dolapo project work lastest review.docx_jm120618

7/28/2019 Dolapo Project Work Lastest Review.docx_jm120618

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Bashirat Suleiman 2012

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TABLE OF CONTENT

CHAPTER ONE

1.0 INTRODUCTION

1.1 Background

1.1.1 What is the cost to Nigeria?

1.1.2 Is Hand Washing The Solution?

1.1.3 Problem Statement

1.1.4 Rationale for This Review

1.1.5 SWOT Analysis1.2 AIM

1.2.1 Objectives

CHAPTER TWO

2.0 REVIEW OF LITERATURE

2.1 Literature Review

CHAPTER THREE

3.0 REVIEW OF RESEARCH METHODOLOGY

3.1 Methodology

3.2 Research Question

3.3 2.3 Electronic Database

2.3.1 Search Strategy

3.4 Inclusion and exclusion criteria

3.4.1 Inclusion criteria

3.4.2 Exclusion criteria

CHAPTER FOUR

4.0 ANALYSIS AND DISCUSSION

4.1 The Practice of Hand washing amongst Health

Workers in a UNIPORT Teaching Hospital4.2 A Ten Year Review (2000-2009) of OAUTHC in


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Nigeria and Hand-washing Practice by the Health Workers

4.3 Discussion

4.3.1 Compliance and Monitoring body in the UK and Nigeria

4.3.2 Compliance and Monitoring body in Nigeria

CHAPTER FIVE

5.0 CONCLUSION

5.1 RECOMMENDATION

5.2 REFERENCES


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CHAPTER ONE

1.0 INTRODUCTION

Health-care-associated infection (HAI) represent a major risk to patient safety and

contribute towards suffering, prolongation of hospital stay, cost and mortality (Graves

et al 2007).

The World Health Organisation in 2002 identify HAI has a major global safety

concern for both patients and health-care professionals (WHO; Prevention of

hospital-acquired infections: a practical guide 2002). Patient care is provided in

facilities which range from highly equipped clinics and technologically advanced

university hospitals to front-line units with only basic facilities.

According to WHO nosocomial infection is defined as an infection occurring in a

patient during the process of care in a hospital or other healthcare facility which was

not present or incubating at the time of admission which includes infections acquired

in the hospital or appearing after discharge, and also occupational infections among

staff of the facility.(WHO; World Alliance for Patient Safety: forward programme2005). Nosocomial infection, also known as HAI, has four common types; namely

surgical wounds, urinary tract infections, lower respiratory tract and blood infections.

Despite progress in public health and hospital care, infections continue to develop

among hospitalized patients, and may also affect hospital staff. Nosocomial

infections may range from mild to severe with an incidence of 5-10 % (Horan et al

2008). Healthcare-associated infection occurs worldwide and affects both developed

and developing countries. Estimates of the global burden of healthcare-associated

infections are hampered by a lack of reliable data but it was reported that at any

time, over 1.4 million people worldwide suffer from infectious complications aired in

hospital (Tikhomirov 1987). Most studies reporting data on the burden of endemic

HCAI were conducted in acute-care settings and in high-income countries. However,

an increasing body of evidence has highlighted the epidemiological differences in

non-acute care settings and in low and middle-income countries.


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The modern evidence-based approach to infection prevention and control clearly

emphasizes that no type of health-care facility in any country can claim to be free

from the risk of HCAI but can only be in control. In a WHO sponsored prevalence

survey study (WHO;guidelines on hand hygiene in health care (advanced draft): asummary,2005) conducted in 55 hospitals of 14 countries representing four WHO

regions (South-East Asia, Europe, the Eastern Mediterranean and the Western

Pacific) it was found that, on average, 8.7% of hospital patients suffer health care-

associated infections. The study showed that the highest prevalence of nosocomial

infections occurs in intensive care units and in acute surgical and orthopaedic wards.

Infection rates are higher among patients with increased susceptibility because of old

age, underlying disease, or chemotherapy (WHO; The Global Patient Safety

Challenge 2005).

Many factors relating to system and processes of care provision as well as to human

behaviour, promote infection among hospitalized patients: decreased immunity

among patients; the increasing variety of medical procedures and invasive

techniques creating potential routes of infection; and the transmission of drug-

resistant bacteria among crowded hospital populations, where poor infection control

practices may facilitate transmission. These infections, often caused by multi-resistant pathogens, take a heavy toll on patients and their families by causing

illness, prolonged hospital stay, potential disability, excess costs and sometimes

death.


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1.1 Background

Hospital-acquired infections (HCAIs) are in no doubt a threat to patient safety and

contribute to unnecessary economy burden to nations in the long run. Nosocomial

infections affect nearly 10% of hospitalized patients and represent a major problem

in healthcare facilities, resulting in prolonged hospital stays, substantial morbidity

and mortality, and excessive costs (Burke 2003).

It has been identified as a threat to global health, affecting both developed and

resource-poor countries.occassionally, results into outbreaks which account for

approximately 2-10% of all hospital-acquired infections (Haley et al 1985). Just like

endemic outbreaks, hospital-acquired infections in outbreaks contribute significantly

to morbidity and mortality, and they may lead to enormous costs for the healthcare

systems.

In the United States of America (USA), one in every 136 patients becomes severely

ill as a result of acquiring an infection in hospital (Starfield 2000) which is equivalent

to 2 million cases per year, incurring additional costs of US$ 4.55.7 billion and

about 90000 deaths. In England, 100 000 cases of HAI are estimated to cost the

NHS a minimum of 1 billion per year (Plowman et al 2001) with more than 5000attributable deaths annually (Mayor .2000).

A prevalence survey conducted under the auspices of WHO in 55 hospitals of 14

countries representing 4 WHO Regions (Europe, Eastern Mediterranean South-East

Asia and Western Pacific) showed an average of 8.7% of hospital patients had

nosocomial infections. The highest frequencies of nosocomial infections were

reported from hospitals Eastern Mediterranean and South-East Asia Regions (11.8

and 10.0% respectively), with a prevalence of 7.7 and 9.0% respectively in the

European and Western Pacific Regions (Mayon et al. 1988). The most frequent

nosocomial infections are infections of surgical wounds, urinary tract infections and

lower respiratory tract infections. According to Mayon international survey study and

others, the highest prevalence of nosocomial infections occurs in intensive care units

and in acute surgical and orthopaedic wards.(Mayon et al. 1988).

Infection rates are higher among patients with increased susceptibility because of old

age, underlying disease, or chemotherapy. There is no national aggregate data on


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the total number of HCAI in England, the Department of Health (DH) and successive

National Audit Office (NAO) reports estimate that 300,000 patients receiving care

and treatment in the NHS acquire a HCAI each year (House of Commons 2009;

NAO, 2009). These infections often worsen the patients underlying medical orsurgical condition and for some result in serious disability or death.

In 2007, meticillin-resistant Staphylococcus aureus (MRSA) bloodstream infections

or Clostridium difficile infection was the underlying cause or a contributory factor in

the deaths of 9,000 patients (Office for National Statistics, 2008; NAO, 2009).It is

estimated that in developed countries 5-10% of patients admitted to acute care

hospitals acquire an infection; the attack rate for developing countries can exceed

25%.( Zaidi et al 2005).

Certain factors increase the risk of infection among hospitalized patients: underlying

diseases and decreased immunity; the increasing use of invasive diagnostic and

therapeutic techniques; the transmission of drug-resistant pathogens; and poor

infection Control measures. However, the available studies indicate that healthcare-

associated infections are likely to be more frequent and serious in developing

countries where the lack of resources and basic facilities for infection control

combine with patients being more susceptible to infection because of malnutrition,

multiple co morbidities, immunosuppressant, and poor personal hygiene. In contrast,

in industrialized countries, this problem is mostly a consequence of sophisticated

and invasive healthcare techniques combined with multi-resistant pathogens. In both

settings, environmental factors may play a crucial role in causing healthcare-

associated infection.

In the USA, the incidence is estimated at around 5-6%, with an attributable mortality

of 3.6% (40 000 to 80 000 deaths annually) and excess costs of at least 4.5 billion

US dollars every year for the healthcare system.( Weinstein, 1998).However, in

Europe well established national and international surveillance systems are largely

lacking, but studies have shown a prevalence of healthcare associated infections

between 4.4 and 14.8% (Nicastri ,2003).


