Research Paper ( Prof Ramos)

Nurses’ Compliance to Handwashing Guidelines In Our Lady of Mercy General Hospital

A Thesis Proposal Presented to The Faculty College of Nursing Lyceum of the Philippines University Intramuros, Manila

In Partial Fulfillment of the Requirements for the Degree Bachelor of Science in Nursing By Jannelle Careese Manguila Dennis Sanchez Rosalynne Santos Section H-222 October 2, 2008 (Note: Insert names of researchers in alphabetical order, section, and date of submission.) (Please do not put a page number in the Title Page and the first page of each chapter. Use the future tense for the thesis proposal.)

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(Format: 1.5 inch (left margin); 1 inch (right margin); 1.5 inch (top margin); 1 inch (bottom margin); double spaced; Times New Roman, font size 12)

CHAPTER I The Problem and Its Background Introduction Handwashing is the simplest form of precautionary measure one should learn to maintain an optimal health. No one is free from microorganisms. We are all bombarded by different types of disease-causing microorganisms. We can never tell when they will attack or invade our whole systems. Moreover, health care providers are not the only ones who should learn to comply with handwashing. It should be taught to everyone especially the young ones. Children need to learn proper handwashing at an early age, for the very reason that they are susceptible to infections more than adults do, because their immune systems are not yet totally developed (Pillitteri, 2003). Nowadays, several health institutions, including the Department of Health, and the media are actively participating in promoting the importance of frequent handwashing. They are able to impart some important facts about the causative agents of different diseases, their mode of transmissions, and ways of preventing them. This is due to the increasing rate of mortality and morbidity in the country caused by diarrheal diseases. Procter and Gamble Philippines Inc., one of the biggest companies pursuing hygiene and health, is presently promoting the importance of frequent and proper handwashing technique using soap and water. This company emphasized the susceptibility of children to infections, and their increased risk in acquiring diarrheal

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diseases which is a major cause of mortality among children in the country (Fucanan, 2006 as cited in http://www.manilatimes.net). To stay healthy, we are often reminded to take the necessary and much-cheaperthan-cure preventive steps. Our mothers would coax us to eat our vegetables; our doctors would advise us to exercise and take vitamins; and our community health workers would encourage our families to get regular medical checkups, and our children, vaccinations. Among these disease prevention measures is another important habit we should observe especially at home: handwashing. Until the deadly respiratory epidemic called SARS (Severe Acute Respiratory Syndrome) hit Asia in 2003, people did not give much importance to keeping their hands clean at all times, especially after going to the toilet, before and after kitchen work, and upon returning home from the school or office (Fucanan, 2006 as cited in http://www.manilatimes.net). Health and disease expert Dr. Anna Beatrice Bowen, who heads the Foodborne and Diarrheal Diseases Branch of the Center for Disease Control Prevention in the United States, spoke before the local media on February 9, 2006, the opening day of the Second International Health and Hygiene Symposium. She said that the very act of handwashing can save an entire family from diseases. She also added that handwashing is still the most important thing we can do to protect ourselves, and it should always be practiced at home. Bowen continued that every year, 3.5 million children die of diarrheal and respiratory illnesses. But in the past years that they had conducted handwashing interventions, this figure was reduced by 40 to 50 percent (Fucanan, 2006 as cited in http://www.manilatimes.net).

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This summit was organized by Procter & Gamble (P&G) Philippines through its flagship brand Safeguard. The two-day summit gathered around 150 health and hygiene experts and workers around the world to discuss breakthroughs in disease prevention and report studies on the significant health benefits of handwashing. Its theme was “Better Health and Hygiene: Today’s Challenges, Tomorrow’s Hopes” (Fucanan, 2006 as cited in http://www.manilatimes.net). Safeguard goes on Nationwide Health and Hygiene Tour on January 6, 2003. Captain Safeguard, the brand’s superhero, extols the benefits of proper handwashing before the pupils of Talomo Elementary School in Davao City. The event, coming on the heels of the highly successful International Health and Hygiene Symposium (IHHS) it recently sponsored in Manila, is part of Safeguard’s nationwide health and hygiene awareness tour covering over 250 schools and 200 barangays. The IHHS health experts have affirmed that hygiene education and the simple habit of handwashing with soap are effective and inexpensive means of reducing the incidence of disease (as cited in http://www.mb.com.ph). Frequently washing your hands, says Captain Safeguard, can help children avoid the trouble of getting contaminated with common ailments. It saves you from so-called “downtime”—the time you spend lying in bed sick, or staying at home sick. That means there will be more time to study, help in the household chores, and, of course, play. Another means of keeping all neat, tidy and fresh is bathing. This way, germs do not stand a chance of lodging onto your skin and eventually finding their way into your respiratory or digestive system. Keeping neat and tidy is the battlecry of Captain

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Safeguard and the Germ Patrol. They have visited various schools all over Cebu Province and discussed with school children the benefits of frequent handwashing and bathing to counter the effects of disease-carrying germs. Captain Safeguard and the Germ Patrol have an interesting space-age contraption called the “Germ Box” under whose light one can literally “see” the germs that are on the hands. Children who have been to one of the fun-filled stagings of “Two Steps to Good Health” topbilled by Captain Safeguard say they have “learned that keeping healthy and well is indeed very simple.” Each child who attended the “Two Steps to Good Health” show was given a shield of protection—a symbolic representation of winning the war against King Duming-dumi, leader of the germ gang. The Germ Patrol also gave away premium items and Captain Safeguard coloring books to lucky kids who participated in the fun mini-quizzes held during the show. Captain Safeguard and the Germ Patrol are, indeed, doing an impressive job bringing the message of personal cleanliness to school-age children. They are helping ensure that children can sing “I have two hands” and have every right to sing the song to the end. Indeed, “clean little hands are good to see” (as cited in http://www.mb.com.ph). According to the Philippine Health Institutions, (1998), some of the leading causes of mortality and morbidity are those diseases which are highly communicable. These diseases include septicemia, diarrheal diseases, pneumonias, all forms of tuberculosis, Chronic Obstructive Pulmonary Disease (COPD), and other respiratory problems. These diseases can be acquired through direct contact, but can be prevented through frequent handwashing with soap and water (Reyala, Nisce, Martnez, Hzon, Ruzol, Dequna, Alcantara, Bermudez, Estpona, 2000).

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This study is a replication of the study conducted by Fortuno in the year 2005. In her study, she developed an intervention program for handwashing to improve the compliance of the nurses. Replications are attempts to validate the findings from one study in an independent inquiry. According to Polit and Beck (2004), authorities on Nursing Research, “replication research is critical for the development of nursing science. Strong evidence-based practice requires replications. Practice cannot be altered on the basis of a single isolated study, but must rely instead on an accumulation of evidence.” Identical replication, a replication strategy, which is an exact duplication of the original method, was used in this study. Statement of the Problem This study aimed to assess the compliance of nurses in Our Lady of Mercy Hospital in Bulacan towards handwashing guidelines, which included the technique, duration, and the use of either soap and water or waterless alcohol-based hand solution. Specifically, the study sought to answer the following questions: 1. What is the demographic profile of the respondents in terms of: a. Age b. Gender c. Civil Status d. Educational Attainment e. Length of Professional Service f. Designated Area?

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2. What is the rate of handwashing frequency and duration of the participants in terms of: a. Age b. Gender c. Civil Status d. Educational Attainment e. Length of Professional Service f. Designated Area? 3. What are the reasons why nurses do not consistently wash their hands? 4. What is the correlation between intensity of patient care activity and handwashing frequency of the respondents? Theoretical/Conceptual Framework Medical asepsis is an important value in the delivery of health care. The safety of most patients is in the hands of the health care providers. This was emphasized by Joseph Lister in his antiseptic technique theory which is a form of aseptic technique. Aseptic technique is designed to eliminate and exclude all pathogens by sterilization of equipment, disinfection of the environment, and cleansing of body tissues with antiseptics. Lister used dilute carbolic acid (phenol) to cleanse surgical wounds and equipment and a carbolic acid aerosol to prevent harmful microorganisms from entering the surgical field or contaminating the patient (Burton and Engelkirk, 2000).

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The least expensive and the most recommended preventive measure in the avoidance and control of nosocomial infections in the health care setting is handwashing. Non-compliance with handwashing guidelines increases the risk of the patients and nurses in acquiring nosocomial infections. And not merely that, it may also contribute in the transmission of infections to other patients. Compliance with handwashing reflects the nurses’ knowledge towards the reason for their duty. Compliance is initiated once the nurses know and value the outcome. It is expected for nurses if they recognize their expected performance and behavior in the clinical setting. The consistency of adopting handwashing behavior is influenced mainly by the knowledge of basic principles, concepts, and hospital policies. Thus, the transmission of nosocomial infections will be diminished, if not totally prevented (Fortuno, 2005). The demographic data and knowledge of nurses affect the perceived value favoring handwashing and subsequently influence the nurses’ decision to wash their hands. Older, female married nurses with a high level of education, are assumed to comply in the handwashing guidelines because they are more prudent and aware of the perceived risks involved in non-compliance with handwashing.

While the younger,

singe, male nurses with lesser experience are perceived to be thoughtless of guidelines and careless in performing patient care activities. Moreover, the intensity of patient care activities, like nurse-patient ratio and unit assignments may alter the nurses’ decision to comply with handwashing guidelines. There is also an assumption that high intensity of patient care activity is associated with low compliance to handwashing for the very reason that the patients’ needs become the nurses’ priority (Fortuno, 2005).

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Figure 1 shows the six components in the infectious disease process. This is also known as the Chain of Infection. The six components in the infectious disease process includes: (1) Pathogen; (2) Reservoir; (3) Portal of exit; (4) Mode of transmission; (5) Portal of entry; and, (6) Susceptible host. The pathogen in the figure below was the cold viruses. The nurse was infected with cold viruses; therefore the nurse was the reservoir. When the nurse blew his/her nose, cold viruses got onto his/her hands, therefore the portal of exit was the nose of the nurse. The nurse attended his/her patient to get vital signs. The nurse had a direct contact with the patient so the cold virus was transferred to the patient. Therefore, handling the patient was the mode of transmission. When the patient rubbed his/her nose, the cold viruses were transferred from his/her hands to the mucous membranes of his/her nose; therefore the patient’s nose was the portal of entry. The patient now was the susceptible host. Source of Infection (Cold Viruses)

Patien t Susceptible host

Nurse Reservoir

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Portal of entry

Portal of exit

Mode of Transmission Figure 1 – Chain of Infection (Note: Please improve your Figure 1.) Figure 2 presents the proper handwashing technique and breaking the chain of infection. To prevent transfer of pathogens or disease-causing microorganisms, a nurse should strictly follow proper handwashing technique.

A nurse must remove all pieces of jewelry and fold sleeves if present to prevent contamination. He/She must open the faucet and rinse hands properly using soap and do the following steps in handwashing: (1) rub hands palm to palm; (2) right palm over the left dorsum and vice versa; (3) finger interlaced; (4) finger interlocked; (5) rotational rubbing of the thumb; (6) rotate fingers in palm; and (7) palm to palm again. He/She must rinse hands without toughing the faucet and dry hands using a clean towel or tissue.

