Audit report: hand washing in a hospital ward setting - Essay Example

AUDIT REPORT: HAND WASHING IN A HOSPITAL WARD SETTING Index Introduction and Rationale 2. Standards for Hand Washing 3. Results 4. Recommendations 4.1 Staff 4.2 Visitors 4.3 Alternatives: use of gloves 5. Conclusion 6. References 1. Introduction and Rationale Infections contracted in hospitals are an everyday occurrence. Due to the intensive media coverage it has received in the past few years, one of the most well known forms of infection is methicillin-resistant Staphylococcus aureus, also known as MRSA (Sheffield Teaching Hospitals NHS Foundation Trust, 2006).These bacteria live on the skin and nose of a third of the population, who are said to be colonised. There, it lays inactive or dormant without causing harm at all. However, it could quickly become a problem after undergoing surgery, suffering a serious illness or in cases where a compromised immune system is present. MRSA can enter the body through wounds, tubes, drips, catheters, etc. and cause serious infections and blood poisoning with potential fatal consequences. Those individuals colonised by the bacteria will be more at risk to be affected if they happen to fall ill but, in any case, MRSA can spread from patient to patient very easily. Worryingly, this type of bacteria has become resistant to certain types of antibiotics overtime and it is thus very difficult to treat. Hand washing is therefore vital to avoid the spread of the disease. Research has shown that in Britain the bacteria that cause MRSA are responsible for 45% of all infections occurring in hospital wards. This rises to 65% when intensive care units are considered. Surprisingly, the European Antimicrobial Resistance Surveillance System has recently published data that shows Britain as having one of the worst MRSA infection rates in Europe (Radnedge, 2006). In fact, the information provided demonstrates that only four out of the total of 32 nations included in the survey had more MRSA cases than Britain in the year 2005. These countries are Malta, Cyprus, Romania and Portugal. Other European countries, such as France or Germany, have infection rates that halve those of Britain. Although the threat to the UK is very low at the present time, the case of Severe Acute Respiratory Syndrome (SARS) is very similar to that of MRSA. Very little is known about the origins of the disease and its behaviour. However, in the current absence of a vaccine or effective drugs for the control of SARS, effective management of an outbreak situation will depend on the quick identification and isolation (where deemed necessary by the physician/-s) of all infected cases thus preventing contact and minimising spread of the disease to other individuals. In this situation, good hand hygiene of staff, patients and visitors is again essential in order to avoid the conversion of the infection into a full-size SARS epidemic (Health Protection Agency, 2005). The World Health Organization (WHO) continues to emphasise the need to prevent patient to patient contamination (World Health Organization, 2006). It is estimated that in the US nearly 2 million people per year suffer from hospital-contracted infections. This directly causes or contributes to an average of 90,000 deaths each year in this country alone (Centers for Disease Control and Prevention, 2005). Hospital-acquired infections are believed to be caused by pathogens transmitted from one patient to another via health care workers who have not washed their hands, or have not done it correctly, between patient contact. Although as early as 150 years ago it was demonstrated that mortality associated with hospital-acquired infections could be considerably reduced when the carers complied with hand washing (Carter, 1983), compliance still remains low. Even the current public awareness of the situation has not encouraged hospital workers to follow the available guidelines and recommendations. Pathogenic micro-organisms (commonly referred to as "gems") are found everywhere and quickly and easily transferred to our hands when we touch food, surfaces, people, body fluids, etc. They can in turn then be passed into our own bodies, other people, surfaces and so on potentially causing infection. The most effective way of stopping germs from getting into our bodies, is by keeping good hand hygiene practices. In fact, hand washing is the single most important procedure for preventing infections since it is believed to suspend and release the micro-organisms present in the skin allowing them to be rinsed off. When hand washing is performed with water alone or with water and soap, the process is known as mechanical removal of micro-organisms, as these will be simply washed away. In turn, the process known as chemical removal of micro-organisms involves washing one's hands with antimicrobial-containing soaps or detergents that will kill existing micro-organisms and inhibit their growth. Two main types of micro-organisms can be found in the microbial flora that resides in the skin: resident and transient (Garner, 1985). Resident micro-organisms survive, reproduce and multiply continuously in the superficial layers of the skin. However, a proportion of around 10 to 20% can be found in deeper layers of the epidermis. Conversely, transient micro-organisms is the term used to refer to recent contaminants that can only survive for a limited period of time. Hand washing performed with plain soaps or detergents will eliminate mainly transient micro-organisms and those resident micro-organisms from the superficial layers. However, a proportion of resident micro-organisms may not be removed in this manner from the deeper layers. In this case, detergents containing antimicrobial agents must be used. Many resident micro-organisms are not involved in infections other than skin infections. Others, on the other hand, can cause severe infections by entering the deep tissues of the skin (e.g. MRSA). This occurs predominantly in patients that have undergone surgery or other invasive procedures and patients that are seriously immunocompromised. The transient micro-organisms most commonly found on the hands of hospital staff have been acquired from infected patients and may, subsequently, cause infections. In fact, research has shown that the lack of good hand hygiene in hospital personnel and the subsequent spread of both transient and resident micro-organisms is more frequent than originally thought. 