Introduction is to long – should be less than 1 page justifying the PICO question

·        Need to present a PICO question in a question format

·        Search strategy you need to state the type of studies retrieved e.g. cross-sectional studies x 2 etc

·        Table of studies need sample sizes – the studies seem to be measuring different outcomes - There must be systematic reviews and RCTs on this subject area

·        Need to appraise 5 appropriate studies in depth present each study with the authors and date when discussing – need to look at the strengths and weaknesses of the studies in detail and determine their validity and reliability – (recruitment, drop-out rates, appropriate analysis, the way the study was conducted) what you have done is summarise the findings of the studies as oppose to actually appraising the studies

Hand hygiene among healthcare workers and rates of hospital acquired infections

Hospital-acquired infections is a major issue that threatens the safety of patients is closely related to the mortality and morbidity of inpatients to some extent (Seo et al., 2019). According to a study by the World Health Organization, which was conducted at 55 medical institutions in 14 different countries, nearly one in ten hospitalized patients acquired a nosocomial infection (Martín-Madrazo et al., 2009). In a report, Bhore (2015) illustrated that more than ten percent of hospitalized patients in developed countries have experienced hospital-acquired infections. Not only that, it is the leading cause of death for 80,000 Americans and 5,000 British each year (Martín-Madrazo et al., 2009). On the other hand, the huge economic burden caused by this has also aroused great public concern. Based on rough estimates, European countries spend �7 billion on related health care (WHO, 2011). Therefore, reducing hospital-acquired infections is urgent and necessary from both a medical and economic perspective.

Notably, healthcare-acquired infections may include all kinds of infections that patients obtain in various healthcare settings, for instance, during ambulatory care, home care, and long-term care. As described by Sharma (2018), these are infections that occur in patients at the healthcare facility during the patient-care process. Clearly, there is a significant link between healthcare workers’ hands and the transmission of these infections. Medical workers' hands are the most critical carriers of microbial transmission, and can be transferred from one patient to another, from one site to another, or from contaminated areas to patients (Martín-Madrazo et al., 2009). A study in Vietnam indicated that improving the hand hygiene of medical workers can significantly reduce the rate of nosocomial infection by 10% (Phan et al., 2018). As such, hand hygiene among healthcare workers is widely recognized as a simple and important technique for reducing hospital-acquired infections. Undeniably, other strategies provide essential complimentary control and prevention options.

Although hand hygiene has been widely documented in the literature to reduce hospital-acquired infections, there is little evidence on how hand hygiene among health-care workers reduces hospital-acquired infections. Considering that healthcare providers’ hands provide principal routes for disease-causing microorganisms to be transmitted to patients, many hospitals and other health care facilities, as a primary condition for health care providers, standardize maintaining hand hygiene in practice (Kampf, et al., 2009). Therefore, this paper aims on presenting an evidence-based review of how hand hygiene among healthcare workers can reduce hospital-acquired infections.

Method

The author of this paper conducted an electronic retrieval of published literature from 2010 to 2020, mainly in three databases (Academic Search Complete, CINAHL Complete and MEDLINE). In addition, Boolean logic was used to combine different keywords such as hand hygiene and hospital-acquired infection, to get as comprehensive a result as possible (see Appendix: Search strategy). Full text, published in English, and peer reviewed are limitations for the potentially qualified articles. The author also referred to the reference list of the original selected articles and conducted manual retrieval in Google Scholar. The inclusion criteria were set as follows: 1. The population with hand hygiene was medical workers; 2. Hospital acquired infection rate was the primary outcome or the second outcome. Finally, five studies were included in this paper (see Appendix: Prisma).

Quality assessment

Critical Appraisal Skills Programme tool, well known as “CASP checklist”, which is a critical evaluation tool that is widely used as a guide for the comprehensive appraisal of articles (Nadelson and Nadelson, 2014). CASP checklist mainly includes three dimensions: firstly, are the results valid? Second, what are the results? Third, will the results help locally? (Critical Appraisal Skills Programme, 2018). According to the CASP tool, the author evaluated the overall quality of 5 articles. All the 5 articles had clear statements of aims and used appropriate methodologies. All articles that involved data analysis described in-dept how it was done and present a clear statement of findings. All the articles presented information that would be helpful in answering the research question mentioned previous.