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1.1.1 What is the cost to Nigeria?

Nosocomial infections poses an enormous problem globally, as well as in hospitals

in Nigeria. Literature show that rate of hospital acquired infections has been found to

vary somewhat at 9% (Emmerson et al. 1996), 8% (Glynn et al.1997), 6% (Haley et

al. 1985) and 6-15% of hospital admissions (Coello et al. 1993) which is a situation

better than Nigeria.

Studies in Nigeria on nosocomial infection shows prevalence rate in different

hospitals and reported 2.7% for Ife (Onipede et al, 2004), while 3.8 %29 from Lagos

and 4.2% from Ilorin (Odimayo 2008).

HAI continues to gain momentum as an important area of concern in medicine asmost specialties, such as surgery and intensive care, are being increasingly offered

to a vulnerable population. Data on infection rates in developing countries are

scarce. Even if available, they may not be fully representative because they are

collected in hospitals with resources exceeding the standards of the country as a

whole. That is why this report will use Obafemi Awolowo as a sample.

A previous study in Obafemi Awolowo University Teaching Hospital investigated the

course and prevalence of nosocomial infections over a period of 5 years in the

teaching hospital. The study found a period prevalence of HAI to be 2.6%. It also

concluded that infection control infrastructure and adherence to infection control

practices was weak (Onipede et al., 2004).

In Nigeria, there have proven favourability in the transmittion of infections due to

existing suitable pathogen-host environment relationship. However, it is important to

realize that this association could be broken, and the rates can be reduced by up to

one-third if healthcare workers comply with guidelines issued by the Centre for

disease control(Haley et al. 1985, Larson 1988, Pittet et al. 2000).


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1.1.2 Is Hand Washing The Solution?

There is substantial evidence that hand antisepsis reduces the incidence of HAI

(Hilburn et al 2003, Lam et al, 2004).

The word hand hygiene includes;

hand washing (washing hands with non-antimicrobial soap)

antiseptic hand wash (washing hands with water and soap or another

detergent containing an antiseptic agent)

antiseptic hand rub (rubbing hands with an antiseptic hand rub) and

surgical hand antisepsis (preoperative antiseptic hand washes or hand rub

performed by surgical personnel (Centres for Disease Control; Guidelines for

hand hygienein healthcare settings 2002). These terms also include hand

drying following hand washing (Jumaa 2004).

Our hands play a vital role in the transmission of infection in healthcare institutions,

(Aiello et al,2002, Curtis et al ,2003). Hand hygiene is therefore a fundamental action

for ensuring patient safety, which should occur in a timely and effective manner inthe process of care. Improving hand hygiene reduces infection in a wide variety of

settings (Stone SP, 2001). Hand hygiene compliance among health care workers is

low despite it being the simplest and most important aspects of infection control

(Pittel et al 2001), however noncompliance with hand hygiene practices is associated

with health care-associated infections, the spread of multi-resistant organisms, and

has been a major contributor to outbreaks of infectious diseases.

Increased patient workload, decreased staffing, limited time, long distances to sinks,

belief that use of glove obviates the need for hand hygiene and ignorance of or

disagreement with guidelines and protocols have all contributed to poor compliance

with hand hygiene and other routine infection control measures (Boyce, 2002, Pittet,

2000).

Subsequent to government and public concern at reported high levels of meticillin

resistant staphylococcus aureus (MRSA) bacteraemia, meticillin sensitive S aureus


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(MSSA) bacteraemia, and Clostridium difficile infection (CDR Weekly:

Staphylococcus aureus bacteraemia; 2004, CDR Weekly: Results of the first year of

mandatory Clostridium difficile reporting; 2005) and low levels of hand hygiene

compliance, the Cleanyourhands campaign (National Patient Safety Agency: Ready,steady, go; 2004) was rolled out in 2004 in England and Wales to healthcare workers

in all acute National Health Service (NHS) hospital trusts.

Improving hand hygiene remains a challenge for infection control practitioners in

healthcare institutions and in the community. Most of literature includes guidelines

for hand hygiene, concerns healthcare institutions in developed countries without

putting developing countries into consideration.

In 2002, the 55th World Health Assembly was confronted by a patient safety issue

and adopted a resolution urging countries to pay the closest possible attention to it

by strengthen safety and monitoring systems. The resolution urged the World Health

Organization (WHO) to lead the process of establishing global norms and standards

and supporting country efforts in developing patient safety policies and practices.

This was followed by creation of the World Alliances for Patient safety in 2004 whom

in every two years covers a topic that significantly put the patient at risk in whenreceiving healthcare. The topic chosen for the first Global Patient Safety Challenge

over the two-year period 20052006 was healthcare associated infectiona major,

global issue in patient safety. (Hambraeus, 2006).

Hand washing has been cited as the most effective measure for preventing

healthcare associated infections, and its impact on the reduction of these infections

is estimated at 50% (Pittet et al. 2000). It has been estimated that hand washing with

soap could save a million lives a year (Curtis V et al 2003).

The knowledge, practices and attitude to hand washing practices is hardly monitored

because of a bad surveillance system. While the spread of infection in developed

countries remains a serious problem, especially in high-risk settings such as

hospitals, the threat of infectious disease in developing countries remains extremely

high. Developing countries present extra hurdles when trying to increase hand

washing.


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Increasing hand washing in developing countries therefore requires a more intense

approach to change the knowledge and practices.

In England Trusts were involved in the large clean-your-hands campaign co-

ordinated by the National Patient Safety Agency. According to Pittet studies (Pittet et

al 2000) on effectiveness of a hospital-wide programme to improve compliance with

hand hygiene show that multi-modal campaign consisting of previously successful

strategies increase compliance. These included the introduction of near-patient

alcohol hand rubs (NPAHs) and a series of posters and supporting marketing

materials such as aprons and badges, aimed at patients, carers and staff.

The campaign also provided patients with leaflets that encouraged them to ask staff

about cleaning their hands. The campaign was aimed at getting people involved to

improve the knowledge on hand washing and change the culture especially the

compliance within the healthcare worker. Many factors play a role in eventually

determining either a hand hygiene action or lack of compliance:

perception and knowledge of the transmission risk and of the impact of HCAI

social pressure

HCWs conviction of their self-efficacy

evaluation of perceived benefits against the existing barriers

the intention to perform the hand hygiene action for example, the lack of

appropriate infrastructure and equipment to enable hand hygiene

performance

the cultural background, and even

religious beliefs can play an important role in hindering good practices. (dress

of muslim women doctors hijab)

This is also in concordance with the fact that care activities with a higher risk of

cross-transmission lead to a higher risk of poor compliance. (Pittet et al 2000).

Individual factors such as social cognitive determinants may provide additional

insight into hand hygiene behaviour. Hence, hand hygiene behaviour appears not to


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be homogeneous so to avoid prolonged hand contamination, it is important to

perform hand hygiene.

The impact of good hand washing practice can be measured by the prevalence rate

of nosocomial infection, the compliance rate and the economical implication of the

infection to the hospital management can also be a tool for measurement. To this

end, there has been limited attention paid to investigating knowledge, attitudes, and

behaviour of hand washing regarding control policies within developing countries.

Therefore, the objectives of this review were to compare the impact of hand washing

in management of HAIs infection, using the level of knowledge, attitudes, and

compliance as measure among HCWs in hospitals in Nigeria and England and to

identify the determinants differences and learn from the better system.

1.1.3 Problem Statement

In Nigerian Hospitals, over two million people develop infections acquired during

their stay in hospital which might have been prevented. Inconsistent poor hand

washing practices often result in nosocomial infections. In fact, hand washingcompliance rates have been seen to be as low as 15-35% due to non convenient

sink locations and absent-mindedness which can create barriers to appropriate hand

washing behaviour.

1.1.4 Rationale for This Review

The rationale for this comparative review is to look at the impact hand washing

hygiene on Nosocomial infection of the two countries England and Nigeria, the

healthcare workers (including management), knowledge and attitude to the hand

washing practice in controlling the infection burdens.

