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Background and Context

 Hand hygiene is one of the most important procedures in the control of infections in various sectors. The infections that are associated with the healthcare is capturing the attention of the governments, insurers, regulatory agencies as well as the patients. This follows the high morbidity and mortality rates that associated with these infections.  Similarly, infectious diseases are also associated with high cost of treatment. Individuals are now beginning to understand that these infectious diseases can be prevented. The medical fraternity has realizing in tandem unmatched   improvements in the   understanding the pathophysiology of infectious diseases. This comes in the wake of the spread of multi-drugs resistant (MDR) infections across the globe (Vermeil et al, 2019). The factors coupled with existence of novel antimicrobials calls for a need of relooking into the role played by basic practices of preventing infection in the present healthcare set up. Undisputed evidence that hand hygiene is capable of reducing the risk of cross-infections is now in existence following several scientific research. The increasing burden on the healthcare together with ballooning severity   of illness as well as the complexity of the treatment due to Multi Drug Resistance (MDR), there is a need to reverse to the basic infections control measures such as hand hygiene.  According to scientific evidence, proper implementation of hand hygiene results in the reduction of cross-transmission of infections within the health care set up (Sharif et al, 2016). 

This essay shall expound on the    hand hygiene in the control and prevention of Hospital Acquired Infections (HACIs) within the ABC hospital.  From the  audit  of the   5 moments of hand hygiene,  it  was observed that there is still lower  percentage of  healthcare workers  who are  adhering to the hand hygiene before attending to a patient(moment 1) .  From the statistics it is only  67% of the  medical staff  observes hand hygiene in Australia before coming into physical contact with the patients.

 Two types of microbes which colonizes the hand are in existence. The two are resident flora and transient flora.  Resident flora is made up of microorganisms which resides in the superficial cells of stratum corneum. On the other hand, the superficial skin layers are colonized by transient flora and   routine hand hygiene can potential remove   them. The skin supports the survival of the microorganism though they cannot multiply.  Health care workers tends to acquire these microorganisms when they are in direct contact with the patients (Chassin, Mayer & Nether, 2015). Transient microorganisms may also be acquired when the health care workers comes into close contact with   environmental surfaces which are contaminated with the infections.

The Benefits of Hand Hygiene

Within the ABC hospital  the healthcare workers  hands  are usually  colonized with  pathogens such as  methicillin  resistant St… Aureus,  vancomycin  resistant Enterococcus, MDR-Gram Negative bacteria  as well as  Clostridium  difficle.  The survival time of these organisms can last up to 150 hours. The epithelial cells that contains viable micro-organisms are shed on daily basis from the normal skin. This may lead to contamination of bed linen,   furniture and gowns which are objects in the close surrounding of the patient.  The carriage of the resistant pathogens by the hand has been found to be associated with the nosocomial infections. The critical   care area accounts for the highest infection rates through the contamination of the hand (Edmisten et al, 2017). Within this sector, cross-transmission is also very high.  Contamination of the hands may occur just by touching either the intact skin of the patient or inanimate objects in the patients room mainly in clean procedures.

Hand hygiene   is a method of controlling infections  through    cleansing of the hands.   Hospital  acquired infections  presents an imminent danger to  patients within the healthcare   environment  as well as the healthcare workers  such as nurses who contributes  to these transmissions. As by the WHO (2009), the rate of   incidence and prevalence of hospital acquired infections has  been on the rise  amongst the world’s population with fourteen  million people    suffering from the infections. The transmission of these infections from one patient  to the other  is occurring through   hands of the healthcare workers(World Health Organization, 2009). This means that hand hygiene has the potential of  reversing this increasing trend.  The patient safety in Australia is threatened by  one  of the factors being  hospital acquired infections.    

In Australia hand hygiene has been seen to  reduce  hospitalizations  occurring due to  Hospital  acquired infections.  Regardless of these efforts,  there is still low  compliance levels  of  hand hygiene in Australia.  The rates of hand hygiene has not attained optimum levels.  Although hand washing is effective for control of infections,  an audit of the 5 moments of hand hygiene in  Australia reveals some gaps(National Health and Medical Research Council (2019).  It was observed that only 67% of the healthcare  staff    adheres to hand hygiene  before attending to a patient ( HH moment one).

