Introduction
Many hospital infections are avoidable and depend on the dedication of healthcare practitioners to apply the guidelines for infection control in the healthcare environment (Pratt et al., 2007). Implementing the existing research evidence and compliance with updated guidelines enhances the safety of the patient and reduces the chances of infection (Pratt et al., 2007). This paper discusses hand-washing evidence in the control and prevention of hospital-acquired infection (HAI) in the operating department and the principles of safe practice. Besides, the paper will identify the effects of behavioural change and improvement science on practice and the healthcare environment. In particular, the focus of this essay will be on control and prevention of infection through hand washing in the perioperative environment and the principles of safe practice whilst recognising practice limitations. Specifically, the paper will focus on hand washing practice in the UK healthcare setting.
Position of Healthcare Providers in Hospital Infection
Cross-contamination of pathogens between people occurs through hands or an environmental source, such as air. According to the Southampton NHS (2015), the significance of hand hygiene in preventing cross-infection was proven in the nineteenth century. Consequently, healthcare staff have been involved in many epidemics of infections in the United Kingdom and other countries.
Epidemiologic evidence shows that hand-mediated transmission is the main risk factor associated with the acquisition and transmission of hospital infections (Loveday et al., 2014). The present guidelines identify that effective hand decontamination results in a reduction in the spread of pathogens from one patient to another. In light of this, it is logical that the incidence of preventable hospital-acquired infections is decreased, thereby reducing the morbidity and mortality of patients (Loveday et al., 2014). Hand hygiene also helps prevent infection among staff.
Healthcare staff, including operating nurses and professionals, are required by standard guidelines, such as the WHO and the entre for Disease Control and Prevention, to wash their hands on multiple occasions. Operating staff must wash their hands before and after wearing theatre attire, including mask, gloves, and gowns, among others (Pratt et al., 2007). Importantly, the staff must keep their fingernails clean, short, and free from nail varnish. Pseudo fingernails, such as acrylic, fibreglass, and gel-coated fingernails, are prohibited as they harbour pathogens even after hand washing, besides interference with the practice itself (Royal Cornwall Hospital, 2015).
Evidence-Based Hand Washing Practice Guidelines
Patients are exposed to the risk of developing a hospital-acquired infection(s) when their ordinary and professional carers or their relations have contaminated hands (Loveday et al., 2014). Consequently, these people must decontaminate their hands before and after providing care to their patients. Both informal carers and healthcare professionals must decontaminate their hands at important occasions before, during, and after patient care procedures to avoid cross-transmission of potential pathogens (Loveday et al., 2014). Based on Loveday et al. (2014), evidence from the National Institute for Health and Clinical Excellence (NICE) showed increased compliance with hand decontamination before and after contact with the patient, about the implementation of the WHO and the United States CDC guidelines of 2002, although compliance was low after contact with the patient environment.
The WHO framework and NICE guidelines (cited in Loveday et al., 2014) recommend that healthcare workers decontaminate their hands shortly before and after each episode of direct contact with the patient, and after contact with body fluids, epithelium, and non-intact skin. In addition, the framework and guidelines recommend decontamination of hands immediately after other activities within the patient environment and after removing gloves (Loveday et al., 2014). There are various methods of decontaminating hands, including hand washing using soap and alcohol-based hand rub (ABHR), among others (Sicoli & Hunter, 2012).
Latest guidelines consider the efficacy of different preparations for decontaminating hands by washing with soap and water, ABHR, and antiseptic agents. In light of this, no compelling evidence favours the overall use of antiseptic hand-washing agents over soap or antiseptic agents (Loveday et al., 2014). Nevertheless, all hand hygiene products for use in clinical care must conform to the updated British Standards.