Hence this comparison will lead to learning from strategies applied in England and

increase the awareness of Nigeria hospital management by improving good hand

washing practices to help in the reduction of nosocomial infections in hospitals.


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Currently, more than 1.4 million patients worldwide in developed and developing

countries are afflicted by healthcare-associated infection (HAIs) (Weinstein 1998).

Nigeria and England are categorised as developing and developed countries and

can present the two countries in the global world for a global concern like HCAI. The

risk of acquiring HAI is universal and a reality. It is an issue which pervades every

healthcare facility and system around the world, regardless of resources

available.These countries have been chosen for this comparative study because of

HCAI is a global challenge and in addition both countries have pledged to WHO to

participate in the hand washing campaign since 2009 (Fig 1 show the numbers of

country that have pledge to fight HAI at the end of 2009) but difference in the health

outcome of nosocomial infections over the years is quite large. In relation to rate of

HCAI and a health system that is centre around patient safety, there is a lot to learn

in a system. In addition, the comparison is based the fact that HAI is a risk to patient

safety regardless of resources available.

Government involvement and commitment to action is essential to make preventive

intervention a successful reality at system and facility level. In developing countries

like Nigeria, the aspect of political engagement is even more important because of

the lack of national policies and inadequacy of infrastructure and equipment for

infection control. This paper will thereby critically analyse the impact of hand washing

on nosocomial infection rate, the knowledge an current attitude of HCW and hospital

management on this simple effective practice in Nigeria hospital, how it has fared in

managing this infection, its high costs for patients and their family, and excess

deaths, and then compare the system in place to that of England that is a have a

framework on hand washing programme, involvement of all, using all means to

change staffs attitude and thus has reported improvements in infection rate and

patient safety.

This study will then make recommendations on possible lessons to be learnt by the

Nigerian hospital management to effective hand washing in the controlling burdens

of HCAI from England health system. However this paper does not imply these

recommendations to be a straight jacket approach knowing the peculiarities in each

of the geopolitical regions in Nigeria, but only gives a hint to the possible way out for


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the reduction in the burden and having a better health care to all, using the example

from another country.

Comparing both countries, it is worthy of note to state that there are disparities in the

population of both countries. While Nigeria is a large country of approximately

923,768 square metres and a population of approximately 148.1 million (WHO; MDG

Monitor Fact sheet; Nigeria. 2008), England on the other hand is a small sized

country of approximately 50,346 square metres and a population of 51 million (WHO;

MDG Monitor Fact sheet; England. 2008) people perhaps the reason why policies

are better adopted and implemented, considering limited complex administrative

management structures in this region when compared with what applies in the

developing world.

Figure 1

National commitment to tackle healthcare-associated infection. Countries committed

at the end of 2009 are shown in orange.

Source: http://www.who.int/gpsc/statements/countries/en/index.htm


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1.1.5 SWOT Analysis

Strengths Weaknesses

Trail delivery record of commercial

management on C diff Can Do approach Trust-wide dedication and loyalty Evidence-based guiding principle Enlightenment Programme Excellent hand hygiene fulfilment Dedicated domestic obligation Infection directive advice being sought after

and taken Improvements on Patient environment

ICT Resources

High occupancy of in medical division

75% Bed Centre distances > 3.6m High rate of Non-clinical Transfers Time to isolate not meeting Conformity with policy & Procedures MRSA failures in Screening Turnout at non-mandatory exercise Storeroom space Regional responsibility SanitizationCluster concern

Opportunities Threats

Partnership with key stakeholders

Setting own principles/objective

Incorporated policy

Separating elective and emergency patient

flows

LEAN programme

Awareness through Website

Strategic Communication y Further enhancing of cleaning standards

Organizing National Patient Safety

Campaign

Excellent quality care for all.

Sanitization challenge

Monetary punishment

Patient Nervousness/Stigmatisation of

Incident/Repute of clinic

New and upcoming Diseases

Unconstructive Pressure Rooms

Altering agenda

Challenging agendas Lack of support for onsite lab


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1.2 AIM

This paper aims to review the impact of good hand washing knowledge and practise

to control of Nosocomial infections, comparing England and Nigerian hospital

management knowledge and practices.

1.2.1 OBJECTIVES

To review based on the literature the impact of hand hygiene on HAI control using

knowledge, attitude, and rate of nosocomial infection as measures.

To review literatures on the rate of nosocomial infection rate in both country and

action taking toward changing the attitude of HCW on hand hygiene.

To develop the awareness ofgood hand washing practice to hospital management

in Nigerian hospital.

To determine the cost of infection control with respect to morbidity and mortality of

disease, patient safety in Nigerian hospitals and hence, comparing the data with

England.

To learn from the impact of hospital management on hand washing policy inEngland and implement that change in hospital management in Nigeria.

Health workers are expected to wash their hands properly.


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CHAPTER 2

REVIEW OF LITERATURE

2.1 Literature Review

A literature review is an organized, extensive and systematic written critique of the

most important published scholarly literature on a topic (LoBiondo-Wood & Haber

2006, Burns & Grove 2005). In order to promote evidence-based in the science

world and to improve the present practice in clinical practise, literature has be review

on different interventions and evaluated their outcomes in terms of improvement of

hand hygiene adherence in clinical practice.

The purpose of this final project is to identify interventions that can improve hand

hygiene adherence in hospital to enhance better management of nosocomial

infection, in addition, influence the implementation of change in clinical practice and

knowledge of healthcare worker to effective hand washing practices.

Far back from the history of hospital infection controls, Semmelweis (Larson et al

1988) demonstrated in 1847 that the mortality rate among mothers delivering at the

first Obstetrics Clinic at the General Hospital of Vienna was significantly lower whenhospital staff cleaned their hands with an antiseptic agent than when they washed

their hands with plain soap and water. Though, research in this field represents a

very challenging activity since methodological and ethical concerns make it difficult

to conduct randomised controlled trials with appropriate sample sizes that could

establish the relative importance of hand hygiene in the prevention of HCAI, but

literature have shown convincing evidence that improved hand hygiene can reduce

infection rates.

In 2004, four hospital-based studies of the impact of hand hygiene on the risk of

HCAI was published (MacDonald A et al 2004; Swoboda SM et al 2004; Lam BC et

al 2004; Won SP et al 2004) and all the reports showed a temporal association

between improved hand hygiene practices and reduced infection and cross-

transmission rates.

Given the complexity of hand hygiene behaviour and the influence of numerous

external factors, promotion of good practices is complex and its potential for success


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depends on the delicate balance between evaluation of benefits and existent

barriers. Demonstration of the effectiveness of recommendations and strategies to

improve hand hygiene on the ultimate outcome, i.e. the HCAI rate, is crucial in both

motivating HCWs behavioural change and securing an investment in this preventivemeasure by policy-makers and healthcare managers.

In 2006 Shimukura (Shimukura et al 2006) review on adherence to hand washing

and identified factors influencing adherence to hand hygiene in clinical practices,

such as attitudes, knowledge, institutional factors, physical barriers, type of

environment, type of staff and the use of automated sinks. Another review by

Allegranzi and Pittet (2009) also showed that the risk of poor compliance is higher

when care occurs in a care activity where there is a higher risk of cross-infection, for

example a busy clinic or ward setting in a developing country. Increased adherence

to hand hygiene is widely acknowledged to be the most important way to reduce

infections in the health care facilities (Maskerine et al, 2006).

Despite this fact, studies in the literature have repeatedly documented that the

importance of hand hygiene is not sufficiently recognized by healthcare workers

(Dubbert et al,1990; Simmons b et al, 1990; McLane C et al,1983) and compliance

with recommended practices is unacceptably low ( Pittet D et al, 2001; Boyce JM et

al,2002) in which average adherence with hand hygiene recommendations is

reported to be below 50%, but varies between different hospital wards, among

professional categories, and according to working conditions. Similarly in the same

2002, Bittner and colleagues (Bittner MJ et al, 2002) observed that hand washing

frequency decreased when the patient-to-nurse ratio increased, which impede the

safety of the patient.

