The indications of hand hygiene were WHOs five moments of hand hygiene. The healthcare workers had two options for practicing hand hygiene i.e. Soap and water or Sterillium (Alcohol based hand rub composed of 70% ethyl alcohol and glycerine). The study was conducted by observing the compliance of hand hygiene directly by the observer. The WHOs observation form for hand hygiene compliance was used in this study. Observers were the infection control nurses who were trained in hand hygiene practices and were taught in detail about how to fill up the WHO observation form. The observer visited the nursery daily for two hours between 9.00 am to 11.00 am during which maximum activity occurred in the nursery and made concealed observations. The healthcare workers were not aware of the purpose of visit of the observer and also of the fact that they were being observed.
7 to 16 percentage points (PPs) before 2009 [7–9] to 30–34 PPs after Five Moments for Hand Hygiene be- came a standard in 2009 [10, 11]. Srigley et al. even noted a surprising 3-fold increase in HH compliance under direct observation vs under an electronic moni- toring system (EMS) . Hagel et al. reported a similar outcome by using electronic handrub dispensers to rec- ord HH events and captured a 2.6-fold higher HH dens- ity when healthcare workers (HCWs) were under observation than when they were not (21 vs 8 HH events per hour) . McLaws and Kwok demonstrated direct observation rates were inflated by an average of 55–64 PPs (2.8–3.1 times higher) than automated surveillance rates by an EMS in a medical ward . The Hawthorne effect may alter HCWs’ usual behaviour and often leads to overestimation of HH compliance [5, 6, 9, 15]. At least three methods have been proposed to help avoid or decrease the Hawthorne effect besides the use of EMS. These include 1) letting HCWs habituate to the presence of observers, although there is still no standard method for clinical application [3, 6]; 2) using indirect methods to monitor HH compliance, such as monitoring con- sumption of alcohol handrubs ; and 3) covertly ob- serving HH compliance [3, 15].
HH opportunities were counted and the actual epi- sodes of HH were scored as no HH, HH with water and soap, or HH with alcohol-based hand rub. If both disin- fection procedures were applied, it was scored as HH with alcohol-based hand rub. Compliance was stratified by the WHO five moments for hand hygiene in health care/indication (before patient contact, after patient con- tact, before an aseptic task, after body fluid exposure risk, after contact with patient surroundings)  and by type of HCW (nurses, nursing assistants, physicians, physiotherapists, other) and was computed as a percent- age of the number of HH episodes with water and soap or with alcohol-based hand rub divided by the number of opportunities. Results were reported by participating hospital as a weighted mean, therefore adjusting for vary- ing number of observed opportunities between hospitals. All data were processed and analysed using SAS 9 soft- ware. Comparison of compliance rates between periods and groups were performed using the Wilcoxon signed rank test with a two sided p value <0.05 considered to be statistically significant.
Introduction: Hand hygiene is an important strategy to prevent health care-associated infections (HAI) and limits the transmission of microorganisms. Poor hand hygiene practices are a major threat and pose a huge risk to the health of the patients. Objective: We compared the level of knowledge attitude and practice regarding hand hygiene among doctors and nurses. Results: Training sessions were conducted for 100 healthcare workers (56 doctors and 44 nurses) and their assessment for knowledge, attitude and practice was done throughpretest andposttest questionnaire. There was a significant improvement in the KAP score for both doctors and nurses after the training sessions. Doctors have better knowledge of hand hygiene. Although nursing staff have relatively less knowledge about the hand hygiene, but a good percentage of this category has a positive attitude and follows the correct practicing habits. WHO recommends alcohol based hand rub (ABHR) for hand antisepsis as it is fast acting and has broad spectrum antimicrobial activity. In our study, most of the doctors still believe that soap and water is the best way of hand hygiene. Nurses were found to be more aware about ABHR as best method. Discussion & Conclusion: Overall, level of awareness regarding the importance of hand hygiene and WHOs five moments of hand hygiene is low in both doctors and nurses and there is a need of regular training sessions and monitoring of hand hygiene compliance under strict supervision. Keywords: Hand hygiene, Healthcare associated infections, Knowledge, Attitude, Practices
Audit trainers were infection control nurses who were trained in hand hygiene observation. The training program was based on the WHO “My 5 moments for hand hygiene” approach [1,7,8]. Each training session required one hour and included lectures and practical auditing using the WHO video tools . Students were also trained to document observations from the video by using a standard audit tool. The training video was chosen by the trainer. Students completed the audit form whilst observing all five indications for hand hy- giene and the trainer marked the audit form according to the answer sheets. Students were required to achieve 9 out of 10 answers correct (90%) to be deemed certi- fied auditors. If they were unable to achieve 90%, then the trainer provided them with another 10 opportun- ities. This cycle was repeated until 90%was achieved.