Hand Hygiene Among Healthcare Workers

Hand-washing should be the top priority of healthcare practitioners because it is an essential measure in preventing hospital-acquired infections (Joshi, et al., 2013). As mentioned earlier, several microorganisms find their way to healthcare workers’ through activities like handling patients’ secretions, wound care as well as ‘clean contact’ exercises like taking patients’ temperatures, blood pressure, and pulses. Thus, regular washing of hands can get rid of bacteria acquired from contaminated surfaces.

According to Sharma (2018, p. 202), hand hygiene should be observed: “before patient contact, before aseptic task, after bodily fluid exposure, after patient contact, and after contact with patient surroundings.” Josh et al. (2013) argued that hand-washing should also be regularly performed after contact with body fluids, exposure to hospital instruments, and coughing, blowing the nose and sneezing. “Healthcare providers might need to clean their hands as many as 100 times per 12-h shift, depending on the number of patients and intensity of care (Sharma, 2018, p. 202). This practice helps to reduce microbial colonization of the skin as well as removing some other visible soiling. Also, washing hands using soap and water help to remove contamination that might have been caused by spore-forming bacteria, which are mainly resistant to alcohol sanitizers.

Markedly, washing hands before and after attending to patients is a simple strategy that can help reduce the spread of bacteria and other disease-causing pathogens from healthcare providers to patients. Handwashing and hygienic disinfection are some of the most significant methods that hospital-care personnel can use to minimize the spread of hospital-acquired infections by ensuring that their hands are in the utmost hygienic state. These strategies of maintaining hand hygiene are essential in reducing nosocomial infections.

Since hand-washing is not always a hundred percent effective, hygienic hand disinfection is another strategy that healthcare givers should continuously practice in all interactions with patients. Healthcare providers should ensure that they disinfect their hands before and after activities that involve direct patient contact or even contact with surfaces that might be potentially infected by pathogens (Kampf, et al., 2009). Also, attending to cases with potential nosocomial infections present essential instances where hand disinfection should be practiced. The most common type of infections that healthcare workers can help to stop from spreading through hand disinfection includes surgical site infections, catheter-associated urinary tract infections, bloodstream infections, and pneumonia (Kampf, et al., 2009). To ensure that prevention is done substantially, hygienic hand disinfection should be done consistently before and after coming into contact with patients.

Besides, hand rubs for the disinfection of hands have high efficacy mostly because they are readily available in healthcare environments. The consistent and correct application of these hand rubs reduces bacteria not only efficiently but also practically eliminates them. Key to the significance of hand disinfection is the large number of disease-causing pathogens that it can eradicate. For instance, hand rubs are considerably more effective in eliminating bacteria such as Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, and Escherichia coli (Kampf, et al., 2009). Disinfecting hands is additionally crucial to removing coated viruses like influenza, HIV, and HCV viruses. Notably, this hand hygiene method eliminates most agents responsible for causing nosocomial infections. 

Importantly enough, only a few pathogens are resistant to the commonly available hand rubs. This may include uncoated viruses such as spores of spore-forming microorganisms and noroviruses. However, there are unique forms of disinfectant hand rubs such as the noroviruses virucidal hand rub that is recommended in such cases (Kampf, et al., 2009). These types of disinfectants can also be used in combination with the washing of hands since disinfecting kills vegetative forms while hand-washing removes spores. Another upside of hand rub disinfectants is that most healthcare workers find them considerably tolerable to use. This improves the compliance rate of hand hygiene maintenance among the providers hence reducing the rate of nosocomial infections significantly. It is, however, essential to note that hand disinfection is more effective when performed correctly. For example, Kampf et al. (2009) note that applying adequate amounts of hand rub to cover both hands completely for approximately 30 seconds increases the efficacy of hygienic hand disinfection.

Also, using the correct application and regularly applying the hand rubs allows healthcare workers to disinfect essential parts of the hand, such as fingertips and thumbs. These are areas that are most likely to come into contact with high proportions of pathogens, and they are also the same parts that continually come into contact with patients during care (Kampf, et al., 2009). Thus, hand disinfection is an essential measure that should always be practiced by healthcare practitioners to reduce and, in essence, eliminate the threat of hospital-associated infections.

Comparison of Other Interventions

Importantly, although handwashing and hygienic hand disinfection are effective ways of reducing healthcare-acquired infections, it is noteworthy that they are not always perfect. Accordingly, it is imperative to consider other viable of curbing the spread of these infections, especially considering that the mentioned primary prevention strategies cannot help to decontaminate reusable hospital instruments. Such cases underpin the need for other quality control and preventive measures. Maintaining contact precautions is one such measure. This is a strategy that entails the utilization of dedicated equipment and single-patient rooms. It also requires healthcare workers to wear protective gear with gloves and gowns during patient care (Fernando, et al., 2017). Notably, contact precaution prudent control and prevention strategy that should be applicable at all times.

