hygiene is the most cost effective method to control the health care
Received 26 December 2014
associated infections. Despite knowing the fact the compliance of health care professionals
Accepted 16 May 2015
with hand hygiene is not up to the mark.
Available online xxx
Methods: An observational, prospective study was designed to assess knowledge, and attitude of health care professionals towards hand hygiene practices. The impact of hand hygiene
Keywords:
awareness programme (HHAP) on the compliance of 106 health care professionals working in
Compliance
paediatric medical and surgical wards of a tertiary care hospital was also evaluated. Clinical
Health care professionals (HCP)
audit comprised of 200 observations each before and after the HHAP was done.
Hand hygiene awareness
Results: Of total 106 health care professionals 73 (68.8%) were nurses, 33 (31.13%) doctors
programme (HHAP)
with mean age (years) of 32.14 7.4. Mean knowledge and attitude scores of HCP were 19.28
Clinical audit
2.4and 39.26 3.9 respectively. Majority HCP had good knowledge (91/106, 85.8%) and favourable attitude (89/106, 83.9%) related to hand hygiene practices. Significant improvement in hand hygiene compliance was observed among the health care professionals following the hand hygiene awareness programme ( p < 0.001). Conclusion: Hand hygiene awareness programme should be continued on ongoing basis to improve the compliance of HCP with hand hygiene practices. # 2015 Hospital Infection Society India. Published by Elsevier B.V. All rights reserved.
* Corresponding author. Hospital Infection Control Nurse, All India Institute of Medical Sciences, New Delhi, India. Tel.: +91 11 26596533; fax: +91 11 2658 8883. E-mail address: [email protected] (E.M Victor). http://dx.doi.org/10.1016/j.jpsic.2015.05.003 2214-207X/# 2015 Hospital Infection Society India. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Victor EM, et al. The impact of hand hygiene awareness programme on health care professionals' compliance with hand hygiene in a tertiary care hospital: A clinical audit, J Patient Saf Infect Control. (2015), http://dx.doi.org/10.1016/j. jpsic.2015.05.003
JPSIC-33; No. of Pages 4
2
journal of patient safety & infection control xxx (2015) xxx–xxx
1.
Introduction
Health care-associated infection (HAI) transmission in the hospital environment remains a significant hazard for hospitalized patients and health-care workers.1 The HAI are the most common serious complication of hospitalization, and the leading cause of death among hospitalized patients.2 Most HAI are thought to be transmitted by the hands of health care workers. Hand hygiene has been recognized for more than 150 years as the single most effective and cost-effective means of preventing hospital acquired infection, as well as an effective means of preventing illness in the community that may lead to hospitalization.3 It has long been known that hand hygiene among health care workers plays a central role in preventing the transmission of infectious agents.1 Handwashing is the most effective way of preventing the spread of infectious diseases. But despite, Centres for Disease Control and Prevention (CDC) hand hygiene guidelines being implemented in hospitals, compliance among health care professionals remains low.4 Studies in the literature have repeatedly documented that the importance of hand hygiene is not sufficiently recognized by health care professionals (HCP) and compliance with recommended practices is unacceptably low.5–7
2.
Aims and objectives
To assess knowledge, and attitude of health care professionals towards hand hygiene practices, and to measure the impact of hand hygiene awareness programme on the compliance of health care professionals.
3.
