Nurses’ Compliance to Handwashing Guidelines

In Our Lady of Mercy General Hospital

A Thesis Proposal

Presented to

The Faculty

College of Nursing

Lyceum of the Philippines University

Intramuros, Manila

In Partial Fulfillment

of the Requirements for the Degree

Bachelor of Science in Nursing

By

Jannelle Careese Manguila

Dennis Sanchez

Rosalynne Santos

Section H-222

October 2, 2008

(Note: Insert names of researchers in alphabetical order, section, and date of

submission.)
(Please do not put a page number in the Title Page and the first page of each
chapter. Use the future tense for the thesis proposal.)
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(Format: 1.5 inch (left margin); 1 inch (right margin); 1.5 inch (top margin); 1 inch
(bottom margin); double spaced; Times New Roman, font size 12)
CHAPTER I

The Problem and Its Background

Introduction

Handwashing is the simplest form of precautionary measure one should learn to

maintain an optimal health. No one is free from microorganisms. We are all bombarded

by different types of disease-causing microorganisms. We can never tell when they will

attack or invade our whole systems. Moreover, health care providers are not the only ones

who should learn to comply with handwashing. It should be taught to everyone especially

the young ones. Children need to learn proper handwashing at an early age, for the very

reason that they are susceptible to infections more than adults do, because their immune

systems are not yet totally developed (Pillitteri, 2003).

Nowadays, several health institutions, including the Department of Health, and

the media are actively participating in promoting the importance of frequent

handwashing. They are able to impart some important facts about the causative agents of

different diseases, their mode of transmissions, and ways of preventing them. This is due

to the increasing rate of mortality and morbidity in the country caused by diarrheal

diseases. Procter and Gamble Philippines Inc., one of the biggest companies pursuing

hygiene and health, is presently promoting the importance of frequent and proper

handwashing technique using soap and water. This company emphasized the

susceptibility of children to infections, and their increased risk in acquiring diarrheal

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diseases which is a major cause of mortality among children in the country (Fucanan,

2006 as cited in http://www.manilatimes.net).

To stay healthy, we are often reminded to take the necessary and much-cheaper-

than-cure preventive steps. Our mothers would coax us to eat our vegetables; our doctors

would advise us to exercise and take vitamins; and our community health workers would

encourage our families to get regular medical checkups, and our children, vaccinations.

Among these disease prevention measures is another important habit we should observe

especially at home: handwashing. Until the deadly respiratory epidemic called SARS

(Severe Acute Respiratory Syndrome) hit Asia in 2003, people did not give much

importance to keeping their hands clean at all times, especially after going to the toilet,

before and after kitchen work, and upon returning home from the school or office

(Fucanan, 2006 as cited in http://www.manilatimes.net).

Health and disease expert Dr. Anna Beatrice Bowen, who heads the Foodborne

and Diarrheal Diseases Branch of the Center for Disease Control Prevention in the United

States, spoke before the local media on February 9, 2006, the opening day of the Second

International Health and Hygiene Symposium. She said that the very act of handwashing

can save an entire family from diseases. She also added that handwashing is still the most

important thing we can do to protect ourselves, and it should always be practiced at

home. Bowen continued that every year, 3.5 million children die of diarrheal and

respiratory illnesses. But in the past years that they had conducted handwashing

interventions, this figure was reduced by 40 to 50 percent (Fucanan, 2006 as cited in

http://www.manilatimes.net).
 4

This summit was organized by Procter & Gamble (P&G) Philippines through its

flagship brand Safeguard. The two-day summit gathered around 150 health and hygiene

experts and workers around the world to discuss breakthroughs in disease prevention and

report studies on the significant health benefits of handwashing. Its theme was “Better

Health and Hygiene: Today’s Challenges, Tomorrow’s Hopes” (Fucanan, 2006 as cited

in http://www.manilatimes.net).

Safeguard goes on Nationwide Health and Hygiene Tour on January 6, 2003.

Captain Safeguard, the brand’s superhero, extols the benefits of proper handwashing

before the pupils of Talomo Elementary School in Davao City. The event, coming on the

heels of the highly successful International Health and Hygiene Symposium (IHHS) it

recently sponsored in Manila, is part of Safeguard’s nationwide health and hygiene

awareness tour covering over 250 schools and 200 barangays. The IHHS health experts

have affirmed that hygiene education and the simple habit of handwashing with soap are

effective and inexpensive means of reducing the incidence of disease (as cited in

http://www.mb.com.ph).

Frequently washing your hands, says Captain Safeguard, can help children avoid

the trouble of getting contaminated with common ailments. It saves you from so-called

“downtime”—the time you spend lying in bed sick, or staying at home sick. That means

there will be more time to study, help in the household chores, and, of course, play.

Another means of keeping all neat, tidy and fresh is bathing. This way, germs do not

stand a chance of lodging onto your skin and eventually finding their way into your

respiratory or digestive system. Keeping neat and tidy is the battlecry of Captain
 5

Safeguard and the Germ Patrol. They have visited various schools all over Cebu Province

and discussed with school children the benefits of frequent handwashing and bathing to

counter the effects of disease-carrying germs. Captain Safeguard and the Germ Patrol

have an interesting space-age contraption called the “Germ Box” under whose light one

can literally “see” the germs that are on the hands. Children who have been to one of the

fun-filled stagings of “Two Steps to Good Health” topbilled by Captain Safeguard say

they have “learned that keeping healthy and well is indeed very simple.”

Each child who attended the “Two Steps to Good Health” show was given a shield of

protection—a symbolic representation of winning the war against King Duming-dumi,

leader of the germ gang. The Germ Patrol also gave away premium items and Captain

Safeguard coloring books to lucky kids who participated in the fun mini-quizzes held

during the show. Captain Safeguard and the Germ Patrol are, indeed, doing an impressive

job bringing the message of personal cleanliness to school-age children. They are helping

ensure that children can sing “I have two hands” and have every right to sing the song to

the end. Indeed, “clean little hands are good to see” (as cited in http://www.mb.com.ph).

According to the Philippine Health Institutions, (1998), some of the leading

causes of mortality and morbidity are those diseases which are highly communicable.

These diseases include septicemia, diarrheal diseases, pneumonias, all forms of

tuberculosis, Chronic Obstructive Pulmonary Disease (COPD), and other respiratory

problems. These diseases can be acquired through direct contact, but can be prevented

through frequent handwashing with soap and water (Reyala, Nisce, Martnez, Hzon,

Ruzol, Dequna, Alcantara, Bermudez, Estpona, 2000).

 6

This study is a replication of the study conducted by Fortuno in the year 2005. In

her study, she developed an intervention program for handwashing to improve the

compliance of the nurses. Replications are attempts to validate the findings from one

study in an independent inquiry. According to Polit and Beck (2004), authorities on

Nursing Research, “replication research is critical for the development of nursing science.

Strong evidence-based practice requires replications. Practice cannot be altered on the

basis of a single isolated study, but must rely instead on an accumulation of evidence.”

Identical replication, a replication strategy, which is an exact duplication of the original

method, was used in this study.

Statement of the Problem

This study aimed to assess the compliance of nurses in Our Lady of Mercy

Hospital in Bulacan towards handwashing guidelines, which included the technique,

duration, and the use of either soap and water or waterless alcohol-based hand solution.

Specifically, the study sought to answer the following questions:

1. What is the demographic profile of the respondents in terms of:

a. Age

b. Gender

c. Civil Status

d. Educational Attainment

e. Length of Professional Service

f. Designated Area?
 7

2. What is the rate of handwashing frequency and duration of the participants in

terms of:

a. Age

b. Gender

c. Civil Status

d. Educational Attainment

e. Length of Professional Service

f. Designated Area?

3. What are the reasons why nurses do not consistently wash their hands?

4. What is the correlation between intensity of patient care activity and

handwashing frequency of the respondents?

Theoretical/Conceptual Framework

Medical asepsis is an important value in the delivery of health care. The safety of

most patients is in the hands of the health care providers. This was emphasized by Joseph

Lister in his antiseptic technique theory which is a form of aseptic technique. Aseptic

technique is designed to eliminate and exclude all pathogens by sterilization of

equipment, disinfection of the environment, and cleansing of body tissues with

antiseptics. Lister used dilute carbolic acid (phenol) to cleanse surgical wounds and

equipment and a carbolic acid aerosol to prevent harmful microorganisms from entering

the surgical field or contaminating the patient (Burton and Engelkirk, 2000).
 8

The least expensive and the most recommended preventive measure in the

avoidance and control of nosocomial infections in the health care setting is handwashing.

Non-compliance with handwashing guidelines increases the risk of the patients and

nurses in acquiring nosocomial infections. And not merely that, it may also contribute in

the transmission of infections to other patients. Compliance with handwashing reflects

the nurses’ knowledge towards the reason for their duty. Compliance is initiated once the

nurses know and value the outcome. It is expected for nurses if they recognize their

expected performance and behavior in the clinical setting. The consistency of adopting

handwashing behavior is influenced mainly by the knowledge of basic principles,

concepts, and hospital policies. Thus, the transmission of nosocomial infections will be

diminished, if not totally prevented (Fortuno, 2005).

