|Year : 2015 | Volume
| Issue : 1 | Page : 125-128
Hand hygiene in reducing transient flora on the hands of healthcare workers: An educational intervention
R Kapil1, HK Bhavsar2, M Madan3
1 Subharti Medical College, Subhartipuram, Meerut, Uttar Pradesh, Gujarat, India
2 Cancer Society Medical College, Ahmedabad, Gujarat, India
3 Department of Microbiology , Subhartipuram, Meerut, Uttar Pradesh, Gujarat, India
|Date of Submission||08-Feb-2014|
|Date of Acceptance||13-May-2014|
|Date of Web Publication||5-Jan-2015|
H K Bhavsar
Cancer Society Medical College, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
Aim: Hand hygiene has now been recognised as one of the most effective intervention to control the transmission of infections in a hospital and education is an important tool to ensure its implementation. In order to convince the users and as a part of education, it is important to generate evidence on the role of hand hygiene in reducing the bacterial flora on their hands. The present study was undertaken in a tertiary care hospital to demonstrate the presence of bacterial flora on the hands of healthcare workers (HCW) in different categories, to teach them proper hand hygiene technique using alcohol-based hand rub and determine the outcome for reduction of bacteria. Materials and Methods: A total sample size of 60 subjects including resident doctors, medical students, nurses and hospital attendants were included in the study after obtaining informed consent. Each person was educated on the technique of hand hygiene with alcohol-based hand rub and hand impressions were cultured before and after hand hygiene. All the subjects were also given a questionnaire to assess their perception on hand hygiene. The WHO posters on proper hand hygiene were displayed in the appropriate areas of the hospital in addition, as an educational tool. Results: Majority (42 out of 60) of the HCWs had bacterial count up to 100 colonies or more on both hands before the application of hand rub while working in the hospital. After use of alcohol hand rub with a proper hand hygiene technique, it was found that the percentage reduction was 95-99% among doctors and nurses, 70% among hospital attendants and 50% among sanitary attendants. Staphylococcus aureus was present on the hands of eight persons of which three were methicillin-resistant Staphylococcus aureus. Conclusions: The study demonstrates that transient bacteria are present on the hands of HCWs but majority could be removed by proper hand hygiene, which needs continuous education to be effective. It also shows that active education by demonstrating the proper hand hygiene technique and direct observation of the practices, though demanding, are ideal to understand the attitudes and practices of HCWs and helps in planning implementation strategies.
Keywords: Alcohol rub, education, hand hygiene
|How to cite this article:|
Kapil R, Bhavsar H K, Madan M. Hand hygiene in reducing transient flora on the hands of healthcare workers: An educational intervention. Indian J Med Microbiol 2015;33:125-8
|How to cite this URL:|
Kapil R, Bhavsar H K, Madan M. Hand hygiene in reducing transient flora on the hands of healthcare workers: An educational intervention. Indian J Med Microbiol [serial online] 2015 [cited 2019 Jul 20];33:125-8. Available from: http://www.ijmm.org/text.asp?2015/33/1/125/148409
| ~ Introduction|| |
Healthcare-associated infections (HAIs) are a major concern in the hospitals. The HAIs has increased the morbidity and mortality of the patients and are responsible for increase in the cost of treatment, prolong the hospital stay, and increase the cost of healthcare, all over the world. HAIs are also responsible for increase in the transmission of multidrug-resistant organisms (MDRO) in a healthcare organisation.
The mode of transmission of HAIs is important to understand in a hospital setting so that the implementation of control measures can be designed to achieve effective control. Many interventions are recommended and the strength of association of the measures with evidence of effective control is published by CDC. 
Hand hygiene has now been recognised as one of the most effective intervention to control the transmission of infections in a hospital as well as control of antimicrobial resistance (AMR). 
Transient flora on the hand is mostly acquired from the hospital environment or poor hygiene and is responsible for cross-infections. The common organisms associated are Staphylococcus aureus - which can be methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella sp, Acinetobacter sp or any other pathogen which is present in the environment of a healthcare facility. ,,,
The proper use of hand hygiene techniques needs continuing education. The display of posters provided by WHO act as effective tools of education. In addition, CME programmes for all level of healthcare providers are important.  The effectiveness of education and its implementation will depend on the level of the healthcare worker (HCW) and some may need more individual level teaching to practice correct technique.