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Figure 2 – Proper Handwashing Technique (Note:

Please

revise

your

theoretical/conceptual

paradigm

using

the

theories/concepts as bases for your study.) Assumptions An “assumption refers to a basic principle that is believed to be true without proof or verification (Polit and Beck, 2003).” This study assumes that: 1. the participants are honest in answering the questionnaires and interviews;

2. the participants are unaware that an observation will take place; 3. the observers are able to record participant’s handwashing duration, frequency, and technique accurately; Significance of the Study This study will provide improvement in the Nursing Service Administration in a sense that the assessment of the nurses’ behavior and perception regarding the importance

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of medical asepsis will pave the way for the administrators to facilitate program planning especially on infection prevention and control. It will also help in determining proper intervention program that will suit the occurrence of consistent compliance, not just for nurses, but for all health care providers with handwashing protocol and guidelines. Furthermore, the available tools may be used to evaluate improvement in their handwashing behavior, and may eventually be incorporated in their performance appraisal in the future. Nursing profession and education will also be improved through the outcome of the study. It will help in eliminating the existing gap between theory and practice. It will provide proof that the ideal setting of imparting basic skills may be employed in the real clinical setting. Moreover, the findings of the study will contribute to the development of handwashing protocol and guidelines in the health care setting regarding the use of waterless alcohol-based hand solution as an alternative to soap and water. Scope and Limitation The study was conducted in Our Lady of Mercy General Hospital from January 20, 2007 to March 2, 2007. Eleven nurses from different areas of the hospital served as participants of this study. The areas of observations included the Operating Room, Pediatric Intensive Care Unit/Neonatal Intensive Care Unit, Ward, Private Ward, and Intensive Care Unit. The study was conducted in forty days because the researchers were required to complete the remaining 336 hours of their duty. The Clinical Instructors and other observers like the senior Nursing students were not allowed to do observations beyond

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their hours of duty. The nurses’ availability in terms of their schedule was taken into consideration in the selection of participants. Definition of Terms The following terms are conceptually and operationally defined in this study: 1. Compliance. The scores gained in the handwashing intervention checklist. The nurse respondent is compliant when: a. The actual handwashing practices using soap and water or waterless alcohol-based hand solution are divided by the total required handwashing practices observed within the two-hour observation period multiplied by the frequency. b. The technique is properly done if the step-by step handwashing procedure is followed. c. The duration of handwashing should be 15 minutes or more. 2. Intensity of Patient Care Activity. Indicators of patient care activity include the following: a. Type of Nursing Unit Non-critical unit. Includes a type of patient care activity wherein the patient admitted in the area requires less monitoring and is less dependent to the health care providers; has a score of 1. Critical unit. Includes a type of patient care activity wherein the patient is subjected to close monitoring and is completely dependent to the health care providers; has a score of 2.

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b. Nurse-Patient Ratio. Refers to the number of patient/s assigned to a nurse in a shift per day. If the number of patients assigned to a nurse in a shift day is the same as the average of number of patients per nurse, the score is 0. If it is above average, the score is 2, and if it is below the average then the score is 1. c. Level of Patient Care Level 1. When the patient is less dependent to the health care provider, the score is 0. Level 2. When the patient requires moderate assistance to the health care provider, the score is 1. Level 3. When the patient is completely dependent to the health care provider, the score is 2. (Scores from each category will be summed up to identify the intensity of patient care activity. The total score of the 3 categories is 6 the lowest score is 1.) Intensity of patient care is characterized as:  High= above 3  Moderate= 3  Low= below 3) (Note: The data in parentheses should be placed in Data Analysis in Chapter IV.) 3. Nurses’ Demographic Data include:

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a. Gender. Refers to human classification based on their anatomical and physiological characteristics. b. Age. Refers to the number of years of existence of life. c. Civil Status. Refers to the individual’s standing in a community (Webster’s Dictionary, 1993). It is operationally characterized in this study as single, married, separated, widow/widower. d. Educational Attainment. Refers to the nurses’ basic and advance professional preparation. It is operationally characterized in this study as formal education: Bachelor of Science in Nursing (BSN), Master of Arts in Nursing (MAN), and non- formal education such as seminars, updates, and in-service training. e. Length of Service or Professional Experience. Refers to the number of years of active nursing service.

CHAPTER II Review of Related Literature This chapter provides information on the importance of handwashing, nosocomial infection, and the factors which affect nurses’ compliance to handwashing guidelines. It

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aims to focus on the analysis of different concepts relevant to handwashing practices in the health care setting. The related literature consists of conceptual and research literature (Sevilla, et. al, 1999). The conceptual literature includes foreign theories about nosocomial infections, and handwashing. The research literature discusses foreign and local studies about nosocomial infections, handwashing, and factors affecting nurses’ compliance to handwashing guidelines. Conceptual Literature Nosocomial Infection Nosocomial infections are classified as infections that are associated with the delivery of health care services in a health care facility. The most common settings where nosocomial infections develop are hospital surgical or medical intensive care units. These types of infections can either develop during a client’s stay in a facility or manifest after discharge. Causative microorganisms (e.g., tuberculosis and HIV) may also be acquired by health personnel working in the facility and can cause significant illness and time lost from work. The responsible microorganisms can possibly originate from the client’s themselves (endogenous sources) or from the hospital environment, and hospital personnel (exogenous sources) (Kozier, et. al., 2004). Handwashing Importance of Hand washing Handwashing is imperative in every setting, most especially in the hospitals. It is considered as one of the most effective infection control measures. Any client may harbor

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microorganisms that are currently harmless to the client, yet potentially harmful to another person or to the same client if they find a portal of entry. Consequently, both nurses, and client’s hands should be washed at the following times to prevent the spread of microorganisms: before eating, after handling the bedpan or toilet, and after the hands have come in contact with any body substances, such as sputum, or drainage from a wound. In addition, health care workers should wash their hands before and after giving care of any kind. (Kozier, et. al., 2004). Research Literature Foreign Literature Nosocomial Infections Reports from the National Nosocomial Infection Surveillance (NNIS) System has revealed that the urinary system, respiratory tract, bloodstream, and wounds are the common nosocomial infection sites (http://www.cdc.gov/ncidod/hip/surveill/nnis.htm). A nosocomial or hospital-acquired infection is a new infection that develops in a patient during hospitalization. It is usually defined as an infection that is identified at least forty-eight to seventy-two hours following admission, so infections incubating, but not clinically apparent, at admission are excluded. With recent changes in health care delivery, the concept of "nosocomial infections" has sometimes been expanded to include other "health care-associated infections," including infections acquired in institutions other than acute-care facilities (e.g. nursing homes); infections acquired during hospitalization but not identified until after discharge; and infections acquired through

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outpatient care such as day surgery, dialysis, or home parenteral therapy (http://www.answers.com ). Early studies reported at least 5 percent of patients became infected during hospitalization. With the increased use of invasive procedures, at least 8 percent of patients now acquire nosocomial infections (http://www.answers.com). The most frequent types of infection are urinary-tract infection, surgical-wound infection, pneumonia, and bloodstream infection. These infections follow interventions necessary for patient care, but which impair normal defenses. At least 80 percent of nosocomial urinary infections are attributable to the use of an indwelling urethral catheter. Surgical-wound infection follows interference with the skin barrier, and is associated with the intensity of bacterial contamination of the wound at surgery. Nosocomial pneumonia occurs most frequently in intensive-care-unit patients with endotracheal intubation on mechanical ventilation—the endotracheal tube bypasses normal defenses of the upper airway. Finally, primary nosocomial bloodstream infection occurs virtually only with the use of indwelling central vascular catheters, and correlates directly with the duration of catheterization (http://www.answers.com ). The clinical status of the patient is important in the development of infection. Many hospitalized patients, such as leukemia patients or transplant patients, have profoundly impaired immunity due to both their disease and therapy. These patients are highly susceptible to infection, frequently with organisms that do not cause infection in normal persons. Patients with neurologic problems may have swallowing difficulties due to aspiration of bacteria from the mouth or stomach, which can lead to pneumonia.

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Patients who have received antimicrobials may develop nosocomial infectious diarrhea caused by Clostridium difficile (http://www.answers.com). The hospital environment may also contribute to infections. Repeated outbreaks of Legionnaire's disease caused by organisms in a hospital's potable water or in air conditioning cooling towers have occurred. Increases in Aspergillus spores in the air during hospital construction cause fungal pneumonia in some immunocompromised patients, with a mortality rate of over 50 percent. Bacterial contamination of sterile intravenous fluids or equipment has repeatedly caused outbreaks of nosocomial infections. Finally, patients may acquire tuberculosis or chicken pox from other patients (http://www.answers.com). The high frequency of nosocomial infections places a substantial burden on individual patients and on the health care system. There is increased morbidity, including delayed wound healing, delayed rehabilitation, increased exposure to antimicrobial therapy and its potential adverse effects, and prolonged hospitalization. The average prolongation of stay is 3.8 days for urinary infection, 7.4 days for surgical-site infection, 5.9 days for pneumonia, and 7 to 24 days for primary bloodstream infection. Some infections, such as infection occurring in a hip or knee replacement, result in prolonged or even permanent disability and require repeated rehospitalization and reoperation. Nosocomial infections also cause mortality. The case-fatality rate for patients with ventilator-associated pneumonia is 42 percent, with an attributable mortality of 15 to 30 percent. For nosocomial bloodstream infection, the case fatality rate is 14 percent, with an estimated attributable mortality of 19 percent. Nosocomial infections are costly. The

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direct cost of hospital-acquired infections in the United States is estimated to be $4.5 billion per year. In England, the cost for one health unit is estimated to be 3.6 million pounds per year. Prolongation of stay necessitated by nosocomial infection limits access of other patients to hospital resources, and contributes to overcrowding on wards and in emergency departments. Nosocomial infections also contribute to the emergence and dissemination of antimicrobial-resistant organisms. Antimicrobial use for treatment or prevention of infections facilitates the emergence of resistant organisms. Patients with infection with antimicrobial-resistant organisms are then a source of infection for other hospitalized patients. Some bacteria, such as methicillin-resistant Staphylococcus aureus, may subsequently spread to the community (http://www.answers.com). Control and Prevention Prevention of nosocomial infections requires a systematic, multidisciplinary approach. This is usually achieved under the leadership of an institutional infectioncontrol program. The principle activities of such a program include surveillance, outbreak management, policy development, expert advice, and education. An optimal program may decrease the incidence of nosocomial infections by 30 to 50 percent (http://www.answers.com). Surveillance of nosocomial infections, by itself, may decrease the incidence. When each surgeon is provided with their own wound-infection rates and with other surgeons' rates for comparison, the institutional surgical-wound infection rate decreases. Outbreak control includes early identification of potential outbreaks, as well as evaluation and intervention if an outbreak is identified. Continuing education of hospital staff about

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the importance of, and their role in, preventing nosocomial infections is necessary. The infection-control program also provides expert consultation to other hospital programs such

as

occupational

health,

clinical

microbiology,

and

pharmacy

(http://www.answers.com). Institutional policies and practices must be developed and adhered to. In particular, optimal handwashing and glove use must be facilitated and reinforced, as transmission of organisms between patients occurs primarily on the hands of staff members. Isolation guidelines to identify and segregate patients who have an increased risk of transmitting infection to other patients or staff are also essential. Other important policies include: for urinary infection, the use and care of the indwelling catheter; and for surgical wound infection, optimal surgical technique including preoperative preparation and prophylactic antimicrobials. Many national or local standards and regulations will also prevent nosocomial infection, and institutions must be in compliance. These regulations cover hospital construction, municipal water supply, laundry management, food handling, waste disposal, sterilization and other reprocessing procedures, as well as standards for pharmacy and microbiology laboratory practice (http://www.answers.com). An effective infection-control program requires dedicated staff with appropriate training and sufficient resources. The number of personnel is determined by the size and complexity of the facility. Infection-control practitioners, usually from a nursing background, are responsible for program activity. In larger hospitals, program leadership is provided by a physician with training in epidemiology and infection control. Smaller facilities may obtain such expertise by contractual arrangement with outside experts.

