Project Report on

   “A research on Compliance with Hand Washing among Health Care Workers during routine Patient Care”

A report submitted as a part fulfillment of the

Postgraduate Diploma in Management (2008 – 2010)

Submitted by:

Khushboo Nagpal (66)

Neeta Dudeja (32)

Nibha Sharma (34)

Nikhil Chaudhary (36)

Shival Chaudhary (48)

Siddharth Tewari (51)

HR4

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INTRODUCTION

REVIEW OF LITERATURE

AIMS AND OBJECTIVES

METHOD

LIMITATION OF STUDY

ANALYSIS OF DATA

RESULTS

DISCUSSION

CONCLUSION

RECOMMENDATIONS

BIBLIOGRAPHY

QUESTIONNAIRE

INDEX:

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Introduction

The hands of physicians and nurses are the most important vehicles for the transmission of microbes. Hands are frequently implicated as the route of transmission in an outbreak of infection. It is well known that pathogens are frequently acquired on the hands in clinical settings. The patient, weakened by disease, surgery or old age, is unable to fight against microbes. Microbes can cause super infections and compromise the successes scored by the nurses and doctors and other healthcare workers. These microbes are invisible; their presence does not engender fear. Anything could happen from wound infections, urinary tract infections, and etc, through sepsis to a preventable life of suffering and possibly even the death of the patient. Hospital-acquired infections exact a tremendous toll, resulting in increased morbidity and mortality, and increased healthcare costs. Since most hospital-acquired pathogens are transmitted from patient to patient via the hands of healthcare workers, hand washing is the simplest and most effective, proven method to reduce the incidence of nosocomial infections.  Despite this well-established relationship, compliance with hand washing among all types of healthcare workers remains variable. Many barriers to appropriate hand hygiene have been reported including: hand hygiene agents cause skin irritation and dryness, patient care takes priority over hand hygiene, sinks are inconveniently located or not available, glove use, insufficient time for hand hygiene, high workload and understaffing, inadequate knowledge of guidelines or lack of protocols for hand hygiene, lack of a role model from seniors or peers, lack of recognition of the risk of cross transmission of microbial pathogens and scientific information showing a definitive impact of improved hand hygiene on nosocomial infection rates, or simply noncompliance. Whatever be the reasons, transmission of microorganisms from the hands of

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health care workers remains the main concern for cross infection in hospitals and can be prevented by hand washing.

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Review of Literature Historical StudyHand washing with soap and water has been considered a measure of personal hygiene, for generations. The concept of cleansing hands with an antiseptic agent probably emerged in the early 19th century. In 1846, Ignaz Semmelweis observed that women whose babies were delivered by students and physicians in the First Clinic at the General Hospital of Vienna consistently had a higher mortality rate than those whose babies were delivered by midwives in the Second Clinic. The maternal mortality rate in the First Clinic subsequently dropped dramatically and remained low for years after intervention by Semmelweis which represents the first evidence indicating that cleansing heavily contaminated hands with an antiseptic agent between patient contacts may reduce health-care–associated transmission of contagious diseases effectively with hand washing with plain soap and water.In 1843, Oliver Wendell Holmes concluded independently that puerperal fever was spread by the hands of health personnel. Although he described measures that could be taken to limit its spread, his recommendations had little impact on obstetric practices at the time. However, as a result of the seminal studies by Semmelweis and Holmes, hand washing gradually became accepted as one of the most important measures for preventing transmission of pathogens in health-care facilities. In 1975 and 1985, formal written guidelines on hand washing practices in hospitals were published by CDC. These guidelines recommended hand washing with non antimicrobial soap between the majorities of patient contacts and washing with antimicrobial soap before and after performing invasive procedures or caring for patients at high risk. Use of waterless antiseptic agents (e.g., alcohol-based solutions) was recommended only in situations where sinks were not available.

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The 1995 APIC guideline included more detailed discussion of alcohol-based hand rubs and supported their use in more clinical settings than had been recommended in earlier guidelines. ). These guidelines also provided recommendations for hand washing and hand antisepsis in other clinical settings, including routine patient care. Although the APIC and HICPAC guidelines have been adopted by the majority of hospitals, adherence of HCWs to recommended hand washing practices has remained low.Normal Bacterial Skin FloraTo understand the objectives of different approaches to hand cleansing, knowledge of normal bacterial skin flora is essential. Normal human skin is colonized with bacteria; different areas of the body have varied total aerobic bacterial counts. Total bacterial counts on the hands of medical personnel have ranged from 3.9 x 104 to 4.6 x 106. In 1938, bacteria recovered from the hands were divided into two categories: transient and resident.Transient floraTransient flora is acquired on the surface of the skin through contact with other people, object or the environment. It survives on the skin for less than 24 hours. These are also easily acquired on the hands when the object touched is moist and heavily contaminated substances such as body fluids and are easily removed mechanically by washing with soap and water even by a brief 10 seconds wash. Eg: Staph aureus (MRSA) is frequently found on the skin of nurses who are caring for patient infected with the organism.Resident Flora or Normal FloraNormally inhabit certain areas of the body without causing infection. They live in deep crevices of the skin, in hair follicles, and sebaceous glands. The type and distribution of organisms varies according to humidity, temp, body site and the person’s general health. Microorganisms present in largest numbers are gram + ve bacteria. They survive and multiply on the skin. These can be repeatedly cultured. Gram –ve bacilli are not considered