Material and methods
The study took place from January 2014 to July 2014 in paediatric medical and surgical wards of a tertiary care hospital. The study targeted 106 health care professionals including doctors and nurses involved in direct patient care in paediatric medical and surgical wards of a tertiary care hospital. Total enumeration technique was used to enrol the health care professionals. All those consented were included in the study. The study was approved by the Ethics Committee of the hospital. Formal information about the research project was given to the assistant nursing superintendents of the wards and heads of the department of paediatric medicine and surgery by infection control nurses before the initiation of project. Subject datasheet, self administered knowledge questionnaire, attitude scale and audit sheets were used for data collection. The subject data sheet had baseline information related to age, basic qualification, professional qualification, designation, total professional experience, experience in the present area of work, in-service education training related to hand hygiene etc. Self administered knowledge questionnaire and attitude scale were prepared with the help of experts after extensive review of literature. The knowledge questionnaire had 31 items. For every correct response a score of one and incorrect response a score of 0 was given. The maximum
obtained score could be 31. Attitude questionnaire had 10 items measured on five point likert scale. The maximum possible obtained score could be 50. Total knowledge and attitude scores were graded as Excellent (>80%), Good (61– 80%), Average (50–60%) and Poor (<50%). Audit sheet were prepared based on hospital infection control policy and experts' opinion to check hand hygiene practices either using hand rub or hand washing. Audit sheet was a checklist indicating absence or presence of short nails, jewellery, six steps of hand washing, duration of hand washing/application of hand rub, through rinsing and drying. Compliance with hand hygiene practices was categorized as appropriate (if all the steps were followed), inappropriate (missed one or more steps) and not at all (no hand hygiene observed). Reliability of knowledge and attitude questionnaire(r = 0.94, r = 0.95) and audit sheet (r = 0.89) was established by test retest method and inter-rater test, respectively. The study was conducted in three phases: pre-intervention phase, intervention and post intervention phase. In preintervention phase baseline knowledge and attitude of 106 health care professionals working in paediatric medicine and surgery wards towards hand hygiene were assessed. A clinical audit of hand hygiene practices was done over a period of one month, which included 200 observations among the available health care professionals including doctors and nurses working in paediatric medicine and surgery wards (Table 1). The hand hygiene practices before and after the invasive procedures like medication injections (bolus/infusion), endotracheal suction, surgical dressing, I/V cannulation, biopsy, peritoneal lavage were observed. The observers were the four infection control nurses who used direct non-participatory observation technique for data collection. Two infection control nurses were present around the patients in each ward, on all working days for a period of 2 h, daily between 9 am and 1 pm. It was ensured that patients' privacy was respected and the observation did not interfere with health-care activities being carried out during the session. Observations in extreme situations like cardiopulmonary resuscitation were avoided. The audit sheet was filled immediately after the observation session. Feedback was given to every HCP individually after the clinical audit. The second phase was an intervention phase of one week duration, in which hand hygiene awareness programme (HHAP) was implemented. The HHAP was a campaign program consisted of displaying pamphlets, posters and reminders related to five moments of hand hygiene, steps of hand washing and application of hand rubs at specified places in the wards like near hand washing area, treatment room, and near the bedside of the patients, where health care professionals– patient contact could occur. During the evaluation or postintervention phase another clinical audit of 200 hand hygiene practices was done in the same manner in one month time as done in pre-intervention phase. Collected data was coded, and entered in Excel sheet and analysed using Stata 9.0 and SPSS 17.0. Descriptive statistics were used to analyse the data. Frequency, percentage, mean, median, range, SD were calculated. Pearson coefficient correlation test was used to find out correlation between knowledge and attitude scores of HCP related to hand hygiene practices. Compliance of the HCP with hand hygiene practices
Please cite this article in press as: Victor EM, et al. The impact of hand hygiene awareness programme on health care professionals' compliance with hand hygiene in a tertiary care hospital: A clinical audit, J Patient Saf Infect Control. (2015), http://dx.doi.org/10.1016/j. jpsic.2015.05.003
JPSIC-33; No. of Pages 4
3
journal of patient safety & infection control xxx (2015) xxx–xxx
Table 1 – Clinical audit of hand hygiene among health care professionals before and after Hand Hygiene Awareness Programme. Method
Appropriate Inappropriate Not at all *
Before HHAP n = 200
After HHAP n = 200
Hand rub n(%) n1 = 160
Soap & water n(%) n2 = 40
Hand hygiene n(%) n = 200
Hand rub n(%) n1 = 174
Soap & water n(%) n(%) n2 = 26
Hand hygiene n(%) n = 200
13 (8.1) 123 (76.9) 24 (15)
10 (25) 25 (62.5) 5 (12.5)
23 (11.5) 148 (76.5) 29 (14.5)
54 (31.0) 105 (60.4) 15 (8.6)
20 (76.9) 4 (15.4) 2 (7.7)
74 (37) 109 (54.5) 17 (8.5)
0.001*
p < 0.05
before and after the HHAP was analysed using chi-square test. The set level of significance was decided at 0.05.
