In promotion for more research to be carried


In
conclusion, hand decontamination has been proven to be the most important
measure that protect patients, healthcare workers and the environment from
microbial contamination. The use of gloves does can not replace the need for
effective hand hygiene practices as they do not fully protect hands from becoming
contaminated. Easy and timely access to hand hygiene facilities, continuing training
and education, continuous compliance observation and performance feedback ,
reminders (written and verbal) in form of poster and education leaflets in
workplaces, promotion of staff skincare, enhanced staff participation both at
individual and organisational levels, continuous multiple interventions in
sustaining behaviour change and effective implementation of guidelines are crucial
steps within the multimodal intervention strategies aim to improve compliance
to hand hygiene. There is need for on going promotion for more research to be
carried out to come up with solutions to improve healthcare workers adherence
thereby enhancing patient safety.

Interventions
primarily focused on individual has been insufficient to effect long term change
to keep hand hygiene compliance higher. Healthcare workers behaviour around
hand hygiene has shown to vary indicating that personality, culture and the
community have significant influence on behaviour. Inability to achieve a
higher level of compliance among healthcare workers indicates that behaviour
change is a complex task to achieve as behaviour is a result of multiple
influences overtime primarily: genes, education, environment and culture.
Compliance with hand hygiene practices among nurses has been frequently
investigated because they spend most of their time in direct contact with the
patient and thus have several opportunities to carry out hand decontamination
while carrying out patient care and treatment. Behavioural modelling has
identified that major influence of nurses’ hand hygiene practices in the
healthcare setting is merely the translation of their community attitudes which
is developed in early childhood. Thus, behaviour change is complex and interventions
to help modify behaviour pattern involves combination of motivation, education
and organisational cultural change.

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The method of
hand decontamination to be used by healthcare workers will largely depend upon
the assessment of what is most appropriate for any episode of care,
availability of hand washing resources at the point of care. Hands can be decontaminated
effectively by: keeping hands and wrist free of any jewellery; having short
sleeve clothing on to expose wrists and forearms when carrying out patient
care; finger nails should be kept short and clean without any false nails nor
nail polish; all cut duly covered with water proof dressing. Hand
decontamination using an effective technique ensures that no part of the hand
surfaces is missed out.

Key
components to be put in place in health settings for effective hand hygiene
include : easy access to soap & water at all point of care; provision of
regular training on importance of hand decontamination for all healthcare workers;
putting in place evaluation of hand hygiene practices with resulting feedback
communicated to staff to help improve and sustain high levels of compliance;
having reminders as posters in place at workplace to prompt and remind staff
about the importance of hand hygiene creating a workplace environment that
continue to create awareness about patient safety. In 2009, WHO launched a
programme themed “SAVE LIVES: Clean Your hands” which aim to reinforce – the Five
Moments for Hand Hygiene. Its an approach that prompts healthcare workers to
clean their hands: before carrying out clean /aseptic procedure; immediately
after been in contact with body fluids, wound dressings, mucous membranes and
non-intact skin; before patient care that involves  use of invasive device regardless of whether gloves
was used or not  ; after moving from
contaminated body site to clean body site of the same patient; after coming in
contact with a patient and immediately before coming in contact with the next patient;
immediately after been in contact with objects or equipment within a patient immediate
surroundings and immediately after removal of gloves.

Hand
decontamination is a core element that promotes patients’ safety, preventing
against healthcare associated infections as pathogens are readily transmitted from
the healthcare workers hands.  Hand
hygiene does have a dual effect, protecting both the patients and health care
workers from acquiring pathogens that could cause ill health. Health workers hands
is of great risk in spreading pathogens at point of care from one patient to
the other; from staff to patient and from patient to staff. Patients and
relative should also be educated about hand hygiene, patients should be
prompted to clean their hands before meals, after been to toilet and at other
appropriate times. Microorganisms can also be transmitted from equipment and
environment to patients resulting in the spread of infections especially in health
care settings. Despite all the awareness and policy over the years of Infection
Prevention & Control, overall compliance over the years is still low across
the NHS settings.

Its been
observed that health care workers adherence to recommended hand hygiene procedures
remain poor. Factors that influence health care workers adherence to hand
hygiene practices include: lack of performance feedback to staff; lack of
knowledge of applicable hand hygiene guidelines; assumptions of low risks of getting
infection from patients; interference of hand hygiene procedures with
healthcare worker-patient relationship;  lack
of active involvement of staff in hand hygiene promotion in the system; not
thinking about it or just being forgetful of hand hygiene practice; lack of
role models from colleagues or superiors; high work load and understaffing;
inaccessible supplies of hand hygiene products; time pressures and tasks
turnaround time ; lack of scientific information on the positive impact of
improved hand wash practices on the drop in the rates of hospital acquired
infections; perceived patient needs over hand hygiene procedures; wearing of
gloves ;irritation and drying  effects of
hand hygiene products on the skin of staff when used on regular basis.