Use of Protective Gloves

After practicing hand hygiene procedures, healthcare workers should always wear protective gloves before coming into contact with patients. Wearing sterile gloves is an essential precaution because it helps curb contamination and cross soiling in various hospital situations (Kampf, et al., 2009). It is also a sensible way of breaking the chain of infections, for instance, Kampf et al. (2009) found that the use of protective gloves at the bedside directly reduce the transmission risk of Clostridium difficile–associated diarrhea significantly. Besides, protective gloves can help in a wide variety of healthcare system functions which include removal of bandages, examination or treatment of patients, handling of patient excretions or secretions, pulse checking, and blood sampling.

Use of Gowns

The use of gowns is another contact precaution that can be used to prevent the soiling of skin and clothing during patient care procedures that involve body fluids, secretions, and blood. According to Bashar (2019, p. 16), “wearing gowns are common applied in rooms of patients with communicable illness.” These gowns assist healthcare workers in avoiding contaminations in areas that contain immunocompromised or surgical patients. Sterile gowns are also essential for healthcare providers since they curb the spread of hospital-associated infections during aseptic procedures (Mehta, et al., 2014). Conspicuously, protective clothing is essential in preventing contact with broken skin, mucous membranes, or bodily fluids that can cause cross infections.

Cleaning and Sterilization of Equipment

Mostly, several healthcare providers' equipment, including ambulances, blood pressure cuffs, laboratory coats, EKG electrodes, artificial nails, rings, and neckties, present various nosocomial pathogens. To control or prevent the transmission of hospital-associated infections through these items, therefore, their frequent sterilization and cleaning are paramount (Bashar, 2019). Notably, reusable items should not be put to use in patient-care before appropriate cleaning and sterilization are performed. From an environmental factors perspective, high-level disinfection and cleaning of all areas involved in patient care, particularly those surfaces that can potentially come into direct contact with patients and healthcare providers, are essential (Mehta, et al., 2014). These areas include doorknobs, bedside tables, and bedrails.

Presently, there is the availability of enhanced technology that can be utilized to clean surfaces and decontaminate apparatus with higher staff acceptability and improved outcomes. For instance, the use of hydrogen peroxide vapor (HPV) and ultraviolet light (UV) devices allows healthcare practitioners to widely permeate surfaces and inactivate disease-causing pathogens (Fernando, et al., 2017). Furthermore, restricting dedicated equipment that cannot be efficiently sterilized like stethoscopes and blood pressure cuffs to single patients can help minimize cross-infections. In sum, enhancing environmental cleaning, especially in high-risk zones is a horizontal strategy that has a high efficacy of reducing or preventing healthcare-acquired infections.

Employing More Healthcare Workers

An insufficient number of hospital personnel increases the chances of healthcare-acquired infections. Less number of staff means that a single healthcare provider will come into contact with a higher number of patients, therefore, increasing the risk of transmitting nosocomial infections from one patient to another. As such, employing adequate healthcare personnel is another essential contact precaution measure that will help, to no small extent, the control and prevention of the spread of hospital-associated infections. Bashar (2019) found that adequate healthcare staff in a facility considerably lowers the probability of infections to lower levels. Health facilities should, however, ensure that their personnel has sufficient knowledge, training, and skills to deal with nosocomial infections. Bashar (2019, p. 16) asserts that “infection prevention behavior is linked with beliefs, values and social under-standing of dirt and infection.” Notably, an adequate number of qualified staff is a sensible way of ensuring minimum contact, therefore, reducing the spread of healthcare-acquired infections significantly.

Conclusion

In sum, hand hygiene measures such as the washing of hands and hygienic hand disinfection using hand rub are essential strategies towards the control and prevention of healthcare-associated infections. Therefore, they should be the topmost priority of all health care staff. Markedly, these hand hygiene measures, when applied correctly and consistently, can prevent the spread of the most common nosocomial microorganisms that cause these infections. In most healthcare facilities, hand disinfection presents the most crucial strategy for the prevention of the transmission of infections, notably because it offers better cutaneous tolerance and higher efficacy. Its combination with hand-washing is, however, the best method to effectively curb the spread of hospital-associated infections.