As a fact, among 1 out of 20 admitted patient acquires HCAIs. 5 University of Geneva Hospital firstly reported that good compliance with hand hygiene practice leads to significant reduction in HCAIs. 5 Rationally the hands of Health care providers during patients care become colonized by germs and potential pathogen. Hence longer extent of patient care with neglected hand hygiene practices leads to higher degree of hand contamination and possess high risk to patients safety.1 HCAIs are also a cause of morbidity in patients, and give away physical and moral suffering to both the patient and their relatives. The resources which could have been utilised on preventive actions or other health priorities are used to treat HCAIs, which surely put a financial burden to the health system. HCAIs can be prevented by proper hand hygiene practices either by hand rub or through disinfectant or hand washing by soap and water. 6 WHO have devised guidelines for hand rub and hand wash and advocated “My five moments for hand hygiene” as shown in Figure 1, as the approach for appropriate performance, teaching and evaluation of hand hygiene. 1
To address the problem of nosocomial infections the World health organisation makes continues efforts to identify effective and sustainable strategies. One of such effort is introduction of an evidence based concept of “my 5 moments for hand hygiene” by WHO and a “save lives: clean your hands” campaign May 5, 2014 to ask the world leaders to show their commitment towards hand hygiene and initiate appropriate action. These five moments that call for the use of hand hygiene include the moment before touching a patient, before performing aseptic and cleaning procedures, after being at risk of exposure to body fluids, after touching a patient, and after touching patient surroundings. 7
multifaceted improvement program included education, feedback, reminders, interviews and the use of role models. The study involved nurses and physicians working in two ICUs of the Dr. Cipto Mangunkusumo Hospital in Jakarta. Results: A total of 97 at baseline, and 72 at post-intervention HH knowledge questionnaires were completed. There was a statistically significant improvement in the median overall HH knowledge score at post-intervention (from 15 to 22, p < 0.001). There was no significant difference between the two ICUs. The overall HH compliance was 27% at baseline and significantly improved to 77% post-intervention ( p < 0.001). For all five HH moments, the compliance of nurses and physicians separately improved significantly from the baseline phase to the post-intervention phase ( p < 0. 001), except for ‘ moment 3 ’ (after body fluid exposure), for which baseline rates were already high. Most of the compliance rates were significantly lower in both groups of healthcare workers upon follow-up three years later. Overall, the HH compliance of the nurses was significantly better than the physicians ’ compliance ( p = 0.005).
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The interventions were the result of two PDSA cycles. In order for the street nurses to succeed in increasing the rate of HH to 90%, they had to implement three changes as part of their process improvement. The first change, made after the first PDSA cycle, was to switch from carrying one backpack full of all of their supplies (medical supplies, wound care supplies, and case management resources) to a backpack with medical supplies and case management resources and a separate caddy for wound care supplies. The caddy design is easy to carry, and allows for the nurses to keep a large pump hand sanitizer that is easy to access in it. The next change that needed to be implemented was a result of the second PDSA cycle, was carrying several small personal sized hand sanitizers (1 or 1.5 ounces) in their backpacks. These are given to patients along with wound care education. The final intervention that needs to be implemented is the HH process. The nurses will carry their backpacks and wound care caddies to see the patient. Once they arrive to perform wound care, they will lay down a disposable under-pad on the ground (or other available surface) and place their wound care caddy on the under-pad. They can then perform HH immediately before and after performing wound care. Once HH is done, the nurses can provide appropriate patient education regarding wound care, and give the patient their own hand sanitizer.
