http://doi.org/10.33698/NRF0080 – Lata Mandal, Sukhwinder Kaur, RK Marwaha, Anindita Das
Abstract : An analytical study was carried out at the Hematology-Oncology units of Advanced Pediatric Centre, PGIMER, Chandigarh to find out the hand hygiene practices of care providers of children admitted with leukemia. The care providers comprised of nurses, physicians and parents of children acting as attendants to them. Purposive quota sampling was adopted and a total of 60 care providers were chosen as sample. The selected subjects were studied for their hand hygiene practices in relation to their compliance to hand hygiene guidelines. This was followed by interviewing them about their preferences about the practices. The fingertips sample of care providers were collected in Agar plates before and after hand hygiene practices during routine care to study the decontamination efficacy of the hand hygiene. The result of the study revealed that compliance among all categories of care providers was between 21 to 40.6 per cent. The preference towards hand hygiene practices also varied considerably among the care providers. In relation to decontamination efficacy, hand rubbing with Sterilium and hand scrubbing with Betadine was found to be superior to hand washing practices.
Key words :
Hand hygiene practices, compliance, preference, decontamination efficacy, care providers, leukemia children
Correspondence at :
Maj. Lata Mandal,
School of Nursing, Command Hospital, Eastern Command, Kolkata.
Introduction
Nosocomial infections constitute a very real and serious threat to all people who are admitted in the hospital. On an average nosocomial infections complicate 5%-10% of all hospital infections.1 However, studies show that in India this rate is more than 30%. 2 Nosocomial infections are the result of three factors occurring in tandem: high prevalence of pathogens, high prevalence of compromised hosts, and efficient mechanism of transmission of pathogens from one patient to the other. 3
A hospital which is the host for patients with various diseases and infections is also a natural host for a large number of microorganisms. The hands of care providers are the primary mode of transmission of these microorganisms from one patient to the other. A pathogen which may be harmless for a normal person can cause disasters for an immunocompromised individual admitted in the hospital. Thus the chain of infection continues in the hospital leading to a high number of nosocomial infections. 3
Measures of hand hygiene are aimed to break this cycle of infection.4 The principles of hand washing are based on the famous work of Semmelweis, a pioneer in the field of hand hygiene practices.5,6 Starting with the primitive method of dipping hands in 4 per cent chlorinated lime solution advocated by Semmelweis, the practice has gone through many changes, tackling in its way the various problems of the ease of operations, harmful side-effects and economy of effort, to name a few. Soaps of different varieties, textures, antimicrobial effectiveness and cosmetic value have come into the health care settings. The persuasive nature of man further led to the discovery of agents which do not require water to clean the hands. Alcohol based solutions like ‘Sterilium’, ‘Bode’, ‘Microshield’, ‘Pure-hand’ are the gels which can be just rubbed on the hands to get the required decontamination efficacy.
In India there are few studies on hand hygiene practices. So the need was felt to analyze the hand hygiene practices of care providers from all aspects so as to have a realistic scenario of the existing practices. As the leukemia children are considered to be the most susceptible group of patients in the hospital, therefore the hand hygiene practices of care providers of leukemia children were studied.
Objective
The study was to analyze the hand hygiene practices in terms of their preference, compliance and decontamination efficacy among the care providers of leukemia children.
Materials and Methods
The study was conducted in the Hematology Oncology units of Advanced Pediatric centre at Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh. Named after the local deity ‘Chandi’, the city of Chandigarh, well known as the “City beautiful” is a model of architectural grandeur in modern India. It has very good health facilities. Post Graduate Institute of Medical Education and Research (PGIMER), a premier institution for medical and health related research of the country is located in this city. The Advanced Pediatric centre located in the PGIMER campus is a multispeciality 300 bedded hospital for children with all facilities under one roof. The beds of the Hematology Oncology unit are distributed in two wards in the 4th and 5th floor of the APC building.
In a month more than 60 children are admitted in the Hematology-Oncology unit to receive treatment related to leukemia. They are cared for by doctors, nurses, and their own parents or closed relatives. Sample for the study was selected from these care providers by purposive quota sampling. From each category of care providers, 60 per cent sample was chosen. A total 60 care providers, were selected to study the preference and compliance to hand hygiene and 316 samples of fingertips were collected from the study subjects’ hands before and after hand hygiene to study the decontamination efficacy of the different hand hygiene techniques.
The research instruments used were observation performa to collect data regarding the hand hygiene compliance of care providers, and interview schedule to collect data regarding their preference about hand hygiene practices.
