Causes of non adherence to hand hygiene practices in out

patient clinics in Suez Canal University Hospital

H.A. El gammal, H.M.Samaha.

MD, Department of Family medicine, Faculty of Medicine, Suez Canal

University.

MD, Department of Family and Community Medicine, Misr University for

Science and Technology.

Dr Hanan Abbas el Gammal: lecturer of family medicine, Faculty of

Medicine, Suez Canal University.

Dr Hanan Samaha, assistant professor, Faculty of Medicine, Misr University

for Science and Technology.

‫اسباب عدم االلتزام بمعايير غسل االيدى فى العيادات الخارجية فى مستشفى جامعة قناة السويس‬
‫ حنان محمد سماحة‬، ‫حنان عباس الجمال‬

‫ جامعة قناة السويس‬- ‫كلية الطب‬-‫ مدرس طب االسرة‬:‫ حنان عباس الجمال‬.‫د‬
‫ جامعة مصر للعلوم والتكنولوجيا‬-‫ استاذ مساعد طب المجتمع‬:‫ حنان محمد سماحة‬.‫د‬

Corresponding author

Dr/ Hanan Abbas el gammal (lecturer of family medicine- Suez

Canal University)

Mobile: 0123808365

Email: hanfmhananfmhan@yahoo.com
 Abstract:

A descriptive cross-sectional study was carried out among 180 of health care

providers, and nursing staff in Suez Canal University Hospital to determine causes of

non adherence to hand hygiene practices in outpatient clinics. All the participants

were assessed by using direct observation checklist. The average score of health care

team orientation by hand hygiene policies and necessary equipments was 42.066%.

The most deficient items was no hand washing before contact with the patients, and

the standard hand washing techniques aren't being followed by the studied health care

personnel specially rotating rubbing of the thumbs and palms. The study showed that

41.3% of the studied health care personnel showed non satisfactory level of

compliance to hand wash, and the mentioned causes of non adherence to hand

hygiene measures were as follows: (83.33%) ascribed the non-adherence to lack of

training, 63.89 % of the studied health care personnel mention that it is due to low risk

of acquiring infection from patients while absence of role model from colleagues or

superiors represent 38.89% of the studied health care personnel. And 5.65% reported

occurrence of skin irritation or dryness with using of hand washing agents.

:‫امللخص العرىب‬

‫ان من اهم سياسات منع العدوى ىف املنشآت الطبية هى غسل االيدى لذا يهدف هذا البحث اىل معرفة اهم االسباب الىت متنع االلتزام‬

‫ من مقدمى اخلدمة من اطباء‬180 ‫بسياسات غسل االيدى ىف العيادات اخلارجية ملستشفى جامعة قناة السويس حيث اجرى البحث على‬

‫ تبني ان متوسط معدل الوعى لدى العاملني بسياسات غسل‬، ‫ومتريض عن طريق اجراء مقابلة ومتابعة مباشرة اثناء تقدمي اخلدمة للمرضى‬

‫ ومن اهم االسباب الىت ذكرت كسبب‬، %41 ‫ وان مستوى الرضا عن غسل االيدى مقارنة بالطريقة املثلى هى‬، %42.066 ‫االيدى‬

:‫لعدم االلتزام هى‬

‫ ينقصهم‬% 38.89 ‫ وان‬،‫ بسبب االعتقاد ىف قلة امكانية االصابة او نقل العدوى هبذه الطريقة‬% 63.89 ، % 83.33 ‫نقص التدريب ىف‬

. ‫ من مقدمى اخلدمة الصحية‬%5.65 ‫القدوة من الزمالء واملرؤوسني بينما ارجع البعض عدم االلتزام اىل التهاب اجللد وجفافه ىف‬

Introduction and Rationale:

Hand hygiene is the simplest, most effective measure for preventing nosocomial

infections (1,2). Despite advances in infection control and hospital epidemiology,

Semmelweis' message is not consistently translated into clinical practice (3,4), and

health-care workers' adherence to recommended hand hygiene practices is

unacceptably low (56‫)و‬.

Average compliance with hand hygiene recommendations varies between hospital

wards, among professional categories of health-care workers, and according to

working conditions, as well as according to the definitions used in different studies.

Compliance is usually estimated as <50%(7).

