ORIGINAL

Compliance with Handwashing in Intensive Care Unit in University Hospitals of La Havana

 

Humberto Guanche Garcell¹, Luisa Nuñez Labrador², Clara Morales Pérez¹, Gloria Fresneda Septiem¹, and Members of Provincial Infection Control Program

 

¹Epidemiology Department. University Hospital ¨Joaquín Albarrán¨, La Havana, Cuba. ²Provincial Department of Hospital Epidemiology, Provincial Center of Hygiene and Epidemiology, La Havana, Cuba.
Correspondence and request reprints: H.Guanche Garcell. Apdo Postal 14072, Marianao 14, La Havana, Cuba. Phone: 053-7-2674367.

 

 

ABSTRACT

 

Observational study to determine handwashing´s compliance was carry out in Intensive Care Units of Havana University Hospitals. Compliance with social and hygienic handwashing was 62,9 % and 58,1 %, better in neonatal ICUs (95,2 %), and in nurses (66,4 %). Is necessary to strengthen educational program and apply interventional strategies.

 

 

Introduction

 

Since Semmelweis[1] showed the real value of hand hygiene in the prevention of infections, it has been the most important preventive measure of health care related infections. Nevertheless, compliance with  handwashing is low according research carry out in different institutions, with average of 28 %-81 % in Intensive Care Units[2],[3]. This low adherence to handwashig is related, according to references, to skin problems produced by hand hygiene product, hand hygiene facilities, type and intensity of patient care and many others[4]-[8], although individual factor could play a role in determining behaviors of health care workers.

 

 

 

 

In Cuba, where the incidence rate of nosocomial infection varies between 2 and 7%, the literature about hand hygiene is scarce, without references about the compliance of handwashing. In this study we evaluated handwashing compliance in Intensive Care Unit of University Hospitals in La Havana (Cuba).

 

Methods

 

Setting

An observational study was carry out in April 2006 in 12 Intensive Care Units (ICU) of  11 University Hospital in La Havana (Cuba), from which 4 were Neonatal ICUs (23 beds), 5 Adults ICUs (92 beds) and 3 Pediatric ICUs (43 beds). According with the National Program for Prevention and Control of Nosocomial Infection hand hygiene with plain soap (social handwashing) is required before any patient contact, and antiseptic solution (hygienic handwashing) may apply only before invasive procedures or previous contact with patients at high risk of infection, always precede by hand hygiene with plain soap.

 

Observations

Thirteen infection control nurses, informed about the aim of the study and trained in research procedures, recorded potential opportunities for and actual performance of handwashing during 2 hours period during day (8:00 a.m. to 4:00 p.m.). The patients of a selected room were chosen for the observation. Two kinds of procedures were considered: 1) invasive procedures, those to involve vascular access (drug administration, place intravascular device, other purposes) or place urinary catheter, contact with non-intact skin, and suctioning respiratory tract secretions, 2) no invasive procedures, those to involve contact with intact skin or mucous membrane. In a specially designed report infection control nurses register if the health care worker wash hand with plain soap and apply antiseptic solutions previous invasive or no invasive procedures and its professional category (physician, nurse, and technician).

 

Analysis

Rates of handwashing were calculated by dividing the number of observations in which social handwashing or hygienic handwashing were used by the total number of handwashing opportunities, according professional status (nurse, physician, technicians), ICU type (Neonatal, Pediatric, Adults), and procedures type (invasive, non invasive).

 

Results

 

In 24 hours of observations, observers recorded 198 opportunities for handwashing (78 previous invasive procedures, and 120 previous non invasive procedures). The average compliance with social handwashing was 62,9 % (table 1), better previous invasive procedures (69,2 %) than non invasive procedures (58,3 %). Hygienic handwashing was done before invasive procedures in 53,7 %, while before non invasive procedures was performed in 61,4 % of instances, and in general in the 58,1 % of opportunities. The better compliance with social handwashing was in neonatal ICUs (95,2 %), while in adult ICUs was 59,2 %, in pediatric ICUs was 57,9 %, while the use of antiseptic solution before invasive procedures was better in pediatrics ICUs (73,3 %), than  adults ICUs (68,9 %) and neonatal ICUs (50,0 %).