Furthermore, OBoyle and colleagues (OBoyle CA et al,2001) conducted a

longitudinal, observational study among critical care nurses and showed that

observed hand hygiene behaviour was more sensitive to the intensity of activity in

the nursing unit, rather than to internal motivational factors taken from the theory of

planned behaviour. Similarly, the results of a questionnaire survey to evaluate

knowledge, attitudes, and behaviour regarding hand hygiene among Italian HCWs

suggested that promotional interventions should not only focus on knowledge, but

also on facilitating and reinforcing factors (Nobile CGA et al 2002).


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Moreover, not only is the average level of compliance with hand hygiene

recommendations low, but time spent is usually insufficient. The duration of hand

washing by HCWs varies between a few seconds and more than 60 seconds,

averaging from as low as 4-7s to 24s in observational studies (Boyce JM et al 2002).In addition to washing their hands for very short periods of time, HCWs often fail to

cover all surfaces of their hands and fingers as well as the technique of hand

hygiene is frequently deficient.

Adherence to effective hand washing is the issue here which is also often referred to

as compliance in the literature, can be defined as how closely a person is able to

follow some guidelines, here hand hygiene. Reasons for non-adherence to hand

hygiene has been widely researched and several theories have been studied to

improve adherence to hand hygiene (Whitby et al. 2007).

These theories are predominantly psychological and focus on behavioural change.

Some of them are particularly interesting, for instance the health belief model and

the theories of reasoned action and planned behaviour, because they highlight the

issues of attitudes and knowledge. According to the health belief model, as

Maskerine and Loeb (2006) describe it, a health care workers actions depend on the

perceived susceptibility of the health threat, the perceived severity of the threat and

the belief that a particular recommendation would be beneficial without costly

barriers or high risks. In other words, when applied to hand hygiene, health care

workers would adhere to hand hygiene if they believed that they were susceptible to

a particular infection and would acquire or transmit to somebody else this infection if

they did not wash their hands. Similarly, the theories of reasoned action and planned

behaviour suggest that a healthcare worker will have a positive attitude if she / he

believes and understands that adherence to hand hygiene prevents infections,

(Maskerine& Loeb 2006).

Furthermore, intervention to change this believe should be our strategy to change

the present situation. It is commonly agreed that situations regarding hand hygiene

must go forward. From a nursing point of view, it is crucial that basic rules of hand

hygiene and asepsis, that are normally well known and well handled, are rigorously

followed. It should already be part of the nurses daily routine but the literature tends

to show the opposite. Infections (including nosocomial) in nephrology patients can be


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reduced or suppressed with a good compliance and adherence to hand hygiene;

infections are the most important causes of the loss of vascular access for dialysis

and have catastrophic consequences (Price et al. 2002).

Although hand hygiene has long been regarded as the most effective preventive

measure (Teare 1999), numerous studies over the past few decades have

demonstrated that compliance with hand hygiene recommendations is poor and

interventions are not effective long term. As the years go the topic of hand hygiene

has received increasing attention globally in the UK, Europe, North America and

Australia but little is done in Africa. The public is alarmed by the high incidence of

HAIs and health providers must now demonstrate the effectiveness of infection

control policies.

Pittet 2000 published the results of a Swiss initiative that used an uncontrolled before

and after design to demonstrate that a hospital wide poster campaign, combined with

performance feedback and alcohol-based hand rub placed at every bedside, led to

sustained improvement in hand hygiene for nursing but not medical staff, as well as

reduction in HAIs and methicillin-resistant Staphylococcus aureus (MRSA)

transmission. Follow-up data published independently revealed continuing success

(Hugonnet 2002). Since then, a number of countries have implemented widespread

hand hygiene campaigns, with little evidence to base decisions about which

interventions are the most effective.

Naikoba (2001) systematically reviewed 21 studies published before the year 2000.

They classified 17 studies as uncontrolled trials, and of these, 15 took place in

intensive care units (ICUs). Numerous different interventions and combinations of

interventions to improve hand hygiene were examined. The reviewers concluded that

multifaceted approaches promoted hand hygiene compliance more effectively than

approaches involving a single type of intervention.

Additionally, education with written information, reminders and continuous feedback

on performance were more useful than the other interventions assessed, such as

automated sinks or provision of moisturised soaps. However, more recently

published work has indicated that multifaceted interventions are not likely to be more

successful than single interventions in changing practice (Grimshaw 2004) and thataudit with feedback has only a modest effect on improving practice (Jamtvedt 2006).


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Hand hygiene compliance is likely to be influenced by factors such as staffing levels

and replacement of the usual staff by agency nurses or float staff at times such as

national holidays or in the event of staff sickness.

An intervention refers to actions taken to improve a situation or to make a significant

change. For instance, a frequent way to remind the nurses to keep a good hygiene is

a poster which seems to be beneficial (Pittet 2001). This is, however, not enough, a

poster alone being not efficient if concrete interventions around it are not

implemented. This final project will show methods and interventions that would

improve the adherence of hand hygiene in the nursing care. According to Maskerine

and Loeb (2006), adherence to hand hygiene has been estimated to be 30-60% in

the absence of any interventions.

Overcrowding and understaffing are commonly observed in health-care settings

throughout the world, particularly in developing countries where limited personnel

and facility resources contribute to the perpetuation of this problem. Overcrowding

and understaffing were documented in the largest nosocomial outbreak attributable

to Salmonella spp. ever reported (123); in this outbreak in Brazil, there was a clear

relationship between understaffing and the quality of health care, including hand

hygiene.

There is a proof that the prevalence of nosocomial infections decreased as HCWs

compliance with recommended hand hygiene measures improved, if only the top

hospital management and medical and nursing leaders provided active support for a

culture change, highlighting and enforcing the expectation for hand hygiene

compliance for all HCWs. In 1998, Coignard and colleagues (Coignard et al 1998)

study the effect of group training intervention to improve the knowledge of hand

washing by using demonstrating hand washing technique, publication in the hospital

newsletter and posters.

This study result a significant increase in the proportion of HCW who could perform a

hand wash according to the protocol (4.2% before intervention, 18% after P< 0.001).

Similarly, Khatib in 1998(Khatib et all 1998) observed the effect of educational

intervention comprising formal lecture, practical demonstration and written

information about hand washing. Observation of 537 occasions in which handwashing was indicated showed high level of compliance (78%) of hand washing both


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before and after patient contact during the first week following the intervention.

Education aims at promoting intellectual curiosity, development and encouraging the

ambition to implement change and training promotes discipline to inhibit

development (Gould et al. 2008). It is acknowledged that adherence withrecommended instructions is commonly poor amongst health care workers (Pittet et

al. 2000; Hussein et al. 2007; Gould et al. 2008; Swoboda et al. 2007). Results on

adherence without any intervention vary from one study to another.

It is reported that the baseline adherence, i.e. the adherence without any

intervention, is situated between 40% and 57% (with two exceptions at 63% and

22%). Studies have shown that educational programmes have produced clear

improvement in hand hygiene adherence, hence reducing the nosocomial and

health-care related infections. A hospital-wide programme, mainly based on a poster

campaign together with a generalised promotion of alcoholic hand rubs, proved to be

efficient in improving significantly hand hygiene adherence and therefore reducing

nosocomial infections and MRSA transmissions (Pittet et al. 2000; Hussein et al.

2007; Creedon 2005).

Posters, reporting strong messages about infections, cross-transmission and hand

hygiene were placed at strategic places and replaced once or twice per week with

other posters. By doing so the posters were visible at different places in the hospital,

creating an illusion that new posters were set regularly (Pittet et al, 2000).

Healthcare personnel feel that a reminder poster yields from a moderate to high level

of motivation for adherence to hand hygiene (Picheansathian, Pearson & Suchaxaya

2008).

The aforementioned hospital-wide protocol developed by Pittet et al (2000) is known

as the Geneva Programme. Whitby et al. (2007) tested and compared it with a very

similar protocol called the Washington Programme, which is targeted at inducing

institutional cultural change toward improved hand hygiene (Larson et al. 2000

quoted in Whitby et al. 2007). Both programmes have a positive effect on increasing

hand hygiene practice with sustained improvement. However the durable effect of

the Geneva Programme, principally based on education, may be limited in wards

where leadership is weak.


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In addition, HCAI surveillance is a very resource- and time-consuming activity

requiring rigorous and standardised methods, and therefore is seldom available on a

regular and reliable basis. One major limitation of the review was that it included

studies that had weak designs for making causal inferences about the effects ofinterventions (mainly uncontrolled before and after studies.

