Hand Hygiene and Health Workers

The purpose of this study to determine the practice of 5 moments of hand hygiene among health care workers in NICU at HRPZ II Kelantan.

Hand hygiene is critical in the prevention of Nosocomial infection but however it poorly carried out among health care workers. Hand hygiene very simple procedure and work well to prevent disease because people are the carrier of germ.

This study will be a descriptive study, involving 30 of health care workers in NICU at HRPZ II. The questionnaire was filled out by them and the observation the practice of hand hygiene was done .In the statistic analysis ,frequency and percentage were measure for all the question and the observation finding. Even those many campaign and effort have been done the compliance in hand hygiene still unsatisfactory. Low staff compliance with hand hygiene practices remains a major problem in most healthcare settings.

CHAPTER 1

1.1. INTRODUCTION

The purpose of this study was to determine the practice of hand hygiene and the application of 5 moments hand hygiene among health care workers in Neonatal Intensive Care Unit (NICU) at HRPZ II

Hand hygiene either by hand washing or hand disinfection( hand rub0 is the single most effective method preventing the spread of health care associated infections but is poorly carried out among healthcare workers.

These study was conducted in Hospital Raja Perempuan Zainab II Kota Baharu Kelantan among 30 health care workers in Neonatal Intensive Care Unit (NICU).

Nosocomial infection are defined as those that occurs beyond 48 hours after birth and are caused by pathogens that are not maternally derived. The infection are 100 times more common than early onset bacterial infections ,which are caused by pathogens acquired in utero or perinatally.

Recent data from the National Institute of child Health and Human Development sponsored “Neonatal Network” indicated that 29% of infants born at 25 to 28 weeks gestation and 46% of infants born at less than 25 weeks gestations experience a serious nosocomial infections during hospitalizations in NICU.

Nosocomial infection increase incidence of mortality and morbidity especially among babies nursed in Neonatal Intensive Care Unit (NICU).Many nosocomial infection are caused by pathogen transmitted from one patient to another patient by health care workers who did not wash their hands between patients or health care workers who do not practice control measure such as use of glove and hand disinfectant (Horn WA et.al 1998).

Hand hygiene is the single most effective method preventing the spread of health care associated infections but is poorly carried out among healthcare workers. Failure to employ correct practices has been responsible for an increased incidence in Nasocomial infections(Leaper DJ, 1995).

Other health care workers involved with neonatal care including radiographers, physiotherapists must observed strict hand hygiene before and after attending to these neonates (Policies and Procedures on Infection Control KKM 2010).

Hand hygiene has been promoted seen 19th century and was formularized in 1970s with subsequent develop of guideline on the practice and now recognized as integral part of the quality of patient care .Even those many campaign and effort have been done the compliance in hand hygiene still unsatisfactory .Through my experiences working at NICU recently researcher found that the rates of death due to nosocomial infection rose to 50% from 2009 to 2010 because of that, researcher would like to carry out short study to look into the level of hand hygiene practices among health care workers in NICU HRPZ 11.

1.2. Problem statement.

Why do so many healthcare professionals regularly neglect to wash their hands? Are they forgetful or too busy? Or is there a lack of washing facilities?

The question to be answer in this study was to determine the practice of hand hygiene and 5 moments of hand hygiene among health care workers in NICU at HRPZ II.

Nosocomial infection increase incidence of mortality and morbidity especially among babies nursed in Neonatal Intensive Care Unit (NICU).

Many nosocomial infection are caused by pathogen transmitted from one patient to another patient by health care workers who did not wash their hands between patients or health care workers who do not practice control measure such as use of glove and hand disinfectant (Horn WA et.al 1998).

Hand hygiene is the single most effective method in preventing the nasocomial infection, failure to employ correct practices has been responsible for an increased incidence in Nasocomial infections(Leaper DJ,1995).

Nosocomial infection increase the costs of neonatal intensive care , prolong hospitalization by several weeks ,and are responsible for almost 50% of the deaths that occur beyond 2 week of age .Although the epidemiology of neonatal nasocomial infections is complex, both simple and theoretical strategies can reduce hospital acquired infection .Health care workers frequently are implicated in transmission from patient to patient by transient hand carriage(Richard A. Pollin ,Lisa Saiman 2003).