The demographic data and knowledge of nurses affect the perceived value

favoring handwashing and subsequently influence the nurses’ decision to wash their

hands. Older, female married nurses with a high level of education, are assumed to

comply in the handwashing guidelines because they are more prudent and aware of the

perceived risks involved in non-compliance with handwashing. While the younger,

singe, male nurses with lesser experience are perceived to be thoughtless of guidelines

and careless in performing patient care activities. Moreover, the intensity of patient care

activities, like nurse-patient ratio and unit assignments may alter the nurses’ decision to

comply with handwashing guidelines. There is also an assumption that high intensity of

patient care activity is associated with low compliance to handwashing for the very

reason that the patients’ needs become the nurses’ priority (Fortuno, 2005).
 9

Figure 1 shows the six components in the infectious disease process. This is also

known as the Chain of Infection.

The six components in the infectious disease process includes: (1) Pathogen; (2)

Reservoir; (3) Portal of exit; (4) Mode of transmission; (5) Portal of entry; and, (6)

Susceptible host.

The pathogen in the figure below was the cold viruses. The nurse was infected

with cold viruses; therefore the nurse was the reservoir. When the nurse blew his/her

nose, cold viruses got onto his/her hands, therefore the portal of exit was the nose of the

nurse. The nurse attended his/her patient to get vital signs. The nurse had a direct contact

with the patient so the cold virus was transferred to the patient. Therefore, handling the

patient was the mode of transmission. When the patient rubbed his/her nose, the cold

viruses were transferred from his/her hands to the mucous membranes of his/her nose;

therefore the patient’s nose was the portal of entry. The patient now was the susceptible

host.

Source of Infection

(Cold Viruses)

Patien
t Nurse

Susceptible host Reservoir

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Portal of entry Portal of exit

Mode of Transmission

Figure 1 – Chain of Infection

(Note: Please improve your Figure 1.)

Figure 2 presents the proper handwashing technique and breaking the chain of

infection.

To prevent transfer of pathogens or disease-causing microorganisms, a nurse

should strictly follow proper handwashing technique.

A nurse must remove all pieces of jewelry and fold sleeves if present to prevent

contamination. He/She must open the faucet and rinse hands properly using soap and do

the following steps in handwashing: (1) rub hands palm to palm; (2) right palm over the

left dorsum and vice versa; (3) finger interlaced; (4) finger interlocked; (5) rotational

rubbing of the thumb; (6) rotate fingers in palm; and (7) palm to palm again. He/She must

rinse hands without toughing the faucet and dry hands using a clean towel or tissue.
 11

Figure 2 – Proper Handwashing Technique

(Note: Please revise your theoretical/conceptual paradigm using the

theories/concepts as bases for your study.)

Assumptions

An “assumption refers to a basic principle that is believed to be true without proof

or verification (Polit and Beck, 2003).”

This study assumes that:

1. the participants are honest in answering the questionnaires and interviews;

2. the participants are unaware that an observation will take place;

3. the observers are able to record participant’s handwashing duration,

frequency, and technique accurately;

Significance of the Study

This study will provide improvement in the Nursing Service Administration in a

sense that the assessment of the nurses’ behavior and perception regarding the importance
 12

of medical asepsis will pave the way for the administrators to facilitate program planning

especially on infection prevention and control. It will also help in determining proper

intervention program that will suit the occurrence of consistent compliance, not just for

nurses, but for all health care providers with handwashing protocol and guidelines.

Furthermore, the available tools may be used to evaluate improvement in their

handwashing behavior, and may eventually be incorporated in their performance

appraisal in the future.

Nursing profession and education will also be improved through the outcome of

the study. It will help in eliminating the existing gap between theory and practice. It will

provide proof that the ideal setting of imparting basic skills may be employed in the real

clinical setting. Moreover, the findings of the study will contribute to the development of

handwashing protocol and guidelines in the health care setting regarding the use of

waterless alcohol-based hand solution as an alternative to soap and water.

Scope and Limitation

The study was conducted in Our Lady of Mercy General Hospital from January

20, 2007 to March 2, 2007. Eleven nurses from different areas of the hospital served as

participants of this study. The areas of observations included the Operating Room,

Pediatric Intensive Care Unit/Neonatal Intensive Care Unit, Ward, Private Ward, and

Intensive Care Unit.

The study was conducted in forty days because the researchers were required to

complete the remaining 336 hours of their duty. The Clinical Instructors and other

observers like the senior Nursing students were not allowed to do observations beyond
 13

their hours of duty. The nurses’ availability in terms of their schedule was taken into

consideration in the selection of participants.

Definition of Terms

The following terms are conceptually and operationally defined in this study:

1. Compliance. The scores gained in the handwashing intervention checklist.

The nurse respondent is compliant when:

a. The actual handwashing practices using soap and water or waterless

alcohol-based hand solution are divided by the total required handwashing

practices observed within the two-hour observation period multiplied by

the frequency.

b. The technique is properly done if the step-by step handwashing procedure

is followed.

c. The duration of handwashing should be 15 minutes or more.

2. Intensity of Patient Care Activity. Indicators of patient care activity include

the following:

a. Type of Nursing Unit

Non-critical unit. Includes a type of patient care activity wherein the

patient admitted in the area requires less monitoring and is less dependent

to the health care providers; has a score of 1.

Critical unit. Includes a type of patient care activity wherein the patient is

subjected to close monitoring and is completely dependent to the health

care providers; has a score of 2.

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b. Nurse-Patient Ratio. Refers to the number of patient/s assigned to a nurse

in a shift per day. If the number of patients assigned to a nurse in a shift

day is the same as the average of number of patients per nurse, the score is

0. If it is above average, the score is 2, and if it is below the average then

the score is 1.

c. Level of Patient Care

Level 1. When the patient is less dependent to the health care provider, the

score is 0.

Level 2. When the patient requires moderate assistance to the health care

provider, the score is 1.

Level 3. When the patient is completely dependent to the health care

provider, the score is 2.

(Scores from each category will be summed up to identify the intensity

of patient care activity. The total score of the 3 categories is 6 the lowest score

is 1.)

Intensity of patient care is characterized as:

 High= above 3

 Moderate= 3

 Low= below 3)

(Note: The data in parentheses should be placed in Data Analysis in Chapter IV.)

3. Nurses’ Demographic Data include:

 15

a. Gender. Refers to human classification based on their anatomical and

physiological characteristics.

b. Age. Refers to the number of years of existence of life.

c. Civil Status. Refers to the individual’s standing in a community

(Webster’s Dictionary, 1993). It is operationally characterized in this

study as single, married, separated, widow/widower.

d. Educational Attainment. Refers to the nurses’ basic and advance

professional preparation. It is operationally characterized in this study as

formal education: Bachelor of Science in Nursing (BSN), Master of Arts

in Nursing (MAN), and non- formal education such as seminars, updates,

and in-service training.

e. Length of Service or Professional Experience. Refers to the number of

years of active nursing service.

CHAPTER II

Review of Related Literature

This chapter provides information on the importance of handwashing, nosocomial

infection, and the factors which affect nurses’ compliance to handwashing guidelines. It
 16

aims to focus on the analysis of different concepts relevant to handwashing practices in

the health care setting.

The related literature consists of conceptual and research literature (Sevilla, et. al,

1999). The conceptual literature includes foreign theories about nosocomial infections,

and handwashing. The research literature discusses foreign and local studies about

nosocomial infections, handwashing, and factors affecting nurses’ compliance to

handwashing guidelines.

Conceptual Literature

Nosocomial Infection

Nosocomial infections are classified as infections that are associated with the

delivery of health care services in a health care facility. The most common settings

where nosocomial infections develop are hospital surgical or medical intensive care units.

These types of infections can either develop during a client’s stay in a facility or manifest

after discharge. Causative microorganisms (e.g., tuberculosis and HIV) may also be

acquired by health personnel working in the facility and can cause significant illness and

time lost from work. The responsible microorganisms can possibly originate from the

client’s themselves (endogenous sources) or from the hospital environment, and hospital

personnel (exogenous sources) (Kozier, et. al., 2004).

Handwashing

Importance of Hand washing

Handwashing is imperative in every setting, most especially in the hospitals. It is

considered as one of the most effective infection control measures. Any client may harbor
 17

microorganisms that are currently harmless to the client, yet potentially harmful to

another person or to the same client if they find a portal of entry. Consequently, both

nurses, and client’s hands should be washed at the following times to prevent the spread

of microorganisms: before eating, after handling the bedpan or toilet, and after the hands

have come in contact with any body substances, such as sputum, or drainage from a

wound. In addition, health care workers should wash their hands before and after giving

care of any kind. (Kozier, et. al., 2004).

