Hand Hygiene Compliance in the Operating Theatre - Essay Example

Psychosocial Predictors of Compliance to Hand Hygiene Practices in Operating Theaters: A Path Analytical Approach Introduction Surgical site infections (SSIs) are grave complications of surgical procedures; they merit attention because they result in significant patient morbidity. In fact, when such site infections occur deep into the operative site, they can cause an alarming mortality of as high as 77%. While there are several channels through which infection may proliferate, for SSIs, the preliminary introduction of pathogens most commonly transpire during the surgical procedure performed at the Operating Theater (OT). Thus, it is imperative that a pragmatic approach be taken in the study of traits of the patient, operation, personnel and health care facility, which all pose some degree of risk to the development of SSIs (Center for Disease Control, 2002). Hand hygiene, has been cited as one of the most effective means of infection prevention in operating theaters (Cookson, Teare, May, Gould, Jeanes, Jenner, Pallett, Schweiger & Stone, 2001; Pittet and Boyce, 2001). Having acknowledged its effectiveness, the current study intends to investigate the psychosocial variables that influence compliance to hand hygiene practices in operating theaters - covering predisposing, enabling and reinforcing factors . Review of Related Literature Sources of SSI Pathogens For majority of SSIs, pathogens stem from the endogenous flora of patient's skin, mucous membranes, or hollow viscera. When mucous membranes or skin is incised, the exposed tissues are at risk for contamination with endogenous flora, which more commonly include aerobic gram-positive cocci. However, this may also be fecal flora; for instance, anaerobic bacteria and gram-negative aerobes, specifically when such incisions are made at the vicinity of the perineum or groin. On the other hand, when a gastrointestinal organ is operated on, gram-negative bacilli, gram-positive organisms, and anaerobes are typically yielded as SSI isolates (Cookson, 2002; Horton and Parker, 2001). Exogenous sources of SSI pathogens include members of the surgical team and other personnel present during the procedure, the operating room environment (including air), and all tools, instruments, and materials exposed to the sterile field. Exogenous flora are mainly aerobes, especially gram-positive organisms (e.g., staphylococci and streptococci). It is thus logical for SSI interventions to be aimed at eliminating or preventing microbial contamination of the patient's tissues or of sterile surgical tools. Other interventions include preoperative antibiotic prophylaxis, prudent surgical technique, optimal ventilation of the OT, among others. Infection Prevention in the Operating Theater Essentially, infection prevention in the operating theater is attained through the sensible use of aseptic techniques to be able to: - Lower or eliminate the probability of contamination of the open wound; - Isolate the operative site from the surrounding unsterile physical environment; and - Create and sustain a sterile area in which surgery can be carried out safely; Although all infection prevention procedures aim for these objectives, aseptic technique refers to those practices carried out prior to or during clinical procedure including: (1) properly preparing a client for clinical procedures; and (2) handwashing (Center for Disease Control, 2002; Gopal, Jeanes, Osman, Aylott & Green, 2001; Rotter, 2001). Hand Hygiene Hand hygiene by Operating Theater (OT) personnel is one of the most potent means of reducing the incidence of infections. Stringently, surgical hand wash or surgical handrub must be done prior to any operative procedure by surgical personnel to kill or reduce transient resident hand microorganisms. The warmth and moisture created by surgical gloves promotes the growth of flora (Girou, Loyeau, Legrand, Oppein & Brun-Buisson, 2002). Using antiseptics, surgical hand wash is done before any surgical procedure for the prevention of such growth, effectively minimizing the risk of infection (Girou et al, 2002; Gopal et al, 2001). Waterless alcohol handrubs have more immediate activity after application and they reduce the number of skin flora to a significant degree; growth is observed only after several hours following its application. All hospital personnel involved in any invasive surgical procedure should carry out surgical hand wash. The following list outlines the conventional steps for carrying this out: Steps for surgical hand wash: 1. Take off all jewelry on hands and wrists. 2. Set water to temperature to warm and thoroughly wash hands and forearms to 5 cm above the elbows to remove dirt and transient flora. 3. Clean under each fingernail and around the nail bed with a nail cleaner prior to performing the first surgical scrub of the day. Nails should be kept short, without artificial nails or fingernail polish. 4. Holding hands up above the level of the elbow, apply antimicrobial agent to hands and forearms up to the elbows. Using a circular motion, begin at the fingertips of one hand and lather and wash between the fingers, continuing from fingertip to 5 cm above the elbow. This same step is repeated for the other hand and arm. Continue rubbing for 3-5 minutes. 5. Rinse each arm individually, fingertips first, holding hands above the level of the elbow. 