 The World Health Organization   in a bid of promoting hand hygiene it has promoted five moments of hand hygiene which are :

  1. Before  client contact;  hands should  be cleaned  before touching the patient  or  when approaching  for protection against the germs  which may be transmitted through the hand(WHO, 2007).
  2. Before Aseptic  ;  the hands should be immediately cleaned  prior to aseptic  task   for protection of the clients  against  dangerous germs   from being transmitted to their  bodies.
  3. After the body fluids;  hands should be immediately cleaned  after being exposed  to risk body fluids  and removal of the gloves.
  4. After patient contact ; hands should be cleaned immediately  after  touching  the patients  when leaving the clients.
  5. After surrounding; it is advisable to clean the hands  after coming into a touch with  any object within the surrounding of the patient  and when leaving do touch the patients.

Hand hygiene  is being promoted because it comes with several benefits  both for the patients and the healthcare staffs. The importance of hand hygiene include the following:

  1. It  prevents the  transmission of the  nosomical  infections
  2. It reduces the incidence and prevalence of  Methicillin  -resistant  Staphylococcus aureus (MRSA). 

Nosocomial Infections and Hand Hygiene

 A nosocomial infection   is a type of infection  in which an hospital environment favors it. This type of infection can be developed by a patient after visiting an hospital set up or  acquired by hospital staff.  There are various  nosocomial infections  but the most common are;   Staphylococcus aureus  , MRSA, gastroenteritis, Clostridium  difficle  and hospital acquired    pneumonia. Nosocomial infections are favored by the  conditions within the hospital set up. Invasive devices in the hospital set up  such as  surgical drains,  intubation  tubes and  catheters  are bypassing the  natural lines of the body defense  against  germs hence  increasing  their penetration((Sparksman, Knowles, Werrett & Holt, 2015). Patients who have been colonized  already are placed at a higher risk when they are subjected to invasive devices. 

MRSA  is  a bacterium that causes difficulties in breathing  among humans.it is any strain  of  Staphylococcus  aureus  which is resistant to  beta- lactam  antibiotics.    The infection is mainly transmitted through direct contact  with either the wounds,  discharge or soil areas.  Besides these, they are other risk factors for this infection. The factors include;  coming into close contact,  poor personal hygiene , catheters and  presence of breaks ups in the skin.  However, when hand hygiene is practiced, it  can be effective method of controlling these infections.   Frequent hand washing before   touching  the mouth,   or eyes will reduce the risk  of this infection. (van, Reinhardt & Grimmelikhuijsen, 2022).   Washing hands immediately after touching public installations  like doors and knobs  helps prevent the transmission of the infection. Wearing gloves  when dealing with soiled objects   followed  by  proper hand hygiene reduces the chances of  contracting and transmitting this infection. 

 Hospital acquired  pneumonia  is a type  of pneumonia  which is developed by a patient  within the hospital environment  in a period between  48-72 hours  following admission. This is the second most  prevalent  nosocomial infection  accounting for fifteen to twenty percent of  the nosocomial infections. It is the primary cause  of death in ICU’s. Proper hand hygiene such as washing hands before touching the  nose , eyes and parts of the body   helps in  reducing the transmission of this infection((Saitoh et al, 2020). Older persons are at higher risk of hospital acquired  infections.  Among  them  respiratory tract infections and  urinary infections are common. Hospital acquired  pneumonia is the most prevalent  respiratory tract infection among the elderly. The elderly are more prone to this infections because  their immunological  competence  is reduced due to age. As individuals grows old, they  become more susceptible to   comorbid conditions such as  diabetes,  arthritis and  renal insufficiency(Azim & Claws, 2014). Comorbid conditions  including the  type and number  predisposes  individuals to infections. When individuals grow old,  immunosenescence  occurs  hence the immune system does not  functions well. The combination of   high comorbid conditions and  reduction in the  immune system  increases the vulnerability of  the older people  to these hospital acquired infections.  Additionally,  as people grows older,  their body mass index also  falls  hence becoming susceptible to  falls and injuries. All these things therefore predisposes them to   hospital acquired infections(Hong et al, 2015).  Older people also tends to be less compliant with hand hygiene thus increasing their vulnerability to these infections.