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part of resident flora, but they are able to survive in some areas, notably moist areas beneath rings. The removal of resident skin flora during routine clinical care is not necessary in many situations as these microorganisms are not readily transferred to other people or surfaces and most are low in pathogenecity. Some resident bacteria could cause infection, if introduced during invasive procedures into normally sterile body sites or on particularly vulnerable individuals and are not easily removed by mechanical action of washing with soap, but their numbers can be reduced by the combination of a detergent and micro biocide.Physiology of Normal SkinThe primary function of the skin is to reduce water loss, provide protection against abrasive action and microorganisms, and act as a permeability barrier to the environment.The basic structure of skin includes, from outer- to innermost layer, the superficial region (i.e., the stratum corneum or horny), the viable epidermis (50- to 100-μm thick), the dermis (1- to 2-mm thick), and the hypodermis (1- to 2-mm thick). The barrier to percutaneous absorption lies within the stratum corneum, the thinnest and smallest compartment of the skin. The stratum corneum contains the corneocytes (or horny cells), which are flat, polyhedral-shaped nonnucleated cells, remnants of the terminally differentiated keratinocytes located in the viable epidermis. Corneocytes are composed primarily of insoluble bundled keratins surrounded by a cell envelope stabilized by cross-linked proteins and covalently bound lipid. Interconnecting the corneocytes of the stratum corneum are polar structures (e.g., corneodesmosomes), which contribute to stratum corneum cohesion.The intercellular region of the stratum corneum is composed of lipid primarily generated from the exocytosis of lamellar bodies during the terminal differentiation of the keratinocytes. The intercellular lipid is required for a competent skin barrier and forms the only continuous domain. Directly under the stratum corneum is a stratified epidermis, which is composed primarily of 10–20 layers of keratinizing epithelial cells that are responsible for

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the synthesis of the stratum corneum. This layer also contains melanocytes involved in skin pigmentation; Langerhans cells, which are important for antigen presentation and immune responses; and Merkel cells, whose precise role in sensory reception has yet to be fully delineated. As keratinocytes undergo terminal differentiation, they begin to flatten out and assume the dimensions characteristic of the corneocytes (i.e., their diameter changes from 10–12 μm to 20–30 μm, and their volume increases by 10- to 20-fold). The viable epidermis does not contain a vascular network, and the keratinocytes obtain their nutrients from below by passive diffusion through the interstitial fluid.The skin is a dynamic structure. Barrier function does not simply arise from the dying, degeneration, and compaction of the underlying epidermis. Rather, the processes of cornification and desquamation are intimately linked; synthesis of the stratum corneum occurs at the same rate as loss. Substantial evidence now confirms that the formation of the skin barrier is under homeostatic control, which is illustrated by the epidermal response to barrier perturbation by skin stripping or solvent extraction. Circumstantial evidence indicates that the rate of keratinocyte proliferation directly influences the integrity of the skin barrier.A general increase in the rate of proliferation results in a decrease in the time available for 1) uptake of nutrients (e.g., essential fatty acids), 2) protein and lipid synthesis, and  3) processing of the precursor molecules required for skin-barrier function. Even chronic but quantitatively smaller increases in rate of epidermal proliferation also lead to changes in skin-barrier function remains unclear. Thus, the extent to which the decreased barrier function caused by irritants is caused by an increased epidermal proliferation also is unknown. The current understanding of the formation of the stratum corneum has come from studies of the epidermal responses to perturbation of the skin barrier. Experimental manipulations that disrupt the skin barrier include 1) extraction of skin lipids with apolar solvents, 2) physical stripping of the stratum corneum using adhesive tape, and 3)chemically

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induced irritation. All of these experimental manipulations lead to a decreased skin barrier as determined by transepidermal water loss (TEWL). The most studied experimental system is the treatment of mouse skin with acetone. This experiment results in a marked and immediate increase in TEWL, and therefore a decrease in skin-barrier function. Acetone treatment selectively removes glycerolipids and sterols from the skin, which indicates that these lipids are necessary, though perhaps not sufficient in themselves, for barrier function.Detergents act like acetone on the intercellular lipid domain. The return to normal barrier function is biphasic: 50%–60% of barrier recovery typically occurs within 6 hours, but complete normalization of barrier function requires 5–6 days.Definition of TermsDetergent .  Detergents (i.e., surfactants) are compounds that possess a cleaning action. They are composed of both hydrophilic and lipophilic parts and can be divided into four groups: anionic, cationic, amphoteric, and nonionic detergents. Although products used for hand washing or antiseptic hand wash in health-care settings represent various types of detergents, the term “soap” is used to refer to such detergents in this guideline. Hand washing .  Washing hands with plain (i.e., non-antimicrobial) soap and water.  Hand hygiene . A general term that applies to hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis.Alcohol-based hands rub. An alcohol-containing preparation designed for application to the hands for reducing the number of viable microorganisms on the hands. Such preparations usually contain 60%–95% ethanol or isopropanol.  Antiseptic hand wash.  Washing hands with water and soap or other detergents containing an antiseptic agent.Antiseptic hand rub .  Applying an antiseptic hand-rub product on the surface of the hands to reduce the number of microorganisms present.

