Literature Review
Literature Review
Watanakunakorn C, Wang C, Hazy J. An observational study of hand washing and infection control practices by healthcare workers. Infect Control Hosp Epidemiol 1998; 19:858-860.
Personnel hand washing has been linked with reduced risk of patient infection, but this study of how often health care workers actually wash their hands reveals disturbing findings.
A preclinical medical student unknown to HCWs at a Midwestern community teaching hospital conducted an observational study of hand washing and infection control practices in all patient care areas and on all three work shifts for six consecutive weeks. The student recorded whether HCWs washed their hands after patient care activities, HCW categories, type of activity, the time, and the patient care area. When relevant, the student also noted glove-wearing practices and compliance with isolation requirements.
Overall prevalence of hand washing was 30.2% (207 of 686 patient encounters). Hand washing prevalence among the three work shifts was similar. However, compliance varied significantly by job category, activity, and location. Residents washed their hands more often (59.2%) than attending physicians (37.4%) or nurses (36.2%). HCWs washed their hands more frequently after certain activities — such as examining patients (47.5%), bathing patients (83.3%), and emptying urine bags (44.1%) — than after others, such as wound care (23.5%) and suctioning (20.7%).
As intensity of care decreased, hand washing prevalence also decreased. Prevalence was highest in the surgical and cardiovascular intensive-care units (56.4%) compared with other areas such as medical and coronary ICUs (39.2%), intermediate units (30%), and general floors (22.8%).
Gloving rates varied for activities requiring glove use or for which glove use is desirable, such as drawing blood (77.6%), suctioning (65.5%), wound care (64.7%), emptying urine bags (45.6%), respiratory treatment (45.5%), and inserting peripheral intravenous lines (42.9%). No HCWs both wore gloves and washed their hands after each patient care activity.
The researchers state that compliance with isolation procedures was "excellent." Of 50 observations during the study period, when the only isolation procedure was contact isolation (requiring gloves, gown, and face mask), the compliance rate was 88%. Rates were similar among the three shifts.
Regarding hand washing, the authors note that "despite the well-known benefits of hand washing and the coaxing, cajoling, threatening, and pleading by experts in infection control, HCWs still neglect to wash their hands."
They also note that both the Centers for Disease Control and Prevention (CDC) and the Association for Professionals in Infection Control and Epidemiology (APIC) have published hand-washing guidelines. In addition, the American Medical Association has instructed physicians to wash their hands with an antiseptic before and between patient encounters.
The researchers also cite a prospective study in ICUs at one hospital in which every HCW knew of the study and participated in a special education program that included a videotaped demonstration, written instructions, educational presentations, mailings, and refresher sessions. Observers monitored hand-washing compliance and posted results of hand cultures.
"A more aggressive program can hardly be imagined," the authors state. "Nonetheless, hand washing rates were as low as 30% and did not exceed 48% in any ICU during the study."
Universal precautions are CDC-recommended standards of care that include glove-use guidelines, yet this study shows that despite frequent educational programs, many HCWs do not comply. The authors also were disturbed to find that HCWs who wore gloves did not wash their hands afterward, despite APIC guidelines to the contrary.
"Gloves may have given HCWs a false sense of security, leading them to neglect hand washing," the authors state. "Such lapses are dangerous, because hands can be contaminated through leaks in gloves or when gloves are removed."
The researchers state that HCWs must be reminded constantly to wash their hands after each relevant patient encounter, as hand washing is the simplest practice shown conclusively to decrease nosocomial infections.
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