Research Literature

Foreign Literature

Nosocomial Infections

Reports from the National Nosocomial Infection Surveillance (NNIS) System has

revealed that the urinary system, respiratory tract, bloodstream, and wounds are the

common nosocomial infection sites (http://www.cdc.gov/ncidod/hip/surveill/nnis.htm).

A nosocomial or hospital-acquired infection is a new infection that develops in a

patient during hospitalization. It is usually defined as an infection that is identified at

least forty-eight to seventy-two hours following admission, so infections incubating, but

not clinically apparent, at admission are excluded. With recent changes in health care

delivery, the concept of "nosocomial infections" has sometimes been expanded to include

other "health care-associated infections," including infections acquired in institutions

other than acute-care facilities (e.g. nursing homes); infections acquired during

hospitalization but not identified until after discharge; and infections acquired through
 18

outpatient care such as day surgery, dialysis, or home parenteral therapy

(http://www.answers.com ).

Early studies reported at least 5 percent of patients became infected during

hospitalization. With the increased use of invasive procedures, at least 8 percent of

patients now acquire nosocomial infections (http://www.answers.com).

The most frequent types of infection are urinary-tract infection, surgical-wound

infection, pneumonia, and bloodstream infection. These infections follow interventions

necessary for patient care, but which impair normal defenses. At least 80 percent of

nosocomial urinary infections are attributable to the use of an indwelling urethral

catheter. Surgical-wound infection follows interference with the skin barrier, and is

associated with the intensity of bacterial contamination of the wound at surgery.

Nosocomial pneumonia occurs most frequently in intensive-care-unit patients with

endotracheal intubation on mechanical ventilation—the endotracheal tube bypasses

normal defenses of the upper airway. Finally, primary nosocomial bloodstream infection

occurs virtually only with the use of indwelling central vascular catheters, and correlates

directly with the duration of catheterization (http://www.answers.com ).

The clinical status of the patient is important in the development of infection.

Many hospitalized patients, such as leukemia patients or transplant patients, have

profoundly impaired immunity due to both their disease and therapy. These patients are

highly susceptible to infection, frequently with organisms that do not cause infection in

normal persons. Patients with neurologic problems may have swallowing difficulties due

to aspiration of bacteria from the mouth or stomach, which can lead to pneumonia.
 19

Patients who have received antimicrobials may develop nosocomial infectious diarrhea

caused by Clostridium difficile (http://www.answers.com).

The hospital environment may also contribute to infections. Repeated outbreaks

of Legionnaire's disease caused by organisms in a hospital's potable water or in air

conditioning cooling towers have occurred. Increases in Aspergillus spores in the air

during hospital construction cause fungal pneumonia in some immunocompromised

patients, with a mortality rate of over 50 percent. Bacterial contamination of sterile

intravenous fluids or equipment has repeatedly caused outbreaks of nosocomial

infections. Finally, patients may acquire tuberculosis or chicken pox from other patients

(http://www.answers.com).

The high frequency of nosocomial infections places a substantial burden on

individual patients and on the health care system. There is increased morbidity, including

delayed wound healing, delayed rehabilitation, increased exposure to antimicrobial

therapy and its potential adverse effects, and prolonged hospitalization. The average

prolongation of stay is 3.8 days for urinary infection, 7.4 days for surgical-site infection,

5.9 days for pneumonia, and 7 to 24 days for primary bloodstream infection. Some

infections, such as infection occurring in a hip or knee replacement, result in prolonged or

even permanent disability and require repeated rehospitalization and reoperation.

Nosocomial infections also cause mortality. The case-fatality rate for patients with

ventilator-associated pneumonia is 42 percent, with an attributable mortality of 15 to 30

percent. For nosocomial bloodstream infection, the case fatality rate is 14 percent, with

an estimated attributable mortality of 19 percent. Nosocomial infections are costly. The

 20

direct cost of hospital-acquired infections in the United States is estimated to be $4.5

billion per year. In England, the cost for one health unit is estimated to be 3.6 million

pounds per year. Prolongation of stay necessitated by nosocomial infection limits access

of other patients to hospital resources, and contributes to overcrowding on wards and in

emergency departments. Nosocomial infections also contribute to the emergence and

dissemination of antimicrobial-resistant organisms. Antimicrobial use for treatment or

prevention of infections facilitates the emergence of resistant organisms. Patients with

infection with antimicrobial-resistant organisms are then a source of infection for other

hospitalized patients. Some bacteria, such as methicillin-resistant Staphylococcus aureus,

may subsequently spread to the community (http://www.answers.com).

Control and Prevention

Prevention of nosocomial infections requires a systematic, multidisciplinary

approach. This is usually achieved under the leadership of an institutional infection-

control program. The principle activities of such a program include surveillance, outbreak

management, policy development, expert advice, and education. An optimal program

may decrease the incidence of nosocomial infections by 30 to 50 percent

(http://www.answers.com).

Surveillance of nosocomial infections, by itself, may decrease the incidence.

When each surgeon is provided with their own wound-infection rates and with other

surgeons' rates for comparison, the institutional surgical-wound infection rate decreases.

Outbreak control includes early identification of potential outbreaks, as well as evaluation

and intervention if an outbreak is identified. Continuing education of hospital staff about

 21

the importance of, and their role in, preventing nosocomial infections is necessary. The

infection-control program also provides expert consultation to other hospital programs

such as occupational health, clinical microbiology, and pharmacy

(http://www.answers.com).

Institutional policies and practices must be developed and adhered to. In

particular, optimal handwashing and glove use must be facilitated and reinforced, as

transmission of organisms between patients occurs primarily on the hands of staff

members. Isolation guidelines to identify and segregate patients who have an increased

risk of transmitting infection to other patients or staff are also essential. Other important

policies include: for urinary infection, the use and care of the indwelling catheter; and for

surgical wound infection, optimal surgical technique including preoperative preparation

and prophylactic antimicrobials. Many national or local standards and regulations will

also prevent nosocomial infection, and institutions must be in compliance. These

regulations cover hospital construction, municipal water supply, laundry management,

food handling, waste disposal, sterilization and other reprocessing procedures, as well as

standards for pharmacy and microbiology laboratory practice (http://www.answers.com).

An effective infection-control program requires dedicated staff with appropriate

training and sufficient resources. The number of personnel is determined by the size and

complexity of the facility. Infection-control practitioners, usually from a nursing

background, are responsible for program activity. In larger hospitals, program leadership

is provided by a physician with training in epidemiology and infection control. Smaller

facilities may obtain such expertise by contractual arrangement with outside experts.
 22

Oversight of the infection-control program is usually provided by a multidisciplinary

infection-control committee. The program director, however, should report directly to

senior hospital management to ensure optimal program effectiveness

(http://www.answers.com).

Postoperative Fever

In the discussion of nosocomial infection from ACS Surgery online it was stated

that many patients experience fever in the postoperative period without infection. In a

prospective study of 871 general surgery patients, 213 (24%) had a documented infection

or an unexplained fever in the postoperative period.149 The most common occurrence was

unexplained fever in 81 cases (38%), followed by wound infection in 55 (26%), UTI in

44 (21%), respiratory tract infection in 27 (13%), and other infections in 6 (3%). Of all

unexplained fevers, 72% occurred in the first 2 days, and of all occurrences in the first 3

days, 67 (71%) of 95 were unexplained, with only 18 (27%) representing true infection.

In another study, 73 (45%) of 162 patients experienced unexplained fever after general

surgical or orthopedic procedures; 25% of the unexplained fevers were at least 38.3° C

(101° F) (Dellinger, 2006 as cited in http://www.medscape.com).

At Harborview Medical Center, 316 (98%) of 322 patients who underwent

laparotomy for penetrating trauma had a temperature of at least 37.5° C (99.5° F) orally

during the first 5 days after operation. Of these patients, however, only 67 (21%) actually

acquired any infection during a 30-day follow-up. Even for the 80 patients whose

temperatures were as high as 39° C (102.2° F) orally, only 48% actually acquired an

infection before discharge. Fever that persisted or began after postoperative day 4 was
 23

more likely to represent true infection. Similarly, an elevated WBC count was

nonspecific during the first 5 postoperative days: 89% of all patients had a WBC count

greater than 10,000/mm3. A high fever should prompt examination of the patient, but in

the absence of systemic signs of sepsis, an extensive laboratory or radiologic workup

during the first 4 to 5 days is usually unhelpful (Dellinger, 2006 as cited in

http://www.medscape.com).

Magnitude and Significance of Nosocomial Infection

An understanding of the prevalence of nosocomial infections and of the factors

predisposing to their occurrence will help in prevention, diagnosis, and treatment. Since

1970, the NNIS system has collected and analyzed data on the frequency of nosocomial

infections in a voluntary sample of hospitals (currently numbering 280) in the United

States.154 Although it has been suggested that the NNIS system underestimates the true

incidence of nosocomial infections by 30% to 40%,3,155,156 the large number of cases

studied during consecutive years provides a useful description of the most frequently

encountered infections, their relative incidences, and the responsible pathogens

(Dellinger, 2006 as cited in http://www.medscape.com).