A breach in infection control practices facilitates transmission of infection from

patients to health care workers, other patients & attendants. It is therefore important

for all health care workers, patients, their family members, friends & close contacts to

adhere to the infection control guidelines strictly. It is also imperative for health care

administrators to ensure implementation of the infection control programme in health

care facilities (8,9).

Finally studies have shown that an average of only 40 % of health care personnel

adhere to hand washing policies in their institutions (10).

The aim of this study is to detect barriers to adherence to hand hygiene practices at

outpatient clinics in Suez Canal University.

Subjects & Methods:

Design and Setting

A descriptive cross-sectional study was carried out in 5 outpatient clinics in Suez Canal

university hospital in Ismailia governorate from September 2008 through Mars 2009.

Study population

Any physician providing care at the outpatient clinics (internal medicine, pediatrics,

dermatology, family medicine and surgery clinics) who were 180 (100 physician and 80

nurses)

Inclusion criteria
Outpatient health care physicians ( residents & assistant lectures ) , and nurses.

Working in outpatient clinics in Suez Canal University Hospital who accepted to be

included in the study.

Exclusion criteria
lecturers , assistant professors & professors-

Sample technique and sampling

Five outpatient clinics were selected randomly. Within each clinic all physicians and

nurses were included matching inclusion and exclusion criteria where recruited until the

total target sample size was reached. Relative equal distribution of numbers of physicians

within each clinic was maintained.

Tools

The subjects were interviewed using a structured interview questionnaire and a direct

observation checklist to collect the following data:

A. Socio-demographic data: Every participant was asked about his age, years of

experience, number of cases observed per day, any training courses for hand hygiene,

causes of non adherence to hand hygiene practice.

B. The semi structured questionnaires & checklist modified from:

www.drguide.mohp.gov.eg/NewSite/E-Learning/InfectionControl/infctrlp1.asp
(11) and www.icna.co.uk (12).
C. The health care personnel (HCP) scoring of 70% or over was classified as
satisfactory hand hygiene.
Compliance of each (HCP) was calculated by adding the scores of all questions

-:together, then of two grades

 If the score ≥ 70 it was considered as satisfied.

 If the score < 70 it was considered as not satisfied.

Each health care personnel were given one point for each correct hand hygiene& zero

point for each inappropriate practice.

The total score was divided by the number of the all items & so the percentage of

compliance to hand hygiene was calculated.

Pilot study

The questionnaire and checklist were pre-tested on five physicians and five

nurses, before the beginning of data collection to:

1- Test the relevancy of the questionnaire to the aim of the work.

2-Determine understanding by the respondents and perform any modification needed.

4-Determine the time required for each observational checklist.

Statistical analysis

Data was analyzed by SPSS statistical packages. The chi-squared test as appropriate was

used to compare categorical data. P-values < 0.05 were considered significant.
 Ethical consideration
1-A simple and clear explanation of the research aims and procedures was provided to
each participant.
2-Verbal consent was obtained from the managers of the outpatient clinics who are
included in the study and a feedback was returned to them.
3- Confidentiality of data was assured.

Results:

Sample Characteristics

Table 1 shows : The study included 180 health care personnel; mean age of physicians was

28. 28.13 ± 1.62, mean years of experience was 7.75 ± 1.65, mean number of cases

observed per day was 50.88 ± 6.24.

Receiving training courses, physical examination, and receiving HBV vaccination:

Table 2 shows that no physician had received training courses regarding prevention of

infection pre-employment, while only 9.6 % of nursing staff had received training courses

regarding prevention of infection. Also only 3% of physicians had received physical

examination, and 4 % of nursing staff had received physical examination prior to

employment. While no physicians had received annual exam during employment, but only

2.5 % of nursing staff had received annual exam during employment. And 4 % of

physicians had received HBV vaccination, while 3.75 % of nursing staff had received

HBV vaccination.

Orientation of Health Care Providers about the hospital policies and equipments for

hand hygiene

Table 3 shows health care providers orientation regarding policies and equipment, average

score was 42.064 %.

Direct observation of the HCP regarding when they do routine hand washing:

Table 4 shows that 33.33 % do routine hand wash after completing invasive procedures,

83.33 % do routine hand wash after dealing with wounds, 22.23 % do routine hand wash

after situation during which microbial contamination of hands is likely to occur, 19.44 %

do routine hand wash after contact with patient, no one do routine hand wash before

patient contact, while 27.22 % do routine hand wash after removing of gloves, but only

27.78 % do routine hand wash before serving meals or drinks, and no one do routine hand

wash before leaving work setting.

