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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 10-13

Hand hygiene: An effective key HIC parameter for reducing healthcare-associated infections in a haemodialysis unit – Identification and analysis of work system factors


1 Department of Hospital Administration; Apex Trauma Centre, SGPGIMS; Kalyan Singh Super Specialty Cancer Institute and Hospital, Lucknow, Uttar Pradesh, India
2 Department of Microbiology, SGPGIMS, Lucknow, Uttar Pradesh, India
3 Department of Hospital Administration, SGPGIMS, Lucknow; Mahamana Pandit Madan Mohan Malviya Cancer Centre and Homi Bhabha Cancer Hospital, Tata Memorial Centre, Varanasi, Uttar Pradesh, India
4 Department of Nephrology, SGPGIMS, Lucknow, Uttar Pradesh, India

Date of Submission16-Feb-2022
Date of Acceptance13-Sep-2022
Date of Web Publication12-Nov-2022

Correspondence Address:
Dr. Ruchi Kushwaha
Mahamana Pandit Madan Mohan Malviya Cancer Centre and Homi Bhabha Cancer Hospital, Tata Memorial Centre, Varanasi, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_6_22

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  Abstract 


Introduction: Infection is the most common cause of hospitalisation and the second most common cause of mortality amongst haemodialysis (HD) patients, after cardiovascular disease. Hand hygiene (HH) reduces infections and enhances patient safety across all settings. However, the lack of compliance with HH amongst health-care providers is problematic worldwide. With the above background, a study was conceptualised to ascertain the current status of the HH practices during a complete HD procedure among nursing staff of an HD unit at a tertiary healthcare teaching institute in India.
Methodology: A prospective cross-sectional study was conducted from 10 October, 2018, to 10 December, 2018. A structured checklist for HH during a complete HD procedure was developed as per the WHO's five moments of HH. One hundred and fifty HD procedures were observed for compliance appropriate number of HH. Data analysis was done using the SPSS version 22.
Results: Despite being a very simple step, the compliance rates of health-care workers (HCWs) in HH were found extremely poor, ranging from 23% to 35% only. Reasons for non-compliance by HCWs told by them were: poor nurse-to-patient ratio, frequent turnover of nursing staff, lack or inadequate training and lower level of competency among HD staff.
Conclusion: The high number of times an HD staff is required to perform HH could be a reason for lack of compliance. However, compliance can be improved by continuous education and supervision and by providing, in convenient locations, sufficient number of sink with soap dispensers, paper towels, hand lotions and Anti-Bacterial Hand Rubs (ABHRs) placed at each patient station.

Keywords: Anti-bacterial hand rubs (AHBRs), Centers for Disease Control and Prevention, haemodialysis, hand hygiene, health-care workers, hospital infection control (HIC)


How to cite this article:
Harsvardhan R, Mishra R, Kushwaha R, Prasad N. Hand hygiene: An effective key HIC parameter for reducing healthcare-associated infections in a haemodialysis unit – Identification and analysis of work system factors. J Patient Saf Infect Control 2022;10:10-3

How to cite this URL:
Harsvardhan R, Mishra R, Kushwaha R, Prasad N. Hand hygiene: An effective key HIC parameter for reducing healthcare-associated infections in a haemodialysis unit – Identification and analysis of work system factors. J Patient Saf Infect Control [serial online] 2022 [cited 2022 Dec 5];10:10-3. Available from: https://www.jpsiconline.com/text.asp?2022/10/1/10/361009




  Introduction Top


Haemodialysis (HD) is a mechanical process that performs the work of healthy kidneys. Patients with chronic HD are at high risk for infection due to impaired immune defences, high severity of illness and the need for routine puncture of a vascular access site to remove blood for HD. Infection is the most common cause of hospitalisation and the second most common cause of mortality among HD patients, after cardiovascular diseases.[1],[2],[3] In addition, the staff of a dialysis unit is uniquely at risk of contracting these infections from contaminated blood and dialysate. Hand hygiene (HH) reduces infections and enhances patient safety across all settings. However, the lack of compliance with HH amongst health-care providers is problematic worldwide.

