Hand hygiene among healthcare workers – theoretical knowledge and microbiological effectiveness of hand disinfection in practice

Introduction

Although the history of hand hygiene is very long, and Semmelweis observations date back to 1847, the problem of accurate hand disinfection is still up to date. Modern medicine faces the problem of health-care-associated infections with all its consequences, such as increasing mortality rate or spreading antimicrobial resistance [1–3]. Hand hygiene with the use of alcohol-based hand disinfectant is a simple and short procedure; however, this basic means of prevention is very often omitted or improperly performed by healthcare workers (HCWs), with mean baseline rates ranging from 5% to 89% and an overall average of 38.7% [1, 3, 4], higher among nurses (75–39%) than doctors (47–15%) [5, 6], and dependent on the observed situation, e.g. 40–85% of doctors and nursing staff perform hand hygiene before touching a patient and 51–89% after touching a patient, with disinfection rates up to 100% after body fluid risk [7]. Potential reasons of poor compliance to hand hygiene include: lack of knowledge of guidelines, failure to identify which situations require hand hygiene, lack of role models from colleagues and superiors, work overload, lack of time, lack of appropriate infrastructure, and scepticism about the value of hand hygiene [1–4, 7, 8]. Therefore, knowledge of hygienic procedures and guidelines among HCWs may play a pivotal role in the effectiveness of hand disinfection; in particular, an insufficient theoretical base can contribute to improper hand hygiene. The World Health Organisation (WHO) underlines the need for comprehensive and constant training and education on the importance of hand hygiene among HCWs [1, 2].

Aim of the research

The assessment of potential correlation between theoretical knowledge of guidelines on hand hygiene among HCWs and its microbiological effectiveness in practice. The assessment of awareness of the constant need for education in hand hygiene among HCWs. Description of the impact of theoretical and practical training in hand hygiene and their frequency on hand disinfection effectiveness.

Material and methods

The study was approved by the Bioethics Committee at Wroclaw Medical University (consent no. KB – 475/2013) and was conducted from October 2013 to November 2013. According to conditions required by the Scientific Committee and due to financial limitations, the study group consisted of 200 healthcare workers from seven hospitals located in the south-west region of Poland. The volunteer participants were practicing doctors and nurses who agreed to participate in the study.
We assumed that a decrease in the number of colony-forming units (CFUs) after hand disinfection is an indicator of the microbiological effectiveness of the performed procedure. In order to quantify the bacterial level on HCW’s hands the palm imprint method was used before and after hand disinfection for each participant. Microbial contamination of the hands was evaluated with the use of TSA with LECITHIN & TWEEN 80 COUNT – TACT according to the manufacturer’s instructions; the surface of all plates was 25 cm². The subjects placed the palm of their right hand on the surface of individual plates for 10 s. All the samples were transported to the laboratory within 2 h and incubated at 35°C for 48 h. After incubation the colonies were counted and the results were expressed as colony-forming units per 100 cm² (CFU/100 cm²).
The assessment of HCWs’ knowledge in the field of hand hygiene recommendations was performed with the use of a self-designed questionnaire. There were 12 questions, including multiple-choice questions, which assessed the knowledge WHO Guidelines on Hand Hygiene in Health Care. Subjects were asked about procedures of hand washing and hand disinfection, in which situations they should be performed, and technical aspects of the procedure (i.e. duration of hand disinfection and volume of hand-disinfectant). For each correct answer one to two points in single-choice and one point in multiple-choice questions was added, with a maximum of 29 points if all the correct answers were chosen. For the statistical analysis participants were divided into two groups according to the results: good or very good knowledge with more than 75% of correct answers, or insufficient knowledge if 75% or fewer of the answers were correct.

Statistical analysis

Data were analysed using MS Excel and Statistica 12 software. ANOVA test was used for testing the equality of mean CFU on HCW’s hands between groups divided due to the results of knowledge assessment and declared frequency of theoretical training in hand hygiene. Statistical significance was set at p < 0.05.

Results

Among participants there were 168 (84%) women and 32 (16%) men, and according to the type of medical profession: 141 (69%) nurses and 62 (31%) medical doctors. The age of the respondents varied from 23 to 66 years.

The knowledge of hand hygiene recommendations and declared need of training

The maximum score in the knowledge test, i.e. 29 points, was achieved only by four healthcare workers. The mean score from the questionnaire was higher among nurses, and was 21.21 points, while among doctors it was 19.92 points. The most common among the wrong answers were: conviction about the necessity of hand wash before each contact with the patient (118; 59%), belief that gloves can replace hand disinfection (62; 31%), or that hand disinfection is not required if glove changing is performed (164; 82%). In addition, participants had many problems with identification of situations in which hand disinfection is obligatory. For instance, participants did not know that hand disinfection must be performed before contact with the patient (60; 30%), before putting on gloves (82; 41%), or after procedures in the patients’ surrounding (74; 37%). The results from the questionnaire and answers for each question are presented in Figure 1, Tables 1 and 2.

Theoretical knowledge and microbiological effectiveness of hand disinfection

The analysis of microbiological tests demonstrated that bacterial colonisation of HCWs’ hands differed significantly between groups depending on their theoretical knowledge of guidelines for hand hygiene. The group that obtained better results in the knowledge test had fewer microorganisms on their hands after hand disinfection, which reflects that knowledge was associated with better microbiological effectiveness of performed procedures (p = 0.004, Table 3).