4.
p value
Results
Of total 106 health care professionals 73 (68.8%) were nurses, 33 (31.13%) doctors with mean age (years) of HCP 32.14 7.4 (22–56). Median total professional experience and experience in present area of work (years) were 4.7 (0.5–34) and 2.2 (1–27) respectively. Majority HCP 73 (68.8%) had undergone training programme related to hand hygiene as part of in-service education programme, while 33 (31.3%) had not undergone any training programme. Majority health care professionals 100 (94.3%) did not complain of any shortage related to items required for hand hygiene maintenance like soap, water and alcohol rub in their units. Mean knowledge and attitude scores of HCP were 19.28 2.4 (13–25) and 39.26 3.9 (26–48) respectively. Majority health care professionals had good knowledge (91/106, 85.8%) and favourable attitude (89/106, 83.9%). A strong positive correlation was observed between the knowledge and attitude scores of HCP related to hand hygiene practices (r = 1.00, p < 0.002). Majority health care professionals (99%) considered hand hygiene to be the single most effective measure against infection control and prevention. Majority health care professionals 77 (72.64%) stated to have coagulase negative staphylococci as part of normal skin flora. The most important component of hand washing recognised by health care professionals were friction 38 (35.5%) followed by soap 36 (33.9%). The most common mode of transmission of pathogen identified by 83 (78.3%) health care professionals was hands. Exactly half of the subjects reported area near the thumb as commonly missed area in the process of hand hygiene maintenance. Hygienic hand washing to be done for 1 min was opined by 80 (75.47%) health care professionals. Using gloves is not a substitute for hand hygiene was reported by 101 (95.28%) professionals. Alcohol rub can be used in between when the hands are not visibly soiled with blood or body fluids was stated by majority 96 (90.6%) HCP. Possible reasons for not frequently washing hands as required, reported by HCP were too much work load 59 (55.7%), increased nurse patient or doctor patient ratio 44 (41.5%), lack of supply for hand washing like soap, water etc 21 (19.8%), inconveniently located
sinks 49 (46.2%), poor skin condition like eczema, contact dermatitis, cut, boil, burn etc 38 (35.8%), and patients needs taking priority 9 (8.5%). In pre-intervention audit, total 200 observations consisted of 160 hand rub applications and 40 hand washing using soap and water. Majority hand rub applications (123/160, 76.9%) were inappropriate, while appropriate were 25% (10/40). In 24 (15%) observations no hand rub application was done prior to the patient care procedures. Pre-intervention clinical audit showed that majority hand hygiene events using hand rub or hand washing (76.5%) were inappropriate, only 23 (11.5%) events of hand hygiene were appropriate and on 29 (14.5%) occasions hand hygiene was not at all maintained. In post-intervention audit another 200 observations consisting of 174 hand rub application and 26 hand washing using soap and water was carried out. Majority observations on hand rub applications were still inappropriate (105/174, 60.5%), while majority observations on hand washing using soap and water were appropriate (20/26, 76.9%). There was significant improvement in hand hygiene practices following the HHAP as evident by p value <0.001. In post intervention clinical audit inappropriate hand hygiene events and not all hand hygiene events were reduced from 76.5% to 54.5% and 14.5%–8.5% respectively and there was increase in appropriate hand hygiene events from 11.5% to 37%.
5.
Discussion
Majority HCP had good knowledge (91/106, 85.8%) and favourable attitude (89/106, 83.9%) related to hand hygiene practices. Significant improvement in hand hygiene compliance was observed among the health care professionals following the hand hygiene awareness programme ( p < 0.001). Results of this study showed that knowledge and attitude of HCP, who participated in the study were good and favourable that is congruent with the findings reported by Payudel et al.8 Majority HCP realized hand hygiene as single most effective method in preventing and controlling health care associated infections, despite that the compliance of HCP towards hand hygiene practices was poor. This finding confirms with the earlier reports.4 According to Boyce et al9 monitoring hand hygiene compliance and providing health care workers with feedback regarding their performance are considered integral parts of a successful hand hygiene promotion programme. The findings of the present study
Please cite this article in press as: Victor EM, et al. The impact of hand hygiene awareness programme on health care professionals' compliance with hand hygiene in a tertiary care hospital: A clinical audit, J Patient Saf Infect Control. (2015), http://dx.doi.org/10.1016/j. jpsic.2015.05.003
JPSIC-33; No. of Pages 4
4
journal of patient safety & infection control xxx (2015) xxx–xxx
revealed that the hand hygiene awareness programme was effective in improving the compliance of HCP towards hand hygiene practices. The improvement in the compliance rate can be attributed to positive effect of the HHAP. Findings from some previous studies10,11 have consistently indicated hand hygiene compliance improves following the interventions. Though perception and compliance can vary with experience and education of health care personnel or doctors,12 in the present study Knowledge scores of Doctors and Nurses were found to be more or less the same. Therefore all further observations of their practices were analysed uniformly as under Health Care Professionals. Further continuation of the hand hygiene awareness programme could have shown further improvement.