Hand hygiene

Contaminated hands of the health-care worker (HCW) are amongst the most common modes of transmission of healthcare-associated infections.[4] Pittet et al. described a five-step sequence resulting in microbial transmission through contaminated hands during health-care delivery.[5] These are '(1) pathogens shed by infected patients can contaminate surrounding environments, (2) HCW's hands get contaminated by contact with patient skin or surrounding environment, (3) pathogen remains viable on the HCW's hands for at least several minutes, (4) HCW may omit hand decontamination or use inappropriate product or procedure and (5) HCW's contaminated hands can either transfer the pathogen directly to another patient or indirectly on a medical device or objects within the patient's immediate vicinity'. Therefore, is singled out as the most important infection prevention intervention. However, the compliance rates of HCWs in HH are very poor, with an overall average of 40% or less.[6],[7]

Aim and objectives

The aim of the study is to ascertain the current status of the HH practices during a complete HD session amongst the nursing staff, deployed at the HD unit at a tertiary healthcare teaching institute in India, with the objectives: (1) to prepare an appropriate study tool (structured checklist), depicting the estimated number of times a single dialysis staff is required to perform HH per HD session per patient, (2) to do a baseline assessment through the study tool, (3) to identify the root cause of non-compliance, if any and (3) to recommend based on analysis of data thus obtained, an evidence-based HIC module on HH practices for use in HD unit in an institutional setting.


  Methodology Top


A prospective cross-sectional study was conducted from 10 October 2018 to 10 December 2018 at the dialysis unit of SGPGIMS. Based on the WHO five moments of HH[8] and as per the recommendations from the Centers for Disease Control and Prevention,[9] a structured checklist depicting the estimated number of times a single dialysis staff is required to perform HH per HD session per patient was prepared [Table 1]. A total of 150 HD sessions were observed for compliance with the appropriate number of HH. The adherence rate was calculated using the formula:
Table 1: Checklist for observation of adherence of to hand hygiene at appropriate opportunities during a complete haemodialysis session

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Adherence rate = (action performed/opportunity present) ×100.


  Observation and Results Top


As per the study tool, i.e. customised structured checklist [Table 1], the estimated total number and a dialysis staff needs to perform HH during a complete dialysis session was a minimum of 18–23 times. Observations were made on each dialysis staff, in morning and evening shifts. Adherence rate was calculated by the total number of times HH was actually performed out of the total number of opportunities available for a particular staff. It was observed that despite being a very simple step, the compliance rates of HCWs for HH were not so good, ranging from 23% to 35% only.

Subsequently, staffs were interviewed to know their concerns about non-compliance. The reasons told by them were classified under broad heads of man, money, material, methodology, equipment supplies, infrastructure and others, for better understanding and their subsequent solution, accordingly. Few of the noteworthy concerns were: apparent and relative reduction in nurse-to-patient ratio due to child care leaves/medical leaves, skin drying due to frequent usage of hand rub, lack of teamwork, relatively congested layout plan (to benefit more patients), wash basin were not easily accessible, no defined standard operating protocol and checklist for HH, absence of the system of structured HH audit, non-availability of hand rub for each dialysis station, at times there was no soap at washbasins, no HH poster near sink, few dialysis machines were not working, increased volume load per machines and consequent reduction in time, frequent alarm from working machines and urgency associated with dialysis complications may sacrifice adherence to standard precautions including HH.

These factors may be better understood by applying a root cause analysis (RCA) model. Several tools and methods exist for RCA, such as the Ishikawa fishbone diagram, the 'five whys' technique', the causal tree analysis or the affinity diagram.[10] The reasons for non-compliance for HH in the present study can be better understood by the Ishikawa fishbone diagram [Figure 1].
Figure 1: Ishikawa fishbone diagram showing the reasons for non-compliance with hand hygiene practices at the dialysis unit

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  Discussion Top


The continuous ambulatory peritoneal dialysis established at SGPGI in 1993 is the largest scale in South East Asia. There are 65 HD machines and four ventilators in the dialysis unit. HD unit runs round the clock in three shifts and about 1500 dialysis are performed on monthly basis. A single dialysis staff has to cater to three patients at a time, preventing them to perform HH at adequate times.

