Handwashing Compliance - Term Paper Example

Switching to waterless scrub solutions from traditional antiseptic soaps: CAT and Applicability Analysis Skin Hygiene has been accepted as a primary mechanism in controlling the spread of infectious agents and a hand free from pathogens is paramount in reducing risks of contamination and spread of infectious diseases through healthcare professionals. Hand hygiene is the most important infection control measures that require 'multimodal interventions' and a 'considerable commitment of resources' as improved hand hygiene practices could help promote healthcare outcomes. The incidence of surgical site infection is also linked with poor adherence to hand hygiene recommendations. Investigations of the effect of frequent soap use and skin changes revealed marked damage of skin for several days, suggesting that persons in healthcare who require frequent hand washing, and thereby long-term changes in skin flora, will have 'chronic damage, irritant contact dermatitis and eczema, and concomitant changes in flora'. It is obvious that more washing and scrubbing damage ecology and health of the skin and harm resistance of the skin flora, rather than reducing the risk of harbouring and transmitting infectious agents. Taking into account the increase in vulnerable patient population, effort should be made to identify proper antiseptic products that provide adequate protection from transmission of infecting agents, at the same time that does not damage skin health. Recent studies propose use of alcohol-based hand rinses as an alternative to detergent-based antiseptic products, because they have 'rapid and broad-spectrum activity, excellent microbicidal characteristics, and lack of potential for emergence of resistance' as well as require no washing or drying. In addition, alcohol-based formulations are found to be superior to antiseptic detergents for rapid microbial killing potential and addition of appropriate moisturizers make it milder and skin friendly. Extensive studies of use of antimicrobial soaps and skin care products in skin hygiene and role of hand-washing in reducing rates of infection abound in number, whereas studies to assess benefits in reducing transmission of infection without added risk or cost of using antimicrobial soaps and to compare efficacy of aqueous alcohol based preparations over plain or antimicrobial soap and water are still in nascent stage. Since outbreaks of Surgical Sight Infections are linked with transmission of micro-organisms from surgical personnel to patients, policies and guidelines for strict adherence to the principles of asepsis by all surgical workers is paramount in preventing surgical site infections. Background: Surgery is aimed to eliminate suffering and prolong life and the principles of antisepses introduced by Joseph Lister in the late 1860s helped reduce 'post operative infectious morbidity'. Healthcare delivery system in the United States has undergone dramatic changes recently with the opening up avenues for long-term care, home-care, and managed-care industries, leading to decrease in number of acute-care facilities. Whereas, there is increase in hospital acquired infections proportionate with the increase of patients requiring intensive care in acute-care facilities, and the number of surgical procedures performed in outpatient settings or surgical centres. "Because of the severely ill and immunocompromised populations in these settings, prevention of infections and other adverse events is a major component of providing quality care." (Emerging Infectious Diseases 173). Despite improved operating room ventilation, sterilization methods, barriers, surgical technique, and availability of antimicrobial prophylaxis Surgical Sight Infection (SSI) is the most common nosocomial infection causing morbidity and mortality among hospitalized patients all over the world. Hospitals are breeding ground for pathogens and spread of antimicrobial-resistant bacteria, because of inefficient hand hygiene by hospital personnel and frequency of bacterial carriage by patients. Literature review on prevalence of Nosocomial Infections (NIs) in the US and recommendations for effective prevention: The prevalence of Nosocomial infections (NIs) in the United States have been projected between '3.5 and 9.9% 'and 'approximately 2 million NIs occur annually,' which forces patients to "additional days of treatment, increase the risk of death, and increase treatment costs." (Kampf and Kramer 863-893). A follow-up study by Pittet et al (2004, p.265) to identify the costs associated with a successful hand hygiene promotion campaign suggest that "modest increases in costs for alcohol-based hand hygiene products are tiny in comparison