5.1.
Limitations
Presence of infection control nurses near the patients could have falsely improved the compliance rate of HCP initially, which might be attributed to the Hawthorn effect seen during the clinical audit. Another important factor is that the clinical audit was done in the morning shift only. Availability of better supervision, resources and manpower in terms of HCP and patient ratio, in the morning might not give the true reflection of the status of hand hygiene practices. Not including other shifts i.e. evening/night and further relatively smaller observations of hand hygiene practices limit the generalizability of the findings of this study. Despite these limitations, the results of the study suggested that hand hygiene awareness programme was useful in sensitizing the health care professionals. Giving performance feedback to the HCP by infection control nurse might have helped in changing the mindset of HCP, which is required to bring the permanent change in one's behaviour. This can be considered as the strength of the study as it helped in improving the compliance rate. There is need to evaluate the long term effects of similar ongoing programmes in terms of compliance rates of HCP with hand hygiene practices. The same can be correlated with the HAI rate in the ward.
6.
Conclusion
Conducting hand hygiene awareness programmes and campaigns in health care setup are feasible and have positive effect on health care professionals hand hygiene practices.
Conflicts of interest All authors have none to declare.
Funding Self funded.
references
1. World Health Organization Save lives clean your handsGuide to Implementation. A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy. Geneva: WHO/IER/PSP/2009.02; 2009. 2. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/ SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Health Care Epidemiology of America/Association for Professionals in Infection Control/Infectious diseases. Society of America. MMWR Recomm Rep. 2002. 51 (RR-16): 1-45 quiz CE1-4 (Accessed 16.09.14). 3. In: WHO Guidelines for Hand Hygiene in Health Care (Advanced Draft). Geneva: World Health Organization; 2006. 4. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet. 2000;356:1307–1312. 5. Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D. ‘‘My five moments for hand hygiene’’: a user-centred design approachto understand, train, monitor and report hand hygiene. J Hosp Infect. 2007;67:9–21. 6. Allegranzi B, Pittet D. Preventing infections acquired during health-care delivery. Lancet. 2008;372:1719–1720. 7. Bittner MJ, Richet EC, Turner PD, Arnold Jr WH. Limited impact of sustained simple feedback based on soap and paper towel consumption on the frequency of hand washing in an adult intensive care unit. Infect Control Hosp Epidemiol. 2002;23:120–126. 8. Paudyal P, Simkhada P, Bruce J. Infection control knowledge, attitude, and practice among Nepalese health care workers. Am J Infect Control. 2008;36:595–597. Mosby, Inc.. 9. Boyce JM. Hand hygiene compliance monitoring: current perspectives from the USA. J Hosp Infect. 2008;70(Suppl. 1): 2–7. 10. Doron SI, Kifuji K, Hynes BT, et al. A multifaceted approach to education, observation, and feedback in a successful hand hygiene campaign. Jt Comm J Qual Patient Saf. 2011; 37:3–10. 11. Allegranzi B, Sax H, Bengaly L, et al. World Health Organization ‘‘Point G’’ Project Management Committee. Successful implementation of the World Health Organization hand hygiene improvement strategy in a referral hospital in Mali, Africa. Infect Control Hosp Epidemiol. 2010;31:133–141. 12. Kapil R, Bhavsar HK, Madan M. Hand hygiene in reducing transient flora on the hands of healthcare workers: an educational intervention. Indian J Med Microbiol. 2015; 33:125–128.