Urinary Tract Infection

With so many cases of bacteriuria occurring in catheterized patients, it would be

easy to become complacent about the problem. Urinary tract catheterization is performed

seven to eight million times a year in acute care hospitals in the United States. 160

Approximately 5% to 8% of catheterized, uninfected patients will acquire a urinary tract

infection for each day of catheterization, leading to a cumulative infection rate of 40% to
 24

50% after 10 days.109 However, the great majority of catheterized patients with bacteriuria

are asymptomatic. It has been estimated that only 0.7% of catheterized patients will

acquire a symptomatic infection and that 8% to 10% of patients will have bacteriuria after

the catheter has been removed. In many of these patients, the bacteriuria resolves without

specific therapy after the catheter has been removed. However, a careful study of more

than 1,458 patients clearly demonstrated that mortality is higher in catheterized patients

who acquire bacteriuria than in those who do not.160 In this study, 9% of all catheterized

patients acquired catheter-related UTIs; these infections were associated with a threefold

increase in deaths occurring during hospitalization, even after correction for other factors

(e.g., age, severity of illness, hospital service, duration of catheterization, and renal

function). In surgical patients between 50 and 70 years of age with normal renal function

and without a fatal underlying disease, a 3% increase in the death rate per patient per

hospitalization was associated with the occurrence of a UTI. Of all deaths occurring in

catheterized patients, 14% were associated with a UTI.160 By extrapolation, this mortality

suggests that as many as 56,000 deaths a year in the United States may be related to

catheter-acquired UTI. Although the risk of bacteremia is small for any individual patient

with bacteriuria, the large number of hospitalized patients with bacteriuria means that

many bacteremic episodes are seen in this population. UTI is the most commonly

diagnosed source of gram-negative sepsis, and the rate of bacteremia secondary to

urinary catheters is estimated to be between 0.7% and 2%.109 In a case-matched study

from 1978, a postoperative UTI was associated with a 2.4-day prolongation of hospital

stay and an excess cost of more than $500.162 A subsequent study revealed that 2.3% of
 25

postoperative patients with UTIs were subsequently diagnosed as having a wound

infection caused by the same organism responsible for the UTI.163 This finding accounted

for 3.4% of the wound infections occurring during the study (Dellinger, 2006 as cited in

http://www.medscape.com).

Infection Associated with Intravascular Devices

Nosocomial infection associated with intravascular devices, which are placed for

either monitoring or therapeutic purposes, assumed increasing importance during the

1970s and 1980s. In the United States, central venous catheters are in place for

approximately 15 million patient-catheter-days per year, resulting in approximately

250,000 catheter-associated bloodstream infections.70 Of all cases of nosocomial

bacteremia occurring in NNIS hospitals between September 1984 and July 1986, 82%

were associated with intravascular devices164: 27% were associated with parenteral

nutrition catheters and 55% with other vascular access devices. Reports from as early as

1963 called attention to the risk of serious systemic infections arising from peripheral

I.V. catheters.165 For ICU patients with bloodstream infections associated with central

venous catheters, the attributable mortality is 25% to 35%, and the excess cost for

survivors is $34,000 to $56,000 per patient, for a total annual cost of $296 million to $2.3

billion. In terms of infection risk, pulmonary arterial catheters are no different from

central venous catheters, except for their potential to cause right-side heart lesions that

could predispose to right-side endocarditis.166 Pulmonary arterial catheters can be

responsible for bloodstream infection, and they require as much attention during insertion

and subsequent care as central venous catheters do. The arterial catheters used for
 26

monitoring purposes in the ICU have been thought to be less frequently associated with

infection than central venous catheters are, but it is clear that life-threatening infections

can originate with peripheral arterial lines.168,169 In early studies of radial artery catheters

in which non quantitative culture techniques were employed, catheter contamination rates

of 4% to 39% were recorded, but there were no cases of CRBSI or clinical infection in

605 catheterizations.170 In these studies, the majority of catheters were removed from

patients within 3 days. Prospective studies of arterial catheters demonstrated that 18% to

35% of the lines were locally infected, as reflected in semi quantitative cultures of at least

15 colonies.171 In one study, five cases of CRBSI occurred, representing an overall

incidence of 4% and an incidence of 23% among locally infected catheters. 171 The

incidence of CRBSI was increased in catheters that were inserted by cut down rather than

by percutaneous puncture and in catheters with signs of local inflammation. In another,

the clinical features of bloodstream infection arising from an arterial catheter were

indistinguishable from the clinical features of episodes arising from a central venous line,

and 12% of all nosocomial bacteremias in the ICU originated from an arterial catheter. 171

Clearly, arterial lines as well as venous lines must be considered in the examination of a

patient for the source of fever or bloodstream infection in the ICU. Twelve cases of radial

artery rupture after arterial line infection have been reported. All but one were associated

with S. aureus infection, and nearly all demonstrated systemic signs of infection for 2

days or longer after catheter removal.169 Although there is no published experience with

the use of guide wires to change and culture arterial lines in relation to possible catheter-
 27

related infection, the technique can be applied with the same rationale used for central

venous catheters ( Dellinger, 2006 as cited in http://www.medscape.com).

Pathogens

In 1984, the NNIS reported on 26,965 infections. Of these cases, 64% were

caused by single pathogens, 20% were caused by multiple pathogens, 6% had no

pathogen identified on culture, and 10% were not cultured [see Figure 4 -- omitted].173 Of

the 84% in which a pathogen was identified, 86% were caused by aerobic bacteria, 2% by

anaerobes, and 8% by fungi [see Figure 4] and [see Table 2 -- omitted]. Overall on the

surgical services, the most common pathogen isolated was E. coli, followed by P.

aeruginosa, enterococci, S. aureus, Enterobacter species, Klebsiella species, coagulase-

negative staphylococci, Proteus species, Candida species, and Serratia species. These 10

types of pathogens accounted for 84% of all isolates. Gram-negative rods were most

common in UTIs and lower respiratory tract infections, though S. aureus was the second

most common pathogen isolated in lower respiratory tract infections. S. aureus was the

most common isolate from surgical wound infections, whereas coagulase-negative

staphylococci, followed closely by S. aureus, were the pathogens most often responsible

for primary bacteremias (Dellinger, 2006 as cited in http://www.medscape.com).

As a consequence of changing hospital practices, hospitalized patients today tend

to be more severely ill than was once the case. Large amounts of antibiotics are being

used in hospitals, and antibiotic-resistant pathogens have become increasingly

problematic. Current NNIS data indicate that the frequency with which antibiotics are

administered to hospitalized patients who are not in an ICU is approximately 468 defined
 28

daily doses (DDD) per 1,000 patient-days.174 For hospitalized ICU patients, the frequency

is between 800 and 1,031 DDD per 1,000 patient-days. MRSA accounts for 51% of total

S. aureus isolates in ICU patients, 40% in non-ICU patients, and 24% in outpatients with

nosocomial infections; the corresponding figures for quinolone-resistant P. aeruginosa in

relation to total P. aeruginosa isolates are 37%, 27%, and 27%.174 In 2002, the second

clinical isolate of vancomycin-resistant S. aureus in the United States was reported

(Dellinger, 2006 as cited in http://www.medscape.com).

Nosocomial infections with resistant enterococci have become a serious problem.

Enterococci were the third most common nosocomial bloodstream isolate reported by

NNIS hospitals between 1990 and 1992.176 The incidence of vancomycin-resistant

enterococci (VRE) increased 26-fold between 1989 and 1993, from 0.3% to 7.9%, with a

34-fold rise in ICUs,177 and the rate has continued to increase. The 2001 NNIS report

stated that 13% of enterococci were resistant to vancomycin in ICU patients, 12% in non-

ICU patients, and 5% in outpatients.174 These strains arise from the patient's endogenous

flora, but nosocomial spread within the hospital environment is also an important

source.177,178 The environment around infected patients is heavily contaminated with VRE,

and gown and glove isolation techniques are required to stop transmission.178 Strict

application of hand hygiene is also important for reducing the spread of VRE and other

nosocomial pathogens. According to the available data and current CDC

recommendations, the use of alcohol-based hand-rub solutions is superior to washing

with soap and water: it can be performed more rapidly and is less damaging to the skin

(Dellinger, 2006 as cited in http://www.medscape.com).

