ASSESSING THE IMPORTANCE OF HAND HYGIENE PRACTICES IN INTENSIVE CARE UNITS AND its APPLICATION TO NURSING: LITERATURE REVIEW
With the increase in prevalence of resistant microorganisms, the risks of such infections occuring in hospitals is an ever growing threat. Infections in intensive care units are perhaps the most dangerous outcomes of patient care, with an average of 5-10% of the patients getting hospital based infections annually (Ott and French, 2009, pp 702). Hand hygiene methods and protocols remain one of the most important components of health care provision (Cohen et al, 2003, pp 494). This is particularly the case because these infections can be so easily prevented through proper hygiene techniques.
Sadly, hand hygiene practices, although much emphasised, are frequently ignored or performed improperly, leading to the spread of nosocomial infections (Rahim and Barnett, 2009, pp 580). There is even less emphasis in following hand hygiene practices in chronic care and non acute medical facilities such as mental and psychiatric health services (Ott and French, 2009, pp 702). Those who can become infected can be of any age group; however, neonates and elderly people are some of the most frequent victims of such neglect. Premature neonates, with low birth weights or on mechanical ventilation are highly likely to become infected (Cohen et al, 2003, pp 494). The GIT and respiratory tracts are the most infectious and fatal of all nosocomial infections. Alongside, neonates at the early stages have very low immunities, putting them the most vulnerable group to get infected (Cohen et al, 2003, pp 498). Therefore, prevention of these drastic faults is essential to ensure a safer hospital environment (Rahim and Barnett, 2009, pp 580).
The importance of hand hygiene practice in the nursing profession is based on the fact that nurses remain the individuals most in contact with the patient. For a great deal of the time, nurses are involved in administrating drugs, IV lines, gastric and tracheal tubes, or in other cases are exposed to the bodily fluids through washing, cleaning and toilet assistance. It is for this reason that nurses can become the most infected health care personnel, and may be the most efficient vector for the spread of nosocomial infections (Ott and French, 2009, pp 702). Educating nurses in this regard therefore should be top priority.
So far, the body of literature shows that a multi method model of hand washing education and training is the best way to promote hand hygiene practices among health care personnel (Ott and French, 2009, pp 702). Alongside this, stringent protocols towards all members of staff in maintaining such practices is another important requirement to ensure positive outcomes (Ott and French, 2009, pp 702). The benefits of such practices are not only for the patient; staff, especially nursing staff, stand to benefit, and perhaps the most. This is because nurses have to manage the changing of patients, catheter management and other such care issues. Exposure to resistant pathogens, therefore, is most likely to take place with nurses (Rahim and Barnett, 2009, pp 580). As well as this, nurses may become the most effective vehicle of transmission of these pathogens from one patient to the next. This, in turn, translates into longer stays, increased morbidity and mortality, and an increase in patient numbers and burden. Consequently, nurses should be educated and trained to practice hand hygiene with utmost importance, specifically with regards procedures of an invasive nature (Rahim and Barnett, 2009, pp 580, Cohen et al, 2003, pp 496).
Current hand washing practices encompass not only the simple procedure of washing the hands with soap, but an array of product use as well, from the start of the procedure till the end of it to ensure there is no spread of the germs to another patient or to oneself (Cohen et al, 2003, pp 495). These procedures include, very briefly, the removal of germs from the staff’s hands with the help of good antiseptic hand washes with certain technique and time duration (Cohen et al, 2003, pp 495). The same should be carried out upon contact with instruments, equipment and waste of the patient, removal of the gloves in a proper manner, and then washing and de-germing the hands again. This procedure needs to be carried out for each patient individually (Cohen et al, 2003, pp 495).