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Antiseptic agent .  Antimicrobial substances that are applied to the skin to reduce the number of microbial flora. Examples include alcohols, chlorhexidine, chlorine, hexachlorophene, iodine.Visibly soiled     hands.  Hands showing visible dirt or visibly contaminated with proteinaceous material, blood, or other body fluids (e.g., fecal material or urine).Waterless antiseptic agent. An antiseptic agent that does not require use of exogenous water. After applying such an agent, the hands are rubbed together until the agent has dried. Transmission of Pathogens on HandsTransmission of health-care–associated pathogens from one patient to another via the hands of Health Care Workers (HCWs) requires the following sequence of events:• Organisms present on the patient’s skin, or that have been shed onto inanimate objects in close proximity to the patient, must be transferred to the hands of HCWs.• These organisms must then be capable of surviving for at least several minutes on the hands of personnel.• Next, hand washing or hand antisepsis by the worker must be inadequate or omitted entirely, or the agent used for hand hygiene must be inappropriate.• Finally, the contaminated hands of the caregiver must come in direct contact with another patient, or with an inanimate object that will come into direct contact with the patient. Health-care–associated pathogens can be recovered not only from infected or draining wounds, but also from frequently colonized areas of normal, intact patient skin. The perineal or inguinal areas are usually most heavily colonized, and the axillae, trunk, and upper extremities (including the hands) also are frequently colonized. The number of organisms (e.g., S. aureus, Proteus mirabilis, Klebsiella spp., and Acinetobacterspp.) present on intact areas of the skin of certain patients can vary from 100 to 106cm2. Persons with diabetes, patients undergoing dialysis for chronic

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renal failure, and those with chronic dermatitis are likely to have areas of intact skin that are colonized with S. aureus. Because approximately 106 skin squames containing viable microorganisms are shed daily from normal skin, patient gowns, bed linen, bedside furniture, and other objects in the patient’s immediate environment can easily become contaminated with patient flora. Such contamination is particularly likely to be caused by staphylococci or enterococci, which are resistant to dessication.In the past, attempts have been made to stratify patient-care activities into those most likely to cause hand contamination, but such stratification schemes were never validated by quantifying the level of bacterial contamination that occurred. Nurses can contaminate their hands with 100–1,000 CFUs of Klebsiella spp.during “clean” activities (e.g., lifting a patient; taking a patient’s pulse, blood pressure, or oral temperature; or touching a patient’s hand, shoulder, or groin). Similarly, in another study, hands were cultured of nurses who touched the groins of patients heavily colonized with P. mirabilis; 10–600 CFUs/mL of this organism were recovered from glove juice samples from the nurses’ hands. Recently, other researchers studied contamination of HCWs’ hands during activities that involved direct patient-contact wound care, intravascular catheter care, respiratory tract care, and the handling of patient secretions. Agar fingertip impression plates were used to culture bacteria; the number of bacteria recovered from fingertips ranged from 0 to 300 CFUs. Data from this study indicated that direct patient contact and respiratory-tract care were most likely to contaminate the fingers of caregivers. Gram-negative bacilli accounted for 15% of isolates and S. aureus for 11%. Duration of patient-care activity was strongly associated with the intensity of bacterial contamination of HCWs’ hands.HCWs can contaminate their hands with gram-negative bacilli, S. aureus, enterococci, or Clostridium difficile by performing “clean procedures” or touching intact areas of the skin of hospitalized patients. Furthermore, personnel caring for infants with respiratory

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syncytial virus (RSV) infections have acquired RSV by performing certain activities (e.g., feeding infants, changing diapers, and playing with infants). Personnel who had contact only with surfaces contaminated with the infants’ secretions also acquired RSV by contaminating their hands with RSV and inoculating their oral or conjunctival mucosa. Other studies also have documented that HCWs may contaminate their hands (or gloves) merely by touching inanimate objects in patient rooms. None of the studies concerning hand contamination of hospital personnel were designed to determine if the contamination resulted in transmission of pathogens to susceptible patients.Other studies have documented contamination of HCWs’ hands with potential health care–associated pathogens, but did not relate their findings to the specific type of preceding patient contact. For example, before glove use was common among HCWs, 15% of nurses working in an isolation unit carried a median of 1 x 104 CFUs of S. aureus on their hands. Of nurses working in a general hospital, 29% had S. aureus on their hands (median count: 3,800 CFUs), whereas 78% of those working in a hospital for dermatology patients had the organism on their hands (median count: 14.3 x 106 CFUs). Similarly, 17%–30% of nurses carried gramnegative bacilli on their hands (median counts: 3,400–38,000 CFUs). One study found that S. aureus could be recovered from the hands of 21% of intensive-care–unit personnel and that 21% of physician and 5% of nurse carriers had >1,000 CFUs of the organism on their hands. Another study found lower levels of colonization on the hands of personnel in a neurosurgery unit, with an average of 3 CFUs of S. aureus and 11 CFUs of gram-negative bacilli. Serial cultures revealed that 100% of HCWs carried gram-negative bacilli at least once, and 64% carried S. aureus at least once.