with excess hospital costs and years of life lost associated with severe nosocomial infections." A cluster randomized, controlled trial by Sandora et al (2005) conducted at homes of 292 families with children enrolled in out of home child care, supplied with educational message and alcohol-based sanitizers, were found to exhibit reduced respiratory and GI illness transmission rates. (Sandora et al 587-594). Another two year, prospective, controlled, cross-over trial of alcohol-based hand gel study conducted by Rupp et al (2007), from 17,994 minutes of observation that included 3,678 opportunities for hand hygiene, found that: (1) there is significant and sustained improvement in the rate of hand hygiene adherence when hand gel was available in the unit.; and (2) Longer finger nails, the wearing of rings, and/or lack of access to hand gel increase the risk of transferring microbes from healthcare worker to patient, and further spread of the disease. (Rupp et al 8-15). Since lack of hand-hygiene is attributed to majority of NIs, the Centers for Disease Control and Prevention (CDC) developed guidelines for hand hygiene in health care settings that provides specific recommendations to promote improved hand hygiene practices and reduce the transmission of pathogenic micro-organisms to patients and personnel in health care settings. The guideline recommends (1) choice of the most appropriate agents for hand hygiene in terms of efficacy and dermal tolerance, and (2) different strategies to improve compliance in hand hygiene, including hand hygiene practices among health care workers, behavioural theories, and methods for reducing adverse effects of agents. The CDC supports hand hygiene to be the most important tool in NI control and recommends application of alcohol-based hand rub as an effective measure for preventing infection. Effect of frequent hand wash on hand flora: While discussing the advantages of alcohol based hand rubs over traditional hand-scrubbing with soap and water it is essential to understand how soap and water affect hand skin flora and makes them a reservoir of pathogens that exacerbate pain and misery of patients rather than acting as a soothing hand. The outmost layer of the skin, stratum corneum made up of approximately 15 layers that is completely replaced every two weeks, is composed of flattened dead cells attached to each other to form a tough, horny layer of keratin mixed with several lipids, which serves as the primary protective barrier. "Water content, humidity, pH, intercellular lipids, and rates of shedding help retain the protective barrier properties of the skin." (Larson 226). Whereas, frequent contact with water and hand hygiene practices such as scrubbing breaches this protective barrier resulting in skin dryness, irritation, cracking, and other problems. . Surveys of nurses with declining skin health and damaged hands found them having "twice as likely to be colonized with S.hominis, S. aureus, gram-negative bacteria, enterococci, and Candida spp., and had a greater number of species colonizing the hand." (Larson 227). Realising that the contaminated hand is primarily responsible for surgical site infections the National Nosocomial Infections Surveillance system has developed criteria fore monitoring SSIs and is actively engaged in promoting hand hygiene among health care providers. The criteria developed by National Nosocomial Infections Surveillance (NNIS) system classify surgical site infections as being either incisional or organ/space, of which fatal infections occur in organ or spaces accessed during the operation. SSI occurs within 30 days after the operation and the signs of infection are pain or tenderness, localized swelling, redness, or heat as well as purulent drainage from the incision. The causative factors of SSIs are traced to 'antimicrobial resistant pathogens' or contamination of surgical site with micro-organisms through 'colonized surgical personnel,' contaminated adhesive dressing, contaminated disinfectant solutions, tap water, operating room environment, and tools, instruments, and materials brought to sterile field during an operation. Endogenous flora of the patient's skin, mucous membranes, or hollow viscera is the major source of pathogens. "Fungi from endogenous and exogenous sources rarely cause SSIs, and their pathogenesis is not well understood." (Mangram et al 254). As such, concerted effort to reduce SSI is required. "An SSI prevention measure can be defined as an action or set of actions intentionally taken to reduce the risk of an SSI" and most techniques are directed at reducing opportunities for microbial contamination of the patient's tissues or sterile surgical instruments. (Mangram et al 254). Preparation of