Please cite this article in press as: Victor EM, et al. The impact of hand hygiene awareness programme on health care professionals' compliance with hand hygiene in a tertiary care hospital: A clinical audit, J Patient Saf Infect Control. (2015), http://dx.doi.org/10.1016/j. jpsic.2015.05.003
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/jpsic
Original Article
The impact of hand hygiene awareness programme on health care professionals' compliance with hand hygiene in a tertiary care hospital: A clinical audit Elpreda M. Victor a,*, Evangelin M. Vasanth a, Mary Thankappan a, Srinithya Raghavan a, Amit Dadhich a, Poonam Joshi b, Rakesh Lodha c, Sanjay Arya d, Arti Kapil e a
Hospital Infection Control Nurse, Department of Nursing Services, AIIMS, New Delhi, India College of Nursing, AIIMS, New Delhi, India c Department of Paediatrics, AIIMS, New Delhi, India d Department of Hospital Administration, AIIMS, New Delhi, India e Department of Microbiology, AIIMS, New Delhi, India b
article info
abstract
Article history:
Background: Hand hygiene is the most cost effective method to control the health care
Received 26 December 2014
associated infections. Despite knowing the fact the compliance of health care professionals
Accepted 16 May 2015
with hand hygiene is not up to the mark.
Available online xxx
Methods: An observational, prospective study was designed to assess knowledge, and attitude of health care professionals towards hand hygiene practices. The impact of hand hygiene
Keywords:
awareness programme (HHAP) on the compliance of 106 health care professionals working in
Compliance
paediatric medical and surgical wards of a tertiary care hospital was also evaluated. Clinical
Health care professionals (HCP)
audit comprised of 200 observations each before and after the HHAP was done.
Hand hygiene awareness
Results: Of total 106 health care professionals 73 (68.8%) were nurses, 33 (31.13%) doctors
programme (HHAP)
with mean age (years) of 32.14 7.4. Mean knowledge and attitude scores of HCP were 19.28
Clinical audit
2.4and 39.26 3.9 respectively. Majority HCP had good knowledge (91/106, 85.8%) and favourable attitude (89/106, 83.9%) related to hand hygiene practices. Significant improvement in hand hygiene compliance was observed among the health care professionals following the hand hygiene awareness programme ( p < 0.001). Conclusion: Hand hygiene awareness programme should be continued on ongoing basis to improve the compliance of HCP with hand hygiene practices. # 2015 Hospital Infection Society India. Published by Elsevier B.V. All rights reserved.
* Corresponding author. Hospital Infection Control Nurse, All India Institute of Medical Sciences, New Delhi, India. Tel.: +91 11 26596533; fax: +91 11 2658 8883. E-mail address: [email protected] (E.M Victor). http://dx.doi.org/10.1016/j.jpsic.2015.05.003 2214-207X/# 2015 Hospital Infection Society India. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Victor EM, et al. The impact of hand hygiene awareness programme on health care professionals' compliance with hand hygiene in a tertiary care hospital: A clinical audit, J Patient Saf Infect Control. (2015), http://dx.doi.org/10.1016/j. jpsic.2015.05.003
JPSIC-33; No. of Pages 4
2
journal of patient safety & infection control xxx (2015) xxx–xxx
1.
Introduction
Health care-associated infection (HAI) transmission in the hospital environment remains a significant hazard for hospitalized patients and health-care workers.1 The HAI are the most common serious complication of hospitalization, and the leading cause of death among hospitalized patients.2 Most HAI are thought to be transmitted by the hands of health care workers. Hand hygiene has been recognized for more than 150 years as the single most effective and cost-effective means of preventing hospital acquired infection, as well as an effective means of preventing illness in the community that may lead to hospitalization.3 It has long been known that hand hygiene among health care workers plays a central role in preventing the transmission of infectious agents.1 Handwashing is the most effective way of preventing the spread of infectious diseases. But despite, Centres for Disease Control and Prevention (CDC) hand hygiene guidelines being implemented in hospitals, compliance among health care professionals remains low.4 Studies in the literature have repeatedly documented that the importance of hand hygiene is not sufficiently recognized by health care professionals (HCP) and compliance with recommended practices is unacceptably low.5–7
2.
Aims and objectives
To assess knowledge, and attitude of health care professionals towards hand hygiene practices, and to measure the impact of hand hygiene awareness programme on the compliance of health care professionals.
3.