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Relation of Hand Hygiene and Acquisition of Health-Care–Associated PathogensHand antisepsis reduces the incidence of health-care– associated infections. Increased hand washing frequency among hospital staff has been associated with decreased transmission of Klebsiella spp. among patients; these studies, however, did not quantitate the level of hand washing among personnel. In a recent study, the acquisition of various health-care–associated pathogens was reduced when hand antisepsis was performed more frequently by hospital personnel; both this study and another documented that the prevalence of health-care– associated infections decreased as adherence to recommended hand-hygiene measures improved.Outbreak investigations have indicated an association between infections and understaffing or overcrowding; the association was consistently linked with poor adherence to hand hygiene. During an outbreak investigation of risk factors for central venous catheter-associated bloodstream infections, after adjustment for confounding factors, the patient-to-nurse ratio remained an independent risk factor for bloodstream infection, indicating that nursing staff reduction below a critical threshold may have contributed to this outbreak by jeopardizing adequate catheter care. The understaffing of nurses can facilitate the spread of MRSA in intensive-care settings through relaxed attention to basic control measures (e.g., hand hygiene). In an outbreak of Enterobacter cloacae in a neonatal intensive-care unit, the daily number of hospitalized children was above the maximum capacity of the unit, resulting in an available space per child below current recommendations. In parallel, the number of staff members on duty was substantially less than the number necessitated by the workload, which also resulted in relaxed attention to basic infection-control measures. Adherence to hand-hygiene practices before device contact was only 25% during the workload peak, but increased to 70% after the end of the understaffing and overcrowding period. Surveillance documented that being

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hospitalized during this period was associated with a fourfold increased risk of acquiring a health-care–associated infection. This study not only demonstrates the association between workload and infections, but it also highlights the intermediate cause of antimicrobial spread: poor adherence to hand-hygiene policies.  Factors influencing adherence to hand-hygiene practices

Risk factors for poor adherence to recommended hand-hygiene practices as per source• Physician status (rather than a nurse)• Nursing assistant status (rather than a nurse)• Male sex• Working in an intensive-care unit• Working during the week (versus the weekend)• Wearing gowns/gloves• Automated sink• Activities with high risk of cross-transmission• High number of opportunities for hand hygiene per hour of patient careSelf-reported factors for poor adherence with hand hygiene• Hand washing agents cause irritation and dryness• Sinks are inconveniently located/shortage of sinks• Lack of soap and paper towels• Often too busy/insufficient time• Understaffing/overcrowding• Patient needs take priority• Hand hygiene interferes with health-care worker relationships with patients• Low risk of acquiring infection from patients• Wearing of gloves/beliefs that glove use obviates the need for hand hygiene

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• Lack of knowledge of guidelines/protocols• Not thinking about it/forgetfulness• No role model from colleagues or superiors• Skepticism regarding the value of hand hygiene• Disagreement with the recommendations• Lack of scientific information of definitive impact of improved hand hygiene on health-care–associated infection ratesAdditional perceived barriers to appropriate hand hygiene• Lack of active participation in hand-hygiene promotion at individual or institutional level• Lack of role model for hand hygiene• Lack of institutional priority for hand hygiene• Lack of administrative sanction of noncompliers/rewarding compliers• Lack of institutional safety climate

 

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Aims and Objectives  To study the compliance with hand washing among health workers (HCW) during routine patient care. To compare the compliance in different types of health care workers (Doctors, Nurses and Ward aids). To investigate the probable factors associated with non-compliance in HCWs and give suggestions to management for improvement of the same.

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Methods Compliance with hand washing is defined as either washing the hands and wrist with water and plain soap or rubbing with an antiseptic solution. We underwent an observation study at Manav Sewa Sang Hospital and its part Parmarth Hospital , Rohtak, Haryana, where doctors of different specialty work on full time and on visit basis with admission and OT facilities.Our group was the observer and we randomly observed the subjects during routine patient care. The study was conducted in June 2009 and the subjects were health care workers working in different units and wards of the hospital which included the general wards, private wards and OPDs. The observation periods were distributed randomly during the day as well as the night for 10 days. In the beginning the subjects were unaware that they were being observed and later a questionnaire was administered among the HCW’s. The opportunities were observed and the observation was recorded with the subject number, type of the event, unit or ward and compliance or failure to comply with hand washing. No judgment was taken into account of the duration and efficacy of hand washing technique. Hand washing facilities were as conveniently located as possible in the hospital. At least one sink was located inside every OPD, examination room and patient ward, along with towels and unmedicated soap. Dispensers of hand antiseptic solutions are available in high-risk areas. Individual bottles containing an alcohol-based hand gels are also available particularly in OPDs. Guidelines for hand washing were consistent with infection-control practice recommendations and with the basic principle of universal precautions. These guidelines suggest that hands be washed with soap and water or be disinfected