2. Standards for Hand Washing Now that the importance of keeping good hand hygiene in a hospital setting has been demonstrated, the necessary steps that should be undertaken to perform this procedure correctly should be defined. The guidelines are (Welsh Assembly Government, 2006): Remove all accessories (watch, bracelets, rings), if any (Note: artificial nails should not be worn when working in direct contact with high-risk patients). Wet your hands under running water (preferably warm) Apply a small amount of soap (preferably from a dispenser) Rub your palms together while keeping away from the water Scrub your fingers, thumbs and the spaces between them Scrub your nails against your palms Wash the back of your hands Rinse your hands thoroughly using clean running water Dry your hands, preferably using paper towels Staff should wash their hands frequently in an especially designated basin, not one that is or has been used with other purposes, such as food preparation, etc. Thorough washing with running water and soap removes most germs from our hands. Liquid soap is better than solid soap because it is less likely to become contaminated. An antibacterial liquid soap and, in extreme cases, an alcohol disinfectant solution provide the best protection. Maintenance personnel should check regularly that the hand washing facility has sufficient amounts of paper towels and that enough soap is available. Reusable liquid containers should be cleaned and dried before being refilled with fresh soap. Disposable paper towels are preferred since damp or wet towels are a good breeding ground for germs. Strict guidelines for the frequency of hand washing are not available due to the shortage of studies. Indications for hand washing will depend on the type, duration and intensity of the activity carried out: while hand washing is not generally required after contact with an individual or item not suspected of being contaminated, it is strictly necessary in case of prolonged and intense contact with vulnerable patients, such as is the case during the performance of invasive procedures (e.g. surgery) or the care of patients of compromised immunity (e.g. patients in a neonatal care unit). In other words, hand washing is indicated after situations in which contamination is likely to occur, i.e. contact with mucous membranes or blood and body fluids, and after touching items that are likely to be contaminated, such as catheters. In summary, staff should wash their hands: when they look dirty after coming in contact with contaminated items after contact with secretions after contact with blood or body fluids (e.g. faeces, vomit, etc.) before handling food or drinks before putting on gloves and after these have been removed and discarded before and after treatment of each patient; e.g. dressing wounds, giving medication, etc. (Centres for Disease Control, 1986) For those involved in surgery, the requirements are tougher. In terms of material, a tap that can be turned on and off without touching with the hands is essential, as is a sterile brush and instrument to help clean under the fingernails, and sterile towels for hand drying. Also a special antiseptic handwash that will eliminate the transient micro-organisms and considerably reduce the resident flora is required in this occasion. Furthermore, the preparations used should contain agents that provide persistent antimicrobial activity. In terms of the process, not only the hands but also the forearms (up to the elbow) should be washed and scrubbed several times. During the rinsing process, no water should be allowed to move from the forearm back to the hands. In any case, hand washing is a vital element of personal hygiene and should be encouraged. Various factors have been associated with poor hand hygiene in hospital workers: high workload, category of the worker and type of care unit (Brown, 2003). Several methods have been implemented to encourage better hand hygiene but only temporary improvements were observed. Some of these methods are: placing warning signs, providing more sinks, etc. These will be analysed in section 4. Hand washing before and after every intervention is not only time consuming but it can also potentially damage the skin and instigate the opposite of the desired effect, i.e. increase contamination levels. Research has shown that alcohol based hand rubs are fast-acting and more harmless for the skin than soaps and detergents. The occasional use of soap and water is still important especially if visible soiling is observed, since alcohol can be ineffective (i.e. non-water agents don't clean, they simply disinfect. If visible soiling is present, hands need to be washed with soap and water). 