It is a simple true that educational and training programmes increase knowledge and

therefore adherence on hand hygiene. They must be continuously reinforced to

achieve optimal adherence to recommended hand hygiene policies (Hussein et al.

2007). Additionally, there are positives outcomes in terms of adherence with nurses

who receive a hospital-wide general overview of infection control and hand hygiene

in their initial orientation to the hospital (Swoboda et al, 2004; Lam et al, 2004).

However, it has also been discussed that multifaceted interventional programmes,

that is to say programmes with multiple approaches, are key factors leading to a

sustained high level of appropriate hand hygiene practices among nurses

(Picheansathian et al. 2008; Hussein et al. 2007; Creedon 2005; Pittet 2000).


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CHAPTER 3

3.0 REVIEW OF RESEARCH METHODOLOGY

3.1 Methodology

The aim of the methodology was to identify an exhaustive list of studies which

investigated the impact of hand washings on nosocomial infection (HAI), the

effectiveness of interventions intended to increase hand hygiene knowledge, attitude

and practices, and to determine their success in terms of patient safety, effect on

rate of HAI, hand hygiene awareness and compliance.

3.2 Research Question

The Research question formed in order to carry out a valid search was what is the

impact of hand hygiene in the management of nosocomial infection?, the evidence

in relation to hand hygiene being a method of reducing the spread of infection? ,

the knowledge, attitude and practice of hand washing in hospitals using England

and Nigeria at separate search.

The following search terms were used: impact/burden. hand hygiene or hand

hygiene alone and combined with the following terms: education; knowledge;

practices; health promotion; audit; compliance; product availability; cross-

infection; nosocomial infection; hospital-acquired infection and health care-

associated infection ,Nigeria, developing countries; developed countries;

England

3.3 Electronic Database

3.3.1 Search Strategy

An initial search was conducted on Medline using possible thought out synonyms to

the keywords indexed above. From the search some relevant literature were

selected and read through. This helped to further inform synonyms to the keywords

that were used for the main searches in the different databases (see annexe A). For

each element a list of keywords synonyms, free text words and relevant medical

subject heading (MeSH) that may have been used by authors was accumulated. The

search strategy and relevant databases were then compiled. In an attempt to include


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every possible indexed article, a literature search using major biomedical databases

was conducted using major databases concerned with biomedical and health issues

(WHO, PubMed, Science direct, Medline, EMBASE,BNI , and Cochrane) were

electronically searched using the designated keywords and search terms. Searchwas carried out within the month of October and December 2010.

A combined keyword and MESH search was done for PubMed, Science direct,

Medline and EMBASE while keyword search was used in Cochrane .The search was

initially global and later narrow to England and Nigeria, it was also limited to articles

in English language. The time frame, 2002 to 2010 was considered. Duplicates were

removed. Truncation symbols were used where possible in order to capture all

articles related to the term. Example hand wash* for words like hand washing and

hand hygiene, Wildcard was used for word like healthcare worker and nosocomial

infections. The Boolean operator OR was used to combine the key synonyms and

the key search with MeSH searches while AND was used to combine the four list of

each of the elements in the search in order to generate a high sensitivity citations.

Table 1:

Databases Used and Reasons

DATABASE REASON FOR THE CHOICE1. Medline Wide coverage of most topics within the area of clinical

medicine including other topics and professions, it

includes more publications in England journals title

2. WHO Wide coverage of most topics within the area of clinical

medicine in different region in the world, data of

countries are ready available there and links to patient

safety journals

3. PubMed The most comprehensive public health database. Good

in international coverage on public health in generally

4. Cochrane Contains information on interventions and contain full

text systematic review.

5. Science Direct Contains information in developing world.


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Grey literatures were searched in Medline databases, which contain information in

developing countries and WHO articles electronically. Hand searching was done

across publications of agencies and organisations involved actively in the field of

hospital acquired infection like WHO, Alliance of Patient safety and Health Protectionagency, Federal Ministry of health Nigeria, journals from British Medical Journal,

Journal of Hospital Infection, American Journal of Infection Control, Infection Control

and Hospital Epidemiology.

Conference proceedings from the UK Hospital Infection Society and the Infection

Control Nurses Association were hand searched. Website was also search like:

Department of health (DH), National patient Safety Agency Cleanyourhands,

Healthcare Associated Infection research Network. Colleagues from Nigeria

hospitals were contacted for information about relevant unpublished work.

Information was sought from pharmaceutical companies online manufacturing hand

hygiene products.

3.4 Inclusion and exclusion criteria

3.4.1 Inclusion criteria

TYPE OF STUDY DESIGN: All Quantitative studies i.e. Randomized control trials

RCTs, cohort studies, case control studies, comparative studies, cross sectional

studies. Studies where the participants or target groups were nurses, doctors and

other allied health professionals and studies in any hospital in the two countries that

involved any type of intervention intended to improve hand hygiene knowledge,

practice compliance using aqueous solutions and/or alcohol products (e.g.

education; audit with performance feedback; health promotion; and variations in

availability and types of hand hygiene products). Studies to promote hand hygiene

compliance as part of a care bundle approach were included, Studies to promote

compliance with universal precautions were included.

POPULATION OF INTEREST: studies from inside hospital population were included

in the review e.g. wards, clinic. Studies included were those carried out globally and

in both countries.

Types of interventions


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I considered any intervention intended to improve compliance with hand hygiene

using aqueous solutions and/or alcohol based products. For example, I considered

education, audit with performance feedback, health promotion, and variations in

availability and type of products used for hand hygiene. Studies of interventions topromote hand hygiene compliance were potentially eligible regardless of whether the

intervention occurred in outbreak or non-outbreak situations.

Studies to promote compliance with universal or infection control precautions were

considered for inclusion, providing data relating specifically to hand hygiene were

presented separately. Similarly, studies to promote hand hygiene compliance as part

of a care bundle approach was eligible, providing data relating specifically to hand

hygiene or a proxy measurement for hand hygiene were presented separately.

Studies were excluded if hand hygiene was assessed in simulations or artificial

settings outside the clinical environment.

OUTCOME MEASURES: included studies are the ones that measured their

outcomes of impact of hand hygiene directly, using observation method, measuring

product use method and conducting survey are included. Study that shows the

effectiveness of hand hygiene as a measure for preventing the spread of infection

was the priority.

Types of outcome measures

My outcome of interest was:

Rates of observed hand hygiene compliance and/or a proxy indicator of hand

washing compliance (e.g. increased use of hand washing products).

Reduction in healthcare-associated infection.

Reduction in colonisation rates by clinically significant nosocomial pathogen

Impact of intervention like education on the knowledge and attitude of healthcare

worker.

Healthcare workers perceptions of their hand hygiene practices was not considered

a valid measure of compliance because there is evidence that self-reports are not

accurate (Haas 2007).


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However, studies that evaluated indirect measures of these indices of measurement

using standard methods were also included rate of HAI infection, cost to the patient

safety, result of intervention like education, compliances to hand hygiene policy,

knowledge and practice of HCW. Socio economic status of the country, risk factorslike cultural belief to hand washing were also used in the selection of articles for this

review

Description of method of measuring impact of hang washing adherence

Observation method is observing peoples hand hygiene behaviour and record

the number of hand hygiene episodes in relation to recommended practices,

which is the most reliable method for assessing adherence rates (WHO: WHO

Guidelines on Hand Hygiene in Health Care (Advanced Draft): 2006.))

Product Measurement is measuring the amounts of liquid soap, alcohol-based

hand rub(ABHR), paper towels, and gloves used in a particular area over a

specified period of time , which is not subject to selection or recall bias(WHO:

WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft):2006.)

Surveys; Surveying health care workers about their own hand hygiene

practices, knowledge, attitudes, and product satisfaction. Surveying patients

and families about their attitudes and perceptions of the hand hygiene

practices of health care workers. Inexpensive (Haas et al 2007) Not resource

intensive, Can provide some information on compliance. (WHO: WHO

Guidelines on Hand Hygiene in Health Care (Advanced Draft):2006.) Focuses

health care workers attention on their own hand hygiene practices (Gould

D.J., et al 2007)

Nosocomial infection rates demonstrate a great deal of natural variability, and it is

difficult to determine whether decreases in rates are due to random chance or

natural variability rather than to the intervention. There are limitations in the study

designs used to investigate the link between hand hygiene and infection rates. Most

studies are uncontrolled, pre- and post-intervention in single sites with addition of

ethical reason when conducting a surgery.


