The effect of a continuous educational program on handwashing compliance among healthcare workers in an intensive care unit

Abstract

Handwashing is simple, cost-effective and the single most important measure in the prevention of transmission of multiple antibiotic-resistant bacteria, which can spread via the contaminated hands of healthcare workers (HCWs) in intensive care units (ICUs). Despite this simplicity and efficacy, compliance with handwashing protocols is unsatisfactory among HCWs in ICUs. No single interventional measure is successful in improving handwashing compliance.

A continuous educational program was started in February 1998 by the department of infection control, emphasising the importance of handwashing in the prevention of nosocomial infections in the ICU. It took the form of posters, lectures and regular discussions. The posters were pasted in all the strategic areas of the ICU, displaying the indications and precise technique of handwashing. HCWs were directly observed for handwashing compliance, while working in the ICU. Each indication of handwashing was counted as an opportunity of handwashing.

Assessment of handwashing compliance was made once a year during the educational programme. In the final annual assessment in February 2002, out of 1,175 opportunities of handwashing, compliance was observed in 856 (72.8%) among all categories of staff. Highest compliance of 97.5% was recorded among nurses. The compliance among technicians was 47.7%, while the lowest compliance of 37.6% was observed among doctors (RR 2.591, p<0.0001). Opportunities of handwashing utilised with good technique were observed among 98.2% nurses. Handwashing compliance among females was significantly higher (76.2% versus 23.8%) than the male HCWs (RR 3.196, p<0.0001).

A comparative study of the yearly assessments made since the start of the educational program also revealed significant increases in handwashing compliance among nurses (p<0.0001) and technicians (p<0.001), while no statistically significant changes in the handwashing behaviour among doctors was observed during the study period (February 1998 to February 2002).

Disappointing handwashing compliance among doctors visiting and working in the ICU, despite their better understanding of hospital-acquired infections (HAI) and continuous educational programme remains a cause for concern. Additional efforts are required to discover more effective interventional measures to improve handwashing compliance among doctors.

Keywords

Handwashing compliance educational intervention intensive care unit

Get full access to this article

View all access options for this article.

References

Albert RK , Condie F. (1981) Handwashing patterns in medical intensive care unit. N Engl J Med 304: 1465-6.

Bryan JL , Cohran J. , Larson EL (1995) Handwashing: a ritual revisited. Crit Care Nurs Clin NA 7: 617-25.

Conly JM , Hill S. , Ross J. , Lertzman J. , Loulie TJ (1989) Handwashing practice in an intensive care unit: the effect of an educational program and its relationship to infection rate . Am J Infect Control 17: 330-9.

Coignard B. , Grandbastien B. , Berrouane Y. (1998). Handwashing quality: impact of a special program . Infect Control Hosp Epidemiol 19: 510-3.

Donowitz LG (1987) Handwashing technique in a pediatric intensive care unit. Am J Dis Child 141: 683-5.

Dubbert PM , Dolce J. , Richter W. , Miller M. , Chapman SW (1990) Increasing ICU staff handwashing: effect of education and group feed back. Infect Control Hosp Epidemiol 11: 191-3.

Dorsey ST , Cydulka RK , Emerman CL (1996) Is handwashing teachable? Failure to improve handwashing behavior in an urban emergency department. Acad Emerg Med 3: 360-5.

Fridkin SK , Welbel SF , Weinstein RA (1996) Magnitude and prevention of nosocomial infections in the intensive care unit. Infect Dis Clin NA 11: 479-96.

Fridkin SK , Gaynes RP (1999) Antimicrobial resistance in intensive care units . Clin Chest Med 20: 303-16.

10.

Garner JS (1996) Hospital infection control practice. Advisory committee: Guidelines for isolation precautions in hospitals. Part 1: evolution of isolation practices. Am J Infect Control 24: 24-31.

11.

Graham M. (1990) Frequency and duration of handwashing in a intensive care unit. Am J Infect Control 18: 77-81.

12.

Gould D. (1994) Nurses hand decontamination practice: results of a local study. J Hosp Infect 28: 15-30.

13.

Greco PI , Eisenberg JM (1993) Changing physician's practices. N Engl J Med 829: 1271-4.

14.

Guinan ME , McGuckin-Guinan M. , Sevareid A. (1997) Who washes hands after using the bathroom? Am J Infect Control 25: 424-5.

15.

Hugonnet S. , Perenger TV , Pittet D. (2002) Alcohol-based hand rub improves compliance with hand hygiene in intensive care unit. Arch Intern Med 162: 1037-43.

16.

Karabey S. , Ay P. , Derbentli S. , Nakipoglu Y. , Esen F. ( 2002) Handwashing frequencies in an intensive care unit. J Hosp Infect 50: 36-40.

17.

Khatib M. , Ghassan J. Abdullah A , Ibrahim Y. (1999) Handwashing and use of gloves while managing patients receiving mechanical ventilation in ICU. Chest 116: 172-5.

18.

Larson EL (1988) A casual link between handwashing and risk of infection? Examination of the evidence. Infect Control Hosp Epidemiol 9: 28-36.

19.

Larson EL (1995) APIC guidelines for handwashing and hand antisepsis in healthcare setting. Am J Infect Control 23: 251-69.

20.

Myer JA , Dubbert PM , Miller M. , Burkett PA , Chapman SW (1986) Increasing handwashing in an ICU. Infect Control 7: 259-62.

21.

Naikoba S. , Hayward A. (2001) The effectiveness of interventions aimed at increasing handwashing in healthcare workers — a systematic review. J Infect Control 47:173-80.

22.

Pittet D. , Mourouga P. , Perneger TV (1999) Compliance with handwashing in a teaching hospital . Ann Intern Med 130: 126-30.

23.

Pittet D. , Hugonnet S. , Harbarth S. (2000) Effectiveness of hospital-wide programme to improve compliance with hand hygiene. Lancet 356: 1307-12.

24.

Pittet D. (2000) Improving compliance with hand hygiene in hospitals . Infect Control Hosp Epidemiol 21: 381-6.

25.

Plowman R. , Craves N. , Roberts J. , Swan A. ( 1997) The socio-economic burden of hospital-acquired infections . Public Health Laboratory Services: London.

26.

Stender J. , Rosenberg FA (1998) Study of handwashing procedures in the bathrooms of Boston area hospitals. Am J Infect Control 26: 451-2.

27.

Tearre EL , Cookson B. , French GL (1999) Handwashing — a modest measure with big effects . British Medical Journal 318: 686.

28.

Tibballs J. (1996) Teaching hospital medical staff to wash hands. Med J Aust 164: 395-8.

29.

van de Mortel T. , Bourke R. , Fillipi L. , McLoughlin L. , Molihan C. , Nonu M. ( 2000) Performance feedback should be repeated within a year to maximise handwashing rates in the critical care unit. Aust Crit Care 13: 91-5.

30.

van de Mortel T. , Bourke R. , McLoughlin J. , Nonu M. , Reis M. ( 2001) Gender influence handwashing rate in the critical care unit. Am J Infect Control 29: 395-9.