When it comes to hand hygiene in a healthcare setting, training and compliance are two important parameters that must be met consistently.
The Association for Professionals in Infection Control and Epidemiology (APIC), USA, defines hand hygiene as ‘the act of cleansing hands with water or liquids and including the use of water, soaps, antiseptics, or other substances, including alcohol-based hand rubs’.
The effectiveness of hand hygiene in preventing infection has been demonstrated for more than 200 years, now. It is one of the cornerstones of reducing healthcare-associated infections (HAI) and preventing occupationally-acquired infections. An HAI is a ‘localised or systemic condition resulting from an adverse reaction to the presence of an infection agent(s) or its toxin(s) that was not present on admission to the acute care facility’. Depending on the type of infection, HAIs can occur between 24 to 72 hours after hospital admission, 3 to 10 days following discharge, or within 30 to 90 days after a surgical procedure. They increase the complexity of treatment, healthcare costs and poor patient outcomes. Because of the negative impact on patients, increased risks for providers and the escalating costs associated with these occurrences, HAI prevention is a major focal point for patients, healthcare personnel, insurers, governments, and regulatory bodies.
In fact, hand hygiene practices are essential to reducing the spread of HAIs. Healthcare personnel across the globe are being held accountable for their hand hygiene practices to prevent transmission of infection, and healthcare institutions are facing increasing regulation and hand hygiene mandates while being challenged with economic consequences of failing to meet those mandates.
In the GCC region specifically, there is quite a contrast. While countries like the UAE and Qatar are almost at par with international standards in hand hygiene, other GCC countries like the Kingdom of Saudi Arabia are struggling with infectious diseases like the Middle East Respiratory Syndrome caused by the Coronavirus (MERS-CoV). Just last month, as stated by the World Health Organisation, the National IHR Focal Point for the Kingdom of Saudi Arabia notified WHO of 12 additional cases of MERS-CoV infection, including 1 death.
In this region, there is no better time to implement strict infection control programmes to improve the quality of care and patient outcomes. Comprehensive infection prevention programmes must address a range of important interventions, including cleaning, disinfection, sterilization, infection monitoring, antibiotic stewardship, and isolation and control measures. And, as the single most important measure to prevent infection, hand hygiene continues to be the cornerstone of infection prevention activities.
According to the Centre for Disease Control, at any given moment, 2 million to 10 million bacteria can be found from the fingertips to the elbow of a human being. The skin contains a mixture of both resident bacteria and transient bacteria – the latter being potentially disease-causing. The number and types of bacteria on the hands increases with contact with the environment, patients or other healthcare workers. Crosscontamination can occur every time healthcare personnel come in contact with a patient, other healthcare personnel, or the environment. While it is not known where infection transmission begins or ends, the chain of infection transmission occurs when the contamination from one surface is transferred to the susceptible host. Interruption of any part of the chain of infection is expected to reduce transmission by interrupting the chain of transmission.
This is where strict hand hygiene practices come in. Michael Rollins, Consultant Environmental Infection Prevention Specialist, UK, says, “The WHO guidelines on hand hygiene in healthcare involve a multi-modal strategy incorporating the use of alcohol-based hand rubs at point of care. The 5 moments of hand hygiene methodology defines when healthcare workers should practice hand hygiene during patient care. Healthcare worker compliance with these indications is part of routine performance feedback - an essential strategy for behaviour change.” To obtain a true picture of hand hygiene compliance in a particular facility, it is important to understand current hand hygiene practices and estimates of compliance. Hence, monitoring hand hygiene practice is an important method to drive compliance in a strong hand hygiene programme.
Dr. Mohamed Berer, Medical Director, Medeorx24 Hospital, says, “We follow the WHOs five moments of hand hygiene. We also educate and train our staff during induction and monitor their hand hygiene activity.” To facilitate compliance, the hospital also conducts surveillance to help managers identify barriers to noncompliance.