Prevention of MRSA

As mentioned earlier, the level of hand hygiene compliance within the Aged  Care  facilities are still very low(Prescott, Mahida, Wilkinson & Gray, 2021). This can be attributed to several barriers. One of these barriers is the stressful working environment   causing the healthcare staff not to  observe hand hygiene. Hence the staff should  constantly be  reminded  to  observe hand hygiene after  assisting an individual. Another  barrier to hand hygiene is  the lack of instruments  within the aged care facilities. The absence of education and training  is also another barrier hindering the  development of   an enabling environment  for practicing proper hand hygiene. Within the ABC  healthcare set up, there  are 52 beds   in single room  accommodation.   Within this 52 bed facility, it is inclusive of  22 dementia  specific wing.  The residents houses comprises of  single, double and  four bedrooms  with  garden views. 22 individuals who are living independently  hence granting the residents with  a free maintenance and  relaxing lifestyle. The facility  provides medical coverage when need arises(Haque et al, 2017). It has recreational  activity officers  responsible for designing  individual as well as group  activity programs  to foster  enjoyment and   self-esteem. It also have   various denominations ministers  who upon request  they visit to minister for the  residents having different  spiritual needs.  

Within the ABC  hospital the staff are required to dry the hands with a towel after washing. This is because the friction aids in the removal of transient organisms from skin surface. Recently, following the advent of Covid-19, the organization recommended the use of disposable paper for drying the hand which is regarded by knowledgeable healthcare professionals as most effective and quickest way. In a situation in where the washing facilities are very poor,   the risk of infection is very high. Within the ABC  Hospital set up there are clinical hand wish sink in all the areas where   clinical activities are carried out. The sinks have been placed in convenient places. To foster frequent and appropriate washing of hands, sinks have been placed in convenient places while soap and water has been provided in   sufficient quantities. To boost the hand hygiene compliance, adequate and relevant facilities should be provided. The factors that hinder adoption of hand hygiene as a routine strategy include; poor facilities and methods as well absence of time (Hosseinialhashem et al, 2015). At the ABC  hospital,    the management has shown commitment for improving resources needed for the improvement of poor hand hygiene amongst the patients and the healthcare workers.

Hospital Acquired Pneumonia

To boost the chances of compliance, there is need for ease accessibility of hand hygiene either the sinks or alcohol handrub.  Health care staff who are very busy tends to find it difficult to reach to the wash basin or even the antiseptic hand agents hence resulting to non-compliance. There are various antiseptic agents that are used in the cleaning of hands.  Within the ABC ,  soap, water  and antiseptics  like  chlorhexidine,  tricosan  and povidone iodine are used for hand washing(Gauge, Fischer  & Lermer,2021). Alcohol which contains 60-90% ethanol is used commonly used.  For the removal of transient microorganisms, liquid soap is being used.  The reason why liquid soap is preferred to bar soap is for the avoidance of the contamination issues. Within this organization, it has been established that hand washing using liquid soap is sufficient for the most routine procedures.  The handling of the equipment that has been used can be removed easily through 15- 30 seconds wash. The liquid soap dispenser prevents the contamination of lead (Tantum et al, 2021).  

In order to boost the hand hygiene compliance as strategy to reducing hospital acquired infections, healthcare organizations should introduce an education program.  The organizations should consider adopting a multi-modal educational  strategies.     Within this strategy,  interventions for prevention and control are developed and  healthcare workers are made aware of them  through education and training. Professionals in the healthcare sector should be  made aware of the theoretical  knowledge.   Most of the hand hygiene knowledge is  acquired by the   nurses and other healthcare staff   in the workplace. This calls for the need of  further education  and training about  the hand hygiene within the clinical environment.

 Multi-modal educational strategy effectiveness in enhancing the compliance of hand hygiene has been the subject of interest for  many researchers. For example  the WHO  multi- modal  education program  which is founded on   ‘My  5 moments  for Hand Hygiene’. The focus of this approach is on the improvement of the  safety of the patient  through  prevention and control of the hospital acquired infections. The strategy   has been confirmed to enhance compliance among the healthcare   staff. Sufficient evidence  exists on the hand hygiene effectiveness  in enhancing compliance  to both the federal and international  requirements of hand hygiene. The educational program  attains their efficacy  for the improvement  of hand hygiene   by increasing the knowledge  about hand hygiene  amongst the healthcare staff. The strategy also instils a positive attitude  about  the hand hygiene  which is an aspect  improving compliance  to  both the  national and  international  legislations principles.

