Hand hygiene practice of health care workers in prevention of nosocomial infection in one hospital in Basrah

Background: The hand hygiene plays an essential role in prevention as well as curing the nosocomial infectious disease. Physicians, nurses and laboratory persons are the major health care workers communicating with patients, could become the transporter in the cycle of infectious diseases. Objective: To evaluate the knowledge and practice of health care workers for hand hygiene in hospital wards and study the predisposing factors effecting the hand hygiene. Methods: A cross-sectional study carried out on doctors, nurses and laboratory men who worked in AlMawane Teaching Hospital in Basrah (Iraq). Questionnaire of hand hygiene for data collection was applied. Results: 401 health care workers were studied, The results showed moderate level of hand hygiene for doctors, nurses and laboratory persons (average score 3.97 + 0.6). Nurses had the highest level of hand hygiene. Perfect hand washing was found in 62%, compared with 56% for laboratory staff and 29% for physicians. Gender was insignificant in the practice of hand hygiene, while age, level of education, duration of service, training courses and vaccination against type B hepatitis had statistically significant impact on hand hygiene. Conclusion: The control of infection in hospitals goes through the care of hand hygiene in health workers, which need more attention. The current study revealed somewhat unacceptable level of knowledge and care of the cleanliness of the hands of doctors, nurses and laboratory persons. The need to develop the level of knowledge and practice by training programs and continuing medical education


INTRODUCTION
and hygiene (HH) of health care workers (HCWs) is a keystone in the control and prevention of hospitalacquired infection (HAI). On the other hand non perfect HH causes direct transmission of infections by contact HCWs and patients during daily practice of health care in hospital. [1] Performing hand hygiene is an easy and effective way to stop and prevent HAI. Cleaning hands can prevent the flare up of microorganisms, including those that are resistant to antibiotics that are becoming untreatable. Standardly, HCWs clean their hands less than half of the times they should. Center of disease control (CDC) assess that each single year approximately 2 million individuals in the United States get an HAI, with high mortality (about 90,000 of these patients). HH decreases the incidence of nosocomial infection, more wide use of HH products that increase adherence to suggested hand hygiene practices will promote patient protection and control of infections, as clean hands are the first essential factor in stopping the spread of pathogens and antibiotic resistance in healthcare settings. [1,2] An infectious microorganism requires three factors for spread within a HCWs setting; a source, liable host, and a method of transmission. Nosocomial infections (HAI) are one of the most important risk factors of morbidity and mortality. HAI occur all over the world in all nations, and over 90% occur in poor governments. Therefore, Nosocomial infections may have lethal outcome in hospitals and transmission from HCWs and patients may also lead to spread of infectious diseases in the community. [2,3] Hand hygiene is a term referring to washing of the hands by plain water and soap, which remains a standard way of HH in non-health care persons advised by CDC. While hand wash with antiseptic solution when using detergents contain a sterilizing antiseptic solution, including hand wash by antiseptic done preoperatively by operation theater staff. Usually antiseptic solution had a long life antimicrobial action. [4,5] Effectiveness of Hand Hygiene agents in sterilization [6] Best Better Good by alcohol hand rub Antimicrobial soap Plain Soap H Hand washing with plain soap and rub for 15 seconds then rinse with water and dry with disposable towel is good and safe at reducing bacterial counts while cleaning with antimicrobial agent is much better, and hand rubs with alcohol covering entire hands till dry are the best of all. These important practical notes will advance the hand hygiene process of HCWs and decrease the flare up of harmful microorganisms to patients and the staff in the hospitals. [7,8] In a large number of studies, hospital acquired infection rates were much less when disinfected hand washing was achieved by HCWs and went down when restriction to suggest HH practices established.

Indication of HH before and after:
1. Health care giver contact to patients or body fluids and excretions 2. Contact with non-intact skin or wound dressings, before wearing and after removing gloves.

when putting a central venous catheter or
Inserting urinary bladder catheters 4. In case of peripheral vascular catheters or other invasive devices that do not require surgery. [7,8] Gloves should be dressed when a HCW liable to come in contact with the blood or body secretions and other potentially infectious elements in agreement with general precautions, HCWs must remove the gloves after finishing the patient care and should not unchanged the gloves when go to another patient for the care and finally gloves should be discard and not washed or reused. [3,10] The use of various sorts of antiseptics in the practice of HH is associated with certain drawbacks and side effects. [11,12] Obstacles to HH are related to the hospital and HCWs. So both institution of occupational safety and health with small-group expert persons need to be available when applying a strategy to secure and improve hospital staff HH practice. [13] The present study was designed to assess the hand hygiene practice in health care worker in the hospital setting. In addition, to find the factors affecting the compliance of hand hygiene in controlling health care related infections.

