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Elaziz & bakr 2008.pdf

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Khaled M. Abd Elaziz and Iman M. Bakr Assessment of knowledge, Attitude Assessment of knowledge, attitude and practice of hand washing among health care workers in Ain Shams University hospitals in Cairo. Khaled M. Abd Elaziz, Iman M. Bakr Community, Environmental and occupational department, Faculty of medicine, Ain Shams University, Cairo Abstract Background: Most nosocomial infections are thought to be transmitted by the hands of health care workers. The aims of this work were to assess th
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  Khaled M. Abd Elaziz and Iman M. Bakr Assessment of knowledge, Attitude Assessment of knowledge, attitude and practice of hand washing among health care workers in Ain Shams University hospitals in Cairo. Khaled M. Abd Elaziz, Iman M. Bakr Community, Environmental and occupational department, Faculty of medicine, Ain Shams University, Cairo Abstract Background : Most nosocomial infections are thought to be transmitted by the hands of health care workers. The aims of this work  were to assess the knowledge, attitude and practice of hand washing among health care workers (HCW) in Ain-Shams University hospitals and to assess its different wards for facilities required for hand washing (HW). Methods:  A cross-sectional descriptive and observational study was conducted for six months from June till November 2006. It included preparatory  phase, observational phase for practice and assessment of knowledge & attitude through self-administered questionnaire to HCW in 10 different departments. 2189 opportunities among HCW were observed. Results:  Doctors showed a significantly higher compliance (37.5%) than other groups of HCW (P=0.000), however only 11.6% of them had done the HW in an appropriate way. The most common type of HW practiced among HCW was the routine HW (64.2%) and the least was the antiseptic HW (3.9%). Having a short contact time and improper drying (23.2%) was the most common form of inappropriate HW. Most of the wards had available sinks (80%) but none of them had available paper towels. The mean score knowledge was higher in nurses than in doctors (42.6±11.7 versus 39.1±10.5). 97.3% of the nurses  believe that administrative orders and continuous observation can improve hand washing practices. Conclusion:  Compliance to hand washing was low. Implementation of multifaceted interventional behavioral hand hygiene program with continuous monitoring and performance feedback, increase supplies necessary for HW and institutional support is important for improving the compliance of hand hygiene guidelines. Keywords : hand washing, medical health care workers, knowledge, attitude, practice Introduction Most nosocomial infections are thought to be transmitted by the hands of health care workers. It has long been known that hand hygiene among health care workers plays a central role in  preventing the transmission of infectious agents. Hand-washing is the most effective way of preventing the spread of infectious diseases. (1) But despite a Joint Commission requirement that Centers for Disease Control and Prevention hand hygiene guidelines be implemented in hospitals, compliance among health care workers remains low. (2)  The reasons of lack of compliance to hand washing include: lack of appropriate equipment, low staff to  patient ratios, allergies to hand washing products, insufficient knowledge among staff about risks and  procedures, the time required and casual attitudes among staff towards  biosafety. (3)  Improved compliance with hand washing was associated with a significant decrease in overall rates of The Egyptian Journal of Community Medicine Vol. 26 No. 2 April 2008    Khaled M. Abd Elaziz and Iman M. Bakr Assessment of knowledge, Attitude nosocomial infection and respiratory infections in particular. (4)  Hand hygiene technique is seldom incorporated into research studies and audits designed to increase compliance. As a result, numerous unanswered questions remain concerning this aspect of hand hygiene. (5)  In order to be effective, efforts to improve compliance with hand washing guidelines must be multifaceted (6)  and should include increasing the availability and accessibility of hand washing sinks and alcohol-based hand rubs. (7)   Aim of the work 1-   Assessment of knowledge, attitude and practice of hand washing among health care workers (HCW) in Ain- Shams University hospitals 2-   Assessment of different wards in Ain- Shams University hospitals for facilities required for hand washing Subjects and methods A cross sectional descriptive & observational study was conducted in Ain Shams University hospitals. The  practical part extended for six months (from June till November 2006) was implemented in three phases: Phase one: Preparatory phase, Two infection control nurses from 10 departments were selected and trained on observing hand washing opportunities and filling out the forms needed. Training included lectures on the importance of hand washing and its impact on nosocomial infection rate and the correct practice of hand washing. Phase two: Observational phase, a) for HCW, Observational forms to record the events in each opportunity observed as regard the hand washing compliance (done or not done) and hand washing technique and practices (if done). The observation was done unobtrusively. The opportunities of hand washing included those opportunities where the HCW could do invasive procedures, come into  personal contact with the patient, do non-invasive procedures as blood  pressure or temperature measurement,  body fluid contact, waste disposal or come in contact with contaminated inanimate objects. Multiple opportunities could be observed for a single health care worker. b) Ward inspection forms were filled throw inspection of the availability of facilities needed for hand washing in each department, as hand hygiene guidelines, posters, sinks, towels, soap, alcohol-based hand rubs and gloves. Phase three: assessment of knowledge and attitude of hand washing through a self-administered questionnaire. It targeted different aspects, indications and types of hand washing for doctors and nurses (20 questions) and workers (10 questions). Questions about knowledge were answered as True, False or Unsure. They included: Is HW indicated even if sterile gloves were used? The most common mode of transmission of infection is through hands of HCW? Four questions on different techniques of hand washing whether routine, antiseptic or alcohol hand rub and the difference between them. Two questions on the minimum time needed for routine and antiseptic HW. Also question on hand drying after antiseptic HW and turning the tap off,. Whether routine HW is done after doing invasive procedure or not, and if the hands are contaminated with blood, is it a must to use antiseptic HW. Also questions on the action of soap and alcohol on the flora