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GEOGRAPHICAL AREA: The global perspective was initially covered but was

narrow to hospitals, clinic in Nigeria and England hospitals.

LANGUAGE: Limitation to articles written in English language only.

TIME RESTRICTION: Studies between 2002 and 2010 were considered. In May

2002, the WHO World Health Assembly passed resolution WHA55.18 which urged

countries to pay the greatest possible attention to patient safety (PittetD,et al 2005)

which lend to creation of the World Alliance for Patient Safety (WAPS) in 2004. But

since this urges by WHO and pledges from countries to work on the effective hand

washing for HAIs, to improve patient safety more need to be done. Studies that did

not meet the above criteria were excluded from the review.

3.4.2 Exclusion criteria

Studies with unclear measurement of impact of hand washing was excluded

Studies without intervention result of hand washing were excluded.

Surveys or Studies were excluded if hand hygiene was assessed in simulations,non-clinical settings or the operating theatre setting

Qualitative studies were excluded.

Time frame outside the scope of this review, both the time of publication and time in

which study was done.

Studies published in language other than English

CHAPTER 4

4.0 ANALYSIS AND DISCUSSION


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Infections acquired in the hospitals which can also is known as nonsocomial infection

are cross infections which show up during an admissive stay at the hospital and

observed up to seventy two hours after a patient being discharged (WHO, 2003).

This could be from the patients, health workers, and/or hospital equipment. My majorfocus is on the health workers considering the major effect of the

disappointment/inadequacies of hospital disease Control Programme.

Infections originating from hospitals consist of about 7% admissions, (Haley et al.

1985). These infections are outcome from the spread of microorganisms from the

hands of health workers in hospitals. The increase in these health issue associated

disease can be curtailed if these health workers in the hospitals can only wash their

hands at peculiar times with the necessary materials. But, unfortunately, regardless

of the ease of hand washing process, various studies and analysis have persistently

shown disappointingly very low hand washing observance rates in the midst of

health workers (Haley et al., 1985; Bischoffet al., 2000; Pittet et al., 1999a; 2004;

1999; 2000;Lankford et al., 2003; Simmons et al., 1990).

Pittet et al. (1999a) in his research reported the level of compliance by health

workers towards hand washing to be about 48%. In that analysis, noncompliance

among physicians, nursing assistants and other health care workers was of higher

rate than among nurses. While in another study highlighted by Pittet et al. (1999a)

conducted by Simmons et al to ascertain the responsibility of hand washing in

deterrence to prevalent intensive care unit infections, the general hand washing rate

was seen to be 22%.

Many of these analytical studies were carried out in Europe and other foreign

countries; its been observed that very few have been carried out in Nigeria. This

analysis is aimed at exploring awareness attitudes and the practice of hand washing

amongst health workers in two different major Hospitals in Nigeria namely University

of Port-Harcourt teaching hospital, (Abinye, Alex-Hart and Opara, 2011) and

Obafemi Awolowo teaching hospital, (Afolabiet al., 2011). The analysis was based

on the descriptive cross sectional based study, which was, carried out amongst the

health workers in these hospitals.


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4.1 The Practice of Hand washing amongst Health Workers in a UNIPORT

Teaching Hospital

The University of Port-Harcourt teaching hospital is a very large hospital located in

Rivers state, Nigeria in West Africa. It carries out its operation as a general andhigher education learning hospital as well as teaching centre. The hospital handles

over 800-bedded patients within the state and also having wards for in-patient

management supervised by clinical specialties. In each of the wards, there is a

provision of two wash hand basins with running water, liquid and bar soap as well as

towel for drying the hand. The towels are removed and replaced with clean ones

thrice in a day. As a result of fluctuations in electricity in Nigeria, the hospital

management provides vessels of stored water for each ward as alternative when the

running tap ceases to run.

According to Abinye, Alex-Hart and Opara, (2011) based on the study carried, the

hospital consisted of four major departments, Surgery, Medicine, Paediatrics and

Obstetrics and Gynaecology which were running both in-patient and out-patient

services. During the study conducted by (Abinye, Alex-Hart and Opara, 2011), the

Doctors and nurses were selected randomly from these four departments. They gave

out a simple structured questionnaire to these health workers to assist in their data

collection which consisted of their bio data, awareness, approach and self reported

conduct regarding hand washing techniques and practices in the hospital.

They carried out their analysis on excel SPSS version 15.0 after having a total of 258

participants, (Abinye, Alex-Hart and Opara, 2011)

Table 2: Age and sex distribution of health workers

Age group Female Male Total (%) % Total


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20-24 7 3 10 3.9

25-29 38 19 57 22.1

30-34 45 15 60 23.3

35-39 39 9 48 18.6

40-44 17 6 23 8.9

45-49 21 5 26 10.1

50-54 22 2 24 9.3

55-59 9 0 9 3.5

60&above 0 1 1 0.3

Total (%) 198(76.7) 60 (23.3) 258 100

Source: (Abinye, Alex-Hart and Opara, 2011)

Table 3: Identified techniques of good hand washing

Technique Frequency Percent %

Use of soapy water in a basin 143 55.4

Use of cold running water 101 39.1

Use of warm running water 79 30.6Rubbing soap on wet hands for about 20seconds before rinsing

67 26Washing front and back of hands including underthe nails

62 24

Rinsing under cold running water 31 12

Rinsing under warm running water 8 3.1


Table4 Self-reported hand washing practices amongst healthworkers


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Hand washing practices Frequency Percentage (%)

Use of soapy water in basin 144 55.4

Washing front and back of handsincluding under the nails 106 41

Use of cold running water 94 36.4

Use of warm running water 68 26.4Rubbing soap on wet hands forabout 20 seconds before rinsing

63 24.4

Rinsing under cold running water 23 8.9

Rinsing under warm running water 6 2.3


The health workers who participated in the study were between the ages of twenty

and seventy and consisted of 60 males and 198 females. Out of this total number,

139 were practicing doctors, and 119 were nurses. In the analysis carried out by

Abinye, Alex-Hart and Opara, (2011), an excellent hand washing method component

was set as; applying soapy water in a basin (55.4%), applying cold running water(39.1%), using warm running water (30.6%) and rasping soap for about 20 seconds

on wethands before rinsing (26.0%).

In the analysis on table 2, it was observed that the health workers showed more

interest in practice on using of soapy water in the basis which was represented by

(55.8%) and which was followed by washing hand front and back including the nails

represented by (41%).

4.2 A Ten-Year Review (2000-2009) of OAUTHC in Nigeria and Hand-washing

practice by the Health Workers

Proper observation and cleanliness have been recognized as key workings in the

battle against Hospital Acquired Infections like Nosocomal infection. Another study

carried out on the pattern of hospital acquired infections and condition of hygiene in

a tertiary hospital located in one of Nigerias major cities. The Data collected by the


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infection control committee regularly was between January 2000 and December

2009. Appropriate statistical techniques were applied in analysing the data. The data

collected showed that a total number of patients admitted during the period under

review were 37,957 and (3.0%) of HAI were reported showing a total of 1129 cases.

The year 2006 showed the highest occurrence of 9.0%. A 14.7% was observed at

the Intensive Care Unit with the highest period prevalence and then followed by

Orthopaedics ward (7.7%). At the Surgical ward were a total of 433 cases were

observed showed the highest number of cases contributed. The Health workers

generally practiced Hand washing but facilities for proper hand washing were

inadequate.

The study which was carried out by (Afolabiet al., 2011) at the Obafemi Awolowo

University Teaching Hospital showing an investigation of the route and occurrence of

nosocomial infections within a five year period in the teaching hospital. An

occurrence level of HAI at 2.6% was discovered within that period. The study then

concluded that contagion control infrastructure and loyalty to contagion management

practices was frail (Onipede et al., 2004).