Material and methods
The study took place from January 2014 to July 2014 in paediatric medical and surgical wards of a tertiary care hospital. The study targeted 106 health care professionals including doctors and nurses involved in direct patient care in paediatric medical and surgical wards of a tertiary care hospital. Total enumeration technique was used to enrol the health care professionals. All those consented were included in the study. The study was approved by the Ethics Committee of the hospital. Formal information about the research project was given to the assistant nursing superintendents of the wards and heads of the department of paediatric medicine and surgery by infection control nurses before the initiation of project. Subject datasheet, self administered knowledge questionnaire, attitude scale and audit sheets were used for data collection. The subject data sheet had baseline information related to age, basic qualification, professional qualification, designation, total professional experience, experience in the present area of work, in-service education training related to hand hygiene etc. Self administered knowledge questionnaire and attitude scale were prepared with the help of experts after extensive review of literature. The knowledge questionnaire had 31 items. For every correct response a score of one and incorrect response a score of 0 was given. The maximum
obtained score could be 31. Attitude questionnaire had 10 items measured on five point likert scale. The maximum possible obtained score could be 50. Total knowledge and attitude scores were graded as Excellent (>80%), Good (61– 80%), Average (50–60%) and Poor (<50%). Audit sheet were prepared based on hospital infection control policy and experts' opinion to check hand hygiene practices either using hand rub or hand washing. Audit sheet was a checklist indicating absence or presence of short nails, jewellery, six steps of hand washing, duration of hand washing/application of hand rub, through rinsing and drying. Compliance with hand hygiene practices was categorized as appropriate (if all the steps were followed), inappropriate (missed one or more steps) and not at all (no hand hygiene observed). Reliability of knowledge and attitude questionnaire(r = 0.94, r = 0.95) and audit sheet (r = 0.89) was established by test retest method and inter-rater test, respectively. The study was conducted in three phases: pre-intervention phase, intervention and post intervention phase. In preintervention phase baseline knowledge and attitude of 106 health care professionals working in paediatric medicine and surgery wards towards hand hygiene were assessed. A clinical audit of hand hygiene practices was done over a period of one month, which included 200 observations among the available health care professionals including doctors and nurses working in paediatric medicine and surgery wards (Table 1). The hand hygiene practices before and after the invasive procedures like medication injections (bolus/infusion), endotracheal suction, surgical dressing, I/V cannulation, biopsy, peritoneal lavage were observed. The observers were the four infection control nurses who used direct non-participatory observation technique for data collection. Two infection control nurses were present around the patients in each ward, on all working days for a period of 2 h, daily between 9 am and 1 pm. It was ensured that patients' privacy was respected and the observation did not interfere with health-care activities being carried out during the session. Observations in extreme situations like cardiopulmonary resuscitation were avoided. The audit sheet was filled immediately after the observation session. Feedback was given to every HCP individually after the clinical audit. The second phase was an intervention phase of one week duration, in which hand hygiene awareness programme (HHAP) was implemented. The HHAP was a campaign program consisted of displaying pamphlets, posters and reminders related to five moments of hand hygiene, steps of hand washing and application of hand rubs at specified places in the wards like near hand washing area, treatment room, and near the bedside of the patients, where health care professionals– patient contact could occur. During the evaluation or postintervention phase another clinical audit of 200 hand hygiene practices was done in the same manner in one month time as done in pre-intervention phase. Collected data was coded, and entered in Excel sheet and analysed using Stata 9.0 and SPSS 17.0. Descriptive statistics were used to analyse the data. Frequency, percentage, mean, median, range, SD were calculated. Pearson coefficient correlation test was used to find out correlation between knowledge and attitude scores of HCP related to hand hygiene practices. Compliance of the HCP with hand hygiene practices
Please cite this article in press as: Victor EM, et al. The impact of hand hygiene awareness programme on health care professionals' compliance with hand hygiene in a tertiary care hospital: A clinical audit, J Patient Saf Infect Control. (2015), http://dx.doi.org/10.1016/j. jpsic.2015.05.003
JPSIC-33; No. of Pages 4
3
journal of patient safety & infection control xxx (2015) xxx–xxx
Table 1 – Clinical audit of hand hygiene among health care professionals before and after Hand Hygiene Awareness Programme. Method
Appropriate Inappropriate Not at all *
Before HHAP n = 200
After HHAP n = 200
Hand rub n(%) n1 = 160
Soap & water n(%) n2 = 40
Hand hygiene n(%) n = 200
Hand rub n(%) n1 = 174
Soap & water n(%) n(%) n2 = 26
Hand hygiene n(%) n = 200
13 (8.1) 123 (76.9) 24 (15)
10 (25) 25 (62.5) 5 (12.5)
23 (11.5) 148 (76.5) 29 (14.5)
54 (31.0) 105 (60.4) 15 (8.6)
20 (76.9) 4 (15.4) 2 (7.7)
74 (37) 109 (54.5) 17 (8.5)
0.001*
p < 0.05
before and after the HHAP was analysed using chi-square test. The set level of significance was decided at 0.05.