 29

VRE are also highly resistant to other available antibiotics. Acquisition of VRE is

significantly associated with prior hospitalization and with use of third-generation

cephalosporins, vancomycin, or multiple antibiotics.180,181 In one study, 16% of stool

specimens submitted for testing for C. difficile toxin were colonized with VRE, and all

surgical patients in that study had the same strain. High mortality can be associated with

VRE infections. In a study comparing the outcome of patients having VRE bacteremia

with the outcome of patients having bacteremia caused by vancomycin-sensitive

enterococci (VSE), mortality was 2.3 times higher in those with VRE bacteremia, and

89% of patients with VRE bacteremia were colonized or infected with VRE at another

site.183 Prior treatment with third-generation cephalosporins is another risk factor for

increased mortality.176 Liver transplant patients with VRE bacteremia had a 92% higher

mortality than comparable patients with VSE bacteremia, and those with VRE bacteremia

also had a higher recurrence rate and greater need for invasive procedures (Dellinger,

2006 as cited in http://www.medscape.com).

Current recommendations include decreased—and possibly restricted—use of

vancomycin, as well as aggressive infection control measures whenever VRE are isolated

in a hospitalized patient. In particular, vancomycin should not be used as primary

treatment for C. difficile-associated diarrhea and should be avoided for surgical

prophylaxis unless the hospital has a specific problem with MRSA or the patient cannot

receive other appropriate antibiotics (Dellinger, 2006 as cited in

http://www.medscape.com).

Enteric Infection
 30

C. difficile is often found in patients with severe antibiotic-associated enteric

infections. In one report, 691 (2%) of 32,757 consecutive postoperative patients

experienced watery diarrhea significant enough to stimulate a request for C. difficile toxin

assay.185 Of this number, 75 (11% of patients with diarrhea) had a positive toxin assay.

All cases were associated with antibiotic administration. Approximately 94% of the

patients had received a cephalosporin either alone or in combination with other

antibiotics; 29% of these responded to cessation of antibiotics and supportive measures,

and the remainders were treated with vancomycin, metronidazole, or bacitracin. Six

(14%) of the patients who required specific therapy relapsed after initial response to

treatment and were subsequently cured with one or more additional courses of treatment.

Two patients died, and the overall hospital stay for the remaining patients was prolonged

by an average of 50%. Most patients with mild cases of antibiotic-associated diarrhea do

not have either positive cultures for C. difficile or positive toxin assays, and the etiologic

role of C. difficile is unclear. Many hospitalized patients without diarrhea also have C.

difficile in the stool, with or without toxin production, 123,186 and the likelihood of isolating

this pathogen increases with patients' increasing length of stay.118 A nonpathogenic yeast,

Saccharomyces boulardii, when administered by mouth to hospitalized patients receiving

antibiotics, significantly reduced the occurrence of antibiotic-associated diarrhea without

affecting the rate of acquisition of C. difficile. Some 3% of asymptomatic adults carry C.

difficile in their stools, but 30% to 40% of healthy neonates may carry the organism. The

rate of carriage declines after the age of 1 to 2 years. C. difficile can be spread in the

hospital and has been isolated from 10% of inanimate objects in the environment of
 31

patients with C. difficile colonization, compared with 3% in hospital areas with no known

cases.187 In one report,187 this organism was recovered from the hands of 13% of medical

personnel working in a ward with affected patients; in another,188 it was recovered from

60% of personnel immediately after they had cared for an affected patient. Soap-and-

water washing was ineffective in preventing acquisition, but the combination of glove use

and chlorhexidine washing was effective. In another medical center,189 clusters of new

nosocomial C. difficile diarrhea were prevented by screening all patients with diarrhea by

active surveillance (using culture to identify C. difficile infection) and by instituting

isolation precautions and daily disinfection of infected patients' rooms. The prevalence of

C. difficile in the environment is increased when a patient has diarrhea.187,188 In one

prospectively studied cohort, 21% of patients without C. difficile in their stools on

admission acquired the organism during hospitalization, and 37% of these patients

experienced diarrhea; no cases of colitis occurred.187 Diarrhea was more common in

patients who received antibiotics. The rate of acquisition of C. difficile was 73% higher if

a patient had a roommate colonized with C. difficile (Dellinger, 2006 as cited in

http://www.medscape.com).

Handwashing

Importance of Handwashing

Bowen’s agency conducted the Handwashing Promotion Program in Chinese

primary schools from January to May 2005. Thirty schools from each of three counties in

Fujian province, China were subjected to a handwashing regimen to determine whether a

more scalable intervention could also reduce illness rates. The result states that children
 32

who belonged to the study groups provided with handwashing interventions experienced

a significant drop in illness rates, thus, also reducing their absences from school

(Fucanan, 2006 as cited in http://www.manilatimes.net)

This study tells us that school-based hand-washing programs with soap could

improve the health of children, and perhaps their communities, worldwide (Bowen, 2006

as cited in http://www.manilatimes.net).

The babies in the intensive care nursery are very susceptible to infections.

Premature babies are especially at risk. These babies have very fragile skin that tears

easily. This allows bacteria from hands to enter your baby's body more easily than it

would a child or adult. The skin is your hands' first defense against infection from

pathogenic organisms. While it's intact, it's impermeable to the likes of human

immunodeficiency virus (HIV) and hepatitis, so its care and hygiene are crucial. Simply

keeping your hands clean is arguably the single most important measure you can take

(http://www.virtua.org).

Proper Handwashing Technique

When should one scrub? The first time you visit the nursery each day and each

time you visit after leaving the hospital.

How should one scrub? (1) Remove watches, bracelets, and rings (except plain

gold bands). (2) Open the scrub brush packet and take out the small stick. Use the stick to

clean under your nails. This is very important because many germs like to hide there. (3)

Once you have cleaned under your nails, put some soap and water on the scrub Brush to

lather up the soap. (4) Scrub from your fingers to your elbows for a full three minutes.
 33

For your convenience there is a three-minute egg timer to guide you. If you prefer you

may use the clock on the wall (http://www.virtua.org).

When is it okay to just wash? If you have already scrubbed for the day and have

not left the hospital; anytime you sneeze, cough, blow your nose, change your baby's

diaper or touch your hair, shoes, etc; if you are visiting twins, triplets or other multiples,

you must wash your hands between babies” (http://www.virtua.org).

How should one wash? (1) Remove any piece of jewelry such as your watch,

bracelet, and ring (except plain gold bands). (2) Place soap and water on your hands and

rub them together, making a good lathe. (3) You must wash for at least thirty seconds for

germs to be killed (http://www.virtua.org).

Choose neutral pH soap with no added substances. Strong perfumes or alcoholic

drying chemicals tend to dry out the skin, especially if you wash frequently. Use a good-

quality moisturizing cream to help restore your hands if they get washed out. The skin is

your hands’ first defense against infection from pathogenic organisms. While it is intact,

it is impermeable to the likes of human immunodeficiency virus (HIV) and hepatitis, so

its care and hygiene are crucial. Simply keeping your hands clean is arguably the single

most important measure you can take (http://www.virtua.org).

Your skin is impermeable to pathogenic organisms only while it is intact. Cuts,

abrasions, lesions and dermatitis should be covered by a waterproof occlusive dressing

for extra protection. To be safe, follow the Center for Disease Control and Prevention’s

(CDC) universal precautions - always wear gloves if you’re in contact with body fluids

(http://www.virtua.org).
 34

Next to your love, proper handwashing is the most important thing you and your

visitors can do for your baby. Studies have shown that artificial nails increase the chances

of infection. Germs love to hide under them. The neonatal staff has removed theirs and it

is our suggestion that moms do the same (http://www.virtua.org).

Guidelines for Handwashing and Hospital Environmental Control

Ranking Scheme for Recommendations

(1) Measures in Category I are strongly supported by well-designed and

controlled clinical studies that show their effectiveness in reducing the risk of nosocomial

infections, or are viewed as effective by a majority of expert reviewers. Measures in this

category are viewed as applicable for most hospitals -- regardless of size, patient

population, or endemic nosocomial infection rates (Garner and Favero, 1985 as cited in

http://vm.cfsan.fda.gov/~comm/lacf-phs.html).

(2) Measures in Category II are supported by highly suggestive clinical studies in

general hospitals or by definitive studies in specialty hospitals that might not be

representative of general hospitals. Measures that have not been adequately studied but

have a logical or strong theoretical rationale indicating probable effectiveness are

included in this category. Category II recommendations are viewed as practical to

implement in most hospitals (Garner and Favero, 1985 as cited in

http://vm.cfsan.fda.gov/~comm/lacf-phs.html).

(3) Measures in Category III have been proposed by some investigators,

authorities, or organizations, but, to date, lack supporting data, a strong theoretical

rationale, or an indication that the benefits expected from them are cost effective. Thus,
 35

they are considered important issues to be studied. They might be considered by some

hospitals for implementation, especially if the hospitals have specific nosocomial

infection problems, but they are not generally recommended for widespread adoption

(Garner and Favero, 1985 as cited in http://vm.cfsan.fda.gov/~comm/lacf-phs.html).

In 1980, the Centers for Disease Control (CDC) began developing a series of

guidelines entitled Guidelines for the Prevention and Control of Nosocomial Infections.