An education program was designed and delivered by the author to address the problem identified in lack of adherence to moment XX of the 5 moments of hand hygiene. The education included use of the Glow Germ tool, which allowed staff to understand the best way to perform hand hygiene.

The education strategy was in delivered  in  various ways such as simulation,  visual cues and through teamwork.  Simulation  is an effective method that can be used in  enhancing  compliance   amongst the nurses  at the ward. Through simulation nurses  was taught in an interactive environment  which provided room for instant feedback  for them to ask  questions  or seek clarifications  regarding the practice. The   nurses were shown by the head nurses  how they should practice   hands hygiene,  the length of time  as well as what is being  used. With this repetitive practice,  the nurses will finally  be competent  in  hand hygiene.

 The education strategy was also delivered using  visual cues. Visual cues were used  to remind the nurses about  of the infections  as well as the importance of hand hygiene. Laminated posters  were  posted in labs  and along the corridors  for the nurses to see them on routine basis.   Screens were mounted on the hospital  corridors  and played videos  talking about hand hygiene   practices occasionally. This ensured that the nurses did not forgot about hand hygiene even after wearing gloves.

The education strategy also emphasized the importance of team work in enhancing hand hygiene compliance. The  education strategy was  established not only to target   nurses  working  in the wards but also the ward as  a whole. Team work enabled  nurses to discuss  together   the best simulation  specifications and methods  implemented  in the wards. Older nurses were tasked with  introducing student and new nurses  for them to establish  a culture  of hand hygiene. 

 The education strategy  also included the provision of  products and sinks  to enhance  access to  hand hygiene. The hand sanitizers should be placed in the washrooms  and across the wards to enhance hand hygiene compliance. Hand sanitizers were also fixed on  the walls and beds in the wards. This was aimed at boosting the  education strategy of  dispenser location. 

  To   evaluate the efficacy of education on improvement of hand hygiene compliance, hand hygiene audit   checklist will be used. The checklist  will  be used to ascertain   whether the  WHO Five Moments  of Hand Hygiene  has been adhered to. The overall compliance   score of  the staff  will be measured.  The following will also be done:

  • The details of  each healthcare staff will be  specified
  • Photos will be taken  to support  key  findings  during the   audit  of hand  hygiene

References

Anderson, M. E., & Weese, J. S. (2016). Self-reported hand hygiene perceptions and barriers among companion animal veterinary clinic personnel in Ontario, Canada. The Canadian Veterinary Journal, 57(3), 282.

Atari, B., Zahra, S. M., Pezeshki, Z., Babak, A., Nokhodian, Z., Mobasherizadeh, S., & Hoseini, S. G. (2013). Baseline evaluation of hand hygiene compliance in three major hospitals, Isfahan, Iran. Journal of Hospital Infection, 85(1), 69-72.

Azim, S., & McLaws, M. L. (2014). Doctor, do you have a moment? National Hand Hygiene Initiative compliance in Australian hospitals. Medical Journal of Australia, 200(9), 534-537.

Batista, J., Silva, D. P. D., Nazário, S. D. S., & Cruz, E. D. D. A. (2020). Multimodal strategy for hand hygiene in field hospitals of COVID-19. Revista brasileira de enfermagem, 73(suppl 2), e20200487.

Chassin, M. R., Mayer, C., & Nether, K. (2015). Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance. The Joint Commission Journal on Quality and Patient Safety, 41(1), 4-12.

Edmisten, C., Hall, C., Kernizan, L., Korwek, K., Preston, A., Rhoades, E., ... & Zygadlo, S. (2017). Implementing an electronic hand hygiene monitoring system: lessons learned from community hospitals. American journal of infection control, 45(8), 860-865.