skin of the patient at the incision site by applying an antiseptic, and washing hands and forearms of surgical team, known as surgical scrub, immediately before donning sterile gowns and gloves is the primary stage in reducing the risk of an SSI. Since alcohol remains most effective germicide and rapid acting skin antiseptic, which is readily available and inexpensive, it is considered the "gold standard for surgical hand preparation in several European countries." (Mangram et al 258). Perceived Barriers to Hand Hygiene: Hands of healthcare worker is considered as major carrier of nosocomial bacterial pathogen and its transfer to susceptible patients, because either hand washing policies are not strictly adhered to by healthcare worker or "different bacterial species may persist more tenaciously on hands." (Bottone, Cheng & Hymes (2004, p.262).The hands of a healthcare worker (HCW) may get contaminated after direct contact with an infected or colonized patient, though the concentration of bacteria acquired may vary, the bacteria can be transmitted to another individual by contaminated hand. Major factors influencing health-care workers for the lack of adherence with hand hygiene recommendations are reported to include "skin irritations, inaccessible supplies, interference with worker-patient relation, patient needs perceived as priority, wearing gloves, forgetfulness, and ignorance of guidelines, insufficient time, high workload and understanding, and lack of scientific information demonstrating impact of improved hand hygiene on hospital infection rates." (Pittet, 2001). Observational studies report that inconveniently located or insufficient number of sinks, low risk for acquiring infection from patients, belief that glove use obviates need for hand hygiene, and ignorance of or disagreement with guidelines and protocols also compound poor compliance and adherence with hand hygiene guidelines. Alcohol-based hand rub require less time, acts faster, and less irritating to hands makes it more suitable in high demand situations for achieving and maintaining a higher level of compliance with hand hygiene. A direct, observational study by Bischoff et al (2000) of hand washing compliance, after an education/feedback intervention program and introduction of increasingly accessible, alcohol based, waterless hand antiseptic in 728-bed, tertiary care, teaching facility found that where "education/feedback intervention and patient awareness program" failed "introduction of easily accessible dispensers with an alcohol-based waterless hand-washing antiseptic" succeeded in enhancing hand-washing rates among health care workers. (Bischoff 1017-1021). According to FDA definition alcohol contains active ingredients of 60% to 95% ethyl alcohol or 50% to 91.3% isopropyl alcohol in an aqueous solution by volume. Though one potential disadvantage of the use of alcohol in the operating room is its 'flammability', it is found that "aqueous 70% to 92% alcohol solutions have germicidal activity against bacteria, fungi, and viruses, but spores can be resistant." (Mangram et al 257). Concerns about flammability and skin irritation is perceived to be the reason for less use of alcohol containing hand scrubs in the United States. 'Povidon-iodine and chlorhexidine gluconate are the current agents of choice for most U.S surgical team members'. Comparisons of antimicrobial activity of chlorhexidine gluconate and iodophors, when used as preoperative hand scrubs, have shown that alcoholic chlorhexidine gluconate had "greater residual antimicrobial activity after a single application" and it is not "inactivated by blood or serum proteins." (Mangram 257-258). Rather than counting the efficacy of any product its acceptability by operating room personnel after repeated use is supreme in choosing and adopting a scrub agent aimed to reduce the risk of SSI. Succinctly put, no scrub agent will be effective without strict observance of proper scrubbing technique, following prescribed duration of the scrub, maintaining hand hygiene, and using gloves. Because most of the earlier studies concentrated on resident flora and microbial count on the hands of surgical team, more clinical trials to evaluate aseptic practices and identifying cost effective scrub agent needs to be undertaken. Critical appraisal of a research paper: A randomized equivalence study to compare the effectiveness of hand-cleansing protocols in preventing surgical site infections during routine surgical practice was conducted in France by Jean Jacques Parienti and team. They perceive that clinical studies comparing the risk of nosocomial infection after different hand antisepsis protocols are scarce and their study is first of its kind. The study was conducted