Through my experiences as a nurse manager in the intensive care unit, researcher found that the hand hygiene are not well practice among health care workers in this unit .From the statistic of neonatal nasocomial rates from 2009-2010 shown that the number of deaths due to nasocomial infection rose to 50%.

1.3. Significant of study relevant

Hand hygiene is considered the most important single and simple procedure for preventing nasocomial infection .Failure to practice or perform hand hygiene is a complex problem that may be caused by the number of factors. To change the behavior to practice hand hygiene is helpful to have some understanding of the factors that influence this behavior

More studies are needed to identify, which of the factors contribute significantly to the problem of poor compliance with hand hygiene recommendation .

The study may provide objective to elevate the quality of care to clients, further nursing care and knowledge to maintain nursing profession.

1.4. Research Objective.

1.4.1 General Objectives

To determine the practice of hand hygiene among the haelth care workers in NICU at HRPZ II ,Kota Baharu, Kelantan.

1.4.2.Specific Objectives;

1-To observe the practice of hand hygiene among health care workers in NICU at

HRPZ II.

2-To determine the application of 5 moments hand hygiene among health care workers.

1.5.Research Questions

Self administer question -pilot study test was done to the all categories for 4 participants.

1.6.Operational Definations

1.6.1 Hand hygiene

A general term that applies to hand washing ,anti septic hand wash,antiseptic hand or surgical hand antiseptic (Boyce & Pittet 2002)

1.6.2 . Hand Washing

Washing hands with plain or antimicrobial ,soap and water.

1.6.3 Nosocomial infections-

Those that occurs beyond 48 hours after birth and are caused by pathogen that are not maternally derived.

1.6.4 Neonates-

Pretaining to the new born period which ,by conventional is the first four weeks after birth.

1. 6.5 Premature-

Baby born less than 37 weeks gestations.

1.6.6 Neonatal Intensive Care Units-

An intensive care unit usually shortened NICU is a special ward of a hospital specializing in the care of ills or premature newborn infants .The NICU is distinct from the special care nursery (SCN) in providing a high level of intensive care to premature infants while the SCN provides specialized care for infants with less severe medical problem.

1.6.7 Health care workers-

Clinical and other staff, including those in primary care, who have regular, clinical contact with patients. This includes staff such as doctors, nurses, paramedical professionals such as occupational therapists, physiotherapists and radiographers.

1.6.8 Hospital Raja Perempuan Zainab 11, Kota Baharu Kelantan.

Hospital Raja Perempuan Zainab 11(HRPZ 11) is a main government hospital for the state of Kelantan. It is located in Kota Baharu, the capital State of Kelantan.

There are 35 wards with 920 beds.

1.6.9 Component of 5 moments:

i.Before client contact.

Clean hands before touching a client when approaching clients,to protect against germs carried on your hands.

ii.Before Aseptic.

Clean hands immediately before an aseptic task,to protect clients against harmful germs,including the clients own,entering their body.

iii.After body fluids.

Cleans hands immediately after an exposure risk of body fluids & after glove removal .

To protect health care workers from harmful germs.

iv.After patient contact.

Clean hands after touching clients immediately when living the clients.

v.After surrounding

Clean hands after touching any object or furniture in the patient surrounding ,when leaving -even not touch clients.

1.7 Hypotheses

1.The successfully of practicing hand washing among the health care workers in NICU during the study period depend on implementation and obedience according to different category of staff:

I .Neonatologist

ii. Doctors(include Medical Officer & House officer)

iii. Staff nurse

iv.Community nurse (Jururawat Masyarakat)

2.The knowledge regarding the importance of hand washing should be optimized among medical staff to deliver a high quality of care to the clients and to prevent cross infection during hospitalization.

3. All the health care workers must be taught regarding the importance of hand washing before and after visiting the hospitalized patients from this action that we can reduce hospital coast by treating patient which primary illness.