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Improving hand hygiene among health care workers (HCWs) is the single most effective intervention to reduce the risk of health care associated infections (HAIs) in hos- pitals. As effective hand hygiene practices can mitigate the occurrence of HAIs, increased hygiene compliance, then, can help reduce the associated detrimental effects on pa- tient health outcomes and the economic burden on health systems . In 2009, the World Health Organization (WHO) adopted new global guidelines for hand hygiene that included adherence to 5 critical moments for hand hygiene for patient care that Hand Hygiene Australia  has worded specifically as: before touching a patient (Mo- ment 1), before a procedure (Moment 2), after a proced- ure (Moment 3), after touching a patient (Moment 4), and after touching a patient’s surroundings (Moment 5). The guidelines refer to alcohol-based hand rub as the recom- mended method for hand hygiene when hands are not vis- ibly soiled and that the rub should contain an emollient to protect the skin. Published hospital HCW compliance data indicate a relatively high level of safe practice al- though the compliance rates differed across some of the moments  suggesting opportunities for improvement. As nurses have the most physical contact with patients , it is important to understand the beliefs underlying hospital-based nurses’ hand hygiene decisions from a sound theoretical framework which can then inform inter- vention strategies to encourage greater compliance.
Kingdom  and China  also showed that training had a positive relationship with HH compliance in all medical staff. This may be due to the fact that training built the knowledge of health care providers which had a significant association in HH compliance and those HCPs who had got training is expected to be a role model for others in terms of practicing good HH, Know- ledge of HCPs will help to identify risk and benefits practice on the way of HCAIs transmission and how to prevent. A single lecture on basic hand hygiene proto- cols had a significant and sustained effect in enhancing hand hygiene compliance in a Swedish hospital . A study conducted in University hospital in central Ethiopia showed compliance with hand hygiene at base- line and at follow up after training have a significant re- lationship with compliance .
Searches were undertaken with the following databases: PubMed, Scopus, Health Business Elite, BNI and CINAHL. In addition, the work of key authors in the field was identified, grey literature primarily from NHS portals was reviewed, suggestions from other experts were sought and hand search of current relevant literature was
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Education and campaigns employing multimodal approaches consistently show improvements in compliance with good hand hygiene practice, but disappoin- tingly, only to a modest extent. Two studies, more than a decade apart but with similar results, provide representative examples. Pittet et al. (2000)  report the results of the implementation of a hospital-wide campaign to improve hand hygiene compliance and effectiveness, placing special emphasis on the increased use of alcohol-based handwipes ( vs washing with soap and water). The three-year campaign produced a sustained increase in hand hygiene compliance, with a corresponding reduction in nosocomial infections. However, the im- provement in compliance rate was modest, from 48% at the outset to 66% at the conclusion of the study. Chavali et al. (2014)  initiated an aggressive multi- modal intervention to improve hand hygiene compliance among healthcare workers in the ICU of a tertiary care hospital in India. After one year, com- pliance had increased, but to an overall rate of only 78%.
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approximately 1 in 10 patients acquiring an infection during a hospital stay (1). Direct contact between healthcare staff and patients is generally considered to be the primary route by which many exogenously-acquired infections are spread within and between wards. Hand washing is therefore perceived as being the single most important preventative measure, which can be employed in the fight against infection (2-4). Unfortunately, hand hygiene compliance in many institutions is relatively low (5, 6) and it is this which is thought to be the principal reason why nosocomial infection rates remain so high (2).
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First of all, it was found that community-acquired infections with hand-transmitted germs are much more common than nosocomial infections, in line with other studies on the etiology of surgical infections [16, 17]. In the 3582 patients, 73 (2.03%) nosocomial infections were recorded during 2017 in the GSD of BMECH, of which 71 (97.26%) by hand-transmitted germs, consistent with data provided by the World Health Organization . On the other hand, considering that these nosocomial infections occurred in a number of 71 patients, resulted in a rate of 1,98% nosocomial hand transmitted surgical infections in the GSD, comparable to other rates (2.1%, 3.8%) published studies with similar design after implementation of the hand hygiene protocols [18, 19]. It was found none nosocomial infections with Clostridium difficile and Streptococcus pyogenes in the GSD, probably because of the "Do not touch your mouth, nose or eyes if you did not wash your hands" protocol, strictly followed by patients.