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Oversight of the infection-control program is usually provided by a multidisciplinary infection-control committee. The program director, however, should report directly to senior

hospital

management

to

ensure

optimal

program

effectiveness

(http://www.answers.com). Postoperative Fever In the discussion of nosocomial infection from ACS Surgery online it was stated that many patients experience fever in the postoperative period without infection. In a prospective study of 871 general surgery patients, 213 (24%) had a documented infection or an unexplained fever in the postoperative period.149 The most common occurrence was unexplained fever in 81 cases (38%), followed by wound infection in 55 (26%), UTI in 44 (21%), respiratory tract infection in 27 (13%), and other infections in 6 (3%). Of all unexplained fevers, 72% occurred in the first 2 days, and of all occurrences in the first 3 days, 67 (71%) of 95 were unexplained, with only 18 (27%) representing true infection. In another study, 73 (45%) of 162 patients experienced unexplained fever after general surgical or orthopedic procedures; 25% of the unexplained fevers were at least 38.3° C (101° F) (Dellinger, 2006 as cited in http://www.medscape.com). At Harborview Medical Center, 316 (98%) of 322 patients who underwent laparotomy for penetrating trauma had a temperature of at least 37.5° C (99.5° F) orally during the first 5 days after operation. Of these patients, however, only 67 (21%) actually acquired any infection during a 30-day follow-up. Even for the 80 patients whose temperatures were as high as 39° C (102.2° F) orally, only 48% actually acquired an infection before discharge. Fever that persisted or began after postoperative day 4 was

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more likely to represent true infection. Similarly, an elevated WBC count was nonspecific during the first 5 postoperative days: 89% of all patients had a WBC count greater than 10,000/mm3. A high fever should prompt examination of the patient, but in the absence of systemic signs of sepsis, an extensive laboratory or radiologic workup during the first 4 to 5 days is usually unhelpful (Dellinger, 2006 as cited in http://www.medscape.com). Magnitude and Significance of Nosocomial Infection An understanding of the prevalence of nosocomial infections and of the factors predisposing to their occurrence will help in prevention, diagnosis, and treatment. Since 1970, the NNIS system has collected and analyzed data on the frequency of nosocomial infections in a voluntary sample of hospitals (currently numbering 280) in the United States.154 Although it has been suggested that the NNIS system underestimates the true incidence of nosocomial infections by 30% to 40%,3,155,156 the large number of cases studied during consecutive years provides a useful description of the most frequently encountered infections, their relative incidences, and the responsible pathogens (Dellinger, 2006 as cited in http://www.medscape.com). Urinary Tract Infection With so many cases of bacteriuria occurring in catheterized patients, it would be easy to become complacent about the problem. Urinary tract catheterization is performed seven to eight million times a year in acute care hospitals in the United States. 160 Approximately 5% to 8% of catheterized, uninfected patients will acquire a urinary tract infection for each day of catheterization, leading to a cumulative infection rate of 40% to

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50% after 10 days.109 However, the great majority of catheterized patients with bacteriuria are asymptomatic. It has been estimated that only 0.7% of catheterized patients will acquire a symptomatic infection and that 8% to 10% of patients will have bacteriuria after the catheter has been removed. In many of these patients, the bacteriuria resolves without specific therapy after the catheter has been removed. However, a careful study of more than 1,458 patients clearly demonstrated that mortality is higher in catheterized patients who acquire bacteriuria than in those who do not.160 In this study, 9% of all catheterized patients acquired catheter-related UTIs; these infections were associated with a threefold increase in deaths occurring during hospitalization, even after correction for other factors (e.g., age, severity of illness, hospital service, duration of catheterization, and renal function). In surgical patients between 50 and 70 years of age with normal renal function and without a fatal underlying disease, a 3% increase in the death rate per patient per hospitalization was associated with the occurrence of a UTI. Of all deaths occurring in catheterized patients, 14% were associated with a UTI.160 By extrapolation, this mortality suggests that as many as 56,000 deaths a year in the United States may be related to catheter-acquired UTI. Although the risk of bacteremia is small for any individual patient with bacteriuria, the large number of hospitalized patients with bacteriuria means that many bacteremic episodes are seen in this population. UTI is the most commonly diagnosed source of gram-negative sepsis, and the rate of bacteremia secondary to urinary catheters is estimated to be between 0.7% and 2%.109 In a case-matched study from 1978, a postoperative UTI was associated with a 2.4-day prolongation of hospital stay and an excess cost of more than $500.162 A subsequent study revealed that 2.3% of

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postoperative patients with UTIs were subsequently diagnosed as having a wound infection caused by the same organism responsible for the UTI.163 This finding accounted for 3.4% of the wound infections occurring during the study (Dellinger, 2006 as cited in http://www.medscape.com). Infection Associated with Intravascular Devices Nosocomial infection associated with intravascular devices, which are placed for either monitoring or therapeutic purposes, assumed increasing importance during the 1970s and 1980s. In the United States, central venous catheters are in place for approximately 15 million patient-catheter-days per year, resulting in approximately 250,000 catheter-associated bloodstream infections.70 Of all cases of nosocomial bacteremia occurring in NNIS hospitals between September 1984 and July 1986, 82% were associated with intravascular devices164: 27% were associated with parenteral nutrition catheters and 55% with other vascular access devices. Reports from as early as 1963 called attention to the risk of serious systemic infections arising from peripheral I.V. catheters.165 For ICU patients with bloodstream infections associated with central venous catheters, the attributable mortality is 25% to 35%, and the excess cost for survivors is $34,000 to $56,000 per patient, for a total annual cost of $296 million to $2.3 billion. In terms of infection risk, pulmonary arterial catheters are no different from central venous catheters, except for their potential to cause right-side heart lesions that could predispose to right-side endocarditis.166 Pulmonary arterial catheters can be responsible for bloodstream infection, and they require as much attention during insertion and subsequent care as central venous catheters do. The arterial catheters used for

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monitoring purposes in the ICU have been thought to be less frequently associated with infection than central venous catheters are, but it is clear that life-threatening infections can originate with peripheral arterial lines.168,169 In early studies of radial artery catheters in which non quantitative culture techniques were employed, catheter contamination rates of 4% to 39% were recorded, but there were no cases of CRBSI or clinical infection in 605 catheterizations.170 In these studies, the majority of catheters were removed from patients within 3 days. Prospective studies of arterial catheters demonstrated that 18% to 35% of the lines were locally infected, as reflected in semi quantitative cultures of at least 15 colonies.171 In one study, five cases of CRBSI occurred, representing an overall incidence of 4% and an incidence of 23% among locally infected catheters. 171 The incidence of CRBSI was increased in catheters that were inserted by cut down rather than by percutaneous puncture and in catheters with signs of local inflammation. In another, the clinical features of bloodstream infection arising from an arterial catheter were indistinguishable from the clinical features of episodes arising from a central venous line, and 12% of all nosocomial bacteremias in the ICU originated from an arterial catheter. 171 Clearly, arterial lines as well as venous lines must be considered in the examination of a patient for the source of fever or bloodstream infection in the ICU. Twelve cases of radial artery rupture after arterial line infection have been reported. All but one were associated with S. aureus infection, and nearly all demonstrated systemic signs of infection for 2 days or longer after catheter removal.169 Although there is no published experience with the use of guide wires to change and culture arterial lines in relation to possible catheter-

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related infection, the technique can be applied with the same rationale used for central venous catheters ( Dellinger, 2006 as cited in http://www.medscape.com). Pathogens In 1984, the NNIS reported on 26,965 infections. Of these cases, 64% were caused by single pathogens, 20% were caused by multiple pathogens, 6% had no pathogen identified on culture, and 10% were not cultured [see Figure 4 -- omitted].173 Of the 84% in which a pathogen was identified, 86% were caused by aerobic bacteria, 2% by anaerobes, and 8% by fungi [see Figure 4] and [see Table 2 -- omitted]. Overall on the surgical services, the most common pathogen isolated was E. coli, followed by P. aeruginosa, enterococci, S. aureus, Enterobacter species, Klebsiella species, coagulasenegative staphylococci, Proteus species, Candida species, and Serratia species. These 10 types of pathogens accounted for 84% of all isolates. Gram-negative rods were most common in UTIs and lower respiratory tract infections, though S. aureus was the second most common pathogen isolated in lower respiratory tract infections. S. aureus was the most common isolate from surgical wound infections, whereas coagulase-negative staphylococci, followed closely by S. aureus, were the pathogens most often responsible for primary bacteremias (Dellinger, 2006 as cited in http://www.medscape.com). As a consequence of changing hospital practices, hospitalized patients today tend to be more severely ill than was once the case. Large amounts of antibiotics are being used in hospitals, and antibiotic-resistant pathogens have become increasingly problematic. Current NNIS data indicate that the frequency with which antibiotics are administered to hospitalized patients who are not in an ICU is approximately 468 defined

28

daily doses (DDD) per 1,000 patient-days.174 For hospitalized ICU patients, the frequency is between 800 and 1,031 DDD per 1,000 patient-days. MRSA accounts for 51% of total S. aureus isolates in ICU patients, 40% in non-ICU patients, and 24% in outpatients with nosocomial infections; the corresponding figures for quinolone-resistant P. aeruginosa in relation to total P. aeruginosa isolates are 37%, 27%, and 27%.174 In 2002, the second clinical isolate of vancomycin-resistant S. aureus in the United States was reported (Dellinger, 2006 as cited in http://www.medscape.com). Nosocomial infections with resistant enterococci have become a serious problem. Enterococci were the third most common nosocomial bloodstream isolate reported by NNIS hospitals between 1990 and 1992.176 The incidence of vancomycin-resistant enterococci (VRE) increased 26-fold between 1989 and 1993, from 0.3% to 7.9%, with a 34-fold rise in ICUs,177 and the rate has continued to increase. The 2001 NNIS report stated that 13% of enterococci were resistant to vancomycin in ICU patients, 12% in nonICU patients, and 5% in outpatients.174 These strains arise from the patient's endogenous flora, but nosocomial spread within the hospital environment is also an important source.177,178 The environment around infected patients is heavily contaminated with VRE, and gown and glove isolation techniques are required to stop transmission.178 Strict application of hand hygiene is also important for reducing the spread of VRE and other nosocomial

pathogens.

According

to

the

available

data

and

current

CDC

recommendations, the use of alcohol-based hand-rub solutions is superior to washing with soap and water: it can be performed more rapidly and is less damaging to the skin (Dellinger, 2006 as cited in http://www.medscape.com).