Engdaw, G. T., Gebrehiwot, M., & Andualem, Z. (2019). Hand hygiene compliance and associated factors among health care providers in Central Gondar zone public primary hospitals, Northwest Ethiopia. Antimicrobial Resistance & Infection Control, 8(1), 1-7.

Gaube, S., Fischer, P., & Lermer, E. (2021). Hand (y) hygiene insights: Applying three theoretical models to investigate hospital patients’ and visitors’ hand hygiene behavior. PloS one, 16(1), e0245543.

Haque, A., Guo, M., Alahi, A., Yeung, S., Luo, Z., Rege, A., ... & Fei-Fei, L. (2017, November). Towards vision-based smart hospitals: a system for tracking and monitoring hand hygiene compliance. In Machine Learning for Healthcare Conference (pp. 75-87). PMLR.

Hong, T. S., Bush, E. C., Hauenstein, M. F., Lafontant, A., Li, C., Wanderer, J. P., & Ehrenfeld, J. M. (2015). A hand hygiene compliance check system: Brief communication on a system to improve hand hygiene compliance in hospitals and reduce infection. Journal of Medical Systems, 39(6), 1-4.

Hosseinialhashemi, M., Kermani, F. S., Palenik, C. J., Pourasghari, H., & Askarian, M. (2015). Knowledge, attitudes, and practices of health care personnel concerning hand hygiene in Shiraz University of Medical Sciences hospitals, 2013-2014. American journal of infection control, 43(9), 1009-1011.

Loftus, M. J., Guitart, C., Tartari, E., Stewardson, A. J., Amer, F., Bellissimo-Rodrigues, F., ... & Pittet, D. (2019). Hand hygiene in low-and middle-income countries. International Journal of Infectious Diseases, 86, 25-30.

National Health and Medical Research Council (2019) available at < https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019>

Prescott, K., Mahida, N., Wilkinson, M., & Gray, J. (2021). Hand hygiene: a COVID beneficiary?. Journal of Hospital Infection, 111, 4-5.

Reichardt, C., Königer, D., Bunte-Schönberger, K., Van der Linden, P., Mönch, N., Schwab, F., ... & Gastmeier, P. (2013). Three years of national hand hygiene campaign in Germany: what are the key conclusions for clinical practice?. Journal of Hospital Infection, 83, S11-S16.

Saitoh, A., Sato, K., Magara, Y., Osaki, K., Narita, K., Shioiri, K., ... & Saint, S. (2020). Improving hand hygiene adherence in healthcare workers before patient contact: a multimodal intervention in four tertiary care hospitals in Japan. Journal of Hospital Medicine, 15(5), 262-267.

Sharif, A., Arbabisarjou, A., Balouchi, A., Ahmadidarrehsima, S., & Kashani, H. H. (2016). Knowledge, attitude, and performance of nurses toward hand hygiene in hospitals. Global journal of health science, 8(8), 57.

Sparksman, K. P., Knowles, T. G., Werrett, G., & Holt, P. E. (2015). A preliminary study on the use and effect of hand antiseptics in veterinary practice. Journal of Small Animal Practice, 56(9), 553-559.

Tantum, L. K., Gilstad, J. R., Bolay, F. K., Horng, L. M., Simpson, A. D., Letizia, A. G., ... & Arthur, R. F. (2021). Barriers and opportunities for sustainable hand hygiene interventions in rural Liberian hospitals. International Journal of Environmental Research and Public Health, 18(16), 8588.

van Roekel, H., Reinhard, J., & Grimmelikhuijsen, S. (2022). Improving hand hygiene in hospitals: comparing the effect of a nudge and a boost on protocol compliance. Behavioural Public Policy, 6(1), 52-74.

Vermeil, T., Peters, A., Kilpatrick, C., Pires, D., Allegranzi, B., & Pittet, D. (2019). Hand hygiene in hospitals: anatomy of a revolution. Journal of Hospital Infection, 101(4), 383-392.

WHO (2007). ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. 

 World Health Organization. (2009). The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations. Infection Control & Hospital Epidemiology, 30(7), 611-622.

Yeung, S., Alahi, A., Haque, A., Peng, B., Luo, Z., Singh, A., ... & Li, F. F. (2016). Vision-Based Hand Hygiene Monitoring in Hospitals. In AMIA.

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