6. Using a sterile towel, dry the fingertips to 5 cm above the elbow. Use one side of the towel to dry the first hand and the other side of the towel to dry the second hand. 7. Keep hands above the level of the waist and do not touch anything before putting on sterile gown and surgical gloves (Creedon, 2005). At first glance, hand hygiene practices may seem overly simple; however, one will be surprised at the high, alarming rates of non-compliance. While it is considered as one of the most basic yet vital infection control measures, it is also one of the most neglected (Leeds Teaching Hospitals, 2005; Center for Disease Control, 2002; Rotter, 2001). The PRECEDE / PROCEED Framework: A Blueprint for Behavior Change The PRECEDE-PROCEED framework of Green and Kreuter (1991) has been adopted as a conceptual framework in the study. It has nine (9) phases. The first five of these are categorized as diagnostic: (1) social diagnosis of the self-determined needs, wants, resources, and obstacles to them in the target community; (2) epidemiological diagnosis of the health problems; (3) behavioral and environmental diagnosis of the specific behaviors and environmental factors for the program to address; (4) educational and organizational diagnosis of the predisposing, enabling, and reinforcing conditions which directly and immediately influence behavior; and (5) administrative and policy diagnosis of the resources needed and available in the organization, as well as the barriers and supports available in the organization and community. These diagnoses involve research in target communities and the change-initiating organization to identify goals and specific objectives and set priorities among the objectives to be addressed in the program. Each diagnosis specifies objectives and sets priorities among them based on their significance, urgency, and changeability. The outcome of these diagnoses is a specific plan which outlines objectives and strategies, with assumptions based on what was learned in the diagnostic phases about problems' contributory causes and factors. Thus, the theory is useful in identifying which factors to examine within each diagnostic category. The plan leads right back to the end-goal of addressing the community's self-prescribed needs and wants. The four remaining phases in the PRECEDE-PROCEED framework are implementation and evaluation (process, impact, and outcome). Evaluation of the process starts concurrently with implementation for immediate problem detection and correction. As implementation proceeds, the planner starts evaluating in the order in which program effects are expected. First, its immediate effects (impacts) are evaluated, in order to determine the extent to which the program needs modification. Lastly, when enough time has elapsed, the ultimate intended effects on morbidity, mortality, and quality of life are assessed. This kind of phased evaluation permits one to evaluate what works and what does not. For example, if one was planning a chronic disease intervention program to reduce cancer risk, this can only be effective if it influences the precursors to behaviors (or environments). Precisely, to influence those precursors, it is a requisite that they be identified, as follows: Predisposing factors provide the motivation or behind a behavior; they include knowledge, attitude, cultural beliefs, readiness to change, and so on. Enabling factors make it possible for a motivation to be realized; that is, they "enable" persons to act on their predispositions; they include available resources, supportive policies, assistance, and services. Reinforcing factors come into play after a behavior has begun, and provide continuing rewards or incentives; they contribute to repetition or persistence of behaviors. Social support, praise, reassurance, and symptom relief might all be reinforcing factors. Empirical Studies on Hand Hygiene Compliance A study conducted Parienti, Thibon and Heller (2002) investigated the efficacy and acceptability of agents used in surgical hand disinfection in three (3) hospitals, on surgical site infection (SSI) rates by using a multiple crossover experimental design. The agents used in the study included aqueous detergent scrubs (either 4% povidone iodine or 4% aqueous chlorhexidine gluconate) and a mixture of alcohol (a mixture of propan- 1-ol and propan-2-ol, totaling 75% alcohol ). The standard protocol was to use aqueous detergents as traditional scrubs for at least 5 minutes and the alcohol, following a plain soap wash at the start of the day, as a handrub of two sequential 5mL applications with a total rubbing duration of 5 minutes. Without including cases of contaminated surgery, the SSI rates were 2.48% (53/2135) and 2.44% (55/2252) in the scrubbing group and handrub groups, respectively. However, the difference between the groups was not significant. Better compliance was observed with alcohol than with aqueous scrubs, and alcohol notably caused less skin dryness and irritation. Another study was conducted by Pittet, Simon, Hugonnet, Pessoa-Silva, Sauvan and Perneger (2004), entitled "Hand Hygiene among Physicians: Performance, Beliefs, and Perceptions". Doctors cleansed their hands 57% of the times that they ought to. They washed hands most often when a hand-rub solution was readily available. Moreover, they did not wash hands as frequently as they should when they had hectic schedules, and with intense patient interface. Precisely, these activities required cleansing hands immediately before patient examination or between examining different body sites on the same patient. Medical students and internists (internal medicine doctors) washed hands most frequently, whereas anesthesiologists, critical care physicians, and surgeons washed hands least often. Doctors who placed high premium on hand hygiene and perceived themselves as role models complied with hand hygiene practices most often. Conceptual Framework PRECEDE-PROCEED is a planning model crafted by Green and Kreuter (1991) as a blueprint for assessing the effectiveness health education and health promotion programs. Its overriding principle is that most enduring health behavior change is voluntary and intrinsic; this is reflected in a systematic planning process which aims to empower individuals with understanding, motivation, and skills and active engagement in community affairs to improve their quality of life. In the current study, predisposing, enabling and reinforcing factors are the independent variables, which shall be regressed against the dependent variable compliance to