29

VRE are also highly resistant to other available antibiotics. Acquisition of VRE is significantly associated with prior hospitalization and with use of third-generation cephalosporins, vancomycin, or multiple antibiotics.180,181 In one study, 16% of stool specimens submitted for testing for C. difficile toxin were colonized with VRE, and all surgical patients in that study had the same strain. High mortality can be associated with VRE infections. In a study comparing the outcome of patients having VRE bacteremia with the outcome of patients having bacteremia caused by vancomycin-sensitive enterococci (VSE), mortality was 2.3 times higher in those with VRE bacteremia, and 89% of patients with VRE bacteremia were colonized or infected with VRE at another site.183 Prior treatment with third-generation cephalosporins is another risk factor for increased mortality.176 Liver transplant patients with VRE bacteremia had a 92% higher mortality than comparable patients with VSE bacteremia, and those with VRE bacteremia also had a higher recurrence rate and greater need for invasive procedures (Dellinger, 2006 as cited in http://www.medscape.com). Current recommendations include decreased—and possibly restricted—use of vancomycin, as well as aggressive infection control measures whenever VRE are isolated in a hospitalized patient. In particular, vancomycin should not be used as primary treatment for C. difficile-associated diarrhea and should be avoided for surgical prophylaxis unless the hospital has a specific problem with MRSA or the patient cannot receive

other

appropriate

http://www.medscape.com). Enteric Infection

antibiotics

(Dellinger,

2006

as

cited

in

30

C. difficile is often found in patients with severe antibiotic-associated enteric infections. In one report, 691 (2%) of 32,757 consecutive postoperative patients experienced watery diarrhea significant enough to stimulate a request for C. difficile toxin assay.185 Of this number, 75 (11% of patients with diarrhea) had a positive toxin assay. All cases were associated with antibiotic administration. Approximately 94% of the patients had received a cephalosporin either alone or in combination with other antibiotics; 29% of these responded to cessation of antibiotics and supportive measures, and the remainders were treated with vancomycin, metronidazole, or bacitracin. Six (14%) of the patients who required specific therapy relapsed after initial response to treatment and were subsequently cured with one or more additional courses of treatment. Two patients died, and the overall hospital stay for the remaining patients was prolonged by an average of 50%. Most patients with mild cases of antibiotic-associated diarrhea do not have either positive cultures for C. difficile or positive toxin assays, and the etiologic role of C. difficile is unclear. Many hospitalized patients without diarrhea also have C. difficile in the stool, with or without toxin production, 123,186 and the likelihood of isolating this pathogen increases with patients' increasing length of stay.118 A nonpathogenic yeast, Saccharomyces boulardii, when administered by mouth to hospitalized patients receiving antibiotics, significantly reduced the occurrence of antibiotic-associated diarrhea without affecting the rate of acquisition of C. difficile. Some 3% of asymptomatic adults carry C. difficile in their stools, but 30% to 40% of healthy neonates may carry the organism. The rate of carriage declines after the age of 1 to 2 years. C. difficile can be spread in the hospital and has been isolated from 10% of inanimate objects in the environment of

31

patients with C. difficile colonization, compared with 3% in hospital areas with no known cases.187 In one report,187 this organism was recovered from the hands of 13% of medical personnel working in a ward with affected patients; in another,188 it was recovered from 60% of personnel immediately after they had cared for an affected patient. Soap-andwater washing was ineffective in preventing acquisition, but the combination of glove use and chlorhexidine washing was effective. In another medical center,189 clusters of new nosocomial C. difficile diarrhea were prevented by screening all patients with diarrhea by active surveillance (using culture to identify C. difficile infection) and by instituting isolation precautions and daily disinfection of infected patients' rooms. The prevalence of C. difficile in the environment is increased when a patient has diarrhea.187,188 In one prospectively studied cohort, 21% of patients without C. difficile in their stools on admission acquired the organism during hospitalization, and 37% of these patients experienced diarrhea; no cases of colitis occurred.187 Diarrhea was more common in patients who received antibiotics. The rate of acquisition of C. difficile was 73% higher if a patient had a roommate colonized with C. difficile (Dellinger, 2006 as cited in http://www.medscape.com). Handwashing Importance of Handwashing Bowen’s agency conducted the Handwashing Promotion Program in Chinese primary schools from January to May 2005. Thirty schools from each of three counties in Fujian province, China were subjected to a handwashing regimen to determine whether a more scalable intervention could also reduce illness rates. The result states that children

32

who belonged to the study groups provided with handwashing interventions experienced a significant drop in illness rates, thus, also reducing their absences from school (Fucanan, 2006 as cited in http://www.manilatimes.net) This study tells us that school-based hand-washing programs with soap could improve the health of children, and perhaps their communities, worldwide (Bowen, 2006 as cited in http://www.manilatimes.net). The babies in the intensive care nursery are very susceptible to infections. Premature babies are especially at risk. These babies have very fragile skin that tears easily. This allows bacteria from hands to enter your baby's body more easily than it would a child or adult. The skin is your hands' first defense against infection from pathogenic organisms. While it's intact, it's impermeable to the likes of human immunodeficiency virus (HIV) and hepatitis, so its care and hygiene are crucial. Simply keeping your hands clean is arguably the single most important measure you can take (http://www.virtua.org). Proper Handwashing Technique When should one scrub? The first time you visit the nursery each day and each time you visit after leaving the hospital. How should one scrub? (1) Remove watches, bracelets, and rings (except plain gold bands). (2) Open the scrub brush packet and take out the small stick. Use the stick to clean under your nails. This is very important because many germs like to hide there. (3) Once you have cleaned under your nails, put some soap and water on the scrub Brush to lather up the soap. (4) Scrub from your fingers to your elbows for a full three minutes.

33

For your convenience there is a three-minute egg timer to guide you. If you prefer you may use the clock on the wall (http://www.virtua.org). When is it okay to just wash? If you have already scrubbed for the day and have not left the hospital; anytime you sneeze, cough, blow your nose, change your baby's diaper or touch your hair, shoes, etc; if you are visiting twins, triplets or other multiples, you must wash your hands between babies” (http://www.virtua.org). How should one wash? (1) Remove any piece of jewelry such as your watch, bracelet, and ring (except plain gold bands). (2) Place soap and water on your hands and rub them together, making a good lathe. (3) You must wash for at least thirty seconds for germs to be killed (http://www.virtua.org). Choose neutral pH soap with no added substances. Strong perfumes or alcoholic drying chemicals tend to dry out the skin, especially if you wash frequently. Use a goodquality moisturizing cream to help restore your hands if they get washed out. The skin is your hands’ first defense against infection from pathogenic organisms. While it is intact, it is impermeable to the likes of human immunodeficiency virus (HIV) and hepatitis, so its care and hygiene are crucial. Simply keeping your hands clean is arguably the single most important measure you can take (http://www.virtua.org). Your skin is impermeable to pathogenic organisms only while it is intact. Cuts, abrasions, lesions and dermatitis should be covered by a waterproof occlusive dressing for extra protection. To be safe, follow the Center for Disease Control and Prevention’s (CDC) universal precautions - always wear gloves if you’re in contact with body fluids (http://www.virtua.org).

34

Next to your love, proper handwashing is the most important thing you and your visitors can do for your baby. Studies have shown that artificial nails increase the chances of infection. Germs love to hide under them. The neonatal staff has removed theirs and it is our suggestion that moms do the same (http://www.virtua.org). Guidelines for Handwashing and Hospital Environmental Control Ranking Scheme for Recommendations (1) Measures in Category I are strongly supported by well-designed and controlled clinical studies that show their effectiveness in reducing the risk of nosocomial infections, or are viewed as effective by a majority of expert reviewers. Measures in this category are viewed as applicable for most hospitals -- regardless of size, patient population, or endemic nosocomial infection rates (Garner and Favero, 1985 as cited in http://vm.cfsan.fda.gov/~comm/lacf-phs.html). (2) Measures in Category II are supported by highly suggestive clinical studies in general hospitals or by definitive studies in specialty hospitals that might not be representative of general hospitals. Measures that have not been adequately studied but have a logical or strong theoretical rationale indicating probable effectiveness are included in this category. Category II recommendations are viewed as practical to implement

in

most

hospitals

(Garner

and

Favero,

1985

as

cited

in

http://vm.cfsan.fda.gov/~comm/lacf-phs.html). (3) Measures in Category III have been proposed by some investigators, authorities, or organizations, but, to date, lack supporting data, a strong theoretical rationale, or an indication that the benefits expected from them are cost effective. Thus,

35

they are considered important issues to be studied. They might be considered by some hospitals for implementation, especially if the hospitals have specific nosocomial infection problems, but they are not generally recommended for widespread adoption (Garner and Favero, 1985 as cited in http://vm.cfsan.fda.gov/~comm/lacf-phs.html). In 1980, the Centers for Disease Control (CDC) began developing a series of guidelines entitled Guidelines for the Prevention and Control of Nosocomial Infections. The purpose of the Guidelines was twofold: 1) to disseminate advice on how to prevent or control specific nosocomial infection problems and 2) to cover the questions most frequently asked of the Hospital Infections Program staff on different aspects of the hospital's inanimate environment. One of the first guidelines to be published was the Guideline for Hospital Environmental Control. It was written by Bryan P. Simmons, M.D. in consultation with Thomas M. Hooton, M.D., and George F. Mallison, M.P.H., and in collaboration with a working group consisting of Edward J. Bertz; Mary K. Bruch; Sue Crow, R.N., M.S.N.; William E. Scheckler, M.D.; Harold Laufman, M.D., Ph.D.; Janet K. Schultz, R.N., M.S.N.; Earle H. Spaulding, Ph.D.; and Richard P. Wenzel, M.D. In February 1981, CDC mailed to each U.S. acute-care hospital Part I of the Guideline for Hospital Environmental Control, which contained sections entitled “Antiseptics, Handwashing, and Handwashing Facilities,” “Cleaning, Disinfection, and Sterilization of Hospital Equipment,” and “Microbiologic Surveillance of the Environment and of Personnel in the Hospital.” In October 1981, Part II of the Guideline for Hospital Environmental Control, which contained the sections “Housekeeping Services and Waste Disposal,” “Laundry Services,” “Intensive Care Units,” and “Pharmacy,” was published.

36

In July 1982, the section on “Cleaning, Disinfection, and Sterilization of Hospital Equipment” was revised. In November 1982, the two parts of the Guideline were combined into a single document entitled Guideline for Hospital Environmental Control, and copies were mailed to all U.S. acute-care hospitals (Garner and Favero, 1985 as cited in http://vm.cfsan.fda.gov/~comm/lacf-phs.html). In October 1983, CDC issued a statement entitled “Clarification of Guideline Recommendations on Generic Antiseptic, Disinfectant, and Other Products,” which was mailed to all U.S. acute-care hospitals. The statement emphasized that CDC recommendations are not intended to endorse any particular commercial product or to exclude the use of other commercial products containing generic ingredients not mentioned in the Guideline for Hospital Environmental Control (Garner and Favero, 1985 as cited in http://vm.cfsan.fda.gov/~comm/lacf-phs.html). In November 1983, a follow-up statement requested that users delete the portion of the Guideline for Hospital Environmental Control that recommended specific generic antimicrobial ingredients for use in health care personnel hand washes and announced that the entire Guideline would be comprehensively revised. In June 1984, a draft of the proposed revision was mailed to 150 scientists and infection control professionals for review and comment. Rather than using an expert working group to finalize the content of this Guideline, we used the written comments and suggestions which we received from the reviewers to determine the final content of the Guideline and the ranking of the recommendations

(Garner

and

Favero,

http://vm.cfsan.fda.gov/~comm/lacf-phs.html).