in six surgical services, three teaching and three non teaching hospitals, in France, after a two month feasibility study to determine training requirements. After discussing the project purpose with surgeons of the candidate centres clinical trial was conducted, which lasted 16 months. The protocol of traditional hand scrubbing or aqueous alcoholic solution (AAS) to be used first in each surgical service was chosen randomly and the antiseptic products were switched at the end of each month in a multiple service crossover design. Antiseptic solution containing 4% povidone iodine or 4% chlorhexidine gluconate was used in hand-scrubbing protocol, whereas 75% AAS containing propanol-1, propanol-2, and mecetronium stilsulfate, three licensed surgical antisepses in France, was used under hand-rubbing protocol. The surgical team using hand-rubbing protocol was instructed to: (1) wash their hands and forearms with nonantiseptic soap and nonsterile tap water (1-minute hand wash) and wipe carefully with nonsterile paper before first procedure of the day or if the hands were visibly soiled; (2) use at least 5 ml or enough of AAS to fully cover the hands and forearms; (3) apply AAS twice for 2 and half minutes without drying; and (4) rub with AAS for 30 seconds when changing gloves. The hand-scrubbing protocol was based on European Norm from the Association Francaise de Normalisation. CDC standards were used in diagnosis for SSI and the surveillance lasted 30 days in each case. There were 2342 patients in the hand-scrubbing protocol and 2481 in hand-rubbing protocol enrolled for the study of which 207 and 229 respectively were excluded from the final analysis due to non-compliance with study standard. Types of surgery covered under the study were Gynaecology, Urology, Abdominal, Orthopaedic, Otolaryngology, and others with Gynaecology ranking top with 629 surgeries under hand-scrubbing protocol and 730 under hand-rubbing protocols. The surveillance system identified 99 in hospital and 9 post-discharge SSIs. In-hospital SSIs were diagnosed by surgeon, infectious disease specialist, or hygiene specialist on a standard data-collection form, whereas, post-discharge surveillance was through telephone contact with either surgeons or patients. Parienti et al found that the SSI rate for clean and clean-contaminated surgery were 2.03% and 3.40% respectively and the SSI rate for clean surgery under their approach was lower than the global SSI rate of 2.46%. Analysis of data for comparing the efficacy of two protocols revealed that there was only 0.04% difference in SSI rate between hand-scrubbing (2.48%) and hand-rubbing with AAS (2.44%) protocols. The study also found that "scrub nurses complied better with the recommended duration of hand antisepsis than did surgeons and assistants. The effect of two protocols on the skin tolerance was estimated by surgical personnel using 10-cm visual analogue scale and it was observed that skin dryness and skin irritation decreased in AAS hand-rubbing, though one nurse reported hand and eye irritation (swelling) when using AAS for hand-rubbing. After analysing the data the researchers admit that "the hand-rubbing with AAS was equivalent to traditional hand-scrubbing in preventing SSI after clean and clean-contaminated surgery" except a very low proportion of post discharge SSIs (8.3%) compared with recent studies (p.726). They further express doubt on the acceptance of AAS by all surgical personnel, and the systematic replacement of traditional hand-scrubbing. Considering the similarities of outcomes in both the protocols it is suggested that pre-operative hand-rubbing with AAS preceded by a non-antiseptic hand wash will be a safe alternative. Researchers submission that "any direct comparison between reported studies would be hazardous, as they differ in several respects, such as the SSI surveillance method, the study period, and the characteristics of the study population" and their "randomized service crossover experimental design" reduce these lacunae itself opens up avenues for criticism. In the cross over design surgical personnel had to shift from one protocol to other after every 30 days, which may expose them to sudden change in routine leading to less adherence to hand hygiene methods. Though workers may have adequate training and awareness of the procedure to be followed in the experimental situation the 15 monthly crossovers may not be having initial enthusiasm after few months of start of experimenting and may adversely affect their performance in the surgical setting and will be reflected in final research outcome. Another point for discussion is the experimental model and sample size. The types of surgery covered for study are more susceptible to SSI