Data was collected in the month of January-February 2007.Observations were carried out in each locations of the Hematology-Oncology units from morning 7 .00 AM to evening 7.00PM. Ten to twelve sessions of observations of 20 minutes duration were carried out during this time period. This was continued for 20 consecutive days to have a realistic picture of the compliance of care providers. After the 20 days period, the care providers were interviewed about their preferences and their fingertips sample was collected on Agar plates before and after they did hand hygiene during routine care.
Results
In 238 sessions totaling 79 hours and 45 minutes of observation, a total of 908 oppor tunities for hand hygiene were observed among 60 care providers. The compliance of physicians was highest at 40.8%, followed by attendants with 39.6% and then the nurses (21%).When the care providers’ compliance was analyzed as per risk of activities it was found that for nurses and physicians the compliance increased with the increase in the risk of activities. The attendants showed maximum compliance to hand hygiene practices while doing activities associated with medium risk of transmission of pathogens to patients. (Table 1) Variation in compliance was also noted with the time of the day. The compliance to hand hygiene among all categories of care providers was found to be more in the afternoon than in the morning. (Table 1)
Compliance of care providers also changed with the day of the week. The hand hygiene compliance in all categories of care providers decreased on holidays, and this difference was statistically significant in case of nurses. The findings also revealed that hand hygiene compliance in case of nurses and attendants were better after contact with the patients. Whereas physicians did hand hygiene more frequently before touching the patient than after finishing their activities. (Table1) The findings of the study depicted that majority of attendants preferred hand washing with soap and water. Physicians showed inclination towards hand scrubbing with Betadine.Nurses had equal preference towards all types of hand hygiene practices. (Figure 1)
Table – 1 : Factors associated with compliance with hand hygiene practices
| Attendants | Nurses | Physicians | |
| Overall | 39.6 | 21.0 | 40.8 |
| Level of activity
High-risk activity |
37.5 |
28.8 |
53.9 |
| Medium risk activity | 40.7 | 7.7 | 26.1 |
| Low risk activity | 22.7 | 26.1 | 0 |
| Day of week | |||
| Working days | 40.2 | 24.0 | 41.9 |
| Holidays | 37.5 | 10.4 | 35.7 |
| Time of the day | |||
| Morning | 36.1 | 17,7 | 39.7 |
| Afternoon | 45.9 | 26.3 | 43.7 |
| Before activity | 31.6 | 18.1 | 58.1 |
| After activity | 47.2 | 23.1 | 26.7 |
Variables Hand Hygiene Compliance (%)
Observed opportunities
* Compliance is calculated by the formula: Utilized opportunities × 100
Figure – 1: Preferences of care providers in relation to hand hygiene practices
A variety of difficulties have been perceived by the care providers in terms of hand hygiene practices. Dryness of hands, unpleasant smell of Sterilium, inconsistent supply of facilities were few among the many difficulties revealed by the care providers. (Table 2)
Table – 2 : Perception of difficulties/ease of study subjects in terms of hand hygiene practices N = 60
| Perceived difficulties | Attendants (n=37) | Nurses (n=16) | Physicians (n=7) | |
| Hand washing | Causes dryness of hands | 13 (35.1) | 10 (62.5) | 4 (57.1) |
| Time consuming | – | 11 (68.7) | 1 (14.2) | |
| Inadequate supplies | – | 4 (25.0) | 1 (14.2) | |
| Hand rubbing | Unpleasantsmell of alcohol Dryness of hands
Causes burning sensation in |
10 (27.0)
3 (8.1) 1 (2.7) |
1 (6.2)
– 2 (12.5) |
1 (14.2)
– – |
| hands |
*More than one response by respondents
In relation to the decontamination efficacy it was found that, among nurses only 60 per cent of hand washing led to effective decontamination. The percentage were even less among attendants (37.0%) and physicians (41.2%).Considerable number of hand washing actually led to increase in contamination of hands. In comparison the practices of hand rubbing and hand scrubbing was found to be effective. More than 95 per cent of occasions, hand rubbing practiced by nurses, attendants and physicians was found to be highly effective. Similarly 90 per cent of hand scrubbing followed by care providers led to effective decontamination. (Table 3)
Table – 3 : Decontamination efficacy of different hand hygiene practices among study subjects
| Study Subjects | No. of fingertip sample tested (pairs) | No. of hand hygiene practice that effected Reduction in CFU count by Increase in CFU count by | |||
| <50%
f (%) |
>50%
f (%) |
<50%
f(%) |
>50%
f (%) |
||
Hand washing
| Attendants | 46 | 12(26.1) | 17(37.0) | 02(04.3) | 15(32.6) |
| Nurses | 15 | 01(06.7) | 09(60.0) | 02(13.3) | 03(20.0) |
| Physicians | 17 | 04(23.6) | 07(41.2) | 03(17.6) | 03(17.6) |
Hand rubbing
| Attendants | 24 | – | 23(95.8) | – | 01(04.2) |
| Nurses | 21 | 01(04.8) | 20(95.2) | – | – |
| Physicians | 25 | 01(04.0) | 24(96.0) | – | – |
Hand Scrubbing
| Care providers* |
10 |
01(10.0) |
09(90.0) |
– |
– |
Hand hygiene leading to > 50% reduction in CFU count is considered as effective practice.