CHAPTER 2

2.0 LITERATURE REVIEW:

2.1.Literature related hand washing

The Centers for Disease Control and Prevention (CDC) recommends that you wash your hands thoroughly for at least 20 seconds with clean, running water and soap using warm water if it is available. If clean water is not available, an alcohol-based hand sanitizer can be substituted, but note that these types of products don’t remove dirt or soil – soap and water really is the best option. CDC reporting that up to 80% of all infections are transmitted by hands.

Proper hand washing is an important way to stay healthy year-round (Vincent Iannelli, M.D., December 11, 2009)

Hand hygiene is the main player in the prevention of cross infection,(WHO, 2004).

Hand washing is simple ,easy implemented and good practice can reduces the risk of cross infection.(Storr et al ,2005).

Low staff compliance with hand hygiene practices remains a major problem in most healthcare settings worldwide. Indeed, when appropriate methodology is used to assess compliance, it rarely exceeds 30% (Didier Pittet, MD,MS,2009)

Chittaro and colleagues found: that the compliance was increase around 20%-26%

when hand rub was used in only one third of hand hygiene activities by the minority group of health care workers.

2.2. Literature related 5 moments component of hand hygiene

“My five moments for hand hygiene” tool, ensures that the five fingers of both healthcare workers’ hands are clean and safe for patient care, (Didier Pittet, MD,MS,2009)

Hand washing or use of an alcohol hand rubs by medical personnel before and after contact is one of the most effective ways to combat nasocomial infection (Wikipedia http://www.answer.com/topic/nasocomial-infection)

“Clean Care is Safer Care” campaign initiative its hand hygiene promotion strategy

in only three years between October 2005 and October 2008.11 Hundreds of healthcare settings around the world have implemented the strategy regardless of their resource level. 5th May 2009 was choose as the first World Hand Hygiene Summit where all health care facilities world wide are invited to promote hand hygiene at the point of care.

Bhalla and colleagues found ,patients with skin colonization the organism was frequently transferred to the hands of Health care workers who touched both the skin of patients and surrounding environmental surfaces.

Chitarro and colleagues found from their study the compliance with hand hygiene practice after contacts with patients or exposure to their body fluids is always higher than before touching, a patient or device use to patient.

Implementation of 5 moments of hand hygiene is the best way of enhancing patient care and no shortage of important health care legislators emphasizing the basic five(Jarvis,2004).

The National Audit Office (2000) provides incontrovertible evidence that infection control is a cornerstone of good clinical practice of hand hygiene and quality patient care (King,2005;Storr et al,2005;Teare et al,1999)

2.3. Literature related nasocomial infection .

Many nosocomial infection are caused by pathogen transmitted from one patient to another patient by health care workers who did not wash their hands between patients or health care workers who do not practice control measure such as use of glove and hand disinfectant (Horn WA et.al 1998).

Most of neonates in newborn intensive care units(NICU) are premature and highly to get infection due to immaturity of immune function and impaired defense mechanism invasive procedures can easily cause the infections to the babies, (Ihn Sook Jeong at el 2006).

“Every year, thousands of lives drift caused by an infection that occurs in the environment of health care facilities in developed countries and developing to be addressed because of this problem happening all over the world,” Chairman of the Organizing Committee APSIC, Assoc. Dr.Nordiah Awang Jalil (Shafinaz Sheikh Maznan, Utusan on line. HAI penyakit jangkitan hospital).

According to Richard A.Polin at el . Potential reservoirs of infections include; resuscitation equipment, humidifier, Incubators, formulas, sinks and tap water ,infants who have prolong hospitalizations and the hands of healthcare workers.

5 May 2009 (5.5.2009) has been chosen by WHO as the date of the First World Hand Hygiene Summit where all healthcare facilities worldwide are invited to promote hand hygiene at the point of care.

Even though recent marked advances in intensive care skill and facilities, they have also increase the frequency of invasive procedures and most of neonates in (NICU) are premature and highly to get infection due to immaturity of immune function and impaired defense mechanism.Invasive procedures can easily cause the infections. Therefore Nosocomial infection are important and critical issue related to high morbidity and mortality in neonates (Ihn Sook Jeong at el 2006).

Some types of contact during routine neonatal care are more frequently associated with higher levels of bacterial contamination of HCWs’ hands: respiratory secretions, nappy/diaper change, and direct skin contact (WHO guidelines of Hand Hygiene).