The Year 2000-2009 Prevalence of Nosocomal infection in OAUTHC

Table 5

Ward Numberdischarged

Number ofinfections

(%)

Surgery 8902 433 4.9

Orthopaedics 2048 157 7.7Obstetrics and

Gynaecology 10472 153 1.5Medicine 6937 208 3

Paediatrics 6272 57 0.9

Neonatal ward 2832 49 1.7

Intensive care unit 489 72 14.7

Total 37957 1129 3Source:www.ajol.info/index.php/sljbr/article/viewFile/71812/60769

Figure 2

Occurrence of HAIs in OAUTHC, 2000-2009
http://www.ajol.info/index.php/sljbr/article/viewFile/71812/60769http://www.ajol.info/index.php/sljbr/article/viewFile/71812/60769http://www.ajol.info/index.php/sljbr/article/viewFile/71812/60769http://www.ajol.info/index.php/sljbr/article/viewFile/71812/60769http://www.ajol.info/index.php/sljbr/article/viewFile/71812/60769http://www.ajol.info/index.php/sljbr/article/viewFile/71812/60769


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Source:www.ajol.info/index.php/sljbr/article/viewFile/71812/60769

Table 6

Hygienic Provision Available in the Wards of OAUTHC and Hand-washing

practice by the Health Workers


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Source:www.ajol.info/index.php/sljbr/article/viewFile/71812/60769

A study which was carried out by the Efficacy of Nosocomial Infection Control

(SENIC), discovered that a lot of hospitals that carried out close watch programmes

and as a result reported feedbacks Health workers showed a reduction of 32%

infection rates when compared to other hospitals not having this programme running.

According to French (1996) the success of repetitive occurrence review and the

National Nosocomial Infections Surveillance (NNIS) system carried out in the United

States has revealed a major decrease of nosocomial infection rates all over the

country (Ramirez Barba et al., 2006).

Wards Availability ofWater

Freeflowing from

Hand -washing

Antiseptic Soap

Cleantowel

Disposabletowel

CleanBeddings

Cleanfloor

Antisepticmoppin

gMale Surgical Ward Yes Yes Yes Yes Yes No Yes No YesFemale SurgicalWard Yes Yes Yes Yes Yes No Yes Yes YesIGE ward (Surgeryextension) Yes Yes Yes No Yes No Yes Yes YesPaediatric SurgicalWard Yes No Yes Yes Yes No No Yes NoChildren

Orthopaedic Ward Yes Yes Yes Yes Yes No No Yes YesAdult OrthopaedicWard Yes No Yes Yes Yes No No Yes Yes

Male Medical Ward No No Yes Yes Yes No No Yes YesFemale MedicalWard Yes Yes Yes Yes Yes No Yes Yes Yes

Renal Ward Yes No Yes No Yes No Yes Yes Yes

Psychiatric Ward Yes Yes Yes Yes Yes No Yes Yes YesAntenatal/Postnatal Ward Yes No Yes Yes Yes No No Yes Yes

Labour Ward Yes Yes Yes Yes Yes No No Yes Yes

Childrens Ward I Yes Yes Yes Yes Yes No Yes Yes Yes

Childrens Ward II Yes Yes Yes Yes Yes No No Yes YesChildrenEmergency Ward Yes Yes Yes Yes Yes No No Yes Yes

Neonatal Ward Yes Yes Yes Yes Yes No Yes Yes Yes

Casualty unit Yes Yes Yes No Yes No Yes Yes Yes

Intensive Care Unit Yes Yes Yes No Yes No Yes Yes Yes


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Sadly, owing to insufficient resources and obligation to set up and cultivate proper

arrangements on HAI supervision and Control of Infection in the majority of the

hospitals in developing countries Nigeria, inclusively, the experience over so many

years in such country is quite demoralizing. The cost can in nowhere be comparedbeyond financial losses to awful loss of life. The reason of observation of nosocomial

infections is to diminish the occurrence of HAI and consequently to decrease the

related morbidity, mortality, and costs (David and Famurewa, 2010).

An earlier research carried out in Obafemi Awolowo University Teaching Hospital

examined the route and occurrence of nosocomial infections in a range of five years

in the hospital. This research discovered the timing of occurrence of HAI to be 2.6%.

According to Onipede et al., (2004), a conclusion was drawn that there is need to put

necessary things in place to b e able to achieve control and adherence. The

research has an aim to ascert6ain the roots of HAIs in OAUTHC over the period of

10 years and as well check if the entire expected infrastructure to checkmate and

encourage this practice that still in place.

4.3 DISCUSSION

The report has shown that over 55% of the health workers in Nigeria have poorknowledge of an effective hand washing application which involves the use of soapy

water in basin. This can be attributed to the fact that in Nigerian Hospitals regular

running water is not always available, so utilization of soapy water in a washing hand

basin may now become an alternative.

By means of its frequent use over time, a good number health worker may have

come to recognize it as the perfect hand washing method rather than the utilization

of running water and applying soap with which was apparently accomplished by a

minimal number health Workers in the two case studies in Nigerian Hospitals. This

report is in support of other findings observed in some studies that scores the level of

hand washings with soap and water previous to any form of interrelation with

patients are low (Bischoff et al., 2000; Pittet et al., 1999a; Lankford et al., 2003;

Sproat andInglis, 1994; Fadeyi et al., 2010).According to these authors, it was

perceived that this rate of not being aware was more when it has to do with patience

and lower when the health workers are at risk. Meaning that, the health workers


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were cautious when it concerns them and the reverse when it has to do with the

patients.

Meanwhile if health workers were to be cautious, the level of infection on patientswould be reduced. It was discovered that hand washing was very low amongst

nurses in Nigeria as of when compared to that of England. The level of awareness in

England was pretty impressive even though there were no full compliance but had

better result of awareness than that of Nigeria. It was also observed that poor

handing washing practice goes along with the days work. As the health workers

carry out their daily activities, they increasingly accumulate these microorganisms on

their palms as a result of direct patience contact or contact from the unclean

environment surfaces as well as equipments. According to Masadeh and Jaran,

(2009), these organisms can be easily eliminated if the health workers carry out

hand washing practice.

The report has shown also that a failure to wash hand properly by health workers

could expose them to diseases caused as a result of Nosocomial Infection. In the

survey carried out by the researchers, it showed that there were conflicting

responses from the health workers when talking on their practice of hand washing

while running the outpatient clinics. Bulk of the health workers stated that they do

wash their hands with running water and soap, which was different with their

previous statement on the use of soapy water in a basin. This supports previous

statements made by Pritchard and Raper, (1996), that self-reporting has its defect as

it is not as dependable as thereal surveillance.

The evaluation also showed that a large number of health staff sometimes use their

handkerchiefs, as some also aloe their hands to dry on their own or personally use

ordinary towel made available for them to dry their hands. Professionals contend that

drying of hand is as significant as washing of hand in maintaining hand hygiene

(Pittet et al., 1999b; Tibballs, 1996). In spite of the battled observation, the well-

known feelings looks to be like that individual use paper towels which are better

hand drying procedure.


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It is noted to clean away fleeting organisms and lifeless skin cells and as well take

away germs from shallower layers based on its connected roughness from

continuous chafing (Tibballs,1996). Though, it lacks the probable electrical danger

related with electric hand dryer machine. Shared material towels and handkerchiefswhich become wet and unclean can portray as reservoirs for germs and therefore

have the likelihood to developing significantly to sources of Nosocomial infection

(Tibballs, 1996; Gould, 1994;WHO, 2008). Nevertheless, the use of hand drying

machine and study towel are quite expensive as regards to most hospitals in Nigeria

and were not made available in many wards, (Abinye Hart and Opara 2011).

The stress-free availability of health workers handkerchiefs or towels given in the

wards can give meaning to the use by these workers since they did not provide the

hand dryer. A study carried out showed that one of the obstacle to washing of hand

by health workers as non-provision of clean towels as they even had to share the

same towel at all times, (Lyle, H., 1997).Serious situations in washing of hand are

usually earlier before meals and snacks and after excretion (WHO, 2008).