hand hygiene practices. The outcome is a model predicting the factors which exert a significant influence on hand hygiene compliance. Predisposing factors shall include an assessment of respondents' knowledge, attitudes and beliefs on hand hygiene. On the other hand, enabling factors shall cover an evaluation of available resources, supportive policies, assistance, and services. Finally, reinforcing factors will entail an assessment of the rewards or incentives that compliance may yield. Social support, praise, reassurance, and symptom relief might all be reinforcing factors. Method Research Design A quasi-experimental design will be used, using convenience sampling in the selection of respondents. A quasi-experiment tends to involve many different, but interlocking relationships among variables; thus, it is advisable to engage in modeling these causal relationships through path analysis. Subjects and Sampling Plan Nurses, doctors, physiotherapists and care assistants directly involved in operating theaters shall be selected as participants in the study. Purposive sampling shall be used in selecting them, ensuring that each one meets the following inclusion criteria: 1.) directly assists or carries out operating theater procedures; 2.) is an employee / affiliate / doctor of Hospital X for at least 6 months; and 3.) has explicitly expressed permission to participate in the study. Instruments Predisposing factors shall be measured using a self-constructed questionnaire; this shall cover the knowledge, attitude, and cultural beliefs of participants. Enabling factors shall similarly be evaluated, allowing them to accomplish a self-constructed tool on the hospital's available resources, supportive policies, assistance, and services, in relation to hand hygiene compliance. Finally, reinforcing factors shall be measured by a questionnaire on social support, praise, reassurance, and symptom relief that are gained from compliance to hand hygiene practices in the hospital. The dependent variable, compliance to hand hygiene practices, shall be measured through a hygiene practices audit. All tools shall undergo content validation by experts (i.e. infectious disease specialists), and shall be pilot tested to ensure utmost clarity and effective, comprehensible phrasing / wording before deployment. Data Gathering Procedure Secondary data shall be gathered from books, internet sources and journals to provide a background for the study and reinforce its rationale. Primary data, on the other hand, shall be gathered through responses to the self-constructed questionnaires - measuring predisposing, enabling and reinforcing factors. Data on the dependent variable shall be garnered through the results of the hand hygiene practices audit. Proposed Method of Data Analysis Path analysis shall be used, which is primarily a regression run of each variable on every other variable (Asher, 1983; Cohen, West, Aiken & Cohen, 2003). Path analysis requires the usual assumptions of regression. It is particularly sensitive to model specification because failure to include relevant causal variables or inclusion of extraneous variables often substantially affects the path coefficients, which are used to assess the relative importance of various direct and indirect causal paths to the dependent variable (Cohen et al, 2003). Discussion The importance of the use of preventive measures in the transmission of pathogens from members of the operating theater to the patient begins with a clear understanding of the significance of hand hygiene pre-, intra, and post-operatively. Understanding the psychosocial variables that influence compliance to hand hygiene practices in operating theaters will provide health providers with a better understanding of the reasons that hinder practitioners from strictly adhering to practice. The effective use of questionnaires in this study shall only be limited by the cooperation of the participants and the institutions wherein the study will be conducted, since the research will be done in the format of a hand hygiene audit. Bibliography Asher, H, 1983. Causal Modeling, California: Sage. Centre for Disease Control, 2002. Guideline for hand hygiene in health care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHCA/APIC/IDSA, Hand Hygiene Task Force Morbidity and Mortality Weekly Report, 51, RR-16. Cohen, J et al, 2003. Applied Multiple Regression/Correlation Analysis for the Behavioral Sciences, New Jersey: Mahwah. Cookson, B et al, 2001. Draft hand hygiene standards. Journal of Hospital Infection, 52,153-154. Creedon, B, 2003. Healthcare workers' hand decontamination practices: compliance with recommended guidelines. Journal of Advanced Nursing, Aug: 208. Foder, G.T. and Dalis, G.T, 1989. Health Instruction: Theory and Application, 4th ed. Philadelphia: Lea & Febiger. Girou et al, 2002. Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial. British Medical Journal, 325. Gopal et al, 2001. Marketing hand hygiene in hospitals a case study. Journal of Hospital Infection., 50, 42-47. Green, L and Kreuter, M, 1991. Health Promotion Planning, 2nd ed. Mountain View, CA: Mayfield Publishing. http://rex.nci.nih.gov., 08/15/05. Horton, R and Parker, L, 2002. Informed Infection Control Practice, 2nd ed. London: Churchill Livingstone. Parienti J.J, Thibon P & Heller R, 2002. Hand-rubbing with an aqueous alcoholic solution vs. traditional surgical hand-scrubbing and 30-day surgical site infection rates: a randomised equivalence study. Journal of American Medical Association, 288, 722-27. http://jama.ama assn.org/issues/v288n6/ rpdf/joc20200.pdf, 08/15/05. Pittet, D et al, 2004. Hand hygiene among physicians: performance, beliefs, and perceptions. Annals of Internal Medicine, 141, 1-8. Pittet D and Boyce J. M, 2001. Hand hygiene and patient care: pursuing the Semmelweis legacy. Lancet Infectious Diseases, Apr: 9-20. Rotter, M.L, 2001. Arguments for alcoholic hand disinfection. Journal of Hospital Infection. Supplement A: S4-8. Read More