Hand Washing practices of Health Care Workers, RMC, Saudi Arabia, 2003

Nosocomial infections have been recognized for over a century as a critical problem affecting the quality of health care provided in hospitals. Hand washing remains the simplest, least expensive, and most important measure to prevent transmission of nosocomial infections. The present study was conducted to determine the degree of compliance of HCWs of the medical and surgical wards of Riyadh Medical Complex (RMC) with hand washing practices.

An observational descriptive cross-sectional study was conducted during a four week period by unobtrusive observation of HCWs without their knowledge. The study population included a sample of HCWs of both the medical and surgical wards. Structured observation sessions were per-formed at random during day shifts on weekdays for four consecutive weeks from 7:00 am €” 3:00 pm each day (the nurses shifts change every 3-4 days). Each study subject was observed only once. The observation period started when the HCW washed his/her hands and ended when either he/she proceeded to wash the hands again or a coherent episode of care was completed as determined by the observer. We documented whether hand-washing was done, duration and type of antiseptic agent used, whether gloves were used for patient care procedures, and type of procedure performed. Data were collected on a pre-prepared data collection form.

On observation of the medical and surgical wards (five wards each), each ward consisted of 6-7 rooms, each room occupied by 3-4 patients according to room size. It was noticed that there was no sink in the patients' rooms but there was one sink in the nurse's station and another in the doc-tor's room which was located away from the patients rooms. The sink was of the manual type i.e. the taps did not have handles or foot controls or automatic shut off. Regarding available cleansing agents, there was plain soap (bar and liquid form); as for antiseptic agents there was liquid form "chlorhexidine gluconate 4%". Non-disposable brushes were available by the sinks, in addition to paper towels for hand drying.

The study sample consisted of 230 HCWs: 10 consultants, 76 residents, 11 Interns, 23 Medical students, and 110 Nurses. Most subjects were females (56.1%). Saudis constituted 51.3%, followed by Philippinos (25.7%) and Indians (16.5%).

The overall frequency of hand washing was 32.2%. The frequency of hand washing was almost the same among HCWs of medical and surgical wards (33.9% and 30.1% respectively, p=NS). On the whole, 9.1% of subjects washed their hands before patient activity and 32.2% after patient activity (p=<0.001).

Hand washing compliance varied significantly by job category and procedure performed. The frequency of hand washing was highest among medical students (91.3%), followed by Interns (81.8%), then nurses (29.1%), and the lowest was among consultants (10%). The duration of hand washing according to occupation was highest among medical students (6.05 sec), Interns (5.44 sec) and lowest among consultants (3.0 sec) (Table 1). Hand washing was more frequent after performing certain procedures such as suctioning (100%), wound care (52.4%), inserting peripheral IV line (40%), examining patients (31.6%), and emptying of urine bags (21.4%).

The overall frequency of wearing gloves for performing procedures was 43.9%. However, rates of gloving varied for certain procedures such as suctioning (100%), wound care (95.2%) emptying of urine bags (82.1%), and inserting peripheral IV line (45.7%). The frequency of hand washing after removing gloves was only 38.6% (39 of 101 glove wearing incidents).

The association between occupation of HCWs who washed their hands and type of cleansing agent used was not statistically significant.

Hospital acquired infection prolongs hospital stays and consumes substantial hospital resources. In the United States, Hospital acquired infections affect over two million patients annually, causing substantial morbidity, contributing to mortality, and generating costs in excess of $4.5 billion.[1] The U.S. Institute of Medicine ranked health care associated infection in the top ten causes of death with such infections being the primary cause of 1% of all deaths and major contributors to death in 3% of all deaths.[1]

Hand washing has been a universally accepted practice to reduce contact transmission of microorganisms for over a century. It is one of the few infection control practices with clearly demonstrated efficacy and remains the cornerstone of efforts to reduce risk of health care associated infections.[2] The Centers for Disease Control and Prevention (CDC) and the Association for Professionals in Infection Control and Epidemiology (APIC) have published specific guidelines for hand washing.[3]

Bartzokas et al. observed that, despite frequent patient contacts, senior doctors washed their hands only twice during 21 hours of ward rounds.[4] Although doctors spend less time than nurses in direct patient contact and may think that they need to decontaminate their hands less often, they have many transient contacts and move from ward to ward.[4] The same is true for phlebotomists, physiotherapists, radiographers, and some technicians.[4]

There is a general perception that physicians are less inclined to follow infection control practices. In a previous study, after unobtrusive observation of doctors to obtain a baseline hand-washing rate, Tibballs asked a sample to estimate their own hand washing rates before patient contact. Their perceived rate of 73% (range 50%-95%) contrasted sharply with the observed frequency of just 9%.[5]

The recommended duration of hand washing should be 20 seconds. In this study the duration of hand washing was much shorter than recommended. This study reveals that the HCWs are not performing hand washing, the simplest infection control procedure, as often as they should.

It is recommended to educate HCWs on the importance and proper technique of hand washing. It is imperative that adequate facilities for hand washing be provided. Efforts to improve hand washing practice should be multifaceted and should involve both medical and administrative staff and include continuing education and feedback to staff on behavior and infection surveillance data.