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1) Before and after patient contact,2)After contact with a source of microorganisms (body fluids and substances, mucous membranes, broken skin, or inanimate objects that are likely to be contaminated), and3) After removing gloves.Because microbial contamination of hands and possible transmission of microorganisms have been reported even when gloves were worn, hand washing with soap and water or hand antisepsis is required after glove removal.Guidelines of Infection Control and Epidemiology state that gloves should be used as an adjunct to (not a substitute for) hand washing. Glove use is required when contact with mucous membranes, broken skin, or any moist body substance is anticipated. During the study, we made no judgment about whether glove use or hand washing was preferred. Departure from room after patient care without hand washing was regarded as noncompliance.Questions were put to HCWs for cause of their non-compliance. They were asked to tick the one most appropriate cause they realized in this hospital setting for  non-adherence to hand washing practices.

       High work load, patient care takes priority over hand hygiene       Sink location inconvenient       Gloves being worn       Lack of suitable hand hygiene agent       Inadequate knowledge of guidelines       Inadequate supply of   hand hygiene agent       Lack of education and encouragement       Lack of role model from seniors       Unable to justify for his Non-compliance

 

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Limitation of study

       The study only covers HCWs working at present time and practices being followed in Manav Sewa Sang Hospital , Rohtak, Haryana. Whether our results can be generalized to other health care institutions is uncertain because both the infrastructure and the organization of work influence behavior.       Duration and proper technique of hand washing, whether HCWs were adherent to, were not taken into account. (Proper technique that is wet hands first with water, apply an amount of product recommended to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers including thumb and pads of fingerprint area, and wrists and knuckles which are commonly missed. Rinse hands with water and dry thoroughly with a disposable towel)       Questionnaires had been set, for non compliance, based on probable causes noticed in the hospital.

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Analysis of data

Presented below is a statistical analysis of the study results made in the hospital covering surgical and medical wards as well as OPDs. Out of a total strength of 70 HCWs, the study covered 50 HCWs. Following health care workers (HCWs) were the participantHCWs Number PercentDoctors 15 30Nurses 20 40Ward Aides 15 30Total 50 100Out of 50 HCWs, 15 were the doctors, 20 nurses and 15 aides taken into study.

 Compliance seen in different departmentsDepartment Number of

opportunities noticed

Compliance Percent

OPDs 

172 65 37.79

Surgical  Wards 88 42 47.71Medical  Wards 80 48 60.00Total 

340 155 45.58

Compliance with hand washing differed among various departments also. Compliance was 37.79% in OPDs, 60% in medical wards and unfortunately 47.71% in surgical wards.

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  Compliance seen among different health care workersHCWs Number of

opportunitiesCompliance Percent

Doctors 102 45 44.11Nurses 118 78 66.10Ward Aides 120 32 26.66Total 340 155 45.58Average compliance seen was very low as 45.6%. Compliance was 44.11% among doctors, 66.10% in nurses and 26.66% in ward aides in present study.

 Insights from questionnaire – reasons for non-adherence to hand washingReasons  Given by no. of

HCWsPercent

High work load, patient care takes priority over hand hygiene

17 34

Justifying that they are using gloves

6 12

Lack of suitable hand hygiene agent

7 14

Inadequate supply of   hand hygiene agent

8 16

Shortage of sinks or inconveniently located

6 12

Lack of Education and encouragement

2 4

Unable to justify for his Non-compliance

4 8

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Total 50 100 34% HCWs say high workload and under staffing is the reason for their noncompliance, 12% say that they are using gloves, 14% say  hand hygiene agent cause irritation, 16% excuse for  inadequate supply of   hand hygiene agent. Shortage of sinks was given as reason by 12% of  HCWs. 8% were unable to justify for noncompliance and lack of education and encouragement were suggested by 4 %.

 

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Results In the present study we observed 340 hand washing opportunities. The categories of staff were doctors, nurses and ward aides.The average compliance was very low as 45.58%. Hand washing was done by soap and water in 108 opportunities. In remaining 47 opportunities hand disinfectant was used.Compliance for hand washing differed among the different categories of HCWs. Nurses  were significantly compliant with a compliance level of 66.10% followed by doctors of  44.11%. Ward aides showed least compliance of 26.66%.Compliance also differed in different department. There was 60.00% compliance in the medical wards unfortunately 47.71% in the surgical wards which is high risk area. Compliance was least in OPDs with level of 37.79% which may be because of high workload.Main reason for noncompliance given by HCWs in present study was high workload followed by shortage of sinks and inadequate supply of   hand hygiene agent followed by lack of encouragement or simply noncompliance. 