Direct observation of the HCP regarding hand washing technique:

Table 5 shows That direct observation reveals that the most missed item in hand

washing technique was rotating rubbing of the thumb in 80 % of the occasions and

rotating rubbing of the palm in 90 % of the occasions.

Causes of non adherence from staff perspectives:

Table 6 shows causes of non adherence to infection control practices were as follows:

The staff mentioned lack of infection control training in 883.33 %, then the next

mentioned cause of non adherence was perception of low risk of acquiring infection

in 63. 89% , followed by absence of role model between staff members in 38.89%,

and lastly hand hygiene agent causing irritation in 5.65 % of responses.

Degree of unsatisfactory hand washing:

Figure 1 shows that 41.3 % had unsatisfactory hand wash.

Discussion:

The aim of this study was to improve the adherence of health care personnel to the
hand hygiene practices in family practice settings. This will be achieved by assessing
the unsafe practices regarding hand hygiene to detect barriers to adherence to
infection control practices.
 By assessing socio-demographic characteristics of the studied health care
personnel, the mean ages of the physicians was (28.13 ± 1.62), nurses (25.11 ± 5.2),
Most of the studied health care personnel were females (87.5% of physicians, 88.9%
of nurses).
Analysis of data in the present study showed that no training was received by the
majority of the studied health care personnel (100% of physicians, and 61.1% of
nurses) about prevention of infection before being employed. It was found that very
low percentages of the studied health care personnel have been subjected to pre-
employment medical examination Also no annual medical examination received by
any of the studied health care personnel except for 11.1% of nurses.
Only very low percentages of the studied health care personnel have received
vaccination against HBV (25% of physicians, and 16.7% of nurses). Absence of pre-
employment training courses can give an idea about how the level of practice of
infection control would be among these health care personnel. Pre-employment and
annual examinations are very important for detection of any occupationally-
transmitted diseases or presence of any infectious disease that can be transmitted to
other health care personnel or to the patients.
In the present study it was estimated that 41.3% of the studied health care
personnel showed no satisfactory level of compliance to hand washing while 58.7%
showed satisfactory level of compliance.
Similar results were estimated by other studies that have shown that an average of
only 40% of HCP adhere to hand washing policies in their institutions (1). This could
be explained that it is due to lack of infection control training courses or lack of
monitoring system.
On studying the causes of non adherence in the present study, we found that most
of the studied health care personnel (83.33%) ascribed the non-adherence to hand
washing to lack of training. 63.89% of the studied health care personnel think that
non-adherence to hand washing is due to perception of low risk of acquiring infection
from patients while 5.65% reported occurrence of skin irritation or dryness with using
of hand washing agents. This was mentioned in multi-observational studies that skin
irritation by hand hygiene agents is an important barrier to appropriate compliance
(13).
Absence of role model from colleagues or superiors was the cause of non-adherence
to hand washing from the point of view of 38.89% of the studies health care
personnel.
Risk factors for noncompliance with hand hygiene have been determined objectively
in several observational studies or interventions to improve compliance. Factors
influencing reduced compliance, identified in observational studies of hand hygiene
behavior, included being a physician rather than a nurse; being male; working in an
intensive care unit (ICU); working during weekdays rather than the weekend; wearing
gown and gloves; using an automated sink; performing activities with high risk for
cross-transmission; and having many opportunities for hand hygiene per hour of
patient care(14).

In the present study and when assessing the adherence of the health care personnel
toward the ideal technique in hand washing, it was estimated that the most frequently
missed technique is the rotating rubbing of the left and right palms (performed by
only 10% of the studied HCP). In other studies, the most frequently missed areas of
the hand were thumb and finger interlaces (15).
By observational assessment of the studied health care personnel, it was
estimated that most of the ideal and standard hand washing techniques aren't being
performed by the studied health care personnel specially rotating rubbing of the
thumbs and palms. This can be explained by deficiency of training courses.
In a study about Improving Adherence to Hand Hygiene Practice: A Multidisciplinary
Approach by Didier Pittet, University of Geneva Hospitals, Geneva, Switzerland, the
study mentioned Several barriers to appropriate hand hygiene have been reported
(16,17,18,19, ). Reasons reported by health-care workers for the lack of adherence
with recommendations include skin irritation, inaccessible supplies, interference with
worker-patient relation, patient needs perceived as priority, forgetfulness, ignorance
of guidelines, insufficient time, high workload and understaffing, and lack of
scientific information demonstrating impact of improved hand hygiene on hospital
infection rates
From these results, we can detect the great importance of pre-employment training
programs and also on-going training programs to improve practice of health care
personnel regarding hand hygiene and the need to implement observational
assessment policy in primary health care centers and use routine self assessment is
 established in a no blame culture aiming to improve and ensure satisfactory level of
hand hygiene practice.