The effects of such interventions are now well known due to a variety of studies carried out about the effectiveness of prevention of nosocomial infections due to hand hygiene practices. A study by Rahim and Barnett in 2009 instituted certain hand hygiene practices in a hospital with nurses as participants. Among the interventions were included a one to one and a half hour duration of intensive educational lecture based on hand hygiene practices, a learning package, instructions about precautions to be taken during hand washing, tracheobronchial suctioning and nasogastric tube feeding (Rahim and Barnett, 2009, pp 580). The nurses were then evaluated on certain hygiene related procedures. These included assessments on whether the hands were washed properly, the assembled equipment being complete and sterile, the proper placement of gastric tube, attachment of the syringe to the end of the feeding tube, connection of the infusion pump and set rate, and the recorded procedure respectively (Rahim and Barnett, 2009, pp 581). The results were very positive: 83% of the participants showed an increase in competency for nasogastric tube feeding and hand washing practice, while 70% of the participants showed a score of 100% in proficiency in each procedure. The number of nosocomial infections dropped drastically as well. The number of blood infections reduced from 6 to 3, the lung infections from 14 to 0, and the total number of infections from 20 to 3 respectively (Rahim and Barnett, 2009, pp 583). The study demonstrates the importance and effectiveness of handwashing and other hygiene practices in the prevention of spread of further disease (Rahim and Barnett, 2009, pp 583).
A similar study assessed the number of times hand washing was carried out in high alert locations such as the neonatal ICUs. The study carried out Cohen et al in 2003, determined whether hand hygiene practices differ between levels of contact with neonates (Cohen et al, 2003, pp 494). Additionally, it aimed to characterize the hand hygiene practices in neonatal intensive care units by using different products (Cohen et al, 2003, pp 494).
Two groups took part in the study. For the first group, an alcohol based rub was selected for the study to be used by the personnel involved in caring for the neonates, and washing of hands was made mandatory when hands would get soiled. Group A was instructed to use a universal gloving policy, in carrying out all and any of the procedures related to neonates. The second group (group B) was given the traditional antimicrobial soaps containing 2% chlorhexidine gluconate. Group B was instructed to follow the gloving protocol only when coming in contact with bodily fluids. Both groups however had to follow the hand washing procedures upon performing invasive procedures, before and after patient contact, and after touching patient equipment and environmental surfaces.
As well as this, the type of touch was also classified to make the study more informative. These were classified as levels 1, 2 and 3 based on the type of procedures carried out and the relative complexity of the procedure carried out on the patient. Then, SPSS software was used to analyze the results.
A total of 1472 touches took place during the study, of which 815 were carried out by nurses, 16.7% by visitors, 13.1% by physicians in training, 7.9% by other health care workers and finally 6.9% by attending physicians respectively (Cohen et al, 2003, pp 498). The study showed that hand hygiene practices improved after direct contact with infants. The results showed that the hand washing practices were not of the required standards in an ICU ward of neonates (Cohen et al, 2003, pp 498). The study emphasized the need to improve the hand hygiene practice in order to ensure the prevention of spread of infections. The study also found better results with the use of alcohol based hand washing equipment, thus advocating it for future use (Cohen et al, 2003, pp 499).
It is important to emphasize the need to develop stringent hand washing protocols in all areas of health care provision, regardless of location or type of service. For comparison, the literature review carried out by Ott and French will be included in this literature review (Ott and French, 2009, pp 702). The review assessed the hand washing compliance among health care staff and student nurses in a mental health setting. It looked into the various factors that can contribute to such neglect, and why mental health care personnel may not be motivated enough to carry out hand hygiene practices in the first place (Ott and French, 2009, pp 702). First and foremost, the lack of enough resources and materials may lead to a reduction in the frequency of hand hygiene practices. This is indeed a matter of concern, as mentally ill patients may not be properly looking after themselves, and statistics show that such patients are very likely to present themselves to the emergency services (Ott and French, 2009, pp 703). Such patients, due to neglect, may have higher chances of acquiring infections, which may take a longer time to treat due to their psychiatric condition. Therefore, the literature suggests that hand hygiene practices along with other personal hygiene practices for patients must be made an essential component of health care provision (Ott and French,2009, pp 703).