  

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Discussion 

Transmission of microorganisms from the hands of health care workers is the main cause of nosocomial infections, and hand washing remains the most important preventive measure. Unfortunately, compliance with hand washing is unacceptably low in the present study.

This study shows that the primary problem with hand washing may be the laxity of practice. During routine patient care, HCWs disinfected or washed their hands in about less than half the indicated instances.  One reason for poor hand washing compliance could be that the importance of this simple protocol for decreasing infections is routinely underestimated by healthcare workers particularly ward aides who showed least compliance in the present study. Many other risk factors for non-compliance with hand hygiene guidelines have been identified, including professional category (e.g., physician, nurse, ward aides), different department, lack of time, heavy workload, and type and intensity of patient care. Nurses showed significant compliance in the present study. A probable reason for the significant compliance level among the nurses could be because they are under constant scrutiny. Doctors on the other hand showed low compliance levels. There has also been some concern about the substitution of glove use for hand washing. One potential adverse effect of hand washing for healthcare workers is skin irritation. Indeed, skin irritation constitutes an important barrier to appropriate compliance with hand washing guidelines. Another potential harm of increasing compliance with hand washing is the amount of time

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required to do it adequately. Current recommendations for standard hand washing suggest 15-30 seconds of hand washing is necessary for adequate hand hygiene. Lack of time is one of the most common reasons cited for failure to wash hands.Since many different risk factors including skin irritation, sinks are inconveniently located, glove use, insufficient time for hand hygiene, high workload and understaffing, inadequate knowledge of guidelines or lack of protocols for hand hygiene have been identified for non-compliance with hand washing, it is not surprising that a variety of different interventions are required in an effort to improve this practice. No single strategy seems to sustain improved compliance with hand washing protocols.Interventions designed to improve hand washing may require significant financial and human resources. This is true both for multifaceted educational/feedback initiatives, as well as for interventions that require capital investments in recruitment of staff to combat the workload and in equipment such as more sinks, automated sinks, or new types of hand hygiene products.Education is a cornerstone for improvement with hand hygiene practices. Topics that must be addressed by educational programs include the lack of1) Scientific information for the definitive impact of improved hand hygiene on healthcare– associated infection and resistant organism transmission rates; 2) Awareness of guidelines for hand hygiene and insufficient knowledge concerning indications for hand hygiene during daily patient care;3) Knowledge concerning the low average adherence rate to hand hygiene by the majority of HCWs; and 4) Knowledge concerning the appropriateness, efficacy, and understanding of the use of hand-hygiene and skin-care–protection agents.Some elements of health-care worker educational and motivational programs discussed are as per given in appendices 

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Minutes of discussion are as under: Interventions discussed with management to improve compliance with hand washing 

Response of management

Proper location of sinks Management feel necessity but apprehensive of  budgetary constraint

Alcohol based hand rubs which are less irritant and  take less time

Assurance given by management

Educational and motivational programs

Management realized  but no commitment for near future

Problem of workload and understaffing

Management will review the problem and then decide

Proving bed side availability of hand hygiene agent

Apprehensive of getting misused by non staff

Hanging posters showing proper technique of hand washing over sinks

 Management ready for that and committed for implication

 Many questions regarding hand-hygiene products and strategies for improving adherence of personnel to recommended policies still remain unanswered. There are several concerns which must still be addressed by researchers in industry and by clinical investigators given in Hand-Hygiene Research Agenda (in appendices)

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Conclusion Noncompliance with hand washing is a substantial problem in a hospital setting. From the responses indicated by the HCWs, it becomes evident that a behavioral change is required. It involves a combination of education, motivation and system change. The factors necessary for change include dissatisfaction with the current situation, the perception of alternatives and the recognition, both at the individual and institutional level, of individual’s ability and potential to change. Intervention must target reasons for non-compliance at all levels of healthcare (i.e., individual, group, institution) in order to be effective. A more detailed study of the cost (and potentially cost savings) of hand washing initiatives would also foster greater enthusiasm among healthcare organization to support such initiatives. The costs incurred by such interventions can be balanced against the potential gain derived from reduced numbers of nosocomial infections with improved quality of patient care.

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 Recommendations

 CDC RecommendationsAs per CDC guidelines these recommendations are designed to improve hand hygiene practices of HCWs and to reduce transmission of pathogenic microorganisms to patients and personnel in healthcare settings.1. Indications for hand washing and hand antisepsisA. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands soap and water.B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situationsC. Decontaminate hands before having direct contact with patientsD. Decontaminate hands before donning sterile gloves when inserting a central intravascular.E. Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical.F. Decontaminate hands after contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient).G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled.H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient.I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity.J. Decontaminate hands after removing gloves.

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K. Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water.L. Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with non-antimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of HCWs, they are not a substitute for using an alcohol-based hand rub or antimicrobial soap.M. Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if exposure to Bacillus anthracis is suspected or proven. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against.N. No recommendation can be made regarding the routine use of nonalcohol-based hand rubs for hand hygiene in health-care settings.2. Hand-hygiene techniqueA. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer’s recommendations regarding the volume of product to use.B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis.