The present project was undertaken to study the role of education and interactive teaching in the practice of hand hygiene and demonstrate the reduction of transient bacteria on the hands by adopting such practice.
The Ethical approval was obtained from the Institute Ethical committee.
| ~ Material and Methods|| |
The study was conducted in a tertiary care hospital attached to a Medical College in North India. A total sample size of 60 subjects was included. Fifteen resident doctors, medical students, nurses, hospital and sanitary attendants, who agreed to participate in the study and were on duty in the in an Intensive Care and Medicine Ward of the hospital during the study period, were included. The informed consent was obtained from all the participants of the study i.e. Doctors, Medical Students, Nurses, and Hospital Attendants.
Interactive educational intervention
- Each person included in the study was demonstrated the correct steps of hand hygiene using alcohol-based hand rub available in the hospital at the time.
(Sterillium i.e. 2-propanol 90 g/1000 ml and 1-propanol 60 g/1000 ml, Mumbai, India). They were then requested to perform the steps and hand impressions were collected before and after hand hygiene as described below .
- Teaching Material: In addition to WHO posters on the steps of hand hygiene were also displayed at the prominent sites in the hospital areas.
- Questionnaire: All the subjects were also administered a questionnaire for assessing their perception about hand hygiene and they were analysed using a standard code.
The cultures from the hands of all the participants were taken touching all the 10 finger tips on the sheep blood agar plates (Biomerieux) before and after hand hygiene. After incubation overnight the manual colony count was done to sum up all the colonies. Those showing >100 colonies were not counted further.
Identification of bacterial morphotypes was done using Standard Methods and  antimicrobial susceptibility was done for the hospital pathogens that are more likely to be transferred by hands in a healthcare setting and included S. aureus, Enterobacteriaceae, and Acinetobacter sp.
| ~ Results|| |
The work experience of the 15 resident doctors included in the study is shown in [Table 1]. Eight doctors were posted in Medicine and 7 in the ICU. All of them were aware through Community Medicine posting or Microbiology Classes or CMEs except two doctors. Thirteen residents practiced hand hygiene before touching the patients; though all of them did so after handling the patients.
The work experience of 15 nurses included is shown in [Table 1]. Eight nurses were posted in the medical ward and seven in the ICU. All of them were aware about hand hygiene, but could not specify any organised source of learning except three nurses who had attended some CMEs. All of them practiced hand hygiene after handling the patients while only 10 nurses practiced hand hygiene before touching the patients.
The 15 medical students studying in the 2 nd year of Medical College who had started the clinical postings, eight in medical ward, and seven in the O.T were included. All of them were aware about hand hygiene through Microbiology Classes or television except three. Twelve of them practiced hand hygiene after case examination during clinical postings but only nine students practiced hand hygiene before handling the patients.
Of the 15 hospital attendants included the experience is shown in [Table 1]. Two attendants were posted in Microbiology laboratory, two in Pathology laboratory, five in medical ward and three in the ICU. Only nine of them were aware about hand hygiene, but could not specify any organised source. It was found that 12 of them practiced hand hygiene at the end of their work while only three did so before the work. None of them had any formal training on the subject during their posting.
Majority of personnel, irrespective of the level of education, were aware of the practice of hand hygiene after, but not before touching patients.
Overall all of them confirmed the availability of soap, water and alcohol-based hand rub in the hospitals but lack of time or attitude was reported to be responsible for non-compliance. Another limitation of practice of soap and water was limited availability of napkins or separate towels after hand wash for drying of the hands.