* Samples of nurses (01 pair of fingertip sample) is merged with the samples of physicians for hand scrubbing
Discussions
Like other studies the compliance of care providers to hand hygiene practices was found to be below 50%.7-9 But contrary to studies found in the west, the compliance of physicians in the current study was better than that of nurses and attendants.10 Fortunately, the compliance to hand hygiene was found to get better with the risk of activities involved. The compliance to hand hygiene also varied with the time of day and day of week. The findings are similar to the ones reported by Pittet D in which he reported that during the morning hours the opportunities for hand hygiene were much more frequent than in the afternoon hours, and hand hygiene compliance was observed to be less during these hours. The findings in the present study in relation to hand hygiene compliance and its association with time of the day confirms reports by health care workers that perceived ‘busyness’ substantially reduces the compliance to hand hygiene.10
The findings of the present study revealed that compliance of nurses and attendants after contact with the patient was better than the compliance before touching the patient. This finding was in agreement with the findings of Sproat and Inglis.11 Standard guidelines suggest that care providers should undertake hand hygiene both before and after patient contact.12 Yet, compliance with pre-activity hand hygiene among both attendants and nurses were lower than post-contact hand hygiene frequency. This clearly indicates that these categories of care providers regard post contact hand hygiene as more important than the pre-contact hand hygiene. However the compliance behavior of physicians was opposite to that of the nurses and attendants in the present study.
While analyzing the preferences of care providers in relation to hand hygiene practices, the present study revealed that majority of attendants preferred hand washing with soap and water as a better practice. This preference might be due to the traditional practice of hand washing they have been following since childhood. The physicians showed their preference towards hand scrubbing over other techniques of hand hygiene. The nurses showed equal preference towards all types of hand hygiene. There was scarcity of literature to discuss this aspect of findings.
In another study done by Pittet he has cited the perceived difficulties of care providers to different hand hygiene practices.10 Skin irritation, dryness of hands due to hand washing, time constraint, inadequate supply, are the reasons reported by Pittet.10 These are similar to the perceived difficulties reported by the study subjects in the present study. In addition, feelings of a choking sensation with alcohol hand rubs, feelings of overburdening the poor families with the economic responsibility of buying hand rubbing solution, and feeling of inadequate cleaning of hands with hand rubs were reported in the present study.
Many studies have evaluated the effectiveness of different hand decontamination measures. However, only few of them have assessed what really occurs in clinical practice. In the current study the decontamination efficacy of different hand hygiene practices done in the leukemia wards was also measured. Findings reveal that hand rubbing with hand rub solutions, and hand scrubbing with Betadine as the two most effectively done practice in the ward. These findings agree with the report of the study by VijayShankar,13 who repor ted superior decontamination efficacy of hand rubbing and hand scrubbing to hand washing. In the present study the rate of successful decontamination by hand washing was 42 per cent, by hand scrubbing 90 percent and by hand rubbing 95 per cent.
Surprisingly, hand washing with soap and water seemed to increase the total bacterial count of the hands. Winnefeld in his study quoted that the bacteria inaccessible to the sampling procedure might be released after hand washing and hence the increase.14 Contact with contaminated towels, or the faucet of the tap was a possible source of infection. Contamination by hand washing might also occur when soaps were extrinsically contaminated as demonstrated in study done by Marmel.15 Karabey in his study on hand hygiene practices of Istanbul also cited that the hands of care providers had an increase in CFUs after hand washing.8
Based on the findings of the present study it is recommended that there is a need to provide guidelines to care providers regarding hand hygiene practices to be followed in the care of leukemia children. Multifaceted interventions like education, regular feedback, reinforcement training needs to be under taken to improve the compliance of care providers to hand hygiene practices. It is also felt that hand rubbing practice among care providers needs to be encouraged as it was found to be having the maximum decontamination efficacy, and ease of operation, among all practices of hand hygiene.
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- WHO guidelines on Hand Hygiene in health http;//www.who.int/patientssafety/ events/05. Cited by Pittet D, Mourouga P, Pernerger TV. Members of the Infection Control Program. Compliance with hand washing in a teaching hospital. Ann Intern Med 1999; 130: 153- 55.
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- Mermel LA et al.Outbreak of shigella sonnei in a clinical Microbiology Laboratory. Journal of Clinical Microbiology 1997; 45: 3163- 65.