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C. Liquid, bar, leaflet or powdered forms of plain soap are acceptable when washing. When bar soap is used, soap racks that facilitate drainage and small bars of soap should be used.D. Multiple-use cloth towels of the hanging or roll type are not recommended for use in health-care settings. 

3. Surgical hand antisepsisA. Remove rings, watches, and bracelets before beginning the surgical hand scrub.B. Remove debris from underneath fingernails using a nail cleaner under running water.C. Surgical hand antisepsis using either an antimicrobial soap or an alcohol-based hand rub with persistent activity is recommended before donning sterile gloves when performing surgical procedures.D. When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, usually 2–6 minutes. Long scrub times (e.g., 10 minutes) are not necessary.E. When using an alcohol-based surgical hand-scrub product with persistent activity, follow the manufacturer’s instructions. Before applying the alcohol solution, prewash hands and forearms with a non-antimicrobial soap and dry hands and forearms completely. After application of the alcohol-based product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves.4. Selection of hand-hygiene agentsA. Provide personnel with efficacious hand-hygiene products that have low irritancy potential, particularly when these products are used multiple times per shift. This recommendation applies to products used for hand antisepsis before and after patient care in clinical areas and to products used for surgical hand antisepsis by surgical personnel.

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B. To maximize acceptance of hand-hygiene products by HCWs, solicit input from these employees regarding the feel, fragrance, and skin tolerance of any products under consideration. The cost of hand hygiene products should not be the primary factor influencing product selection.C. When selecting non-antimicrobial soaps, antimicrobial soaps, or alcohol-based hand rubs, solicit information from manufacturers regarding any known interactions between products used to clean hands, skin care products, and the types of gloves used in the institution.D. Before making purchasing decisions, evaluate the dispenser systems of various product manufacturers or distributors to ensure that dispensers function adequately and deliver an appropriate volume of product.E. Do not add soap to a partially empty soap dispenser. This practice of “topping off” dispensers can lead to bacterial contamination of soap.5. Skin careA. Provide HCWs with hand lotions or creams to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or hand washingB. Solicit information from manufacturers regarding any effects that hand lotions, creams, or alcohol based hand antiseptics may have on the persistent effects of antimicrobial soaps being used in the.6. Other Aspects of Hand HygieneA. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms).B. Keep natural nails tips less than 1/4-inch long.C. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin could occur.

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D. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients.E. Change gloves during patient care if moving from a contaminated body site to a clean body.F. No recommendation can be made regarding wearing rings in health-care settings. Unresolved issue.7. Health-care worker educational and motivational programsA. As part of an overall program to improve hand hygiene practices of HCWs, educate personnel regarding the types of patient-care activities that can result in hand contamination and the advantages and disadvantages of various methods used to clean their.B. Monitor HCWs’ adherence with recommended hand-hygiene practices and provides personnel with information regarding their performance.C. Encourage patients and their families to remind HCWs to decontaminate their hands.8. Administrative measuresA. Make improved hand-hygiene adherence an institutional priority and provide appropriate administrative support and financial.B. Implement a multidisciplinary program designed to improve adherence of health personnel to recommended hand-hygiene.C. As part of a multidisciplinary program to improve hand-hygiene adherence, provide HCWs with a readily accessible alcohol-based hand-rub product.D. To improve hand-hygiene adherence among personnel who work in areas in which high workloads and high intensity of patient care are anticipated, make an alcohol-based hand rub available at the entrance to the patient’s room or at the bedside, in other convenient locations, and in individual pocket-sized containers to be carried by HCWs.E. Store supplies of alcohol-based hand rubs in cabinets or areas approved for flammable materials.

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 Elements of health-care worker educational and motivational programsRationale for hand hygiene• Potential risks of transmission of microorganisms to patients• Potential risks of health-care worker colonization or infection caused by organisms acquired from the patient• Morbidity, mortality, and costs associated with health-care–associated infectionsIndications for hand hygiene• Contact with a patient’s intact skin (e.g., taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed)• Contact with environmental surfaces in the immediate vicinity of patients• After glove removalTechniques for hand hygiene• Amount of hand-hygiene solution• Duration of hand-hygiene procedure• Selection of hand-hygiene agents1. Alcohol-based hand rubs are the most efficacious agents for reducing the number of bacteria on the hands of personnel. 2. Antiseptic soaps and detergents are the next most effective, and non-antimicrobial soaps are the least effective.3. Soap and water are recommended for visibly soil hands.4. Alcohol-based hand rubs are recommended for routine decontamination of hands for all clinical indications (exceptwhen hands are visibly soiled) as one of the options for surgical hand hygiene.Methods to maintain hand skin health• Lotions and creams can prevent or minimize skin dryness and irritation caused by irritant contact dermatitis• Acceptable lotions or creams to use• Recommended schedule for applying lotions or creams