4.
p value
Results
Of total 106 health care professionals 73 (68.8%) were nurses, 33 (31.13%) doctors with mean age (years) of HCP 32.14 7.4 (22–56). Median total professional experience and experience in present area of work (years) were 4.7 (0.5–34) and 2.2 (1–27) respectively. Majority HCP 73 (68.8%) had undergone training programme related to hand hygiene as part of in-service education programme, while 33 (31.3%) had not undergone any training programme. Majority health care professionals 100 (94.3%) did not complain of any shortage related to items required for hand hygiene maintenance like soap, water and alcohol rub in their units. Mean knowledge and attitude scores of HCP were 19.28 2.4 (13–25) and 39.26 3.9 (26–48) respectively. Majority health care professionals had good knowledge (91/106, 85.8%) and favourable attitude (89/106, 83.9%). A strong positive correlation was observed between the knowledge and attitude scores of HCP related to hand hygiene practices (r = 1.00, p < 0.002). Majority health care professionals (99%) considered hand hygiene to be the single most effective measure against infection control and prevention. Majority health care professionals 77 (72.64%) stated to have coagulase negative staphylococci as part of normal skin flora. The most important component of hand washing recognised by health care professionals were friction 38 (35.5%) followed by soap 36 (33.9%). The most common mode of transmission of pathogen identified by 83 (78.3%) health care professionals was hands. Exactly half of the subjects reported area near the thumb as commonly missed area in the process of hand hygiene maintenance. Hygienic hand washing to be done for 1 min was opined by 80 (75.47%) health care professionals. Using gloves is not a substitute for hand hygiene was reported by 101 (95.28%) professionals. Alcohol rub can be used in between when the hands are not visibly soiled with blood or body fluids was stated by majority 96 (90.6%) HCP. Possible reasons for not frequently washing hands as required, reported by HCP were too much work load 59 (55.7%), increased nurse patient or doctor patient ratio 44 (41.5%), lack of supply for hand washing like soap, water etc 21 (19.8%), inconveniently located
sinks 49 (46.2%), poor skin condition like eczema, contact dermatitis, cut, boil, burn etc 38 (35.8%), and patients needs taking priority 9 (8.5%). In pre-intervention audit, total 200 observations consisted of 160 hand rub applications and 40 hand washing using soap and water. Majority hand rub applications (123/160, 76.9%) were inappropriate, while appropriate were 25% (10/40). In 24 (15%) observations no hand rub application was done prior to the patient care procedures. Pre-intervention clinical audit showed that majority hand hygiene events using hand rub or hand washing (76.5%) were inappropriate, only 23 (11.5%) events of hand hygiene were appropriate and on 29 (14.5%) occasions hand hygiene was not at all maintained. In post-intervention audit another 200 observations consisting of 174 hand rub application and 26 hand washing using soap and water was carried out. Majority observations on hand rub applications were still inappropriate (105/174, 60.5%), while majority observations on hand washing using soap and water were appropriate (20/26, 76.9%). There was significant improvement in hand hygiene practices following the HHAP as evident by p value <0.001. In post intervention clinical audit inappropriate hand hygiene events and not all hand hygiene events were reduced from 76.5% to 54.5% and 14.5%–8.5% respectively and there was increase in appropriate hand hygiene events from 11.5% to 37%.
5.
Discussion
Majority HCP had good knowledge (91/106, 85.8%) and favourable attitude (89/106, 83.9%) related to hand hygiene practices. Significant improvement in hand hygiene compliance was observed among the health care professionals following the hand hygiene awareness programme ( p < 0.001). Results of this study showed that knowledge and attitude of HCP, who participated in the study were good and favourable that is congruent with the findings reported by Payudel et al.8 Majority HCP realized hand hygiene as single most effective method in preventing and controlling health care associated infections, despite that the compliance of HCP towards hand hygiene practices was poor. This finding confirms with the earlier reports.4 According to Boyce et al9 monitoring hand hygiene compliance and providing health care workers with feedback regarding their performance are considered integral parts of a successful hand hygiene promotion programme. The findings of the present study
Please cite this article in press as: Victor EM, et al. The impact of hand hygiene awareness programme on health care professionals' compliance with hand hygiene in a tertiary care hospital: A clinical audit, J Patient Saf Infect Control. (2015), http://dx.doi.org/10.1016/j. jpsic.2015.05.003
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revealed that the hand hygiene awareness programme was effective in improving the compliance of HCP towards hand hygiene practices. The improvement in the compliance rate can be attributed to positive effect of the HHAP. Findings from some previous studies10,11 have consistently indicated hand hygiene compliance improves following the interventions. Though perception and compliance can vary with experience and education of health care personnel or doctors,12 in the present study Knowledge scores of Doctors and Nurses were found to be more or less the same. Therefore all further observations of their practices were analysed uniformly as under Health Care Professionals. Further continuation of the hand hygiene awareness programme could have shown further improvement.