1985

as

cited

in

37

Major Changes in the Guidelines Since these guidelines contain many important changes from the original Guidelines for Hospital Environmental Control, it is important that users read the entire guidelines carefully. The major changes in the titles and content of sections are listed below: 1. The section “Handwashing,” which replaces the old section entitled “Antiseptics, Handwashing, and Handwashing Facilities,” contains updated recommendations for handwashing with plain soaps or detergents and with antimicrobial-containing products. Rather than recommending specific generic ingredients for handwashing with antimicrobial containing products, the Guideline indicates that hospitals may choose from appropriate products in categories defined by the U.S. Food and Drug Administration (FDA), since preparations used to inhibit or kill microorganisms on skin are categorized by an FDA advisory review panel for nonprescription (over-the-counter {OTC}) antimicrobial-drug products (2). Manufacturers of antimicrobial containing products voluntarily submit data to the review panel, which categorizes the products according to their intended use, i.e., antimicrobial soaps, health-care personnel hand washes, patient preoperative skin preparations, skin antiseptics, skin wound cleansers, skin wound protectants, and surgical hand scrubs. Generic antimicrobials for each use category are further divided: Category I (safe and efficacious); Category II (not safe and/or efficacious); and Category III (insufficient data to categorize). Consequently, chemical germicides formulated as antiseptics are categorized by the FDA into groupings by use and efficacy, but they are not regulated or registered in the same fashion as chemical germicides are by the U.S. Environmental Protection Agency (EPA). Persons responsible

38

for selecting commercially marketed health-care-personnel hand washes can obtain information about categorization of products from the Center for Drugs and Biologics, Division of OTC Drug Evaluation, FDA, 5600 Fishers Lane, Rockville, MD 20857. In addition, information published in the scientific literature, presented at scientific meetings, documented by manufacturers, and obtained from other sources deemed important may be considered. 1. The section "Cleaning, Disinfecting, and Sterilizing of Patient-Care Equipment" has been rewritten. Medical devices, equipment, and materials are divided into three categories (critical, semicritical, and noncritical) based on the risk of infection involved in their use. Revised recommendations for sterilizing and disinfecting items in these categories are included in this section. Rather than listing specific chemical germicides, the Guideline indicates that hospitals may choose from sterilant and disinfectant formulations registered with the EPA, since chemical germicides are regulated and registered by the EPA (3). Manufacturers of chemical germicides formulated as general disinfectants, hospital disinfectants. and disinfectants used in other environments, such as the food industry, are required by EPA to test their formulations using specific protocols for microbicidal efficiency, stability, and toxicity to humans. In past years, the EPA has reserved the right to test and verify formulations of chemical germicides for their specified efficacy; however, in practice only those formulations to be registered as sterilants or sporicides were actually tested. In 1982, the EPA discontinued this testing. Currently, formulations of chemical germicides are registered by the EPA based on data obtained from the manufacturer. Persons responsible for selecting chemical germicides

39

should keep in mind that the field is highly competitive, and exaggerated claims are often made about the germicidal efficiency of specific formulations. When questions regarding specific claims or use arise, the Disinfectants Branch Registration Division, Office of Pesticides, EPA, 401 M Street, S.W., Washington, D.C. 20460, can be consulted. As with handwashing products, information in the scientific literature, presented at scientific meetings, documented by manufacturers, and obtained from other sources deemed important may be considered. The recommendation against reprocessing and reusing single-use items has been removed. Since there is lack of evidence indicating increased risk of nosocomial infections associated with the reuse of all single-use items, a categorical recommendation against all types of reuse was not considered justifiable. Rather than recommending for or against reprocessing and reusing single-use items, the Guideline indicates that items or devices that cannot be cleaned and sterilized or disinfected without altering their physical integrity and function should not be reprocessed. In addition, reprocessing procedures that result in residual toxicity or compromise the overall safety or effectiveness of the items or devices should be avoided. Arguments for and against reprocessing and reusing single-use items have been summarized in a report from the International Conference on the Reuse of Disposable Medical Devices in the 1980's (4). 1. The section “Microbiologic Sampling” replaces the old section entitled “Microbiologic Surveillance of the Environment and of Personnel in the Hospital.” The recommendation for microbiologic sampling of infant formulas prepared in the hospital has been removed, since there is no epidemiologic

40

evidence to show that such sampling reduces the infection rate in hospitals. Information and recommendations for microbiologic surveillance of personnel have been deleted, since this topic is addressed in the Guideline for Infection Control in Hospital Personnel (5). 2. A new section, “Infective Waste,” has been added. It contains information about identifying infective waste and recommendations for its handling and disposal. 3. The section “Housekeeping” replaces the old section “Housekeeping Services and Waste Disposal.” Recommendations against use of carpets in patient care areas have been removed, since there is no epidemiologic evidence to show that carpets influence the nosocomial infection rate in hospitals (6); whether to use carpets, therefore, is not considered an infection control issue. 4. The section “Laundry” contains a discussion of and recommendations for both hot-water and reduced temperature washing. 5. The section “Intensive Care Units” has been deleted, since it primarily dealt with information and recommendations that are covered elsewhere in this Guideline and in the Guideline for Isolation Precautions in Hospitals (Garner and Favero, 1985 as cited in http://vm.cfsan.fda.gov/~comm/lacf-phs.html). The recommendations presented in this Guideline were chosen primarily for their acknowledged importance to infection control, but other factors, such as the feasibility of implementing them and their potential costs to hospitals, were also considered. Many recommendations are intended to reduce or eliminate expensive practices that are not likely to prevent infections. Some of the recommendations are based on well-documented

41

epidemiologic studies; others are based on a reasonable theoretical rationale, since for many of these practices little or no scientifically valid evidence is available to permit evaluation of their effect on the incidence of infection. Because new studies are constantly revealing pertinent information in this field, users of this Guideline should keep informed of other sources. The recommendations presented in this Guideline may be modified as necessary for an individual hospital and are not meant to restrict a hospital from developing recommendations that may be more appropriate to its own unique needs. The recommendations have no force of law or regulation (Garner and Favero, 1985 as cited in http://vm.cfsan.fda.gov/~comm/lacf-phs.html). Fourteen studies of practices to improve handwashing compliance are as follows: 1. The setting of the study was practice. All medical staff in a neurologic ICU and a surgical ICU in a 350-bed tertiary care teaching hospital in Washington, DC, 1983-84; multifaceted intervention (education, automatic sinks, feedback). Study Design and Outcome was Level 2, Level 2. And the Handwashing Compliance (unless otherwise noted) was 69% vs. 59% (p=0.005). 2. Medical staffs in 2 ICUs in a university teach hospital in Philadelphia; increase number of available sinks. Study Design and Outcome was Level 2 and the Handwashing Compliance was 76% vs. 51% (p<0.01). 3. Medical staff in a 6-bed post-anesthesia recovery room and a 15-bed neonatal ICU in a tertiary care hospital in Baltimore, 1990; automatic sink compared with

42

standard sink. Study Design and Outcome was Level 2, Level 2. Mean handwashes per hour: 1.69 vs. 1.21 on unit 1; 2.11 vs. 0.85 on unit 2; (p<0.001). 4. All staff at a large acute-care teaching hospital in France, 1994-97; hand hygiene campaign including posters, feedback, and introduction of alcohol-based solution. Study Design and Outcome was Level 3, Level 1. Nosocomial infections: 16.9% vs. 9.9% Handwashing: 66.2% vs. 47.6% (p<0.001). 5. Medical staff in a 6-bed pediatric ICU in a large academic medical center in Virginia, 1982-83; mandatory gowning. Study Design and Outcome was Level 3, Level 2. The Handwashing Compliance was 29.6% vs. 30.7%. 6. Medical staff in 2 ICUs in a community teaching hospital in Tennessee, 1983-84; sequential interventions of lectures, buttons, observation, and feedback. Study Design and Outcome was Level 3, Level 2.

Handwashing Compliance was

29.9% vs. 22% (p = 0.071). 7. Medical staff in an 18-bed ICU in a tertiary care hospital in Australia; introduction of chlorhexidine-based antiseptic handrub lotion. Study Design and Outcome was Level 3, Level 2. . Handwashing Compliance was 45% vs. 32% (p<0.001). 8. 12 nurses in a 12-bed ICU in Mississippi, 1990; education/feedback intervention. Study Design and Outcome was Level 3, Level 2. Handwashing Compliance was 92% vs. 81%.

43

9. Medical staff in an 18-bed pediatric ICU in a children's teaching hospital in Melbourne, 1994; 5-step behavioral modification program. Study Design and Outcome was Level 3, Level 2. Handwashing rates after patient contact: 64.8% vs. 10.6%. 10. Medical staff in a 3000-bed tertiary care center in France, 1994-95; 13-step handwashing protocol. Study Design and Outcome was Level 3, Level 2. Handwashing Compliance was 18.6% vs. 4.2% (p<0.0001). 11. Medical staff in two ICUs at a teaching hospital in Virginia, 1997; 6 education/feedback sessions followed by introduction of alcohol antiseptic agent... Study Design and Outcome was Level 3, Level 2. Results include: Baseline 22%; Education/feedback 25%; Alcohol antiseptic 48%; (p<0.05). 12. Medical staff in a 14-bed ICU in a tertiary care hospital in France, 1998; introduction of alcohol-based solution... Study Design and Outcome was Level 3, Level 2. Handwashing Compliance was 60.9% vs. 42.4% (p=0.0001). 13. All staff in a medical ICU and step-down unit in a large teaching hospital in Virginia; installation of alcohol-based solution.. Study Design and Outcome was Level 3, Level 2. Handwashing Compliance was 52% vs. 60% (p=0.26). 14. Medical staff on 2 general inpatient floors at each of 4 community hospitals in New Jersey; patient education intervention... Study Design and Outcome was Level 3, Level 3. Soap usage (as an indicator of handwashing) increased by 34% (p = 0.021).