Limitations:

These results were based on a cross-sectional descriptive analysis and therefore didn't

provide cause-and-effect relationship; it can only suggest association for further analytic

research. Evaluation by direct observation need to be supported by system based

assessment including staff motivators, presence of a monitoring system, rewarding of

those compliant to standards of infection control practices, and involvement of the whole

health care team. Finally, another area of research including adequacy of educational

materials tailored to family practice setting.

Conclusion:

The present study concluded that there is lack of satisfactory level of orientation to

standards of infection control practices by medical staff, the causes of this level of low

orientation is due to lack of training courses, low perception of risk of infection while

contacting the patient, absence of role model among the health care team, and irritation

from hand hygiene agent. The level of unsatisfactory hand hygiene washing was 41.3 %,

and the most missed item was rotating rubbing of the palms and thumbs This requires that

health care personnel should be offered well structured continuous work-shops for

improving infection control knowledge and practice, outpatient clinics should be provided

with all infection control equipments, immunization of health care personnel against the

most common occupationally acquired infections (HBV), hospital should have an infection

control committee responsible for monitoring infection control practices and giving

regular feedback, a periodic auditing system of infection control practices should be

established.
Acknowledgment

My deepest thanks extended to all physicians of outpatient health care clinic in Suez Canal

Hospital, which this study was carried for their help and co-operation and also for every

health care personnel who participated in this study.

References:

1. Semmelweis I. The etiology, concept and prophylaxis of childbed fever

[excerpts]. In: Buck C, Llopis A, Najera E, Terris M, editors. The challenge of
epidemiology--issues and selected readings. Washington: PAHO Scientific
Publication; 1988. p. 46-59.
2. Rotter ML. 150 years of hand disinfection--Semmelweis' heritage. Hyg Med
1997;22:332-9.
3. Jarvis WR. Handwashing--the Semmelweis lesson forgotten? Lancet
1994;344:1311-2.
4. Rotter ML. Semmelweis' sesquicentennial: a little-noted anniversary of hand
washing. Current Opinion in Infectious Diseases 1998;11:457-60.
5. Albert RK, Condie F. Hand-washing patterns in medical intensive-care units. N
Engl J Med 1981;304:1465.
6. www . searo.who.int/ link files/publications-practice guidelines, SEARO pub-41.p

7. Larson EL, CIC 1992-1993, 1994 APIC Guidelines Committee. APIC guideline
for handwashing and hand antisepsis in health care settings. Am J Infect Control
1995;23:251-69.

8. Pittet D, University of Geneva Hospitals, Geneva, Switzerland, CDC, Improving

Adherence to Hand Hygiene Practice: A Multidisciplinary Approach, Vol. 7, No.
2, Mar–Apr 2001.

9. Rotter ML. 150 years of hand disinfection--Semmelweis' heritage. Hyg Med

1997;22:332-9.
10. www.enotes.com/medicine-encyclopedia/infection-control

11. www.drguide.mohp.gov.eg/NewSite/E-learning/InfectionControl/infctrlp1.asp

12. www.icna.co.uk
13. Larson E. Handwashing and skin: physiologic and bacteriologic aspects. Infect
Control 1985;6:14-23.

14. http://www.nelmht.nhs.uk/downloads/CG0 Hand Hygiene Policy.doc

15. Pittet D, Mourouga P, Perneger TV, members of the Infection Control Program.
Compliance with handwashing in a teaching hospital. Ann Intern Med
1999;130:126-30.