Various studies were conducted within the past two decades to compare ABHR, gels, liquid soap, and antiseptic hand-wash (Loveday et al., 2014). In this vein, randomized controlled trials (RCTs) and some quasi-experimental studies have demonstrated alcohol-based agents to be more efficacious compared to soaps and antiseptic hand-washing preparations. On the other hand, some studies have shown no statistical difference between these preparations (Loveday et al., 2014). Many studies involve the use of ABHR as part of multiple practices and have different methodological limitations that weaken the validity of these studies about the effectiveness of the technique in reducing hospital-acquired infections. Nonetheless, evidence from laboratory studies underscores the benefit of ABHR in reducing pathogen counts on the healthcare workers’ hands in addition to helping overcome challenges to hand washing practice. Specifically, ease of use makes ABHR the preferred method of hand decontamination over hand washing (Loveday et al., 2014).
Factors that Inform the Choice of Technique for Handwashing
Selecting the technique for hand hygiene depends on the analysis of what is necessary for the care episode, the available resources, and personal preferences about preparations (Pratt et al., 2007). Thorough hand washing with soap and water or the use of ABHR eliminates transient microbes and leaves the hands clean. The latter technique also reduces the normal flora. While this degree of sterilisation is adequate for overall social contact and some care activities, the use of antiseptic preparations is essential in settings where prolonged sterility of the hands is needed, such as in surgery and in outbreaks (Loveday et al., 2014). Washing hands using antiseptic soap helps reduce both transient and resident microorganisms, and specific antiseptic soaps have residual effects (Loveday et al., 2014). This process is especially important given that ABHR is insufficient against some microorganisms, such as Norovirus and spore-forming bacteria like C. Difficile. Furthermore, this technique does not remove dirt and organic materials, and is not effective in certain epidemics (Loveday et al., 2014). Certain studies support this position (Jabbar et al., 2010; Grayson et al., 2009; Turner et al., 2010).
Loveday et al. (2014) identified two laboratory studies that prove the inefficiency of ABHR in eliminating the spores of C. difficile from the hands of healthcare workers (Oughton et al., 2009; Jabbar et al., 2010). Oughton et al. (2009) compared different techniques for hand decontamination, including liquid soap, chlorhexidine gluconate (CHG) soap, which involves, antiseptic hand wipes, and ABH, which do not involve water. The researchers found that all protocols that involved water and soap had a greater mean reduction in the colony-forming unit (cfu). Antiseptic hand wipes came second in efficacy, and ABHR was the least of the three and was equivalent to control – no intervention (Oughton et al., 2009).
Jabbar et al. (2010) compared three different concentrations of ABHR with antiseptic CHG soap and water. The CHG soap and water decontamination technique was superior to the different concentrations of ABHR. In addition, the researchers found that the use of ABHR allowed the cross-transfer of about 30% of the residual spores via handshake. In the same vein, a more recent study showed that ABHR and liquid soap and water with and without CHG had equal effect in reducing H1N1 virus copies (Grayson et al., 2009). However, Turner, Fuls, and Rodgers (2010) found that 65% ethanol sanitizers were superior to soap and water in removing Rhinovirus.
Based on the guidelines for operating departments for prevention of hospital-acquired infections, soap and water are the preferred procedure over alcohol rub for prevention of transmission of infections in operating theatres and emergency rooms. The guideline also requires staff to encourage patients to wash their hands, although they can use alternative wet wipes if they are bed-bound (Royal Cornwall Hospitals, 2017).
Hand washing plays a central role in the prevention of hospital-acquired infection. Staff are required to wash their hands before coming out of the patient zone as a precaution after removing personal protective equipment (PPE) while still in the patient zone (Royal Cornwall Hospital, 2017). Operating staff must always wear gloves when entering the theatre and put on a protective apron in anticipation of substantial contact with the patient.