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Expectations of patient care managers/administrators• Written statements regarding the value of, and support for, adherence to recommended hand-hygiene practices• Role models demonstrating adherence to recommended hand hygiene practices Indications for, and limitations of, glove use• Hand contamination may occur as a result of small, undetected holes in examination gloves• Contamination may occur during glove removal • Wearing gloves does not replace the need for hand hygiene• Failure to remove gloves after caring for a patient may lead to transmission of micro organisms from one patient to another.   Hand-hygiene research agenda Education and promotion• Provide health-care workers (HCWs) with better education regarding the types of patient care activities that can resultin hand contamination and cross-transmission of microorganisms.• Develop and implement promotion hand-hygiene programs in pregraduate courses.• Study the impact of population-based education on hand-hygiene behavior.• Design and conduct studies to determine if frequent glove use should be encouraged or discouraged.• Determine evidence-based indications for hand cleansing (considering that it might be unrealistic to expect HCWs toclean their hands after every contact with the patient).• Assess the key determinants of hand-hygiene behavior and promotion among the different populations of HCWs.• Develop methods to obtain management support.• Implement and evaluate the impact of the different components of multimodal programs to promote hand hygiene.Hand-hygiene agents and hand care

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• Determine the most suitable formulations for hand-hygiene products.• Determine if preparations with persistent antimicrobial activity reduce infection rates more effectively than do preparationswhose activity is limited to an immediate effect.• Study the systematic replacement of conventional handwashing by the use of hand disinfection.• Develop devices to facilitate the use and optimal application of hand-hygiene agents.• Develop hand-hygiene agents with low irritancy potential.• Study the possible advantages and eventual interaction of hand-care lotions, creams, and other barriers to help minimizethe potential irritation associated with hand-hygiene agents. Laboratory-based and epidemiologic research and development• Develop experimental models for the study of cross-contamination from patient to patient and from environment topatient.• Develop new protocols for evaluating the in vivo efficacy of agents, considering in particular short application times and volumes that reflect actual use in health-care facilities.• Monitor hand-hygiene adherence by using new devices or adequate surrogate markers, allowing frequent individual feedback on performance.• Determine the percentage increase in hand-hygiene adherence required to achieve a predictable risk reduction in infection rates.• Generate more definitive evidence for the impact on infection rates of improved adherence to recommended hand hygiene practices.• Provide cost-effectiveness evaluation of successful and unsuccessful promotion campaigns.   

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Bibliography 1. Haley RW, Culver DH, White JW, Morgan WM, Emori TG, Munn VP. The efficacy of infection surveillance and control programs in preventing nosocomial infection in US hospitals. Am J Epidemiol1985;121:182-205.2 John M, Pitter D. Guideline for hand hygiene in health care settings vol. 51/RR-16.3. Larson E. A causal link between handwashing and risk of infection? Examination of the evidence. Infect Control Hosp Epidemiol 1988;9:28-36.4. Doebbeling BN, Stanley GL, Sheetz CT, Pfaller MA, Houston AK, Annis L, et al. Comparative efficacy of alternative handwashing agents in reducing nosocomial infections in intensive care units. N Engl J Med1992;327:88-93.5. Jarvis WR. Hand washing the Semmelweis lesson forgotten? Lancet 1994;344:1311-2.6. Larson EL. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control. 1995;23:251-69.7. Voss A, Widmer AF. No time foe handwashing? Handwashing versus alcoholic rub: can we afford Control Hosp Epidemiol. 1997;18:205-8.8. Steere AC, Mallison GF. Handwashing practices for the prevention of nosocomial infections. Ann Intern Med. 1975;83:683-90.

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9. Coppage CM. Hand washing in patient care [Motion picture]. Washington , DC : US Public Health Service, 1961.10. Larson E, Killien M. Factors influencing handwashing behavior of patient care personnel. Am J Infect Control 1982;10:93–9.11.OJHAS Vol 5 Issue 4(2) - Suchitra JB, Lakshmidevi N. Hand washing Compliance - Is It A Reality?12 Chapter 12. Practices to Improve Handwashing Compliance Ebbing Lautenbach, M.D., M.P.H., MSCEUniversity of Pennsylvania School of Medicine13.Didier Pittet, MD, MS; Philippe Mourouga, MD, MSc;Thomas V. Perneger, MD, PhD; and the Members of the Infection Control Program. Compliance with Handwashing in a Teaching Hospital.

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Questionnaire1. Please select your profession:

Doctor  Nurse Ward Aide

2. Please select the department you belong to:

OPD Surgical Ward Medical Ward

3. In your opinion what is the main reason for non - adherence to hand washing by Health Care Workers in this hospital: (Please tick one option)

High work load

Causes skin irritation

Inconvenient sink location

 Gloves are used

Lack of suitable hand hygiene agent

Unaware of guidelines

Inadequate supply of   hand hygiene age

Lack of education and encouragement

Patient care is more important than hand hygiene

Cannot say

Others (please specify)……………………………………

Thank you

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