44

“A structured search of the PubMed database (including MEDLINE) and review of the bibliographies of relevant articles identified 14 studies that have examined methods to improve handwashing compliance. Three studies were non-randomized controlled trials (Level 2) that directly compared separate units, or parts of units, in which one area received the intervention and another did not. Eleven studies were before-after studies (Level 3), in which baseline data regarding handwashing rates were obtained during an initial observation period, and then measured again in the time period after a particular intervention. Regardless of the type of study design, details regarding the comparability of the groups under observation were reported in only 4 studies” (as cited in http://vm.cfsan.fda.gov/~comm/lacf-phs.html). Factors Affecting Proper Handwashing According to APIC, handwashing associated with general patient care occurs in approximately half of the instances in which it is indicated and usually is of shorter duration than recommended. A recent study supports that figure, finding that average handwashing compliance was 48% in a teaching hospital. The study concluded that the primary problem with handwashing is laxity of practice and that high workload among healthcare workers was associated with low compliance (http://en.wikipedia.org). Other factors influencing handwashing behavior include placement of sinks, unacceptable handwashing products, the effect of handwashing on skin condition, and awareness

of

the

(http://en.wikipedia.org).

importance

of

handwashing

in

preventing

infection

45

The convenient placement of sinks, handwashing products, and paper towels is often suggested as a means of encouraging frequent and appropriate handwashing. Sinks with faucets that can be turned off by means other than the hands (e.g., foot pedals) and sinks that minimize splash can help personnel avoid immediate recontamination of washed hands (http://en.wikipedia.org). Local Literature Nosocomial Infections In the study conducted by Fortuno (2005), she stated that the common complications which occur in the hospitals, particularly in the Intensive Care Unit (ICU), are nosocomial Infections. This hospital-acquired infection occurs in the ICU at a much higher rate compared with those other areas of the hospital (Weinstein, 1998). In her study, she enumerated the associated risk factors for infections: (a) intrinsic factors which are associated with the severity of the patient’s illness and underlying conditions like malnutrition, age, and immunosuppression; (b) invasive medical devices and length of exposure to them; (c) increased patient contact; (d) length of stay in the ICU; and (e) use of antibiotic and special environmental characteristics of the unit like space limitations (Nguyen, et. al., 2003; Floros & Roussos, 2001; Weber, Raasch, & Rutala, 1999). She emphasized that contamination which occurs between patients and health personnel is a challenge in the delivery of health care in the hospital (Larson, Bryan, Adler, & Blane, 1997; Haley & Bregman, 1982; Pittet et. al., 1999). Handwashing

46

Importance of Handwashing In 1843, Oliver Wendell Homes; an obstetrician suspected that the hands of health care providers could be the culprit for “childbed fever” (Rotter, In Wenzel, 1997 as cited in Fortuno, 2005). Four years have passed, Ignaz Semmelweiz, a French obstetrician, noticed that most parturient women assisted by his students and other physicians have higher mortality rate than those women whose babies were delivered by midwives. Then he found out that his students and other physicians entered the obstetrics ward without proper washing of their hands with soap and water. Semmelweiz postulated that the cause of the puerperal fever experienced by the parturient mothers was “cadaverous particles” brought by his students and other physician in the obstetrics ward. Consequently, their recommendations for handwashing which resulted from their observation became the most important measure in preventing nosocomial infections in the healthcare setting (Boyce and Pittet, 2002 as cited in Fortuno, 2005). The US public health service developed a film demonstrating handwashing technique in 1961. This was developed to train health care providers to wash their hands for one-two minutes with soap and water before and after contact with patient. Another was the formal written guideline on handwashing practices in the health care setting which was published by CDC in 1975 and 1985 (Garner, 1985, CDC Guidelines for handwashing and hospital environment control as cited in Fortuno 2005). Its recommendation was to wash hands with adequate friction for at least 30 seconds with non-antimicrobial soap for all and between patient contacts, before and after performing invasive procedures, and before and after providing care for high risk patients. Washing

47

hands for 30 minutes using soap and water accompanied by friction is almost as effective as washing hands for 2 to 3 minutes (Boyce and Pittet, 2002). It is only when sinks are not accessible when waterless antiseptic solution is recommended. She also cited in her study that the Association for professionals in Infection

Control (APIC) published

another guideline in 1988 and 1995 (Larson, 1995, APIC Guideline for Handwashing and Hand Antisepsis in Health Care Setting) which discusses in detail the use of alcohol based hand rubs and supported their use in health care setting. Likewise, in 1995 and 1996, the use of antimicrobial soap or waterless antiseptic solution was recommended by the Healthcare Infection Control Practices Advisory (HICPA), to clean hands after direct care of patients with multi-drug resistant pathogens, such as Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant enterococci (VRE). Guidelines for handwashing and hands antisepsis along with routine patient care were provided in the recommendation. However, compliance with handwashing practices among health care providers remained low (Boyce and Pittet, 2002; Pittet et al, 1999).

Factors Affecting Nurses’ Compliance with Handwashing Guidelines Compliance is defined as “the act of complying, yielding, or acting in accord.” It is the power exerted by an individual to control his acts based on perception, past learning and working experiences, and the influence of others. It becomes habitual if related acts are repeated, reinforced, or rewarded. The behavior of a compliant lasts for as long as the promise of reward or punishment exists. One goes back to his old behavior

48

once the reward or punishment is given (Fortuno, 2005). The compliant understands the force of the circumstances and can easily change his or her behavior when the circumstances no longer prevail. In the study of Fortuno (2005), she enumerated the causes for healthcare providers’ low compliance to handwashing guidelines: lack of awareness, forgetfulness, interference with provider-patient relationship, insufficient time/too busy, overcrowding or understaffing, inaccessibility of sinks, lack of soap and paper towels, irritating washing agents, laxity, and many other factors (Rosenthal et. al., 2003; Boyce & Pittet, 2002; Rumbaua et. al., 2001; Pittet et. al., 1999) According to Gomez (2004) through personal interview, the reason was because of the unavailability of supplies. The result was revealed in the unpublished clinical trial conducted at the Philippine General Hospital (Fortuno, 2005). Through observations and anecdotal reports in the local setting, poor compliance with the use of soap and water could be possibly brought about by myriad of contacts with patients over a limited time span. Attending patients’ need become the priority, thus, the preventive measure against transmission of pathogens is taken for granted (Fortuno, 2005). Fortuno (2005) also stated in her study that the increased staphylococcal infections is caused by the understaffing and overcrowding during recurrent outbreaks of staphylococcal infections in the neonatal special care units (Haley & Bregman, 2001). She also mentioned that staphylococcal infection is 16 times higher when the unit is understaffed (that is, when the nurse-patient ratio exceeds 7); 7 times higher when the

49

unit is not crowded (that is, when the number of infant exceeded at 33); 3 times higher in the summer months and 1.5 times higher in the absence of bathing infants with hexachlorophene. Healthcare providers found it difficult to wash their hands with soap and water when they are understaffed and need to attend to more patients (Haley & Bregman, 1982; Pittet et. al., 2000). According to Fortuno (2005), noncompliance may also be a result of individual’s perception of the risk involved in terms of beliefs, norms, attitude, risk for contamination, and intensity of nursing activities. Attitudes and beliefs of the health care providers toward handwashing are crucial for any compliance program to succeed (Larson & Killien, 1982).

CHAPTER III Methodology This chapter presents the research design of the study, the procedure of data collection as well as the statistical treatment of the findings. Research Design The study used the descriptive-survey research design. Descriptive-survey is a “method of research which intends to gather relatively limited data from a relatively large

50

number of cases” (Sevilla, et.al, 1992). This research design was chosen because the researchers gathered their data by conducting a survey of selected nurses in a hospital. The purpose of the survey is to determine the nurses’ demographic data, relationship between their demographic data and compliance with handwashing frequency, duration and technique, factors which affect their compliance, and if they use either soap and water or waterless alcohol-based hand solution. Research Setting, Population, and Sampling Technique This study was conducted in Our Lady of Mercy General Hospital in Pulilan, Bulacan. It is an ideal setting for this study because it is a tertiary hospital, the highest level of health care delivery system wherein complete health services are rendered (Kozier et.al., 2004). Tertiary hospitals in the country are required to promote provision of quality health care because they are the major sources of health services needed by Filipinos. This was also the affiliated hospital where the researchers were required to complete the number of hours of their duty. At the time of the study, this hospital had a 55-bed capacity and had 30 nurses in the following areas: emergency room, dialysis, ward, private ward, operating room, intensive care unit, and pediatric intensive care unit/neonatal intensive care unit. However, only the following areas were included in this study: Operating Room (OR), Pediatric Intensive Care Unit (PICU)/Neonatal Intensive Care Unit (NICU), Private Ward, Ward, and Intensive Care Unit (ICU). There were eleven nurses who served as participants of this study. In particular, there were three nurses from the Private Ward and Operating Room, two nurses from the

51

Pediatric Intensive Care Unit/Neonatal Intensive Care Unit and Ward, and one from the Intensive Care Unit. In order to complete the observations and interviews, at least four shifts in each area were covered. The study utilized purposive sampling. Purposive sampling was used to enable the researchers to select participants who should be in the study. The participants were selected based on their availability during the duty of the clinical instructors, head nurses and senior Nursing students because observations beyond duty hours are not allowed. In the operating room and pediatric intensive care unit/neonatal intensive care unit, the researchers had only one participant for each shift because there was only one nurse on duty per shift. In the private, ward, and intensive care unit, two nurses were on duty per shift. This helped the researchers facilitate observations simultaneously.

Research Instrument The instrument used was based on the Handwashing Assessment Tool, Handwashing Observational Checklist, and Handwashing Technique Observation Checklist developed by Fortuno (2005). It is the main tool in collecting the data. The instrument was divided into four phases: (1) Informal Observations, (2) Handwashing Assessment Tool, (3) Handwashing Observational Checklist, and (4) Handwashing Technique Observation Checklist.

52

The first phase included informal observation. This phase was an observation without the use of the observational checklist. The second phase was Handwashing Assessment Tool. The first part of the Handwashing Assessment Tool includes the participants’ demographic data (Name, Age in years, length of professional service, gender, civil status, educational attainment, and area of assignment). The second part comprised of the following questions: (1) How important is handwashing for you?, (2) Are handwashing guidelines available and easily accessible in your unit?, (3) Is handwashing seminar/update regularly made in your hospital? If yes how frequent?, (4) Write your reasons why handwashing should be consistently done in your place of work, (5) Write your reasons why at times washing your hands in your place is not consistently done, (6) Write the factors that will influence your decision to consistently wash your hands in your place of work. The third phase of the instrument was the Handwashing Observational Checklist. This phase enumerated all the nursing interventions of the participants. It also revealed if the nurses washed their hands before and after each nursing intervention; if they used either soap and water or waterless alcohol-based hand solution; if they followed the proper handwashing technique; and how many seconds they cleaned their hands using soap and water or waterless alcohol-based hand solution. The fourth phase of the instrument was the Handwashing Technique Observation Checklist. This showed how the nurses clean their hands using soap and water or waterless alcohol-based hand solution. It also revealed if the nurses followed the proper handwashing technique: (1) wet hands with running water (2) soap hands until lather

53

develops (3) rub hands vigorously for 15 seconds covering all surfaces of the hands and fingers (4) perform the following sequence five times for each hand palm to palm (5) right palm over left dorsum (6) left palm over right dorsum (7) left palm to the back of the right hand with finger interlaced (8) right palm to the back of the left hand with finger interlaced (9) back of right fingers rub against left palm with fingers interlocked (10) back of left fingers rub against right palm with fingers interlocked (11) rotational rubbing of left thumb clasped by the right hand (12) rotational rubbing of right thumb clasped by the right hand (13) rinse hands with water (14) dry hands thoroughly with a disposable towel (15) turn faucet with the used of disposable towel. Data Collection Procedure The informal observations were done two months before the formal observations were conducted. The results of the informal observations showed that the nurses were not able to comply with the proper handwashing technique and only a handful of them washed their hands before and after contact with patients. This prompted the researchers to conduct a research about nurses’ compliance with handwashing guidelines. The researchers asked permission from the Chief Nurse of Our Lady of Mercy General Hospital through a letter noted by the Dean of Trinitas College. As soon as the letter of consent was approved by the Chief Nurse, the observational checklists were distributed to the trained nurses, clinical instructors, and senior Nursing students. The research study was conducted with a pair of observer (a trained nurse, clinical instructor or senior Nursing student) and interviewer (student researcher). Each area of the hospital

54

(ward, private ward, pediatric intensive care unit/neonatal intensive care unit, intensive care unit and operating room) had a designated pair of researchers. When the observers were already done in observing the nurses on how they performed the proper handwashing technique, the interviewers then distributed the questionnaires in each area of observation. The participants answered the questionnaires during their free time. The observation checklist and the questionnaires revealed how consistent the nurses were in washing their hands and how honest they were in answering the questionnaires. Three questionnaires were distributed in the private ward and operating room, two questionnaires in the pediatric intensive care unit/neonatal intensive care unit and ward, and a single questionnaire in the intensive care unit. The participants were given one week to answer the questionnaire, but this was not followed because many of the participants lost the questionnaires. The researchers again distributed questionnaires to replace the lost questionnaires After collecting all the needed information, the researchers computed the percentage and mean of the nurses’ demographic data (age, gender, civil status, educational attainment, designated area, and length of professional service). Handwashing frequency was obtained by dividing the actual handwashing practices using soap and water or waterless alcohol-based hand solution to the total required handwashing practices observed within the hours of observation period multiplied by 100. The researchers used the Pearson Correlation to find out the correlation between the intensity of patient care and handwashing frequency. Data Analysis

55

The statistical treatment used for the demographic data (age, gender, civil status, educational attainment, designated area, and length of professional service) of the participants was percentage and mean. The handwashing frequency in terms of the participants’ demographic data was obtained through dividing the total actual handwashing practices divided by the required handwashing practices multiplied by 100.