In United States more than 2,000,000 Nosocomial infection in infant and adult occurs each years and 50%-60% are caused by resistant organisms (Richard A.Polin,at el.)

According to Horn WA et.al 1998 they found many nosocomial infections are caused by pathogen transmitted from health care workers who have not wash their hands between patients or health care workers who do not practice control measure such as use of glove ,hand disinfectant.

Other health care workers involved with neonatal care,including radiographers,physiotherapists must observed strict hand hygiene before and after attending to these neonates.(Policies and Procedures on Infection Control KKM 2010).

However, it is not sufficient as a single measure alone, and its integration among the other components is critical to achieve behavior modification and sustainability.

For more than a century, health care providers’ hands have been recognized as major reservoirs of pathogens that may cause clinical infections.

Several new evidence-based practices such as an alcohol-based hand sanitizer to replace traditional hand washing for all patient contacts except if hands are visibly soiled.Critical thinking about hand hygiene. According to mainstream thinking and many healthcare professionals, the National Audit Office (2000) provides incontrovertible evidence that infection control is a cornerstone of good clinical practice and quality patient care (King, 2005; Storr et al, 2005; Teare et al, 1999).

CHAPTER 3

RESEARCH METADOLOGY

3.1. Research Design

This was an evaluation study of hand hygiene and 5 moments of hand hygiene practice among health care workers in NICU at Hospital Raja Perempuan Zainab II.

Test questions were taken from the following:

Hospital hand washing protocol.

Hand hygiene compliance data collection format.

Self questionnaire – pilot study was done before administer the question.

3.2. Study Setting.

This study have involves all the health care workers in NICU during periods of study to determine the practice of hand hygiene and 5 moments of hand hygiene.

3.3.Population and Sampling.

3.3.1.Sampling size

This is the convenient sampling method. Involve 30 person all the categories

health care workers in NICU .

3.3.2. Criteria for inclusion

Community Nurse(J/ Masyarakat), Nurses ,House officer(HO),Medical officer(MO) and Neonatalogist in NICU at Hospital Raja Perempuan Zainab II Kota Baharu.

3.3.3 Criteria for Exclusion

Pembantu Perawatan Kesihatan(PPK), Parents.

3.4 . Instrument use to collect data.

3.4.1 Observation.

Hand washing compliance data collection was used in this study for self report of the performance. Descriptive research is aimed to explain a phenomena that is happening or discover something areas that have not been review or less(Mohd Majid,1994),Descriptive research consist of several types ,such as survey research, correlation research and development ,for this study researcher have using a descriptive survey research. According to Blake and Champion (1976) the view that the survey method is specific way gather the information about large information. According to Didier Pittet, MD,MS( 2009) the observation is universal.

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3.4.2 Questionnaire

To achieve the objective of the study a questionnaire design to obtain feedback from respondents. The instrument used in this study are questionnaire, such research commonly used in the descriptive study. Questionnaire instrument was the most effective for obtaining information from respondents (Tuckman ,1978).The questionnaire is a tool or instrument used to measure behavior of the respondent (Mohd Najib,2003) . The use of questionnaire is appropriate and practical, effective and save. It would be avoid (bias) to the researcher and provide the an opportunity for respondent to think.

3.5 Data collection procedure and data analyzed.

Data practice 5 moments of hand hygiene and knowledge among health care workers were collected by self report. The observation for 5 moments hand hygiene was done , Furthermore, self report data on Hand Hygiene was analyzed using SPSS version 16.

The following steps were performed during the data collection procedure .First the sign consent from the participant in the study was obtained from all prospective participants on the unit. Second the participants completed the self report instrument.

If the participants not understand they can ask researcher immediately or can contact Hand phone 013-9274340.It look about 10 minutes to answer and finish all the questionnaires. The questionnaire was administered at the end of January 2011.

For the observation was done without informed to participants.The observation was done according the hand hygiene and 5 moments condition include before patient,before asptic /clean procedure, after body fluids,after touching the patient and after touching patient surrounding.