Therefore, the reasons as told during the interview and described in the fishbone diagram [Figure 1] seem justified to some extent. A study conducted by Ayman Karkar in the Department of Nephrology, Kanoo Kidney Centre, Dammam Medical Complex, Dammam, KSA, in 2016 was having similar findings wherein it was said that the estimated number of HH can be a minimum of 60–100 times when multiplied by the number of patients assigned per staff (e.g. 2–3 patients). A large number of times an HD staff is required to perform HH could be a reason for lack of compliance.[11]

In another study by Moustapha A Ramadan, Wafaa said that skin irritation and dryness from frequent washing, availability of hand washing solutions, inconvenience or time constraints and limited awareness of, or partial agreement with, HH guidelines were important barriers to doctors' ultimate HH compliance.[12]


  Conclusion Top


The high number of times an HD staff is required to perform HH could be a reason for lack of compliance. However, compliance can be improved by continuous education and supervision and by providing, in convenient locations, sufficient number of sink with soap dispensers, paper towels, hand lotions (e.g. one for every two to four dialysis stations) and ABHRs placed at each patient station.[13] Monitoring HH compliance is crucial and direct observation is the current gold standard method. However, direct observation has several limitations, amongst which are being labour intensive, small sample size (may cover only 1% of total HH activity) and not standardised.[11]

Recommendations

The information drawn from this study can serve as guidelines to institute and improve existing hospital services related to infection control and make new ones to achieve excellent services. This study demonstrated an operationalisation of the Ishikawa fishbone diagram in an HD unit to identify barriers to infection prevention measures such as HH and implemented in an attempt to reduce infection in an HD unit. Health-care providers may initiate a similar analysis of a health-care unit or facility that will provide detailed information on variances within a working system that might be contributing to the achievement of a safety goal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rayner HC, Pisoni RL, Bommer J, Canaud B, Hecking E, Locatelli F, et al. Mortality and hospitalization in haemodialysis patients in five European countries: Results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant 2004;19:108-20.  Back to cited text no. 1
    
2.
Dalrymple LS, Johansen KL, Chertow GM, Cheng SC, Grimes B, Gold EB, et al. Infection-related hospitalizations in older patients with ESRD. Am J Kidney Dis 2010;56:522-30.  Back to cited text no. 2
    
3.
Lafrance JP, Rahme E, Iqbal S, Leblanc M, Pichette V, Elftouh N, et al. Magnitude of discordance between registry data and death certificate when evaluating leading causes of death in dialysis patients. BMC Med Res Methodol 2013;13:51.  Back to cited text no. 3
    
4.
Hand Hygiene in Haemodialysis Units. Available from: www.researchgate.net/publication/306383042. [Last accessed on 2022 Jan 31].  Back to cited text no. 4
    
5.
Pittet D, Allegranzi B, Sax H, Dharan S, Pessoa-Silva CL, Donaldson L, et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006;6:641-52.  Back to cited text no. 5
    
6.
Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee, HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. Recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. Society for healthcare epidemiology of America/association for professionals in infection control/infectious diseases society of America. MMWR Recomm Rep 2002;51:1-45, quiz CE1-4.  Back to cited text no. 6
    
7.
Arenas MD, Sánchez-Payá J, Barril G, García-Valdecasas J, Gorriz JL, Soriano A, et al. A multicentric survey of the practice of hand hygiene in haemodialysis units: Factors affecting compliance. Nephrol Dial Transplant 2005;20:1164-71.  Back to cited text no. 7
    
8.
WHO Five Moments of Hand Hygiene. Available from: https://www.who.int/campaigns/world-hand-hygiene-day. [Last accessed on 2022 Jan 31].  Back to cited text no. 8
    
9.
Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. https://www.cdc.gov/hai/settings/outpatient/outpatient-care-guidelines.html, [Last accessed on 2022 Jan 31].  Back to cited text no. 9
    
10.
Root_Cause_Analysis_to_Support_Infection_Control_in_Healthcare_Premises. Available from: www.researchgate.net/publication/270595050. [Last accessed on 2022 Jan 31].  Back to cited text no. 10
    
11.
Karkar A. Hand hygiene in haemodialysis units. Open Access Libr J 2016;3:e2953.  Back to cited text no. 11
    
12.
Impact of an Intervention on the Hand Hygiene Compliance Rates in Paediatric Surgical Intensive Care Units in Two Tertiary Care Hospitals. Available from: www.ijic.info/article/download/18025/12053. [Last accessed on 2022 Jan 31].  Back to cited text no. 12
    
13.
Allegranzi B, Gayet-Ageron A, Damani N, Bengaly L, McLaws ML, Moro ML, et al. Global implementation of WHO's multimodal strategy for improvement of hand hygiene: A quasi-experimental study. Lancet Infect Dis 2013;13:843-51.  Back to cited text no. 13
    


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