(F= AHP x100) RHP (Note: Please improve the formula.) The intensity of patient care was the sum total of the type of nursing unit, nursepatient ratio and level of patient care. Nursing unit may be classified as a critical unit with a point score of two, or non-critical unit with a point score of one. The nurse-patient ratio depends on hospital protocol but in general the ideal ratio of nurse and patient is “one is to five” in non-critical area and “one is to one” in critical areas or special areas. The level of patient care was identified by assessing if the patient was less dependent with a point score of zero; if the patient needs moderate assistance with a point sore of one; and if the patient was completely dependent with a point score of two. The relationship between the intensity of patient care and handwashing frequency was measured using Pearson Correlation.

56

CHAPTER IV Presentation and Interpretation of Data This chapter presents the data gathered in Our Lady of Mercy General Hospital. The main objective of the study was to conduct a survey of nurses’ compliance to handwashing guidelines. The sequence of the presentation followed the research objectives found in Chapter I.

57

Originally, fifteen nurses were chosen to respond in the study, three nurses from the operating room, pediatric intensive care unit/neonatal intensive care unit, emergency room, ward, and private ward. Two nurses were already observed in the emergency room and two questionnaires have been distributed, but none of the nurses submitted the questionnaires. They were not able to answer the questionnaires for the very reason that they had many patients to attend, and they could not use their free time answering the questionnaires because they had to do a lot of paper works. At first the area of the intensive care unit was not included because student researchers even the clinical instructors and head nurse are not allowed to conduct observation until the senior nursing students were assigned in the special areas. Two nurses were observed by the senior nursing students in the intensive care unit and two questionnaires were also distributed, unfortunately only one nurse answered the questionnaire. Objective 1: (Note: Please specify Objective 1. State the same objectives from Chapter 1.) a. Sex Figure 3 presents the classification of the participants according to sex. (Note: Insert Figure 3 here.) There were eleven participants observed by the researchers, seven participants were female and the remaining four participants were male. This also means that sixtyfour percent were female and thirty-six percent were male. There were two female participants from the operating room, ward, and private and one female participant from

58

the PICU/NICU. There was only one male participant in the operating room, private, PICU/NICU, and ICU.

36%

Female 64%

Male

(Note: Please label Figure 3.) b. Civil Status Figure 4 shows the classification of participants according to civil status. There were eight participants who were not yet married and three participants who were already married. This means that seventy-three percent were single and twentyseven percent were married. There were three single participants in the ward, two single participants in the operating room, and one single participant in the ward, PICU/NICU, and ICU.

59

80% 60% Single

40%

Marred

20% 0% Single

Married

(Note: Please label Figure 4.) c. Age Figure 5 presents the classification of participants according to length of professional service. The mean age of the participants was 23.5. Eight participants were aged 20 to 23 years. This also means that seventy-three percent of the participants were aged 20 to 23 years. Two participants were aged 24 to 27 years old. This also means that eighteen percent of the participants were aged 24 to 27 years old. Only one participant was 35 years old. This also means that nine percent was age 35.

18% 20-23

0%

24-27 28-31

73%

(Note: Please label Figure 5.) d. Educational Attainment

9%

32-35

60

Figure 6 shows the classification of participants according to educational attainment. All the participants finished their baccalaureate degree, but none of them holds masteral degree because most of the participants were young and according to them a masteral degree is expensive. This also means that eleven participants finished their Bachelor of Science in Nursing Course.

0% BSN MSN MAN

100%

(Note: Please label Figure 6.) e. Length of Professional Service Figure 7 presents the classification of participants according to the length of professional service. The mean professional service of the participants was 19.3 months. Among the eleven nurses who participated in the study, only one has been practicing her profession in the hospital for ninety-six months. This also means that nine point one percent of the participants have been practicing her profession in the hospital for eight years. Another participant has been practicing his profession for thirty-six months. This also means that another nine percent of the participants have been practicing their profession for three

61

years. Two out of the eleven participants have been practicing their profession from eighteen to twenty-four months. This also means that eighteen point two percent of the participants have been practicing their profession for one and a half to two years. Four out of the eleven participants were practicing their profession from almost seven to twelve months. This also means that thirty-six point four percent of the participants have been practicing their profession for one year. The remaining three participants, who were newly graduates, were practicing their profession for five months and less. This also means that twenty-seven point two percent of the participants have been practicing their profession for five months or less.

40% 30% 6 m onths

20%

7-12 m onths

10%

18-24 m onths 30- 34 m onths

0% less than 7-12 six months months

f. Designated Area

18-24 months

30- 34 above 42 months months

62

Figure 8 shows the classification of participants according to designated area of the hospital.

The areas which were observed by the researchers include the following: ward, private, operating room, PICU/NICU, and intensive care unit. Originally the intensive care unit was not included in the list because students who were not assigned to work in the area were strictly prohibited to enter. The areas which were supposed to be observed were emergency room and dialysis, but the nurses from the emergency room could not find their time to answer the questionnaires and there were no available observers in the dialysis area. Among the eleven participants, there were three participants from the OR. This also means that twenty-seven point two percent of the participants were assigned in the OR. There were also three participants from the private. And this means that twentyseven point two percent of the participants were assigned in the private. Out of the eleven participants, two participants were from the ward. This also means that eighteen point two percent of the participants were assigned in the ward. Another two participants were from the PICU/NICU. This also means that another eighteen point two percent of the participants were assigned in the PICU/NICU. The remaining participant was from the ICU. This also means that only nine point one percent of the participants was assigned in the ICU. Objective 2: (Please insert Objective 2.)

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Table 1 presents the summary of the participants’ handwashing frequency, duration, and technique in terms of their demographic data (age, sex, civil status, educational attainment, length of professional service, and area of responsibility). Based on the findings of the study, all the participants did not comply in terms of handwashing duration and technique because the maximum duration reached was only 14 seconds without completing the nine steps of proper handwashing. The handwashing frequency was obtained according to their age, sex, civil status, educational attainment, length of professional service, and area of responsibility. In terms of their age, participants whose age ranged from 24 to 27 years old got the highest handwashing frequency of 150 with a total duration of 8 seconds. Those who got the second highest score of 33, with a total duration of 14 seconds, were ages 28 to 31 years old. This showed that older nurse-participants were not compliant to handwashing frequency but they did wash their hands longer than the young ones. Those who got the lowest score of 28 with a duration of 8 seconds were the youngest in the group, their ages ranged from 20 to 23 years old. Male participants were more compliant to handwashing frequency compared to female participants because they received the total score of 100 with a total duration of nine seconds while the female participants received only 26 with the same duration as the male. This result supports the study of Fortuno (2005) that more male nurses were washing their hands frequently than female nurses. Married participants were more compliant with handwashing frequency than those who were still single. The handwashing frequency of married participants reached

64

83 with a total duration of 9 seconds, while the single participants’ handwashing frequency was 23 and with a duration of 8 seconds. In terms of their educational attainment, all the participants were able to finish their baccalaureate degree. Their handwashing frequency was only 55 and the total handwashing duration was only 9 seconds. Participants who practiced their profession from 18 to 24 months, whose score was 100 with a duration of 7 seconds, were more compliant with handwashing frequency than those who practiced their profession for almost 54 months and above, whose score was only 33 and with a duration of 14 seconds. The participants who served in the hospital for 30 to 48 months had the lowest score of 25 with a duration of 8 seconds. These findings did not support the theory of Fortuno (2005) that “compliance is the power exerted by an individual to control over his acts based on past learning and working experiences”. Participants who were assigned in the PICU/NICU were the most compliant with handwashing frequency for they earned the highest score of 106 with a duration of 8 seconds. There were only two participants in this area. This proves that they were honest with their answers that they consistently washed their hands before and after handling patients because their patients were children and newborns, who are more susceptible to infections than older patients. The lowest score was from the ward, which was only 11 and a with duration of 6 seconds though they had an equal number of participants with the PICU/NICU.

65

In general, the findings revealed that most male both single and married nurses, whose ages ranged from 21 to 26 years, and with a professional service of five months to 36 months were more compliant with handwashing frequency to female married nurses, whose ages ranged from 23 to 35 years old, with a length of professional service of 24 months to 96 months. (Note: Please improve the table on the next page.)

Demographi

Total number of Total

Frequen

Average

Techniq

c data

required

number

cy

Duratio

ue

handwashing

of actual

pratices

handwashing

n

ID- incorrectly done Age in years

pratices

20-23

46

13

28

8

ID

24-27

12

18

150

seconds

ID

28-31

0

0

0

8

32-35

6

2

33

seconds

Total=64

Total=33

ID

0 14 seconds

Sex Male

22

22

100

9

ID

Female

42

11

26

seconds

ID

Total=64

Total=33

9 seconds

Civil status Single

40

13

33

8

ID

Married

24

20

83

seconds

ID

Total=64

Total=33

9 seconds

Educational attainment BSN

64

33

52

9

MSN

0

0

0

seconds

MAN

0

0

0

Total=64

Total=33

ID

66

67

Objective 3: (Note: Please insert Objective 3 here.) Figure 9 presents the reasons for compliance of participants to handwashing guidelines. There were ten participants who expressed that the primary reason why they were able to comply with handwashing was to “prevent transfer of microorganisms from one patient to another and lessen the risk for acquiring nosocomial infections”. This also means that ninety-one percent of the participants expressed that the primary reason why they were able to comply with handwashing was to “prevent transfer of microorganisms from one patient to another and lessen the risk for acquiring nosocomial infections”. Only one of the participants answered “to maintain the sterility of our own workplace”. This also means that only nine percent of the participants answered “to maintain the sterility of our own workplace”. Apparently the only participant who answered in a different way was from the operating room because it is the responsibility of an OR nurse to maintain sterility and prevent microbial contamination, although it should be practiced in any area of the hospital. This finding showed that the nurses were aware of their role as healthcare providers that their duty was to maintain optimal health and preserve life and not to be a cause in acquiring nosocomial infections.

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prevent nosocomial infections

100% 80%

maintain sterility

60% 91% 40% 20% 9% 0%

Figure 10 shows the reasons of the participants for non-compliance to handwashing guidelines. The participants were also asked why they were not able to comply with handwashing for most of the time, thirty-seven percent of the participants honestly answered that most of the time they were really unable to wash their hands or even clean them with alcohol because there were too many patients to attend to and that most of the relatives of the patients were very demanding. Majority of these participants were from the private. The researchers were that aware of this scenario because they witnessed how the participants provide nursing care to their patients and that they handled the same patients. During the time when the researchers were still completing their duty hours in Our Lady of Mercy General Hospital, staff nurses often asked the help of Nursing students (with the guidance of their Clinical Instructors) in performing other nursing activities to diminish their workload.