The purpose of the Guidelines was twofold: 1) to disseminate advice on how to prevent

or control specific nosocomial infection problems and 2) to cover the questions most

frequently asked of the Hospital Infections Program staff on different aspects of the

hospital's inanimate environment. One of the first guidelines to be published was the

Guideline for Hospital Environmental Control. It was written by Bryan P. Simmons,

M.D. in consultation with Thomas M. Hooton, M.D., and George F. Mallison, M.P.H.,

and in collaboration with a working group consisting of Edward J. Bertz; Mary K. Bruch;

Sue Crow, R.N., M.S.N.; William E. Scheckler, M.D.; Harold Laufman, M.D., Ph.D.;

Janet K. Schultz, R.N., M.S.N.; Earle H. Spaulding, Ph.D.; and Richard P. Wenzel, M.D.

In February 1981, CDC mailed to each U.S. acute-care hospital Part I of the Guideline for

Hospital Environmental Control, which contained sections entitled “Antiseptics,

Handwashing, and Handwashing Facilities,” “Cleaning, Disinfection, and Sterilization of

Hospital Equipment,” and “Microbiologic Surveillance of the Environment and of

Personnel in the Hospital.” In October 1981, Part II of the Guideline for Hospital

Environmental Control, which contained the sections “Housekeeping Services and Waste

Disposal,” “Laundry Services,” “Intensive Care Units,” and “Pharmacy,” was published.
 36

In July 1982, the section on “Cleaning, Disinfection, and Sterilization of Hospital

Equipment” was revised. In November 1982, the two parts of the Guideline were

combined into a single document entitled Guideline for Hospital Environmental Control,

and copies were mailed to all U.S. acute-care hospitals (Garner and Favero, 1985 as cited

in http://vm.cfsan.fda.gov/~comm/lacf-phs.html).

In October 1983, CDC issued a statement entitled “Clarification of Guideline

Recommendations on Generic Antiseptic, Disinfectant, and Other Products,” which was

mailed to all U.S. acute-care hospitals. The statement emphasized that CDC

recommendations are not intended to endorse any particular commercial product or to

exclude the use of other commercial products containing generic ingredients not

mentioned in the Guideline for Hospital Environmental Control (Garner and Favero,

1985 as cited in http://vm.cfsan.fda.gov/~comm/lacf-phs.html).

In November 1983, a follow-up statement requested that users delete the portion

of the Guideline for Hospital Environmental Control that recommended specific generic

antimicrobial ingredients for use in health care personnel hand washes and announced

that the entire Guideline would be comprehensively revised. In June 1984, a draft of the

proposed revision was mailed to 150 scientists and infection control professionals for

review and comment. Rather than using an expert working group to finalize the content

of this Guideline, we used the written comments and suggestions which we received from

the reviewers to determine the final content of the Guideline and the ranking of the

recommendations (Garner and Favero, 1985 as cited in

http://vm.cfsan.fda.gov/~comm/lacf-phs.html).
 37

Major Changes in the Guidelines

Since these guidelines contain many important changes from the original Guidelines

for Hospital Environmental Control, it is important that users read the entire guidelines

carefully. The major changes in the titles and content of sections are listed below:

1. The section “Handwashing,” which replaces the old section entitled “Antiseptics,

Handwashing, and Handwashing Facilities,” contains updated recommendations for

handwashing with plain soaps or detergents and with antimicrobial-containing products.

Rather than recommending specific generic ingredients for handwashing with

antimicrobial containing products, the Guideline indicates that hospitals may choose from

appropriate products in categories defined by the U.S. Food and Drug Administration

(FDA), since preparations used to inhibit or kill microorganisms on skin are categorized

by an FDA advisory review panel for nonprescription (over-the-counter {OTC})

antimicrobial-drug products (2). Manufacturers of antimicrobial containing products

voluntarily submit data to the review panel, which categorizes the products according to

their intended use, i.e., antimicrobial soaps, health-care personnel hand washes, patient

preoperative skin preparations, skin antiseptics, skin wound cleansers, skin wound

protectants, and surgical hand scrubs. Generic antimicrobials for each use category are

further divided: Category I (safe and efficacious); Category II (not safe and/or

efficacious); and Category III (insufficient data to categorize). Consequently, chemical

germicides formulated as antiseptics are categorized by the FDA into groupings by use

and efficacy, but they are not regulated or registered in the same fashion as chemical

germicides are by the U.S. Environmental Protection Agency (EPA). Persons responsible
 38

for selecting commercially marketed health-care-personnel hand washes can obtain

information about categorization of products from the Center for Drugs and Biologics,

Division of OTC Drug Evaluation, FDA, 5600 Fishers Lane, Rockville, MD 20857. In

addition, information published in the scientific literature, presented at scientific

meetings, documented by manufacturers, and obtained from other sources deemed

important may be considered.

1. The section "Cleaning, Disinfecting, and Sterilizing of Patient-Care Equipment"

has been rewritten. Medical devices, equipment, and materials are divided into three

categories (critical, semicritical, and noncritical) based on the risk of infection involved

in their use. Revised recommendations for sterilizing and disinfecting items in these

categories are included in this section. Rather than listing specific chemical germicides,

the Guideline indicates that hospitals may choose from sterilant and disinfectant

formulations registered with the EPA, since chemical germicides are regulated and

registered by the EPA (3). Manufacturers of chemical germicides formulated as general

disinfectants, hospital disinfectants. and disinfectants used in other environments, such as

the food industry, are required by EPA to test their formulations using specific protocols

for microbicidal efficiency, stability, and toxicity to humans. In past years, the EPA has

reserved the right to test and verify formulations of chemical germicides for their

specified efficacy; however, in practice only those formulations to be registered as

sterilants or sporicides were actually tested. In 1982, the EPA discontinued this testing.

Currently, formulations of chemical germicides are registered by the EPA based on data

obtained from the manufacturer. Persons responsible for selecting chemical germicides
 39

should keep in mind that the field is highly competitive, and exaggerated claims are often

made about the germicidal efficiency of specific formulations. When questions regarding

specific claims or use arise, the Disinfectants Branch Registration Division, Office of

Pesticides, EPA, 401 M Street, S.W., Washington, D.C. 20460, can be consulted. As with

handwashing products, information in the scientific literature, presented at scientific

meetings, documented by manufacturers, and obtained from other sources deemed

important may be considered. The recommendation against reprocessing and reusing

single-use items has been removed. Since there is lack of evidence indicating increased

risk of nosocomial infections associated with the reuse of all single-use items, a

categorical recommendation against all types of reuse was not considered justifiable.

Rather than recommending for or against reprocessing and reusing single-use items, the

Guideline indicates that items or devices that cannot be cleaned and sterilized or

disinfected without altering their physical integrity and function should not be

reprocessed. In addition, reprocessing procedures that result in residual toxicity or

compromise the overall safety or effectiveness of the items or devices should be avoided.

Arguments for and against reprocessing and reusing single-use items have been

summarized in a report from the International Conference on the Reuse of Disposable

Medical Devices in the 1980's (4).

1. The section “Microbiologic Sampling” replaces the old section entitled

“Microbiologic Surveillance of the Environment and of Personnel in the

Hospital.” The recommendation for microbiologic sampling of infant formulas

prepared in the hospital has been removed, since there is no epidemiologic

 40

evidence to show that such sampling reduces the infection rate in hospitals.

Information and recommendations for microbiologic surveillance of personnel

have been deleted, since this topic is addressed in the Guideline for Infection

Control in Hospital Personnel (5).

2. A new section, “Infective Waste,” has been added. It contains information about

identifying infective waste and recommendations for its handling and disposal.

3. The section “Housekeeping” replaces the old section “Housekeeping Services and

Waste Disposal.” Recommendations against use of carpets in patient care areas

have been removed, since there is no epidemiologic evidence to show that carpets

influence the nosocomial infection rate in hospitals (6); whether to use carpets,

therefore, is not considered an infection control issue.

4. The section “Laundry” contains a discussion of and recommendations for both

hot-water and reduced temperature washing.

5. The section “Intensive Care Units” has been deleted, since it primarily dealt with

information and recommendations that are covered elsewhere in this Guideline

and in the Guideline for Isolation Precautions in Hospitals (Garner and Favero,

1985 as cited in http://vm.cfsan.fda.gov/~comm/lacf-phs.html).

The recommendations presented in this Guideline were chosen primarily for their

acknowledged importance to infection control, but other factors, such as the feasibility of

implementing them and their potential costs to hospitals, were also considered. Many

recommendations are intended to reduce or eliminate expensive practices that are not

likely to prevent infections. Some of the recommendations are based on well-documented

 41

epidemiologic studies; others are based on a reasonable theoretical rationale, since for

many of these practices little or no scientifically valid evidence is available to permit

evaluation of their effect on the incidence of infection. Because new studies are

constantly revealing pertinent information in this field, users of this Guideline should

keep informed of other sources. The recommendations presented in this Guideline may

be modified as necessary for an individual hospital and are not meant to restrict a hospital

from developing recommendations that may be more appropriate to its own unique needs.