While the promotion of a safety-oriented ‘hand hygiene culture’ at the organisational level can have a broad impact, affecting change requires time and should be considered a long-term goal. Education and training must be accessible in a range of formats for different audiences. The WHO guideline on hand hygiene in healthcare has produced success globally.
It offers standardised content and training components. Having hand hygiene principles incorporated into local medical and nursing educational curricula can also strengthen hand hygiene programmes. Skills training is an integral component of learning appropriate hand hygiene techniques and should include a variety of methods like supervised activities, selfdirected group sessions, mentored oneon- one instruction, or short web-based modules. Skill testing may be advisable to assess the effectiveness of training.
In the Middle East, it has been seen that while hand hygiene is given importance, it is not yet on top of the priority list at most hospitals. Henrik Mahaini, COO, Viking Gulf, says, “We have observed through our training and presentations that the level of hand hygiene is not up to the mark in the Middle East. There is definitely room for improvement. Moreover, while the infection control departments are interested in improving hygiene in general in their hospital, we would like to see the hospital administrators take more interest in this concept.” Viking Gulf distributes and promotes Surewash - a computerised machine that aids in training health-care professionals in proper hand hygiene techniques. The machine has a camera and a very sophisticated motion-recognition technology. It records hand movements.
The moment one places ones hands under the lens, the movements are recorded and simultaneously compared with the correct poses that have been pre-programmed into the machine. Correct movements elicit a good score. Along with equipment like Surewash, it is important that training and education sessions be well planned, skillfully conducted, and contain the most up-to-date information.
Effective education and training programmes need to connect individual existing knowledge with the organization’s policies, compliance expectations, and hand hygiene culture. Once training is done, compliance monitoring comes into effect. Compliance monitoring can increase and sustain engagement, resulting in increased compliance and commitment to process improvement.
One effective way of ensuring compliance is through reminders - targeted messages that are focused on improving hand hygiene practices. These should be regularly updated and changed to remain effective. This can trigger knowledge to action and motivate individual practice improvement. At Medeor 24x7, hand washing posters are available above any hand wash facility within the hospital, describing the right technique and the time required for hand washing as a constant reminder. Similarly, Surewash can monitor, report and train people in hand hygiene without the need for any supervision staff. Through its consistent reports, the machine can improve the base level of hand hygiene significantly and effectively. According to Mahaini, “Our research has revealed that significant results can be obtained within a month of starting training with Sure Wash.”
Challenges in hand hygiene training In an article on Patient Safety, Rollins mentions that a study of 60 professional infection control healthcare workers and epidemiologists concluded that technique is of crucial importance in hand hygiene Moreover, significantly, major deficiencies in the hand hygiene technique were detected amongst even highly trained healthcare workers.
There are several challenges that obstruct training in hand hygiene. One is low motivation amongst healthcare workers. And, this can be due to several factors – handwashing agents causing irritation and dryness, inconveniently located sinks, lack of soap and paper towels, lack of time, understaffing or overcrowding, and patient needs taking priority. Other challenges include lack of knowledge of guidelines/ protocols, forgetfulness, and disagreement with the recommendations.
While monitoring for compliance is crucial, ensuring that healthcare workers adhere consistently to hand-hygiene training is paramount. For that, motivation is a strong factor. Mahaini suggests, “Hospital housekeepers can motivate their staff to train and practice hand hygiene by turning it into a fun game. Maybe a contest between departments would work. The idea is to ensure that people who are curious about a machine like Sure Wash try and use it at least once. This sends a message to the entire staff about the importance and seriousness of hand hygiene.”
Equipment like Surewash, which is computerised, accurate and efficient seems to be the need of the hour. The lower the need for manual supervision and the higher accuracy in report generation can aid in motivating healthcare workers to engage in proper hand hygiene training and technique. And, going beyond that, the importance of the need for awareness, consistent training and compliance can never be undermined.