METHOD
A cross-sectional study was adopted in the period of October to the end of December 2018, the studied group included in this study was 401 health care workers comprise of doctors, nurses and laboratory persons, invited to involve in this study from Al-Mawanee teaching governmental hospitals in Al Basrah, south of Iraq. Data were obtained using pre-test questionnaire from HCWs working in different hospital wards including, coronary care unit, intensive care unit, emergency unit, medical ward, surgical wards, operational unit, pediatric ward and obstetric wards. First the data recorded from the HCWs regard their general demographic data like age, sex, years of service in health care centers, level of education and vaccination. The second part of information is about the hand hygiene including knowledge and practice regarding some aspects of infection control programs in hospitals. This part contained 9 assessment questionnaires regard the practice of aseptic hand washing measures, with 5 choice Likert scale from 5 for strongly agree "always", 4 for agree "almost", 3 for sometimes "neutral", 2 for disagree, 1 for strongly disagree. [14]  Assessment of healthcare workers' was based on mean score for practice parameters, equal to 3 or more is recorded as an acceptable (3-4 revealed as a moderate and 4-5 reflected as a high), while mean score for practice items less than 3 is recorded as a un acceptable (low). [14] As the environment of job differs for each group of HCWs, the chances for hand hygiene are also quite unlike; therefore modified questionnaire forma were applied for each of these groups. First part of the data covers the general and occupational characters of HCWs and the second part regard the practice and precautions of hand hygiene, ranging from always, often, sometimes, seldom to never. A pretest questionnaire with 30-day intervals and performing test-retest technique, the correlation coefficient of r = 0.73 established the reliability of the questionnaire. Statistical analysis of the data in term of frequency, mean with standard deviation, mean of score and other statistical tests using the Statistical Package for the Social Sciences for Windows (SPSS-PC, version 20).

RESULTS
( Table-1 -4), reveals that no-significant difference between the practice of hand hygiene in HCWs in relation to gender, while there is significant difference regarding the other parameters as age, level of education, years of experience, training session and hepatitis B vaccination.  (Table-1), shows equal gender distribution of demographic parameters of the studied group, 48.1% were men and 51.9% were women of the HCWs, with 64.3% of the studied subject at age 20-39 years old. This findings agree with study which was done in Iran, which showed 45.9% men and 54.1% women. [15] and the study of Iraq, which reveal that most 64.3% of healthcare workers at age of 20-39 years. [16] Regarding to the level of education, the study results showed that 46% of the HCWs graduated by bachelor from university institute, most of them were doctors, diploma form 32% and 22% were graduate from secondary nursing school. Regarding the year of service and experiences, 60% of the healthcare workers were less than 10 years. This results less than the Egypt study, which shown that three quarters 73.3% of subjects their experience reached from 1 to 10 years. [17] In spite of 40% of the studied group had long period of experience, more than 55% had no training course for infection control in hospital, which is like other study in Iraq 24.3%. [16] Studies have reported significant improvement in compliance with the standard precautions from 48% to 74% after an educational symposium. [18,19] The knowledge and practice of hand hygiene in HCWs were assessed in the present study which shows that most of the hospital staff had a moderate level of knowledge (48%). This finding mimic Jordanian study which reported moderate knowledge of 49%, [10] but lower than results reported in an Egyptian study (57%) [17] while other studies in Iraq one in Kirkuk city revealed a poor practice, [20] and the other in AL Amara city shows a high level of knowledge and practice of infection control of standard precautions in HCWs. [21] Our study also shows that doctors gained the lowest evaluation degree of hand hygiene (29%) as compare to nurses (62%) and laboratory men had 56% possibly because of low experience and less training courses in junior doctor, this result differ from other study in Palestine which reveal equal level in both doctors and nurses. [22] Regarding the association between HCWs practices with their demographic parameters, the study shows that there is statistically significant difference among healthcare workers' practice with age, level of education, training courses, hepatitis vaccination and years of experience at P-value < 0.05. While, it shows no significant difference with gender at Pvalue > 0.05. This results differ from other