3.6 Variable :Dependent and Independent.

The dependent variable is Hand Hygiene and the 5 moments of hand hygiene, example before and after touching the patient,before aseptic procedure or after body fluid exposure, after touching patient surrounding.

Independent variable in descriptive study are the health care workers formal training of hand hygiene ,the technique of hand hygiene wash or hand rub.

and demographic characteristics (age, gander, years of service and experience )

3.7 Ethical consideration.

In order to ensure informed health care workers consent , we gave oral information including outline of the study ,method data collection except the observation and

The need of the agreement to be involve of the study. On the day data collection ,completion of the questionnaire was taken as consent participate, and they were under obligation to do this.

3.8 Limitation of the study.

This was due to limit number of participants needed to meet the minimum required

Sample size which determine before the study commenced. In this study ,30 health care workers was involved but the researcher failed to get the consent from the radiographer and the physiotherapist.

The generalization of our result was limited to only this unit in Kelantan due to coverage of whole NICU in Hospital in Kelantan could not be made.

All respondent who fulfilled the inclusion criteria and gave their verbal consent were recruited into the study.

3.9 Pilot Study.

For the pilot study 2 participants each group were chosen.

CHAPTER 4

RESULT.

In this chapter ,the main purpose were to describe the social demographic factor, the knowledge and practice of 5 moment of hand hygiene among the participants in this study .This study was focusing into two main aspect which were the practicing hand hygiene and the 5 moments of hand hygiene among the participants. Instead of that, this study also was looking forward to the relationship between the social demographic factors and two main aspect which is the practice and the 5 moments of hand hygiene .According to that ,the analyses have been done towards all this factors to see whether there was a correlation among all factors.

30 health care workers from NICU in Hospital Raja Perempuan Zainab II,Kota Baharu were taken as participants in this research.

Gender was one of the social demographic factors that had been taken as a consider in the analysis.

 

cross tabulation

Table 1 above shows the data that gain from the cross tab. Refer to the data, 2 of respondents each of them was a degree and diploma holder only use the microbial, soap and water before they handle their patients at NICU. The rest of 28 respondents admit that they used all method on hand hygiene practice. 3 of certificate’s respondent with 10.7 percent perform the same method too followed by 20 diploma’s respondents with 71.4 percent that also perform the similar method and the rest of 5 degree’s holder with 17.9 percent. From above table showed that the educational level are not influence the practice of hand hygiene

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among health care workers in NICU, researcher said that because from the table above showed that the respondents which diploma or degree holder still not practice the standard procedure while performed the task.

Experience working in NICU * Hand hygiene practice refer to Cross tabulation

Table 2 .Experiance working in NICU * Hand hygiene practice refer to Cross tabulation

Experiance working in NICU

Hand hygiene practice refer to

hand washing using anti microbial,soap &water

PERCENT

all of the above

PERCENT

Lees than 1 years

1

50.0

11

39.3

2-5years

0

0

4

14.3

6-10years

0

0

11

39.3

more than 11 years

1

50.0

2

7.1

TOTAL

2

100.0

28

100.0

Table 2 show cross tabulation among experience working respondent in NICU regarding the hand hygiene practice. From the data, the researcher found out that from 30 respondents only 2 of them used microbial, soap and water to wash hand,

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which each of them only having 1 year experience working at NICU and another one having 11 years experience.

28 of respondents choose all to the answer are listed, the researcher found that the respondents experience working in NICU are equal between less than 1 years experience with 6 to 10 years experience are about 11 of respondents with 39.2%.Only 4 respondents or 14.2% having experience between 2 to 5 years working experience. Use all the method in the questionnaire,2 of respondents or 7.1% having 11 years experience and above, are agree with the answered. From the finding, researcher can conclude the working experiences not influence the practice of hand hygiene.

Table 3 :How many moments do you know in hand hyigene procedures * Hand hygiene practice refer to Cross tabulation.

How Many Moments Do You Know In Hand Hyigene Procedures

Hand hygiene practice refer to

Hand washing using anti microbial,soap &water

PERCENT

All of the above

PERCENT

5 moment

1

23

82.2

6 moment

0

1

3.6

8 moment

1

4

14.2

TOTAL

2

28

100.0

28

Table 3 above show cross tabulation with the 5 moments component in hand hygiene practice .From the table researcher found out that 2 of respondents of 30 knows that the 5 moments of hand hygiene, however they only using anti microbial, soap and water in hand hygiene practice meanwhile other 28 of respondents stated that they choose all the answer in the questionnaire.