of the skin,  bacteria and viruses, the type of the antimicrobial used in relation to the The Egyptian Journal of Community Medicine Vol. 26 No. 2 April 2008    Khaled M. Abd Elaziz and Iman M. Bakr Assessment of knowledge, Attitude onset and duration of action. Types of alcohol used in alcohol hand rub. Whether adding glycerine can reduce skin irritation and whether rinsing  betadine scrub should be done immediately (before iodine irritates the skin) Attitude questionnaire included 4 questions and were filled by nurses in different departments. They included: Whether HW is protective to HCW, whether it could be improved by administrative orders and continues observation, whether it lowers the nosocomial infection rate more than any other measure and whether it could  be improved in their hospitals by good role models by doctors. A total score was given to the knowledge (out of 20) and attitude questionnaire (out of 20). Attitude questions were four questions based on Likart scale. Totally agree and agree answers were considered as positive attitude and a percentage was calculated. Forms were revised for completeness and consistency. Data entry, data checking and data analysis were done with the program SPSS (Statistical  package for social science) version 11.0.5. Ethical consideration : approval of the design and steps of the study were conducted with members of the infection control unit in Ain Shams University hospitals. A consent was taken from the participants of the study  before answering the questionnaires. Also the observation of the hand washing practices was among the routine work of the infection control nurse responsible for all the activities of infection control in the studied units. Results 2189 opportunities among health care workers in Ain Shams University hospital were observed for compliance to hand Hygiene. Most of the observed opportunities for hand washing were done by nurses (1180) followed by doctors (465). Collectively doctors (37.5%) showed a significantly higher compliance to hand washing than the other groups of health care workers (P=0.000), however only 11.6% of them had done the hand hygiene in an appropriate way (Table 1). Departments included in the observations were the Orthopedic, neurosurgery, plastic and general surgery (722 observations), pediatric, gynecology and chest intensive care units (1193 observations) and the hematology departments.(Table 2) The most practiced type of hand washing among the health care workers was the routine hand washing (64.2%) and the least was the antiseptic hand wash (3.9%). (Table 2) Hand washing was observed during different intervention. Hand washing was performed at a higher rate after doing the different intervention than  before doing them, however hand washing was done in a more appropriate way before doing the different intervention than after doing them except for the non-invasive  procedures were it was nearly similar  before and after. A self-administered questionnaire containing twenty different aspects, indications and types of hand washing was filled by 152 HCW. Workers were allowed to answer only 10 of these items. The mean score knowledge was higher in nurses than in doctors (42.6±11.7 versus 39.1±10.5). The assessment of the knowledge of HCWs in different departments showed that the highest mean scores was in the NICU pediatric department. Doctors had high mean score in knowledge in General surgery department 7 (47.5±8.6), nurses The Egyptian Journal of Community Medicine Vol. 26 No. 2 April 2008    Khaled M. Abd Elaziz and Iman M. Bakr Assessment of knowledge, Attitude (48±2.7) and workers (63.3±1105) in the NICU pediatric department. (Table 4) Although the highest mean knowledge of hand washing was among nurses in the NICU pediatric 48.0±2.7 yet the lowest attitude scores were found among nurses in the same department 68.0± 7.5 (results not shown in tables). As regards the attitude of nurses towards hand hygiene, it was found that 96% of nurses believe that hand washing is protective health care  personnel from infection. Also it is noted that 97.3% of the nurses believe that administrative orders and continuous observation can improve hand washing practices. As regards lowering of nosocomial infection rates 92% of the nurses believe that this method (Hand washing) can lower nosocomial infection rates more than any other method of infection control Only 70.7% of the nurses had positive attitude towards the improvement of hand washing by watching role models do hand washing. (Table 5) The most common form of inappropriate hand washing was in the improper drying and having short contact time(23.2%).(Figure 1). As regards the ward assessment, most of the wards had available sinks (80%) and none of them had available paper towels. (Table 6) Discussion Hand hygiene prevents cross infection in hospitals, however adherence to guidelines is commonly poor. (8)  While the techniques involved in hand hygiene are simple, the complex interdependence of factors that determine hand hygiene behavior makes the study of hand hygiene complex. (9)  In our study the overall hand hygiene compliance among Health care workers is 34%, this agrees with Patarakul et al., (2005) who had found from their observational study that hand hygiene among HCWs before  patient contact was less than 50%. (10) Also it agrees with Pittet et al., (2000) who had observed 20000 opportunities for hand hygiene before implementing a hand – hygiene campaign during routine patient care in a teaching hospital in Geneva to be 48%. (11) This gives an idea for our need to such  programs in order to raise our compliance to hand hygiene. Our result was much better than Kim et al., (2003) study who had found the overall compliance of hand washing to  be 22.1%. ( 12 )  As regard compliance to hand hygiene in ICU. Our results in the chest ICU=33.4%, NICU ped.= 62.5% &NICU gyn.39.4%, were much better than Rosenthal et al., (2003) who had found a rate of 23.1% before implementing a hand hygiene education, training and performance feedback program in one medical surgical ICU and one coronary ICU of one hospital in Argentina. (13) Also our results lie within the range of Lipsett & Swoboda (2001) which is 28%-74%. (14) Our results were comparable with Won et al., (2004) who had conducted their study in NICU in a level III teaching hospital where they found compliance to hand hygiene to  be 43%. (4) As regard the variation in compliance to hand washing hygiene among different health care workers. Doctors showed the highest compliance (37.5%) in comparison to nurses (36.4%) and housekeepers (22.6%) and this disagree with Lipsett and Swoboda (2001) who had found that nurses showed higher compliance (50%) than doctors (15%) and nursing supporting  personnel (37%). (14)  Minimizing the gap found between the knowledge and attitude in nurses as found in Pediatric The Egyptian Journal of Community Medicine Vol. 26 No. 2 April 2008  
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