The three
levels of hand hygiene include: Routine hand hygiene whereby liquid soap is
used with warm running water to remove dirt, body fluids, dead skin and most
transient microorganisms that have been acquired through direct contact with
the patient and its immediate environment. Second level is the antiseptic hand
hygiene, using antimicrobial solution or liquid soap with warm running water
which is followed by application of antiseptic hand wash agent i.e. Hydrex that
disinfects the hands removing transient microorganisms and skin resident flora.
This is often done prior to invasive procedures and for high risk areas e.g.
Isolation units as well as in Intensive care unit on the ward; before and after
wound care, urethra or Intravenous catheters etc. The third level is the Surgical
hand hygiene which is carried out using antimicrobial hand wash, the solution
binds to the skin creating an effective barrier that removes and kills the
transient microorganisms and reduce substantially the resident flora on the
hands of the surgical healthcare practitioners for the duration of the surgery,
in case a surgical glove gets torn or punctured during surgery. This level is
carried prior to all surgical procedures e.g. vasectomy.

Effective
hand washing techniques involves three stages: preparation, washing and
rinsing, drying. Hands can be decontaminated preferably with an alcohol based handrub
which has a wide antimicrobial spectrum, less damaging to the skin than soap with
little often common side effects from its usage. Alcohol hand rubs are highly
recommended based on the following factors: suitable for use in remote
healthcare settings that lack basic hand washing facilities, promotes hand washing
compliance with healthcare workers as the procedure is convenient and faster,
great spreading quality, evaporates rapidly, act rapidly against all bacteria yeast
and fungi with minimal risk of generating resistance to antimicrobial agents. However,
soap and water must be used: after caring for patients with potential for the
spread of alcohol-resistant microorganisms such as Clostridium difficile and organisms
that cause diarrhoea, norovirus etc; when hands are visibly or potentially
soiled with body fluids. An emollient hand cream should be applied regularly to
keep the skin moist to protect it from the irritant and drying effects of
regular use of hand decontamination products, therefore promoting compliance
with hand hygiene amongst health care workers as the irritant and drying effect
of hand wash has been identified as one of the reasons for non-adherence to
hand wash guidelines. Example of side effects of frequent use of hand washing
products( particularly soaps and detergents) is irritant contact dermatitis
which is extremely common among nurses, ranging in surveys from 25% to 55% and
as many as 85% with history of skin problems(WHO, 2009).However, various approaches
have been identified in reducing incidence of irritant dermatitis among healthcare
workers : use of less irritant hand hygiene products, use of emollient cream to
act as moisturisers following hand washing procedure.; avoidance of certain
practices that could increase the likelihood of skin irritation for example the
use of hand wash with soap and water immediately before or after the use of
alcohol-based hand wash product ; so also the use of gloves when hands are
still wet from either cleansing or use of alcohol also increases the risk of
dermatitis. The emollient cream contains humectants, various fats and oil that
help increase skin hydration and replace altered or depleted skin lipids that
aid barrier function of normal healthy skin.

Majority of
healthcare associated infections can be treated with antibiotics, but the
inappropriate use of antibiotics overtime led to emergence of highly resistant
strains of bacteria which are difficult to treat. There is a continuous
awareness on Hand Hygiene especially in the healthcare setting due to the emergence
of pathogens that are highly resistant and difficult to treat such as methicillin-sensitive
and methicillin-resistant Staphylococcus Aureus (MSSA/MRSA), penicillin-resistant
Streptococcus pneumoniae, Clostridium difficile, multi-resistant Gram-negative
bacteria such as Acinetobacter species and vancomycin resistant enterococci
(VRE). In 2007, MRSA and Clostridium difficile were identified as the
underlying cause of approximately 9,000 deaths in hospitals and primary care
settings in England (NICE Clinical Guideline, March 2012). Current National and
International guidance have identified that the simple act of hand hygiene does
help significantly in vast reduction of transmitted hand pathogens which in
turn reduces avoidable infections but compliance among healthcare workers
continue to be a problem. Published studies show that on average at any one
time, hand hygiene compliance is only about 40% (WHO Guidelines on Hand Hygiene
in Health Care, 2009).

Health care
associated diseases are caused by a wide range of microorganisms which are
often carried by the patients and on the health care practitioners’ hands,
infection then arise when these get transmitted to susceptible sites on the
patient body such as surgical wounds, urinary tract, lower respiratory tract
and the bloodstream or through insertion of an invasive device or procedures such
as tubes for pulmonary ventilation and catheter insertion. For example, patients
often get catheter-associated urinary tract infections and blood stream
infections from vascular devices. Transmission to non-critical body sites of
patients can still leave the patient colonised with pathogens which if
opportunity arise, might result in infection in the future. HCAI affects
hundreds of millions of people worldwide and has been a major global issue
around patient safety. It has been identified that at any one time 8% of
inpatients in England and 6% in Wales have acquired HCAI; Statistics from
England and Wales shows 5,109 MRSA death & 13,189 Clostridium difficile
during 2001-2006 in NHS in-patient setting (Office for National Statistics,
2008). Impact of HCAI includes prolonged hospital admission, further distress
for patients, higher cost of care for patients and their families, slow
recovery, prolonged or permanent disability, increased resistance of pathogens
to antimicrobials, high financial burden on the NHS and excess preventable
deaths.

Hand
decontamination is the process of cleaning hands to help prevent spread of
infection caused by germs, dirt and microorganisms. Effective hand hygiene is
the simplest means in preventing healthcare associated infections(HCAI) because
it disrupts the chain of infection. Healthcare associated diseases has proven
to be a serious disease burden with significant economic consequences on health
care systems worldwide with physical, social & psychological costs to
patients and their relatives.

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