The main question that bothers many health care practitioners is why hand washing is not carried out properly when its importance is already established. It is important to realize the importance of certain other factors that may motivate hand washing among people (Park et al, 2010, pp 222). A study in South Korea aimed to identify the perceptions, motivating factors and behaviours associated with the use of hand washing. This study was carried out under the context of the spread of H1N1 influenza (‘Swine Flu’) transmission during its peak period in the country (Park et al, 2010, pp 222). As documented extensively, H1N1 has claimed a large number of lives and is spread very easily through contact with the infected person. With no vaccination to prevent the disease from spreading, the study aimed towards increasing awareness among the Korean people of healthy hygiene practices in order to prevent the spread (Park et al, 2010, pp 222). The two most common instructions given to the public were to sneeze in a tissue, and to wash hands regularly with soap and water. The study, therefore, aimed at identifying hand washing habits before, during and after the pandemic of the influenza virus among the target population, and the perceptions and any changes in the approach towards them in this regard (Park et al, 2010, pp 222). A total of 8,485 and 2,600 female students were enrolled in the study from the public university of Sungkyunkwan (Park et al, 2010, pp 223). The students were given a questionnaire, which targeted questions related to hand washing behaviour, knowledge about the hand washing procedures and its relative effectiveness, and the presence of any flu like symptoms. The study showed that women had increased their frequency of hand washing compared to men (Park et al, 2010, pp 227). Moreover, the participants (30.3%) claimed that they had increased their total frequency of washing their hands in the past year. More than 90% of the students from both genders were aware of the effectiveness of washing hands as a preventive measure for acquiring H1N1 (Park et al, 2010, pp 227). Men believed H1N1 to be a disease of milder consequences, while majority of the women believed otherwise. The study therefore, showed a high interest and awareness about the efficacy of hand washing behaviour, which had increased that year due to an awareness of the spread of H1N1 (Park et al, 2010, pp 227).
The key point to be noted is the efficacy of hand washing regarding the potential spread of not only H1N1 but also many other communicable diseases (Park et al, 2010, pp 228). Hand washing remains one of the primary and foremost safeguards to health, in general population as well as in challenging settings such as the ICUs (Park et al, 2010, pp 228).
Another question in this regard is whether hand washing improves when the staff are educated or motivated to do so (Hand Washing Compliance Goes from 33% to 95%,, 2010, p 5). The study at the Bay Medical Center in Panama City, FL, USA, showed an increase in hand washing compliance by up to 95%. The management believed that the collective effort towards the goal was the key to the promotion of good hand hygiene practice (Hand Washing Compliance Goes from 33% to 95%,, 2010, pp 5). No extensive effort was made; staff were simply told of the need to wash hands if they were seen not doing so where there was a requirement. The use of educational posters everywhere in the hospital also helped (Hand Washing Compliance Goes from 33% to 95%,, 2010, pp 5). This study is an example that proper motivation and guidance can improve hand hygiene rates and can ensure protection from spread of nosocomial infections (Hand Washing Compliance Goes from 33% to 95%,, 2010, pp 5).
Hand washing remains one of the primary methods of infection spread and prevention. It is a practice that not only should be applied by health professionals, but also by the general public in order to prevent and reduce the risks and rates of infections. Hospital acquired infections, such as MRSA, are arguably becoming more common for multifarious reasons, and these are some of the most deadly forms to infect humans; therefore, all steps should be taken to ensure that this spread of infection due to lack of hand washing is prevented. Doing so will help to reduce the number of patients acquiring infections, thereby improving overall health outcomes.
Cohen B, Saiman L, Cimiotti J, Larson E, 2003. Factors Associated with Hand Hygiene Practices in Two Neonatal Intensive Care Units. Pediatr Infect Dis J 22(6): 494-499.
Hand Washing Compliance Goes from 33% to 95%. Steering Team of Key Players Drives Process, 2010. Health Care Bench Marks and Quality Improvement, pp 5 and 6.
Ott M and French R, 2009. Hand Hygiene Compliance Among Health Care Staff and Student Nurses in a Mental Health Setting. Issues in Mental Health Nursing 30: 702-704.
Park JH, Cheong HK, Son DY, Kim SU and Ha CM, 2010. Perceptions and Behaviors Related to Hand Hygiene for the Prevention of H1N1 Influenza Transmission Among Korean University Students during the Peak Pandemic Period. BMC Infectious Diseases 10, 222-229.
Rahim RH and Barnett T, 2009. Reducing Nosocomial Infection in Neonatal Intensive Care: An Intervention Study. International Journal of Nursing Practice 2009; 15, 580-584.