This study developed a training-to-proficiency program for hand hygiene following the deliberate practice framework. We also measured how many training sessions were required to achieve proficiency. To address issues of implementation prac- ticality, hand hygiene training was delivered within the context of a 5-day Yale Physician Assistant induction program. In line with the literature on duration and intensity, training was delivered as repeated short training sessions evenly spaced out over the 5 days, but students could complete additional self- directed training sessions at any time.
Overall 49 separate observations were performed, providing 45 hours of research material from 560 healthcare professional interactions featuring 729 HHO. The study found that when a higher ranking healthcare professional was present in the room and did not perform hand hygiene, other healthcare professionals in the room were significantly less likely to perform hand hygiene. Similarly, having a peer (a healthcare professional of the same rank) in the room that did not perform hand hygiene was also found to be an independent predictor of an individual’s hand hygiene non-compliance. These two findings, that an individual appears influenced by the behaviour of those who are ranked higher, or equally, link to the findings of Donaldson and Carter (2005). They discussed the value attributed to role models in the learning experiences of nurses during their educational process. Donaldson and Carter (2005) found that individuals expected, once they entered the clinical setting, to seek direction from those around them, and monitor and modify their behaviour accordingly.
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Numerous strategies have been evaluated in an at- tempt to improve rates of hand hygiene, including those that focus on infrastructure changes, education, visual reminders, or ongoing monitoring and feedback pro- grams. While these individual components have proven effective, interventions that combine these strategies into multimodal hand hygiene campaigns appear to be the most successful in improving hand hygiene adherence by health care workers (HCWs) [1,4-7]. The World Health Organization (WHO) has adopted an evidence- based multimodal hand hygiene strategy as part of the First Global Patient Safety Challenge . The WHO Multimodal Hand Hygiene Strategy has been imple- mented extensively in high income, resource intensive countries, however there remains limited data on the impact of such programs in resource-limited countries, especially in Sub-Saharan Africa [8-11].
The committee met monthly and documentation reviewed showed that membership included representation from infection prevention and control nursing staff from Cork University Hospital, Cork University Maternity Hospital, Bantry General Hospital, Mallow General Hospital, in addition to representation from clinical microbiology, nursing and midwifery management, hygiene services, decontamination, medical engineering, the microbiology laboratory, quality and risk management, pharmacy, occupational health; diagnostics, medical, and surgical directorates and public health. Minutes of meetings of the Infection Prevention and Control Committee reviewed by inspectors showed that the terms of reference did not include named representatives from medical and surgical directorates in Cork University Hospital. This requires review.
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Since the American Academy of Pediatrics published a statement titled “Infection Control in Physicians’ Offices” (Pediatrics. 2000;105:1361–1369), there have been significant changes that prompted this updated statement. Infection preven- tion and control is an integral part of pediatric practice in ambulatory medical settings as well as in hospitals. Infection prevention and control practices should begin at the time the ambulatory visit is scheduled. All health care personnel should be educated regarding the routes of transmission and techniques used to prevent transmission of infectious agents. Policies for infection prevention and control should be written, readily available, updated annually, and enforced. The standard precautions for hospitalized patients from the Centers for Disease Control and Prevention, with a modification from the American Academy of Pediatrics exempting the use of gloves for routine diaper changes and wiping a well child’s nose or tears, are appropriate for most patient encounters. As employers, pedia- tricians are required by the Occupational Safety and Health Administration to take precautions to identify and protect employees who are likely to be exposed to blood or other potentially infectious materials while on the job. Key principles of standard precautions include hand hygiene (ie, use of alcohol-based hand rub or hand-washing with soap [plain or antimicrobial] and water) before and after every patient contact; implementation of respiratory hygiene and cough-etiquette strat- egies for patients with suspected influenza or infection with another respiratory tract pathogen to the extent feasible; separation of infected, contagious children from uninfected children when feasible; safe handling and disposal of needles and other sharp medical devices and evaluation and implementation of needle-safety devices; appropriate use of personal protective equipment such as gloves, gowns, masks, and eye protection; and appropriate sterilization, disinfection, and antisepsis.
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