than routine surgical practices, and the sample size is not representative of a particular community or group, which limit the scope for comparing efficacy in routine surgical setting or specialised areas. The observation duration of 30 days for SSI is within the expected range for any infection after surgery, yet the total 15 monthly shifts will be inadequate to give a precise picture to the comparative study. The data collected from patients who have been discharged from hospital may not be conforming to the standard of SSI monitoring and individual reporting may also be at variance. In addition, there is no inbuilt system for assessing the capability of their surveillance method, which is crucial in compiling data. In GATE approach it is suggested that only Cohort studies are appropriate in epidemiological studies, whereas Parienti et al (2002) used randomized equivalence study and this study design may also affect the quality of research findings and conclusions. While propagating AAS as the best alternative to antiseptic soap and water based hand-scrub the researchers have not ventured into analysing its inflammability or explaining the reason for swelling and irritation experienced by nursing personnel after AAS rub, even though isolated. However, their conclusion that pre-operative hand-rubbing with AAS preceded by a non-antiseptic hand wash will be a safe alternative is a viable solution till conclusive evidence is derived from future studies. Recent research findings by Kampf & Kramer (2004) recommend that well-formulated preparations based on propanol have better acceptability in terms of skin tolerance and skin dryness, and they are in favour of CDC guidelines for using an alcohol based hand rub for better hand hygiene and disinfection. It may be worth noting that "ethanol is a well-known antimicrobial agent, which was first recommended for the treatment of hands in 1888" and the antimicrobial activity of isopropanol and n-propanol was first investigated in 1904." (Kampf & Kramer 863-893). Why these findings has not percolated in practical use, even after a century, needs to be analysed before recommending AAS handrubbing in place of traditional soap water scrub. Another important aspect for greater incidence of Nosocomial Infections that comes to light from all the research findings is nonadherence to aseptic practices by health care workers. It is suggested that educational and motivational campaign that include "rationale for hand hygiene, indications for hand hygiene, techniques of hand hygiene, methods to maintain hand skin health, and correct use of gloves" as well role model function of physicians will enhance compliance rate in hand hygiene practices. (Kampf & Kramer 863-893). Work Cited Bischoff, Werner E et al. Handwashing Compliance by Health Care Workers: The Impact of Introducing an Accessible, Alcohol-based Hand Antiseptic. Archives of Internal Medicine. 2000. Vol.160. No.7. P.1017-1021. 08 Jul. 2008. . Emerging Infectious Diseases: Special Issue. Department of Health and Human Services: CDC. 2001. Vol. 7. No.2. p.173. 08 Jul. 2008. . Kampf, Gunter., and Kramer, Axel. Epidemiological Background of Hand Hygiene and Evaluation of the Most Important Agents for Scrubs and Rubs. Clinical Microbiology Reviews. 2004. Vol. 17, No. 4. P.863-893. 08 Jul. 2008. . Larson, Elaine. Emerging Infectious Diseases: Hygiene of the Skin: When Is Clean Too Clean. Department of Health and Human Services: CDC. 2001. Vol. 7. No.2. p.226. 08 Jul. 2008. . Larson, Elaine. Emerging Infectious Diseases: Hygiene of the Skin: When Is Clean Too Clean. Department of Health and Human Services: CDC. 2001. Vol. 7. No.2. p.227. 08 Jul. 2008. . Mangram, Alicia J et al. Guideline for Prevention of Surgical Site Infection, 1999. Infection Control and Hospital Epidemiology. 1999. Vol. 20, No. 4. P.254. 08 Jul. 2008. . Mangram, Alicia J et al. Guideline for Prevention of Surgical Site Infection, 1999. Infection Control and Hospital Epidemiology. 1999. Vol. 20, No. 4. P.258. 08 Jul. 2008. . Mangram, Alicia J et al. Guideline for Prevention of Surgical Site Infection, 1999. Infection Control and Hospital Epidemiology. 1999. Vol. 20, No. 4. P.257-258. 08 Jul. 2008. . Rupp, Mark E et al. Prospective, Controlled, Cross-Over Trial of Alcohol Based Hand Gel in Critical Care units. Chicago Journals: Infection Control & Hospital Epidemiology. 2007. Vol. 29. P.8-15. 08 Jul. 2008. . Sandora, Thomas J et al. A Randomized, Controlled Trial of a Multifaceted Intervention Including Alcohol-based Hand Sanitizer and Hand Hygiene Eduction to Reduce Illness Transmission in the Home. Pediatrics. 2005. Vol. 116. No.3. p. 587-594. 08 Jul. 2008. . http://www.journals.uchicago.edu/doi/pdf/10.1086/502388cookieSet=1 Read More