3. Results The hand washing habits of the workers of the health care sector are poor in spite of the efforts of hospitals and health authorities to highlight contamination as the most important method to prevent, or at least minimise, transmission of hospital-acquired infections. A case study carried out at the University Hospital Lewisham (London, UK) showed that placing a bottle of the alcohol-based gel Spirigel at the bedside of every patient played a very important role in improving the hand hygiene of the workers of the hospital (Gopal Rao, 2002). The cost of providing the gel amounted to circa 5,000. In the 12 months (2000-2001) following the purchase of the gel, it was used at least 440,000 times. During this time, a steady reduction in the amount of hospital acquired infections was observed. In the case of MRSA, the proportion of patients that acquired the illness at the hospital in the period 2000-2001 was 39% in comparison with a 50% for the previous year. The amount of hospital-acquired cases of other infections was also considerably reduced: Clostridium difficile associated diarrhoea (CDAD) showed a remarkable reduction of 17.4% with respect to data from the previous year. In the period 1999-2000, 11.5 cases were observed for every 1,000 admissions, while in the period 2000-2001, when the hand washing scheme was introduced, this value decreased to 9.5 cases. Research regarding hand washing practices by staff has also been carried out in neonatal care units. In this environment, patients are extremely susceptible to infection as the immune system of those treated there is generally not mature enough to effectively fight infection (Lam, 2004). Also, the constant use of antibiotics and the performance of invasive interventions provide a good ground for the invasion of micro-organisms and pathogens and the subsequent development of infection. Additionally, the overcrowding often observed in many of these units assists the transfer of these pathogens from patient to patient due to their close spatial proximity. In the first stage of the study (observation phase, where workers habits were noted and recorded) it was found that health care workers failed to wash their hands more than half of the recommended times. In many cases the procedure was classified as inadequate. Taking into consideration the observations made in the first phase, a series of hand hygiene education programs were developed and delivered to doctors and nurses. As a consequence of this training, overall hand hygiene compliance before contact with the patient increased from 40% prior to the training sessions to 53% afterwards. Similarly, overall hand hygiene after contact with the patient increased from 39% prior to the training sessions to 59% afterwards. Interestingly, a greater improvement was detected for high-risk procedures (35%-60%), such as the administration of intravenous medication or surgery. Consequently, the infection rate observed in this environment associated with health care decreased from 11.3 to 6.2 per 1,000 patient. 4. Recommendations 4.1 Staff As aforementioned, hospital staff shows unacceptably low compliance with hand washing guidelines. The average level of compliance in British hospitals is 48%. Many factors are involved. Logistical obstacles and conduct patterns adversely influence hand washing. In terms of logistics, the lack of sinks or these being inconveniently located has been discussed as a factor that discourages hand hygiene. Other reasons are: understaffing or overcrowding of the facilities, time constraints, the belief that the patients are the priority, lack of soap or towels, forgetfulness, disagreement with the guidelines, skin irritation and dryness, etc. One of the main issues is the lack of awareness about the situations that require hand washing. Contact with low-risk patients is not considered by many workers as an occasion that requires hand washing. This derives from the belief that practices like touching a patient's skin (if no wound is present) does not put them at risk of contracting an infection (Boyce, 1999). Additionally, it has been observed that different health care workers show different hand washing habits. Nurses show the highest levels of compliance, followed by physicians and other personnel. Interestingly, those members of staff that wear gloves when caring for patients show the worst hand washing habits. In terms of the activities carried out, hand washing compliance is worst when high-risk procedures are performed; this is, in intensive care units. As a consequence, the spread of pathogens in hospitals has continued to increase in spite of available written infection-preventing guidelines. Health care workers not only wash their hands less frequently than recommended but may also do it incorrectly or inefficiently. Although a minimum of 10 seconds is suggested, the average wash ranges from 8.5 to 9.5 seconds (Pittet, 1999). It must be noted that most published guidelines are based on protocols that require 30 seconds of hand washing. This severely limits the efficacy of the procedure and increases the risk of infection of patients and workers. A series of measures have been recommended to improve hand hygiene in health care workers: Fitting of "hands-free" taps. Increasing the number and improving the location of sinks Providing staff with pocket-size soap containers Placing individual bottles at the bedside of every patient Incorporating hand hygiene procedures in staff induction and training Supply by agencies and government bodies, such as the Environmental Health Department, of information to keep the staff up-to-date with the current recommendations. 