[Table 2] depicts the bacterial growth before and after hand hygiene in different categories of the hospital staff. To summarise the table majority (42 out of 60) of the HCWs had bacterial count up to 100 or more in both hands while 18 had less than 100 counts before hand hygiene. Following hand hygiene, the percentage reduction was 95-99% in all except for in attendants where it was 70-90% for lab attendant and only 50% in sanitary attendants [Figure 1].
|Figure 1: BEFORE image shows bacterial growth on the thumb and fingersæ impression on sheep blood agar plate. AFTER image shows no bacterial growth on thumb and fingers impression after education and application of alcohol hand rub|
Click here to view
|Table 2: Analysis of the bacterial growth on the hands of the study subjects n=60 |
Click here to view
A total of eight persons carried S. aureus on their hands of which three were MRSA [Table 2], five persons had Klebsiella sp. or E. coli on their hands of which three were ESBL producers, and eight had Acinetobacter sp. on the hands of which three were carbapenem resistant. The growth in all these persons was absent after hand hygiene.
| ~ Discussion|| |
The presence of transient bacteria carried on the hands of HCWs is significant in persons working in a hospital as the environment and patients are commonly colonised with bacteria. Hand hygiene has been shown to be an effective method to control transmission of infection by reducing the transient flora. ,,,,
Our study demonstrates that the pathogens are present on the hands but could be removed effectively by proper hand hygiene using alcohol-based hand rub. In the present study 35% of the HCW carried pathogens on the hand and of S. aureus 45% were MRSA. Somehow it was observed that despite of personal interaction, sanitary attendants were not able to follow the steps effectively as demonstrated by the bacterial counts after the use of hand rub.
Though there was 95-99% reduction in the bacterial load in majority, the ability to perform correct steps is also dependant on the level of education as the growth of bacteria on the hand was not reduced significantly in the sanitary attendants. This also demonstrates the need of repeated demonstration of the steps and importance of hand hygiene among sanitary attendants. ,
The other possibility could be that the organic burden on the hands of sanitary workers may be high that might require the use of soap and water first.
This kind of study can be a good module for education. It provides a convincing evidence that the transient flora can be reduced after appropriate hand hygiene. The important aspect which must be considered in all settings is a need for CMEs or induction training at all levels as awareness on use before patient care in lacking and needs strengthening.
The available methods of hand hygiene are soap and water, alcohol-based hand rubs and chlorhexidine-based hand rubs. The advantage of cholohexidine is the residual activity but it is expensive. Soap and water are economical but need for safe running water and sterile towels to dry hands is a limitation. In a busy hospital alcohol-based hand rubs may help in improving compliance and also maybe cost-effective. 
| ~ Conclusion|| |
Hand hygiene is an effective method of reducing the bacterial flora on the hands of the HCWs. In a hospital setting, the hands of the HCWs get colonised with transient flora comprising of pathogenic bacteria. The continuing medical education is one of the most important tools to reiterate the need for hand hygiene and ensure the implementation of the proper hand hygiene at all categories of HCW.
| ~ Acknowledgment|| |
The study was undertaken as a part of STS project of ICMR.
| ~ References|| |
Siegel JD, Rhinehart E, Jackson M, Chiarello L. Healthcare Infection Control Practices Advisory Committe. Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. Available from: http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
[Last accessed on 2013 Jun 16].
Rosenthal VD, Guzman S, Safdar N. Reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in Argentina. Am J Infect Control 2000;28:3.
Slack RCB. Hospital Infection In: Greenwood D, Slack RC, Peutherer J, Barer M, editors. Seventeenth ed.; Chruchll Livingstone, Elsever. p. 693-701.
Pittet D. Infection control and quality health care in the new millennium. Am J Infect Control 2005:33:258-67.
Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 2009;73:305-15.
Win W, Aleen S, Koneman E, Procop G, Schrechenberger P, Woods W. In Koneman′s Color Atlas and Textbook of Diagnostic Microbiology, 6 th
ed. Philadelphia: J. B. Lippincott Company; 2006. p. 1441-533.
Longtin Y, Sax H, Allegranzi B, Schneider F, Pitter D. Hand hygiene. N Engl J Med 2011;364:e24.
Ashraf MS, Hussain SW, Agarwal N, Ashraf S, EL-Kass G. Hand hygiene in long-term care facilities: A multicenter study of knowledge, attitudes, practices, and barriers. Infect Control Hosp Epidemiol 2010;3:758-62.
[Table 1], [Table 2]