5.1.
Limitations
Presence of infection control nurses near the patients could have falsely improved the compliance rate of HCP initially, which might be attributed to the Hawthorn effect seen during the clinical audit. Another important factor is that the clinical audit was done in the morning shift only. Availability of better supervision, resources and manpower in terms of HCP and patient ratio, in the morning might not give the true reflection of the status of hand hygiene practices. Not including other shifts i.e. evening/night and further relatively smaller observations of hand hygiene practices limit the generalizability of the findings of this study. Despite these limitations, the results of the study suggested that hand hygiene awareness programme was useful in sensitizing the health care professionals. Giving performance feedback to the HCP by infection control nurse might have helped in changing the mindset of HCP, which is required to bring the permanent change in one's behaviour. This can be considered as the strength of the study as it helped in improving the compliance rate. There is need to evaluate the long term effects of similar ongoing programmes in terms of compliance rates of HCP with hand hygiene practices. The same can be correlated with the HAI rate in the ward.
6.
Conclusion
Conducting hand hygiene awareness programmes and campaigns in health care setup are feasible and have positive effect on health care professionals hand hygiene practices.
Conflicts of interest All authors have none to declare.
Funding Self funded.
references
1. World Health Organization Save lives clean your handsGuide to Implementation. A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy. Geneva: WHO/IER/PSP/2009.02; 2009. 2. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/ SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Health Care Epidemiology of America/Association for Professionals in Infection Control/Infectious diseases. Society of America. MMWR Recomm Rep. 2002. 51 (RR-16): 1-45 quiz CE1-4 (Accessed 16.09.14). 3. In: WHO Guidelines for Hand Hygiene in Health Care (Advanced Draft). Geneva: World Health Organization; 2006. 4. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet. 2000;356:1307–1312. 5. Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D. ‘‘My five moments for hand hygiene’’: a user-centred design approachto understand, train, monitor and report hand hygiene. J Hosp Infect. 2007;67:9–21. 6. Allegranzi B, Pittet D. Preventing infections acquired during health-care delivery. Lancet. 2008;372:1719–1720. 7. Bittner MJ, Richet EC, Turner PD, Arnold Jr WH. Limited impact of sustained simple feedback based on soap and paper towel consumption on the frequency of hand washing in an adult intensive care unit. Infect Control Hosp Epidemiol. 2002;23:120–126. 8. Paudyal P, Simkhada P, Bruce J. Infection control knowledge, attitude, and practice among Nepalese health care workers. Am J Infect Control. 2008;36:595–597. Mosby, Inc.. 9. Boyce JM. Hand hygiene compliance monitoring: current perspectives from the USA. J Hosp Infect. 2008;70(Suppl. 1): 2–7. 10. Doron SI, Kifuji K, Hynes BT, et al. A multifaceted approach to education, observation, and feedback in a successful hand hygiene campaign. Jt Comm J Qual Patient Saf. 2011; 37:3–10. 11. Allegranzi B, Sax H, Bengaly L, et al. World Health Organization ‘‘Point G’’ Project Management Committee. Successful implementation of the World Health Organization hand hygiene improvement strategy in a referral hospital in Mali, Africa. Infect Control Hosp Epidemiol. 2010;31:133–141. 12. Kapil R, Bhavsar HK, Madan M. Hand hygiene in reducing transient flora on the hands of healthcare workers: an educational intervention. Indian J Med Microbiol. 2015; 33:125–128.
Please cite this article in press as: Victor EM, et al. The impact of hand hygiene awareness programme on health care professionals' compliance with hand hygiene in a tertiary care hospital: A clinical audit, J Patient Saf Infect Control. (2015), http://dx.doi.org/10.1016/j. jpsic.2015.05.003