 

 

 

Social handwashing compliance also varied with professional status. Nurses had better compliance with 66,4 %, and physicians and technicians had compliance rates of 59,1 % and 46,7 %.  Nevertheless, before invasive procedures physicians wash hands 87,5 % of opportunities, while nurses and technicians do in 68,2 % and 50 %. The lowest compliance with hygienic handwashing was found in technicians with 28,6 %, which wash hands 20 %  of opportunities before non invasive procedures and 50 % before invasive procedures. Physicians and nurses had better hygienic handwashing compliance with 57,7 % and 60,4 %.

 

Discussion

 

This is the first report about handwashing adherence in Cuban hospitals that confirm that low compliance in Intensive Care Units, especially in adults ICU, is an important problem related with infection control. As other literature reports[8] we found better compliance in neonatal and pediatrics ICUs, nevertheless is obvious that adherence in pediatrics ICUs was very low in comparison with neonatal ICUs, although both groups of  patients had high risk of acquired infections. In a recent published report, quality of handwashing was considered good in 71,4 % of opportunities in a neonatal ICU in Cuba, without specify adherence[9].

 

In the same way, as other report, we have found that nurses had higher compliance when compared with others health care professional (physicians, technicians), in spite of nurses had the greatest number of opportunities for patient contact, specially in intensive care units where the majority of procedures are doing by them[10].

 

Differences between adherence to social and hygienic hangwashing according ICU type and professional status can be explained by differences in training of health care workers and the perception of risk of infectious diseases transmission. Also  guidelines of hand hygiene in Cuba no approve handrubs as an alternative of handwashing with plain soap in specific conditions.

 

Some limitations regarding this study should be acknowledged. First, the observations were carried out during day time (8:00 a.m. – 4:00 p.m.) and due the intensity of labour is variable during working day the adherence could change. Second, brief period of observations (only two hour per ICU) could be insufficient to estimate handwashing compliances. Is clear the necessity to perform new researchs that explore handwashing adherence, and include others aspect related to adherence to handwashing.

 

For more than a century healthcare worker know that the best way to prevent the transmission of infections is wash hand before and after every contact with patient or other environmental sources of infections, however the problem still exists. The low adherence with handwashing demonstrated in our study make necessary to strengthen the educational program of health care workers and apply interventional strategies to solve this problem strongly related with healthcare quality.

 

Acknowledgements: The authors thank the infection control nurses who participated and conducted field observations.

 

References

 

1. Guideline for Hand hygiene in health-care settings.  MMWR 2002; vol. 51, no. RR-16.

 

2. Akyol A, Ulusoy H, Ozen I. Handwashing: a simple, economical and effective method for preventing nosocomial infections in intensive care units. J Hosp Infect. 2006; 62: 395-405.

 

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

 

4. Kuzu N, Fadine O, Semra Aydemir, et al. Compliance with hand hygiene and glove use in a university-affiliated hospital. Infect Control Hosp. Epidemiol 2005; 26:312-5.

 

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6. Pittet D, Mourouga P, Perneger TV; and the Members of the Infection Control Program. Compliance with handwashing in a teaching hospital. Annals of Internal Medicine 1999 ; 130:126-30.

 

7. Lankford MG, Zembower TR, Trick WE, et al. Influence of role models and hospital design on hand hygiene of health care workers. Emerging Infectious Diseases 2003; 9:218-23.

 

8. Pittet D, Simon A, Hugonnet S, Pessoa et al. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med. 2004; 141:1-8.

 

9. Urbiza Laza O, Foler Cardena SF, Otero Ceballos M. Evaluación del desempeño  del profesional de enfermería del servicio de neonatología. Educ Med Sup 2006; 20(1). http://www.bvs.sld.cu/revistas/ems/vol20_1_06/ ems04106.htm.  access June 2, 2006.

 

10. Lipssett P, Swoboda SM. Handwashing compliance depends on professional status. Surgical Infections 2001; 2:241-5.