Nonetheless, hand hygiene can not be solely relied on to prevent or, in general, stop the transmission of healthcare-acquired infections on its own. As such, other strategies may be necessary to ensure more efficiency. For instance, the use of personal protective equipment such as gloves and gowns to help health care providers avoid getting infected when they come into contact with contaminated surfaces, hospital tools, or patients. Also, transmissions through contaminated surfaces can be restricted through regular cleaning and sterilization of those environments. Contact isolation and barrier precautions are other essential measures that can significantly help to mitigate the threats of healthcare-acquired infections. This method is additionally beneficial because it allows for patients to be put in private environments where there is minimum noise interference.

Increasing the number of healthcare staff has also be found to be a significant intervention strategy. Health care providers should ensure that they have a high number of qualified personnel to reduce contact and prevent the spread of infections. With the availability of all the mentioned intervention strategies, healthcare managers only need to ensure total compliance on the part of their workers for the transmission of hospital-associated infections to stop completely.

Reference:

Bashar, J. F., 2019. Methods of Preventing Hospital Acquired Infection. Advances in Bioscience and Clinical Medicine, 7(3), pp. 13-19.

Bhore, D.N., 2015. Disease burden of nosocomial infections and knowledge of nurses regarding the nosocomial infections: A Review. International Journal of Nursing Research (IJNR), 1(2), pp.138-145.

Critical Appraisal Skills Programme, 2018. CASP Checklist. [online] Available at: https://casp-uk.net/casp-tools-checklists/. Accessed: April 20, 2020.

Fernando, S., Gray, T. & Gottlieb, T., 2017. Healthcare‐acquired infections: prevention strategies. International Medicine Journal, 47(12), pp. 1341-1351.

Haque, M., Sartelli, M., McKimm, J. & Bakar, A. M., 2018. Health care-associated infections – an overview. Infection and Drug Resistance, Volume 11, pp. 2321-2333.

Joshi, K. S., Park, B., Joshi, A. & Umesh, R., 2013. Hand Washing Practice among Health Care Workers in a Teaching Hospital. Journal of Nepal Health Research Council, 11(23), pp. 1-5.

Kampf, G., Lofller, H. & Gastmeier, P., 2009. Hand Hygiene for the Prevention of Nosocomial Infections. Dtsch Arztebl International, 109(40), pp. 649-655.

Martín-Madrazo, C., Cãada-Dorado, A., Salinero- Fort, M.A., Abanades-Herranz, J.C., Arnal-Selfa, R., García-Ferradal, I., Espejo-Matorral, F., Santa-Pau, E.C. De and Soto-Diaz, S., 2009. Effectiveness of a training programme to improve hand hygiene compliance in primary healthcare. BMC Public Health, 9, pp.1–8.

Mehta, Y. et al., 2014. Guidelines for prevention of hospital acquired infections. Indian Journal of Critical Care Medicine, 18(3), pp. 149-163.

Nadelson, S. and Nadelson, L.S., 2014. Evidence-Based Practice Article Reviews Using CASP Tools: A Method for Teaching EBP. Worldviews on Evidence-Based Nursing, 11(5), pp.344–346.

Nekkab, N., Astagneau, P., Temime, L. & Crepey, P., 2017. Spread of hospital-acquired infections: A comparison of healthcare networks. Plos Computational Biology, 13(8), pp. 1-22.

Phan, H.T., Tran, H.T.T., Tran, H.T.M., Dinh, A.P.P., Ngo, H.T., Theorell-Haglow, J. and Gordon, C.J., 2018. An educational intervention to improve hand hygiene compliance in Vietnam. BMC Infectious Diseases, 18(1), pp.1–7.

Seo, H.J., Sohng, K.Y., Chang, S.O., Chaung, S.K., Won, J.S. and Choi, M.J., 2019. Interventions to improve hand hygiene compliance in emergency departments: a systematic review. Journal of Hospital Infection, [online] 102(4), pp.394–406. Available at: <https://doi.org/10.1016/j.jhin.2019.03.013>. Accessed: April 3, 2020.

Sharma, S., 2018. Hand hygiene and hospital-acquired infections. Med J DY Patil Vidyapeeth, 11(3), pp. 201-202.

World Health Organization (WHO), 2011. Report on the burden of endemic health care- associated infection worldwide. Geneva: World Health Organization Press. Available http://apps.who.int/iris/bitstream/10665/80135/1/ 9789241501507_eng.pdf. Accessed: April 25, 2020.

Appendix: Search strategy

Appendix: Prisma