16. Dubbert PM, Dolce J, Richter W, Miller M, Chapman S. Increasing ICU staff
handwashing: effects of education and group feedback. Infect Control Hosp
Epidemiol 1990;11:191-3.
17. Larson E, Kretzer EK. Compliance with handwashing and barrier precautions. J
Hosp Infect 1995;30:88-106.
18. Conly JM, Hill S, Ross J, Lertzman J, Louie T. Handwashing practices in an
intensive care unit: the effects of an educational program and its relationship to
infection rates. Am J Infect Control 1989;17:330-9

19. Larson E, Killien M. Factors influencing handwashing behavior of patient care

Group Characteristic
Physicians Age (years) Mean ± SD 28.13 ± 1.62
(n=100) Years of experience
Mean ± SD 7.75 ± 1.65
(years)
Number of cases
Mean ± SD 50.88 ± 6.24
per day
Nurses Age (years) Mean ± SD 25.11 ± 5.2
(n=80) Number of cases
Mean ± SD 50.39 ± 5.72
per day
personnel. Am J Infect Control 1982;10:93-9.

Table1. Sociodemographic characteristics of the studied subjects: -

Table 2. Pre employment training, medical examination and vaccination: -
Item physicians Nurses
(n=100) (n=80))
No. % No. %
Receiving training courses about Yes 0 (0%) 7 (9.6%)
prevention of infection No 100 (100%) 73 (91.4%)
Pre-employment medical Yes 3 (3%) 4 (5%)
examination No 97 (97%) 76 (95 %)
Annual medical examination Yes 0 (0%) 2 (2.5 %)
No 100 (100%) 78 (97.5%)
Vaccination against HBV Yes 4 (4 %) 3 (3.75 %)
No 96 (96 %) 77 (96.25%)
Table 3. Assessment of orientation of Health Care Providers about the hospital
policies and equipments for hand hygiene: -

Staff orientation
Item
N. %
Presence of comprehensive policy for Yes 40 22.23 %
hand hygiene No 140 77.77 %
manager encourage hand hygiene Yes 30 16.67 %
No 150 83.33 %
Presence of Soap and running water Yes 180 100 %
No 0 0%
Presence of alcohol hand rubs Yes 0 0%
No 180 100%
Presence of hand wash basins in each Yes 180 100%
clinical room dedicated for this only No 0 0%
Hand drying materials are placed Yes 30 16.67 %
near the sink away from splashing
No 150 83.33 %
Presence of appropriate disposable Yes 70 38.89 %
gloves No 110 61.11 %

Average score of health care providers' orientation was 42.066 %

 Table 4. Results of direct observation of the HCP regarding when they do routine
hand washing: -
Yes No
Items
N. % N. %
Do routine hand

After completing invasive procedures 60 (33.33%) 120 (66.67%)

After dealing with wounds 150 (83.33%) 30 (16.67%)
washing

After situation during which microbial

40 (22.23%) 140 (77.77%)
contamination of hands is likely to occur
After contact with patient 35 (19.44%) 145 (80.56%)
Before contact with patient 0 (0%) 180 (100%)
After removing gloves 49 (27.22%) 131 (72.78%)
Before serving meals or drinks 50 (27.78%) 130 (72.22%)
Before leaving work 0 0% 180 (100 %)
The most deficient missed item was washing hand before contact with patient
 Table 5. Results of direct observation of the HCP regarding hand washing
technique: -

Yes No
Items
N. % N. %
Hand washing

Rub wash palm to palm 108 (60%) 72 (40%)

Right palm over left dorsum 108 (60%) 72 (40%)
Left palm over right dorsum 108 (60%) 72 (40%)
Fingers interlace palm to palm 81 (45%) 99 (55%)
Back of fingers to opposing palm 54 (30%) 126 (70%)
Rotating rubbing of right thumb 36 (20%) 144 (80%)
Rotating rubbing of left thumb 30 (20%) 144 (80%)
technique

Rotating rubbing of left palm 18 (10%) 162 (90%)

Rotating rubbing of right palm
18 (10%) 162 (90%)

The most deficient item by direct observation was rotating rubbing of the thumbs and
palms
Table 6: - Causes of non adherence to hand washing as reported by the studied
health care personnel : -

Causes of non-adherence Number Percent

Lack of training 150 83.33%
Perception of low risk of acquiring
115 63.89%
infection from patients
No role model from colleagues or
70 38.89%
superiors
Hand washing agents cause skin
10 5.56%
irritation or dryness
Figure 1. Compliance of studied health care personnel to hand washing as obtained
by direct observation: -

41.3%

58.7%

Not satisfactory (<70%)

Satisfactory level (>70%)