4.2 Visitors All visitors are potentially infectious. It is important that they adhere and comply with existing infection control precautions in order to minimise the risk of exposure to patients' blood or body fluids. From the point of view of the hospital, the main aim is to reduce the risk of transmission of infection and disease from patient to visitor and viceversa. It is believed that one in ten visitors acquire an infection during their hospital stay (BBC News, Scotland, 2004). Therefore, It is required from visitors that they wash their hands before entering and after leaving the hospital and that they avoid contact with drips, dressings and material (catheters, feeding tubes, etc.) that could potentially be contaminated (NHS Quality Improvement Scotland, 2004). It is also advised that family and friends visit in small numbers and sit on the chairs provided instead of sitting in the patient's bed. Recommendations to improve compliance with guidelines by visitors are the use of clear, informative and visible notices and posters to promote good hygiene practice. 4.3 Alternatives: use of gloves As an alternative to hand washing, the use of non-sterile, medical grade, disposable examination gloves by hospital staff has been suggested. The consistent wearing of gloves will reduce the risk of potential exposure by protecting the wearer from contact with cuts, secretions, microlesions, etc. Hand washing is, however, still recommended to those wearing gloves as perforations may have occurred during use and bacteria can multiply rapidly on gloved hands. Washing of the gloves is not recommended as detergents may cause deterioration of the glove material increasing the possibility of leaking (American Electrology Association, 2002). Obviously, gloves should be worn on one occasion only to treat just one patient and then disposed of in specially designated containers. 5. Conclusion Hand washing is the single most important procedure for preventing the contraction and spread of infections in hospitals. The culture of hand washing, however, needs to be reinforced in staff and visitors so it becomes second nature. These groups of individuals do not wash their hands as often as they should. As a consequence, hospital-acquired infection rates are unacceptably high causing an intolerable amount of unnecessary deaths worldwide every year. Research has shown that infection rates can be lowered when the hand hygiene practices especially of the staff but also of those visiting are improved. Therefore, it is of paramount importance that adequate and easy-to-use facilities are provided and that staff and visitors trained and encouraged to wash their hands efficiently and frequently since unwashed hands spread germs! 6. References American Electrology Association (2002). Standards. Retrieved December 10, 2006, from http://www.electrology.com/standards.htm. BBC News, Scotland (2004). Hygiene plea to hospital visitors. Retrieved December 14, 2006, from http://news.bbc.co.uk/2/low/uk_news/scotland/4088935.stm. J. M. Boyce (1999). It is time for action: improving hand hygiene in hospitals. Ann Intern Med 1999, Vol. 130, pp. 153-155. S. M. Brown, A. V. Lubimova, N. M. Khrustalyeva, et al. (2003). Use of an alcohol-based hand rub and quality improvement interventions to improve hand hygiene in a Russian neonatal intensive care unit. Infection control and hospital epidemiology, pp. 172-180. K. C. Carter (1983). The Etiology, Concept, and Prophylaxis of Childbed Fever. Madison, University of Wisconsin, 1983, pp. 1. Centers for Disease Control (1986). Guideline for hand washing and hospital environmental control. Infect Control, Vol. 7. pp. 231-243. Centers for Disease Control and Prevention (2005). Hand hygiene in health care settings. Retrieved December 14, 2006 from http://www.cdc.gov/handhygiene/download/hand_hygiene_core.pdf. G. Gopal Rao, A. Jeanes, M. Osman, C. Aylott and J. Green (2002). Marketing hand hygiene in hospitals - a case study. Journal of Hospital Infection, Vol. 50, Issue 1, pp. 42-47. J. S. Garner, M. S. Favero, Hospital Infections Program Center for Infectious Disease, Centres for Disease Control and Prevention. Guideline for Handwashing and Hospital Environmental Control, 1985. Retrieved December 10, 2006, from http://wonder.cdc.gov/wonder/prevguid/p0000412/p0000412.asp#head003000000000000 Health Protection Agency (2005). SARS - hospital infection control guidance. Retrieved December 13, 2006. NHS Quality Improvement Scotland (2004). Raising Healthcare Standards: 13-12-04 Visitors Targeted in Hospital Infection Campaign. Retrieved December 12, 2006, from http://www.nhshealthquality.org/nhsqis/qis_display.jsp;jsessionid=2F35BE03EAB7CBDB24CD8AC389936971pContentID=1756&p_applic=CCC&p_service=Content.show&. B. C. C. Lam, J. Lee and Y. L. Lau (2004). Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection. Pediatrics, Vol. 114, No. 5, pp. e565-e571. D. Pittet, P. Mourouga, T. Perneger (1999). Compliance with handwashing in a teaching hospital. Members of the Infection Control Program. Ann Intern Med 1999, Vol. 130, pp. 126-130. A. Radnedge (2006). MRSA timebomb. Metro, Issue of December 12, 2006, pp. 1. Available at www.metro.co.uk. Sheffield Teaching Hospitals NHS Foundation Trust, 2006. Action on infection - What is MRSA. Retrieved December 13, 2006, from http://www.sth.nhs.uk/patients/2-9-1.php. Welsh Assembly Government (2006). Mind the germs!. Retrieved December 10, 2006, from http://www.his.org.uk/_db/_documents/Mind_the_germs_english_LowRes.pdf. World Health Organization (2006). Update 84 - Can SARS be eradicated or eliminated. Retrieved December 13, 2006, from http://www.who.int/csr/don/2003_06_19/en/. Read More