The hands of healthcare workers can act as a vehicle for the carriage of norovirus. Consequently, all staff should essentially wash their hands as deemed necessary with the correct washing procedure to reduce transmission of this organism. Washing hands with soap and water before and after contact with a patient is preferred because alcohol gel is ineffective on many microbes (Jabbar et al., 2010). The same practice should be observed also after contact with infectious equipment and furnishings. These workers should bear in mind that gloves do not obviate hand washing (Royal Cornwall Hospitals, 2017). Although alcohol gel is recommended for use when entering and leaving the isolation area and after contact with a patient, health staff are required to wash their hands with soap after contact with body fluids, including sputum and contaminated items (Royal Cornwall Hospitals, 2017).
Impact of Behavioural Change and Improvement Science on Practice and the Healthcare Environment
Hospital-acquired infections and heightened resistance to antimicrobials have made infection prevention and control (IPC) a priority of the initiatives to boost care quality. Based on Edwards et al. (2012), the incidence of meticillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile infections (CDI) reduced by 59% and 64% respectively, in England since 2007. This trend is attributed to the UK government policy of compulsory surveillance, evidence-based guidelines, and initiation of hospital infection reduction programmes (Edwards et al., 2012). However, the review of research revealed a universal suboptimal adherence to infection control guidelines. According to Edwards et al. (2012), adherence to the hand-washing practice has remained at 40% despite evidence of its benefits in reducing hospital infections. As a result, effective approaches for changing the infection prevention behaviours of healthcare professionals are necessary to reduce infections and enhance the safety of patients (Edwards et al., 2012).
A systematic review of studies by Edwards et al. (2012) on infection prevention and control behaviours revealed that behaviours of healthcare workers are led by environmental, emotional factors that explain the inconsistency in adherence to guidelines advocating hand washing for control of hospital-acquired infection. The studies also revealed that while infection prevention is a major concern for patients, for some healthcare staff, it is not necessarily a priority (Edwards et al., 2012). Such workers perceive the physical environment, personal protection, and medication as the greatest risk to safety. Some nursing staff attach more weight to the external circumstances than their behaviours about preventing cross-contamination by observing hand hygiene.
Limitations of Hand-Washing Practice
Studies suggest that hand washing is an acquired behaviour as opposed to a logical process, such that interventions to reinforce hand hygiene behaviour must target experiential reasoning (Edwards et al., 2012). In addition, environmental factors such as sink location influence the tendency to wash hands (Deyneko et al., 2016). The location of the sink for washing hands is a major hindrance to the practice of hand washing. Therefore, understanding the hindrances and enablers to the handwashing practice is crucial to fostering compliance with the handwashing guidelines (WHO, 2009). Deyneko et al. (2016) highlighted that many healthcare settings face a significant gap between patient rooms with Clostridium difficile infections (CDI) and accessible hand-washing sinks, pointing to a widespread insufficiency in sink availability. This situation is attributed to the fact that most of the hospitals are old – they were built when the significance of hand hygiene was underestimated.
In the United States, the incidence of CDI has increased significantly, affecting about half a million patients, leading to 29,000 deaths every year (Lessa et al., 2015). International guidelines require CDI patients to be isolated from other patients to reduce cross-transmission of the pathogen (Deyneko et al., 2016). However, this decision distances these patients from sinks for hand washing, which makes adherence to hand washing guidelines a challenge in preventing the spread of CDI. In this vein, Deyneko et al. (2016) showed that the availability of sinks for washing hands affects compliance with hand washing practice independently. Therefore, the distance of hand-washing sinks from the patient zone decreases compliance with the practice. Compliance with hand washing can be enhanced by constructing hand-washing sinks in different locations at hospitals and other healthcare facilities.
Conclusion
Various techniques are used to reduce the spread of HAI, although many guidelines recommend hand washing with water and soap as the most effective technique to reduce the incidence and spread of new infections in healthcare settings. Environmental factors and personal beliefs about infection prevention hinder compliance of healthcare workers with hand washing guidelines. While other preparations, such as ABHR and antiseptic hand wipes, are easy to use, effective hand washing with liquid soap is proven as an efficacious way of reducing colonies on hands.
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