Training in hand hygiene – declared participation and its effectiveness

An education program for improvement of hand hygiene is one of the essential components of the WHO multi-modal Hand Hygiene Improvement Strategy. Most of the respondents stated that they took part in a hand hygiene training at least once during the previous year, either theoretical (52%) or practical training (55.5%) (Table 4). In our study about 93% of HCWs declared the need for training in hand hygiene. We observed that those who declared that they required training in hand hygiene had slightly lower average scores in our questionnaire (20.78 points) than those who did not expect more training in hand hygiene (22.17 points). This observation might reflect the accuracy of self-assessment among HCWs in the scope of the knowledge of hand hygiene recommendations in clinical care. We also aimed to ascertain whether those HCWs who were convinced that they had sufficient knowledge of hand hygiene were aware of the constant need for training. Seventy-five percent of the HCWs who subjectively assessed their knowledge of hand hygiene as sufficient also declared that they still needed training in that field.
The correlation between the declared frequency of participation in educational training and its impact on microbiological effectiveness of performed hand hygiene was examined. More than one theoretical training per year was associated with fewer microorganisms on the hands after hand disinfection (p = 0.02, Table 5). We also observed that the number of CFUs on hands after hand disinfection was lower if HCWs took part in practical training twice or more per year, although this was statistically insignificant (Table 6).

Discussion

Several studies have focused on the problem of improper hand hygiene among healthcare workers and healthcare students and have aimed to identify reasons for non-compliance with the guidelines for hand hygiene. However, the number of studies assessing both theoretical knowledge and microbiological effectiveness of hand hygiene is rather limited.
Similarly to our findings, insufficient knowledge of hand hygiene guidelines was underlined as one of the important reasons for improper hand hygiene in hospital settings. According to Nair et al., only 9% of medical and nursing students had good knowledge regarding hand hygiene, with significantly better knowledge, attitude, and practice among nursing students [9]. Also, our study suggests that theoretical knowledge of hand hygiene is better among nurses, which corresponds with results obtained by van de Mortel, who identified the type of medical profession as a risk-factor for non-compliance with hand hygiene guidelines, and revealed better compliance among nursing students in comparison to medical students [10], as well as Azim’s study in which hand hygiene compliance rates were better among nurses [11].
Healthcare workers have problems with identification of situations in which hand hygiene is recommended and necessary, such as the moment before touching a patient, which may suggest a tendency toward self-protection rather than protection of patients [11, 12]. Our study also indicates that 30% of HCWs are not aware that they should perform hand disinfection before contact with patients. This corresponds with the rates reported by Kawalec et al. or Wałaszek et al., in which, respectively, about 35% and 39% of HCWs did not disinfect their hands in this situation [13, 14], or the study by Lytsy et al., in which 18-60% of medical stuff omitted hand disinfection before touching a patient [7]. According to Garus-Pakowska et al., HCWs obeyed the hand washing procedure before patient contact only in 5.2% of situations [15].
Another problem is a misconception among one third of HCWs that the use of non-sterile gloves may replace the need for hand disinfection, which was previously highlighted by Scheithauer and Lemmen [16]. Many studies underlined problems with incorrect use of clinical gloves, i.e. improper use for low-risk procedures, failure to change them between procedures, and failure to remove gloves or to perform hand hygiene after their use [17, 18]. In Poland the overall level of compliance with the guidelines regarding the use of protective gloves is about 50% [19].
To improve compliance with hand hygiene among medical staff, an educational programme focusing on the WHO guidelines and the “Five Moments” for hand hygiene is needed. Our study showed that more than one theoretical training per year is associated with a lower number of microorganisms on hands after disinfection. The need for training has also been highlighted previously, e.g. by Silva et al., who reported that 34% of HCWs did not attended specific training on hand hygiene [20]. Similarly, a study conducted among Polish medical students by Różańska et al. reported that the professional practice of 22.9% of students was not preceded by any training in the field of hospital hygiene and in 28% of cases training did not cover hand hygiene [21]. According to Jarosik and Garus-Pakowska’s findings, HCWs are aware of the need for constant education and obligatory training, and these actions are most frequently indicated as possible factors for improvement of hand hygiene [22]. Sadeghi-Moghaddam et al. reported that educational intervention improved hand hygiene compliance from 30% to 70% [23]. Also, Niecwietajewa et al. revealed that personalised and group training combined with microbiological hand hygiene control among HCWs resulted in higher consumption of alcohol-based hand disinfectant in hospital wards [24], while Stock et al. observed that hands-on training conducted in small groups with a wide array of interactive teaching methods significantly improved hand hygiene compliance among nurses [25]. Nonetheless, more studies are needed to optimise strategies for better compliance with guidelines and monitoring of hand hygiene, to determine which additional promotional activities can augment improvements in hand hygiene and its quality, and to establish the most effective methods of providing feedback [26]. Recent studies suggest that simplifying the procedure of hand hygiene by reducing the number of recommended six-steps to three, providing the same level of microbiological effectiveness, might be a possible way to improve adherence to hand hygiene actions [27].
To summarise, for better compliance with hand hygiene among HCWs, there is still a need to design a multi-modal and combined strategy, which should focus not only on theoretical knowledge and the need for training but also on many other aspects in clinical settings.

Conclusions

The HCWs are not aware of the situations in which they should perform hand disinfection. Theoretical knowledge of guidelines for hand hygiene is related with fewer microorganisms on the hands after hand disinfection. Educational training is an important element increasing the efficacy of performed hand hygiene procedures. More than one theoretical training per year was associated with better hand disinfection efficiency. There is a need to design and implement multi-modal educational strategies to improve hand hygiene among HCWs.

Conflict of interest

The authors declare no conflict of interest.

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Address for correspondence:

Anna Maria Kawalec MD
Department of Hygiene
Wroclaw Medical University
ul. J. Mikulicza-Radeckiego 7
50-345 Wroclaw, Poland
E-mail: anna.kawalec@student.umed.wroc.pl