Table 4 Formal Training on hand hygiene * designation Cross tabulation

Count

Formal traning on hand hygiene

Designation

Total

Specialist

MO

HO

SN

JM

yes

6

4

7

8

3

28

no

0

0

1

0

1

2

Total

6

4

8

8

4

30

Table 4

Table 4 represent that from 30 respondents, 2 of them never attend any training regarding the hand hygiene procedures. The rest of 28 already have knowledge and experience through the training attend before. Refer to 28 respondents with different position of job; the researchers gain the different statement. 8 of respondent whose are SN admit that they already attend the training before. The amounts lead them to

29

become the highest rating of percentage followed by HO, 7 people. The data also show that, the 6 specialist got attend the training of hygiene procedures too and same goes to MO, 4 people and JM, 3 people.

Table 4 represent that from 30 respondents, 2 of them never attend any training regarding the hand hygiene procedures. The rest of 28 already have knowledge and experience through the training attend before. Refer to 28 respondents with different position of job; the researchers gain the different statement. 8 of respondent whose are SN admit that they already attend the training before. The amounts lead them to become the highest rating of percentage followed by HO 7 people. The data also show that, the 6 specialist got attend the training of hygiene procedures too and same goes to 4, MO and 3, JM.

3o

Table 5 Practice on hand *cross tabulation

count

Practice on hand hygiene

DESIGNATION

Total

Specialist

MO

HO

SN

JM

hand rub

0

0

1

3

3

7

wash

6

4

2

3

0

15

miss

0

0

5

2

1

8

Total

6

4

8

8

4

30

31

Table 6 Formal Training on hand hygiene * designation Cross tabulation

Count

Formal traning on hand hygiene

Designation

Total

Specialist

MO

HO

SN

JM

yes

2

4

7

12

3

28

no

0

0

1

0

1

2

Total

6

4

8

8

4

30

Table 6

Table 6 represent that from 30 respondents, 2 of them never attend any training regarding the hand hygiene procedures. The rest of 28 already have knowledge and experience through the training attend before. Refer to 28 respondents with different position of job; the researchers gain the different statement. 12 of respondent whose are SN admit that they already attend the training before. The amounts lead them to become the highest rating of percentage followed by HO, 7 people. The data also show that, the 2 specialist got attend the training of hygiene procedures too and same goes to MO, 4 people and JM, 3 people.

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Technique * Designation Cross tabulation

Count

technique

Designation

Total

Specialist

MO

HO

SN

JM

hand rub

0

0

1

3

3

7

wash

6

4

2

3

0

15

miss

0

0

5

2

1

8

Total

6

4

8

8

4

30

Table 5

The table 5 above showed the cross data between the techniques and designation. The researcher concluded that 15 out of 30 respondents washed their hand before handling the infant which is 50% of the total respondent. This technique is widely implemented by the Specialist as 6 out of 15 respondents (40 percent). It is followed by the Medical Officer (MO) with 26.6 percent which is 4 respondents. Whereas, only 3 respondents who is Staff Nurse (SN) that represent 20 percent and 13.4 percent or 2 respondents who is Hospital Officer (HO) implemented this technique. Besides, only 7 out of 30 respondents implement the hand rub technique and they are SN and JM with 3 respondents each which are 42.8 percent of total respondent.

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However, only 1 HO admits that he implement the technique which carries out 14.2 percent. Nevertheless, there are also 8 respondents which are 26.6 percent out of

total respondent who did not implement the hand wash and hand rub technique. The data showed that 5 out of 8 respondents are HO which carries out 62.5 percent. It is followed by SN with 25 percent and JM with 12.5 percent.

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As conclusion, Table 4 and Table 5 are linked to each other as from the both table we can see that most of the respondents previously attending a formal courses regarding hand wash technique before handling the infant. However, there were still a few respondents particularly HO, SN and JM who did not take it seriously as showed in Table 5.

Design