The recommendations have no force of law or regulation (Garner and Favero, 1985 as

cited in http://vm.cfsan.fda.gov/~comm/lacf-phs.html).

Fourteen studies of practices to improve handwashing compliance are as follows:

1. The setting of the study was practice. All medical staff in a neurologic ICU and a

surgical ICU in a 350-bed tertiary care teaching hospital in Washington, DC,

1983-84; multifaceted intervention (education, automatic sinks, feedback). Study

Design and Outcome was Level 2, Level 2. And the Handwashing Compliance

(unless otherwise noted) was 69% vs. 59% (p=0.005).

2. Medical staffs in 2 ICUs in a university teach hospital in Philadelphia; increase

number of available sinks. Study Design and Outcome was Level 2 and the

Handwashing Compliance was 76% vs. 51% (p<0.01).

3. Medical staff in a 6-bed post-anesthesia recovery room and a 15-bed neonatal

ICU in a tertiary care hospital in Baltimore, 1990; automatic sink compared with
 42

standard sink. Study Design and Outcome was Level 2, Level 2. Mean

handwashes per hour: 1.69 vs. 1.21 on unit 1; 2.11 vs. 0.85 on unit 2; (p<0.001).

4. All staff at a large acute-care teaching hospital in France, 1994-97; hand hygiene

campaign including posters, feedback, and introduction of alcohol-based solution.

Study Design and Outcome was Level 3, Level 1. Nosocomial infections: 16.9%

vs. 9.9% Handwashing: 66.2% vs. 47.6% (p<0.001).

5. Medical staff in a 6-bed pediatric ICU in a large academic medical center in

Virginia, 1982-83; mandatory gowning. Study Design and Outcome was Level 3,

Level 2. The Handwashing Compliance was 29.6% vs. 30.7%.

6. Medical staff in 2 ICUs in a community teaching hospital in Tennessee, 1983-84;

sequential interventions of lectures, buttons, observation, and feedback. Study

Design and Outcome was Level 3, Level 2. Handwashing Compliance was

29.9% vs. 22% (p = 0.071).

7. Medical staff in an 18-bed ICU in a tertiary care hospital in Australia;

introduction of chlorhexidine-based antiseptic handrub lotion. Study Design and

Outcome was Level 3, Level 2. . Handwashing Compliance was 45% vs. 32%

(p<0.001).

8. 12 nurses in a 12-bed ICU in Mississippi, 1990; education/feedback intervention.

Study Design and Outcome was Level 3, Level 2. Handwashing Compliance was

92% vs. 81%.

 43

9. Medical staff in an 18-bed pediatric ICU in a children's teaching hospital in

Melbourne, 1994; 5-step behavioral modification program. Study Design and

Outcome was Level 3, Level 2. Handwashing rates after patient contact: 64.8%

vs. 10.6%.

10. Medical staff in a 3000-bed tertiary care center in France, 1994-95; 13-step

handwashing protocol. Study Design and Outcome was Level 3, Level 2.

Handwashing Compliance was 18.6% vs. 4.2% (p<0.0001).

11. Medical staff in two ICUs at a teaching hospital in Virginia, 1997; 6

education/feedback sessions followed by introduction of alcohol antiseptic agent...

Study Design and Outcome was Level 3, Level 2. Results include: Baseline 22%;

Education/feedback 25%; Alcohol antiseptic 48%; (p<0.05).

12. Medical staff in a 14-bed ICU in a tertiary care hospital in France, 1998;

introduction of alcohol-based solution... Study Design and Outcome was Level 3,

Level 2. Handwashing Compliance was 60.9% vs. 42.4% (p=0.0001).

13. All staff in a medical ICU and step-down unit in a large teaching hospital in

Virginia; installation of alcohol-based solution.. Study Design and Outcome was

Level 3, Level 2. Handwashing Compliance was 52% vs. 60% (p=0.26).

14. Medical staff on 2 general inpatient floors at each of 4 community hospitals in

New Jersey; patient education intervention... Study Design and Outcome was

Level 3, Level 3. Soap usage (as an indicator of handwashing) increased by 34%

(p = 0.021).
 44

“A structured search of the PubMed database (including MEDLINE) and review of

the bibliographies of relevant articles identified 14 studies that have examined methods to

improve handwashing compliance. Three studies were non-randomized controlled trials

(Level 2) that directly compared separate units, or parts of units, in which one area

received the intervention and another did not. Eleven studies were before-after studies

(Level 3), in which baseline data regarding handwashing rates were obtained during an

initial observation period, and then measured again in the time period after a particular

intervention. Regardless of the type of study design, details regarding the comparability

of the groups under observation were reported in only 4 studies” (as cited in

http://vm.cfsan.fda.gov/~comm/lacf-phs.html).

Factors Affecting Proper Handwashing

According to APIC, handwashing associated with general patient care occurs in

approximately half of the instances in which it is indicated and usually is of shorter

duration than recommended. A recent study supports that figure, finding that average

handwashing compliance was 48% in a teaching hospital. The study concluded that the

primary problem with handwashing is laxity of practice and that high workload among

healthcare workers was associated with low compliance (http://en.wikipedia.org).

Other factors influencing handwashing behavior include placement of sinks,

unacceptable handwashing products, the effect of handwashing on skin condition, and

awareness of the importance of handwashing in preventing infection

(http://en.wikipedia.org).
 45

The convenient placement of sinks, handwashing products, and paper towels is

often suggested as a means of encouraging frequent and appropriate handwashing. Sinks

with faucets that can be turned off by means other than the hands (e.g., foot pedals) and

sinks that minimize splash can help personnel avoid immediate recontamination of

washed hands (http://en.wikipedia.org).

Local Literature

Nosocomial Infections

In the study conducted by Fortuno (2005), she stated that the common

complications which occur in the hospitals, particularly in the Intensive Care Unit (ICU),

are nosocomial Infections. This hospital-acquired infection occurs in the ICU at a much

higher rate compared with those other areas of the hospital (Weinstein, 1998). In her

study, she enumerated the associated risk factors for infections: (a) intrinsic factors which

are associated with the severity of the patient’s illness and underlying conditions like

malnutrition, age, and immunosuppression; (b) invasive medical devices and length of

exposure to them; (c) increased patient contact; (d) length of stay in the ICU; and (e) use

of antibiotic and special environmental characteristics of the unit like space limitations

(Nguyen, et. al., 2003; Floros & Roussos, 2001; Weber, Raasch, & Rutala, 1999). She

emphasized that contamination which occurs between patients and health personnel is a

challenge in the delivery of health care in the hospital (Larson, Bryan, Adler, & Blane,

1997; Haley & Bregman, 1982; Pittet et. al., 1999).

Handwashing
 46

Importance of Handwashing

In 1843, Oliver Wendell Homes; an obstetrician suspected that the hands of

health care providers could be the culprit for “childbed fever” (Rotter, In Wenzel, 1997 as

cited in Fortuno, 2005). Four years have passed, Ignaz Semmelweiz, a French

obstetrician, noticed that most parturient women assisted by his students and other

physicians have higher mortality rate than those women whose babies were delivered by

midwives. Then he found out that his students and other physicians entered the obstetrics

ward without proper washing of their hands with soap and water. Semmelweiz postulated

that the cause of the puerperal fever experienced by the parturient mothers was

“cadaverous particles” brought by his students and other physician in the obstetrics ward.

Consequently, their recommendations for handwashing which resulted from their

observation became the most important measure in preventing nosocomial infections in

the healthcare setting (Boyce and Pittet, 2002 as cited in Fortuno, 2005).

The US public health service developed a film demonstrating handwashing

technique in 1961. This was developed to train health care providers to wash their hands

for one-two minutes with soap and water before and after contact with patient. Another

was the formal written guideline on handwashing practices in the health care setting

which was published by CDC in 1975 and 1985 (Garner, 1985, CDC Guidelines for

handwashing and hospital environment control as cited in Fortuno 2005). Its

recommendation was to wash hands with adequate friction for at least 30 seconds with

non-antimicrobial soap for all and between patient contacts, before and after performing

invasive procedures, and before and after providing care for high risk patients. Washing
 47

hands for 30 minutes using soap and water accompanied by friction is almost as effective

as washing hands for 2 to 3 minutes (Boyce and Pittet, 2002). It is only when sinks are

not accessible when waterless antiseptic solution is recommended. She also cited in her

study that the Association for professionals in Infection Control (APIC) published

another guideline in 1988 and 1995 (Larson, 1995, APIC Guideline for Handwashing and

Hand Antisepsis in Health Care Setting) which discusses in detail the use of alcohol

based hand rubs and supported their use in health care setting. Likewise, in 1995 and

1996, the use of antimicrobial soap or waterless antiseptic solution was recommended by

the Healthcare Infection Control Practices Advisory (HICPA), to clean hands after direct

care of patients with multi-drug resistant pathogens, such as Methicillin-resistant

Staphylococcus aureus (MRSA) and Vancomycin-resistant enterococci (VRE).