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About thirty-six percent of the participants insisted that they were indeed washing their hands. They also added that there was no reason for them not to comply with handwashing guidelines because it was a strict regulation in their area to consistently wash their hands. These participants were all from the PICU/NICU, and OR There were twenty-seven percent of the participants who reasoned that liquid soap and water was not available. They used alcohol as an alternative to soap and water. These participants were mostly from the ward. In the OR, nurses and even doctors were having a hard time in scrubbing their hands due to the absence of water. They used mineral water to wash their hands, which was definitely not sufficient because this could result to improper handwashing and scrubbing and might lead to compromised sterility of the area. None of the participants answered that no sink was available. Through the observation it was found out that sinks were accessible in all areas of the hospital. This finding is not congruent with the study of Fortuno (2005) and Gomez (2004) that inaccessible sink is one of the reasons why nurses do not comply with handwashing guidelines. The participants were asked if handwashing guidelines or protocols were readily accessible in their unit and only one of them answered negatively. This also means that only nine percent of them answered negatively. This participant was from the intensive care unit. Majority of the participants answered positively. This also means that ninetyone percent of the participants answered positively. Through further investigations made by the researchers, not all areas of the hospital had handwashing guidelines or protocols

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and the only areas where handwashing guidelines were accessible was in the PICU/NICU, and OR. The participants were also asked if seminars and updates were regularly done in their hospital. Only two replied yes and it was usually done semi-annually. The rest answered negatively. This also means that eighteen percent of them answered yes and eighty-two percent of them answered no. The researchers again made further investigations and it was found out from the nurses who worked in Our Lady of Mercy General Hospital for about 5 years, no seminars and updates were done in the hospital. Objective 4 : (Please insert Objective 4.) Table 2 presents the Intensity of Patient Care (Type of Unit, Nurse-patient Ratio, and Level of Patient Care), and Handwashing Frequency in each Area of Observation. The intensity of patient care was the sum total of the type of nursing unit, nurse patient ratio and level of patient care. Using the Pearson Correlation, the score obtained was +.54. There was a moderate or average positive correlation between the intensity of patient care and handwashing frequency. This also means that the higher the intensity of patient care, the higher the handwashing frequency; the lower the handwashing frequency, the lower the intensity of patient care. The intensity of patient care activity was associated with handwashing frequency but this was not valuable because only thirty-three percent of the participants from the special areas complied with handwashing frequency. These findings were consistent with the study of Fortuno (2004) that high intensity of patient care was associated with low compliance to handwashing frequency.

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(Note: Please improve the table on the next page.)

Area

Type

of

unit

Observation Ward Private OR PICU/NICU ICU

1 1 2 2 2

of Nurse-

Level

Intensity of Handwashin

patient

of

patient

ratio

patient

care

2 2 0 0 2

care 1 1 2 2 2

(total) 4 4 4 4 6

g frequency

11 33 43 106 100

Objective 5 Figure 11 shows the nurses’ use of soap and water or waterless alcohol-based hand solution. Thirty-seven percent of the participants washed their hands incorrectly using soap and water after nursing intervention. Eighteen percent washed their hands incorrectly using soap and water before and after nursing intervention. Nine percent used waterless

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alcohol-based hand solution in cleaning his hands incorrectly before and after nursing intervention. Eighteen percent used both water and soap and waterless alcohol-based hand solution in cleaning their hands incorrectly before nursing intervention. Another eighteen percent used both water and soap and waterless alcohol-based hand solution in cleaning their hands incorrectly before and after nursing interventions. These findings shows that majority of the nurses are using soap and water in cleaning their hands and that all of them did not comply with the ideal handwashing duration.

soap & w ater B&A intervention

18%

18%

soap & w ater A intervention WABHS B&A intervention

18% 9%

37%

both soap & w ater & WABHS B&A intervention both soap & w ater B intervention

B- before

A- after

WABHS- waterless alcohol-based hand solution

73

CHAPTER V Summary, Conclusions, and Recommendations Summary of Findings The summary of the findings of this study are as follows: 1. Most of the participants were female, single, ages 20 to 23 years old, and with a length of professional service of seven months to 12 months. 2. The findings of the study revealed that most male both single and married nurses, whose ages range from 21 to 26 years old, and with a professional service of five months to 36 months were more compliant in terms of handwashing frequency than female married nurses, whose ages range from 23 to 35 years, with a length of professional service of 24 months to 96 months. 3. The major reason why nurses cannot consistently wash their hands was that they were too busy attending the needs of their patients. And the major reason why they should consistently wash their hands was to prevent transfer of microorganisms from patient to another. 4. There was a moderate or average positive correlation between the intensity of patient care and handwashing frequency. This also means that the higher the intensity of patient care, the higher the handwashing frequency; the lower the handwashing frequency, the lower the intensity of patient care. 5. Nurses prefer the use of soap and water to clean their hands. Alcohol is the most preferred alternative to soap and water.

74 Conclusions Based on the findings of the study, the following conclusions were drawn: 1. The major reason why nurses cannot consistently wash their hands was that they were too busy attending the needs of their patients. The major reason why they should consistently wash their hands was to prevent transfer of microorganisms from patient to another. 2. There was a moderate or average positive correlation between the intensity of patient care and handwashing frequency. This also means that the higher the intensity of patient care, the higher the handwashing frequency; the lower the handwashing frequency, the lower the intensity of patient care. 3. Nurses prefer the use of soap and water to clean their hands. Alcohol is the most preferred alternative to soap and water. (Note: Please revise your conclusions. Conclusions should not be a repetition of your findings. Conclusions must be based on the findings.) Recommendations Based on the conclusions of the study, the following recommendations are given: 1. Nurses should strictly follow the proper handwashing guidelines to prevent the spread of hospital acquired infections. . 2. Tertiary hospitals should strictly follow the ideal nurse-patent ratio which is one is to four in non-special units, and one is to one in special units so that nurses will be able to consistently wash their hands.

75 3. Future researchers are urged to develop handwashing assessment tools and observational checklists in assessing other healthcare providers like nursing assistants, midwives, physical therapists, radio therapists, and medical technologists. 4. Researchers are encouraged to develop an intervention program applicable for young children. It is better to teach them proper handwashing techniques as early as possible because they were more susceptible to infections.

76 BIBLIOGRAPHY Books Burton, Gwendolyn R. and Paul G. Engelkirk. 2000. Microbiology. Philadelphia: Lippincott Williams and Wilkins, Inc. Kozier, Barbara.,et.al. 2004. Fundamentals of Nursing. Philippines: Pearson Education South Asia PTELTD. Pillitteri, Adele. 1992. Maternal and Child Health Nursing. Philadelphia: J. B. Lippincott Company. Polit, Denise F. and Cheryl T. Beck. 2003. Nursing Research: Principles and Methods. Philadelphia: Lippincott Williams and Wilkins, Inc. Reyala, Jean P. et.al.2000. Community Health Nursing Services in the Philippines. Manila: Community Health Nursing Section, National League of Philippine Government Nurses, Inc, Sevilla, Consuelo G., et. al. 1992. Research Methods. Manila: Rex Printing Company, Inc. Researches/Internet Articles Barrs, Amy W. Handwashing: Breaking the Chain of Infection. Available: http://en.wikipedia.org. Retrieved January 15, 2007. Case, Christine L. Handwashing. Available: http://www.accessexcellence.org. Retrieved January 15, 2007. Dellinger, Patchen E. 2006. Nosocomial Infection: Discussion. Available: http://www.medscape.com. Retrieved January 15, 2007. Fortuno, Carolina. 2005. An Intervention Program to Improve Nurses’ Compliance to Handwashing Guidelines in a Tertiary Hospital in Manila. Fucanan, Terrie B. 2006. Handwashing-the hottest thing in Health Care. Available: http://www.manilatimes.net. Retrieved January 15, 2007. Garner, Julia S., et.al. 1985. Guideline for Handwashing and Hospital Environmental Control. Available: http://vm.cfsan.fda.gov/~comm/lacf-phs.html. Retrieved January 15, 2007. Lautenbach, Ebbing. Practices to Improve Handwashing. Available: http://vm.cfsan.fda.gov/comm//acf-phs.html. Retrieved January 15, 2007.

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Pittet, Didier. Imposing Adherence to Hand Hygiene Practice: A Multidisciplinary Approach. Available: http://www.cdc.gov/ncidod/eid/vol7no2/pittet.htm. Retrieved January 15, 2007. Zanni, Guido R. Good Hand Hygiene Includes More than Hands. Available: http://www.pharmacytimes.om. Retrieved January 15, 2007. http://www.answers.com. Nosocomial Infection. Retrieved January 15, 2007. http://www.cybervitamins.com. Retrieved January 15, 2007 http://www.mb.com.ph. 2003. Captain Safeguard, Germ Patrol Campaign for Frequent Handwashing. Retrieved February 20, 2007. http://www.kcprofessional.com. Breaking the Chain of Infection. Retrieved January 15, 2007. http://complab.nymc.edu/Curriculum/ComPrevMed/NosoomialInfections.htm. Nosocomial Infections and Infection Control in the Hospital. Retrieved January 15.2007. http://www.vrtua.org Handwashing. Retrieved January 15, 2007.

78 Appendix A Communication Letter for the Chief Nurse January 15, 2007 (Name of Chief Nurse) Chief Nurse Our Lady of Mercy General Hospital Dear Mrs. Villanueva: We, the BSN III students of (name of college), would like to ask your permission to conduct a study in your hospital. The study will entail the nurses’ compliance to handwashing guidelines. Data gathering will be done through written questionnaires, and observational checklists. This study aims to assess the degree of compliance of nurses with regard to handwashing. We look forward to your support. Thank you very much and God Bless!

Truly yours, (4 spaces) (Insert name of the group leader.)

Noted by: (Dean’s Name) Dean (Thesis Adviser’s or Clinical Instructor’s Name) Clinical Instructor Appendix B

79 Handwashing Assessment Tool

(Note: Please improve your Appendix B.) Code Code No. PART I. Respondent’s Demographic Data Name:(Optional) ________________________________________________________________ Age in Years: _____________________________________________________________________ Length of service/professional experience (in years) ________________________________ Gender: ( ) Male ( ) Female Civil Status: ( ) Single ( ) Married ( ) Separated ( ) Widow/widower Educational Attainment: ( ) BSN ( ) MAN/MS/MA ( ) Ph D Area of Assignment:_____________________________________________________________ __ PART II BASIC INFORMATION 1. How important is handwashing for you? ( ) not so important ( ) important ( ) very important 2. Are handwashing guidelines available and easily accessible in your unit? ( ) yes ( ) no 3. Is handwashing seminar/update regularly made in your hospital? ( )yes ( )no If yes how frequent? ( ) monthly ( ) quarterly ( ) semi-annually ( ) annually (If you need more space for question #4-6, please use the back of this sheet) 4. Write your reasons why handwashing should be consistently done in your place of work? _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _____ 5. Write your reasons why at times washing your hands in your place is not consistently done? Write the factors that will influence your decision to consistently wash your hands in your place of work? ____________________________________________________________________ ____________________________________________________________________

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