In England, the observed rate with washing of hand using soap at critical periods

range between 0 and 54% (WHO, 2008). In the study carried out by (Abinye Hart

and Opara 2011), the level of hand washing is more than in before meals than

snacks, while the level of hand washing utilizing soap and running water is less than

50%. This is quite discouraging amongst health workers who are supposed to be the

frontiers when it comes to issue of good hygiene and deterrence of diarrheal

illnesses. It is more worrying that great fractions of (47.3%) as stated in their report

were those reported using water alone to wash their hands.

The general acceptance that using water alone to wash hands by eliminating seen

dirt is enough to keep the hand clean is very common even in Nigeria and England

as well as many other countries, (Samuel et al., 2005). Using only water to wash

hands in at all times less active than wash with soap when there need to ensure that

the hands are properly clean in order to eliminate germs. Though the use of soap

when one needs to wash hands removes the grease and dirt that comes along with

most germs, applying soap would mean extra time used during falsifying, rubbing


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and resistance to remove them from the finger and in between the fingers as at when

compared with just using water alone in washing the hands, (Samuel et al., 2005).

The utmost in spring influence for hand washing among the health workers was

terror of being infected by illness. This has been noted in some other research

carried out among health personnel (Bischoff et al., 2000; Pittet et al., 2004;

Pritchard and Raper, 1996). Their discovery could be as a result of their

understanding of transmission of diseases. Safety from illness was stated as a

dynamic vigor but was not a main persuader of hand washing (Scott et al., 2007b).

Absence of soap and water are the collective restraints to hand washing in this study

and are the cause of Nosocomial infection in hospitals. Others causes noted were

obliviousness, lack of patience, awkwardly located sinks for hand washing and no

proper motivation. All these factors and several other shave existed in so many

other reports and in other studies as obstacles to hand washing by health workers

(Sharma et al., 2005; Gould, 1996; Dubbert et al.,1990).

Most of these boundaries are beyond the control of the health workers due to the

fact that if such amenities such as soap and water are not made available, then the

health workers cannot be blamed for not washing their hands.


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4.3.1 Compliance and monitoring body in the UK

Standard Infection Control Precautions Clinical Governance v3 (2010)

Source:

http://www.nhsprofessionals.nhs.uk/download/comms/CG1_NHSP_Standard_Infecti

on_Control_Precautions_v3.pdf
http://www.nhsprofessionals.nhs.uk/download/comms/CG1_NHSP_Standard_Infection_Control_Precautions_v3.pdfhttp://www.nhsprofessionals.nhs.uk/download/comms/CG1_NHSP_Standard_Infection_Control_Precautions_v3.pdfhttp://www.nhsprofessionals.nhs.uk/download/comms/CG1_NHSP_Standard_Infection_Control_Precautions_v3.pdfhttp://www.nhsprofessionals.nhs.uk/download/comms/CG1_NHSP_Standard_Infection_Control_Precautions_v3.pdfhttp://www.nhsprofessionals.nhs.uk/download/comms/CG1_NHSP_Standard_Infection_Control_Precautions_v3.pdf


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Source:

http://www.nhsprofessionals.nhs.uk/download/comms/CG1_NHSP_Standard_Infecti

on_Control_Precautions_v3.pdf

4.3.2 Compliance and monitoring body in Nigeria

In the case of Nigeria, there is no monitoring body that handles the compliance of

hand hygiene in the health institution. The federal ministry of health supervises this

act by sending out inspectors who once a year visit these hospitals and as such any

impression gotten for that day creates an impression for the whole of the year. When

most health clinics are aware the inspector would be visiting, they ensure they to put

everything in the hospital working right, but after the visit they become complaisant.
http://www.nhsprofessionals.nhs.uk/download/comms/CG1_NHSP_Standard_Infection_Control_Precautions_v3.pdfhttp://www.nhsprofessionals.nhs.uk/download/comms/CG1_NHSP_Standard_Infection_Control_Precautions_v3.pdfhttp://www.nhsprofessionals.nhs.uk/download/comms/CG1_NHSP_Standard_Infection_Control_Precautions_v3.pdfhttp://www.nhsprofessionals.nhs.uk/download/comms/CG1_NHSP_Standard_Infection_Control_Precautions_v3.pdfhttp://www.nhsprofessionals.nhs.uk/download/comms/CG1_NHSP_Standard_Infection_Control_Precautions_v3.pdf


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5.2 RECOMMENDATION

Several health strategies have been developed and examined in order to give room

for improvement on hand hygiene exercise by health care workers. These

innovations are hereby recommended to ensure effectiveness in carrying out these

practices;

There should be incorporation in the signal for hand hygiene in educational materials

given to health workers and such educational materials could include;

Regular lectures anchored by professional people in the field of hand hygiene

compliance, also interactive and listeners retort software.

Visuals and presentations on power point slide demonstrating the necessity of

effective hand hygiene techniques in the care sector.

Interrelated computer based learning to be made available to the health

workers through the hospital Internet.

Carrying out academic curriculum for health workers that would consist of

instructions for absolute application when washing hands with soap and water or

when applying the alcohol-based hand rub to ensure proper cleanliness.

Making sure of the providers ability in acquiring knowledge of the underlying

principles for hand hygiene and should comply with best practices as well as

enhance patient results.

Carrying out multi-component campaign publicly through the use of posters, photos,

pictures showing well known doctors and staff recommending hand hygiene through

proper hand washing, as well as paintings by children in hospitals and computer

screen savers targeted at the message on hand hygiene.

Creating an invitation for opinion leaders to act as role models and educators. They

would make presentations during several meetings, as well as key speeches to the

health workers to ensure their full compliance.

Embarking into a culture where bringing to the knowledge of everyone through

reminders for everyone on the issue of hand hygiene is promoted and complying

with the social norms.


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Health workers should be enabled to comply with hand hygiene best practices

through creation of reliable process that would ensure proper hand washing

materials like soap, water in peculiar sizes and should at all times made available at

each time.

It is a simple true that educational and training programmes increase knowledge and

therefore adherence on hand hygiene. They must be continuously reinforced to

achieve optimal adherence to recommended hand hygiene policies.

Patients family members should be engaged in hand hygiene procedures by

ensuring to provide safety tip sheets that would enlist specific hand hygiene and

encourage them to remind health care workers to ensure they comply with these

standards.

There has to be an effective compliance monitoring on health workers with a

proffered indications for hand hygiene including on time feed back to staff and

inclination compliance over time.

Based on the recommendation of the Institute for Health care improvement, it was

recommended that a major disciplinary team process to enhance hand hygiene

amongst health workers. The team for improvement should be diverse in make -up,

but together in approach. The worth of bringing along various people as one is that

all group members of the care team are given responsibility in the result and work in

harmony in order to attain the same goal and objective.

Inclusions of all stakeholders in the method to carry out effective hand hygiene

practices will assist achieve buy-in and collaboration of all sundries. Take for

instance, teams operating without having a nurse amongst them has tendency to fail,

while teams consisting of nurses and therapists may doing well and also a physician

should be among the group. For an effective team to carry out their function

appropriately, they should also consist of an administrator or senior personnel who

assist in eliminating any form of barrier to bring to the execution as well as a

departmental member that delivers hand hygiene agents to hospitals.


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Every medical worker shou ld deem it a responsibi l i ty to

Regular ly w ash their hands.

The washing h and faci l i ty should be made easi ly accessib le and close to every

un i t .


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Posters s hou ld be kept on every area at the health centres to create further

awareness.


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REFERENCES

Abinye B Hart A and Opara P I (2011); Hand washing Practices amongst Health

Workers in a Teaching Hospital Department of Pediatrics and Child Health, Faculty

of Clinical Sciences, University of Port Harcourt, American Journal of Infectious

Diseases 7 (1): 8-15, ISSN 1553-6203. Science Publications

Aiello AE, Larson EL. (2002) What is the evidence for a causal link between hygiene

and infections? Lancet Infect Dis;2:10310

Benenson AS. (1995) Control of communicable diseases manual, 16th edition.

Washington, American Public Health Association.

Bischoff, W.E., Reynolds T.M., Sessler C.N., Edmond M.B. and Wenzel R.P., (2000).

Hand washing compliance by health care workers: The impact of introducing an

accessible, alcohol-based hand antiseptic. Arch. Intern. Med., 160: 1017-1021.PMID:

dolapo project work lastest review.docx_jm120618

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