Guidelines for handwashing and hands antisepsis along with routine patient care were

provided in the recommendation. However, compliance with handwashing practices

among health care providers remained low (Boyce and Pittet, 2002; Pittet et al, 1999).

Factors Affecting Nurses’ Compliance with Handwashing Guidelines

Compliance is defined as “the act of complying, yielding, or acting in accord.” It

is the power exerted by an individual to control his acts based on perception, past

learning and working experiences, and the influence of others. It becomes habitual if

related acts are repeated, reinforced, or rewarded. The behavior of a compliant lasts for as

long as the promise of reward or punishment exists. One goes back to his old behavior
 48

once the reward or punishment is given (Fortuno, 2005). The compliant understands the

force of the circumstances and can easily change his or her behavior when the

circumstances no longer prevail.

In the study of Fortuno (2005), she enumerated the causes for healthcare

providers’ low compliance to handwashing guidelines: lack of awareness, forgetfulness,

interference with provider-patient relationship, insufficient time/too busy, overcrowding

or understaffing, inaccessibility of sinks, lack of soap and paper towels, irritating washing

agents, laxity, and many other factors (Rosenthal et. al., 2003; Boyce & Pittet, 2002;

Rumbaua et. al., 2001; Pittet et. al., 1999)

According to Gomez (2004) through personal interview, the reason was because

of the unavailability of supplies. The result was revealed in the unpublished clinical trial

conducted at the Philippine General Hospital (Fortuno, 2005).

Through observations and anecdotal reports in the local setting, poor compliance

with the use of soap and water could be possibly brought about by myriad of contacts

with patients over a limited time span. Attending patients’ need become the priority, thus,

the preventive measure against transmission of pathogens is taken for granted (Fortuno,

2005).

Fortuno (2005) also stated in her study that the increased staphylococcal

infections is caused by the understaffing and overcrowding during recurrent outbreaks of

staphylococcal infections in the neonatal special care units (Haley & Bregman, 2001).

She also mentioned that staphylococcal infection is 16 times higher when the unit is

understaffed (that is, when the nurse-patient ratio exceeds 7); 7 times higher when the
 49

unit is not crowded (that is, when the number of infant exceeded at 33); 3 times higher in

the summer months and 1.5 times higher in the absence of bathing infants with

hexachlorophene. Healthcare providers found it difficult to wash their hands with soap

and water when they are understaffed and need to attend to more patients (Haley &

Bregman, 1982; Pittet et. al., 2000).

According to Fortuno (2005), noncompliance may also be a result of individual’s

perception of the risk involved in terms of beliefs, norms, attitude, risk for contamination,

and intensity of nursing activities. Attitudes and beliefs of the health care providers

toward handwashing are crucial for any compliance program to succeed (Larson &

Killien, 1982).

CHAPTER III

Methodology

This chapter presents the research design of the study, the procedure of data

collection as well as the statistical treatment of the findings.

Research Design

The study used the descriptive-survey research design. Descriptive-survey is a

“method of research which intends to gather relatively limited data from a relatively large
 50

number of cases” (Sevilla, et.al, 1992). This research design was chosen because the

researchers gathered their data by conducting a survey of selected nurses in a hospital.

The purpose of the survey is to determine the nurses’ demographic data, relationship

between their demographic data and compliance with handwashing frequency, duration

and technique, factors which affect their compliance, and if they use either soap and

water or waterless alcohol-based hand solution.

Research Setting, Population, and Sampling Technique

This study was conducted in Our Lady of Mercy General Hospital in Pulilan,

Bulacan. It is an ideal setting for this study because it is a tertiary hospital, the highest

level of health care delivery system wherein complete health services are rendered

(Kozier et.al., 2004). Tertiary hospitals in the country are required to promote provision

of quality health care because they are the major sources of health services needed by

Filipinos. This was also the affiliated hospital where the researchers were required to

complete the number of hours of their duty.

At the time of the study, this hospital had a 55-bed capacity and had 30 nurses in

the following areas: emergency room, dialysis, ward, private ward, operating room,

intensive care unit, and pediatric intensive care unit/neonatal intensive care unit.

However, only the following areas were included in this study: Operating Room (OR),

Pediatric Intensive Care Unit (PICU)/Neonatal Intensive Care Unit (NICU), Private

Ward, Ward, and Intensive Care Unit (ICU).

There were eleven nurses who served as participants of this study. In particular,

there were three nurses from the Private Ward and Operating Room, two nurses from the
 51

Pediatric Intensive Care Unit/Neonatal Intensive Care Unit and Ward, and one from the

Intensive Care Unit. In order to complete the observations and interviews, at least four

shifts in each area were covered.

The study utilized purposive sampling. Purposive sampling was used to enable the

researchers to select participants who should be in the study. The participants were

selected based on their availability during the duty of the clinical instructors, head nurses

and senior Nursing students because observations beyond duty hours are not allowed. In

the operating room and pediatric intensive care unit/neonatal intensive care unit, the

researchers had only one participant for each shift because there was only one nurse on

duty per shift. In the private, ward, and intensive care unit, two nurses were on duty per

shift. This helped the researchers facilitate observations simultaneously.

Research Instrument

The instrument used was based on the Handwashing Assessment Tool,

Handwashing Observational Checklist, and Handwashing Technique Observation

Checklist developed by Fortuno (2005). It is the main tool in collecting the data.

The instrument was divided into four phases: (1) Informal Observations, (2)

Handwashing Assessment Tool, (3) Handwashing Observational Checklist, and (4)

Handwashing Technique Observation Checklist.

 52

The first phase included informal observation. This phase was an observation

without the use of the observational checklist.

The second phase was Handwashing Assessment Tool. The first part of the

Handwashing Assessment Tool includes the participants’ demographic data (Name, Age

in years, length of professional service, gender, civil status, educational attainment, and

area of assignment). The second part comprised of the following questions: (1) How

important is handwashing for you?, (2) Are handwashing guidelines available and easily

accessible in your unit?, (3) Is handwashing seminar/update regularly made in your

hospital? If yes how frequent?, (4) Write your reasons why handwashing should be

consistently done in your place of work, (5) Write your reasons why at times washing

your hands in your place is not consistently done, (6) Write the factors that will influence

your decision to consistently wash your hands in your place of work.

The third phase of the instrument was the Handwashing Observational Checklist.

This phase enumerated all the nursing interventions of the participants. It also revealed if

the nurses washed their hands before and after each nursing intervention; if they used

either soap and water or waterless alcohol-based hand solution; if they followed the

proper handwashing technique; and how many seconds they cleaned their hands using

soap and water or waterless alcohol-based hand solution.

The fourth phase of the instrument was the Handwashing Technique Observation

Checklist. This showed how the nurses clean their hands using soap and water or

waterless alcohol-based hand solution. It also revealed if the nurses followed the proper

handwashing technique: (1) wet hands with running water (2) soap hands until lather
 53

develops (3) rub hands vigorously for 15 seconds covering all surfaces of the hands and

fingers (4) perform the following sequence five times for each hand palm to palm (5)

right palm over left dorsum (6) left palm over right dorsum (7) left palm to the back of

the right hand with finger interlaced (8) right palm to the back of the left hand with finger

interlaced (9) back of right fingers rub against left palm with fingers interlocked (10)

back of left fingers rub against right palm with fingers interlocked (11) rotational rubbing

of left thumb clasped by the right hand (12) rotational rubbing of right thumb clasped by

the right hand (13) rinse hands with water (14) dry hands thoroughly with a disposable

towel (15) turn faucet with the used of disposable towel.

Data Collection Procedure

The informal observations were done two months before the formal observations

were conducted. The results of the informal observations showed that the nurses were not

able to comply with the proper handwashing technique and only a handful of them

washed their hands before and after contact with patients. This prompted the researchers

to conduct a research about nurses’ compliance with handwashing guidelines.

The researchers asked permission from the Chief Nurse of Our Lady of Mercy

General Hospital through a letter noted by the Dean of Trinitas College. As soon as the

letter of consent was approved by the Chief Nurse, the observational checklists were

distributed to the trained nurses, clinical instructors, and senior Nursing students. The

research study was conducted with a pair of observer (a trained nurse, clinical instructor

or senior Nursing student) and interviewer (student researcher). Each area of the hospital
 54

(ward, private ward, pediatric intensive care unit/neonatal intensive care unit, intensive

care unit and operating room) had a designated pair of researchers.

When the observers were already done in observing the nurses on how they

performed the proper handwashing technique, the interviewers then distributed the

questionnaires in each area of observation. The participants answered the questionnaires

during their free time. The observation checklist and the questionnaires revealed how

consistent the nurses were in washing their hands and how honest they were in answering

the questionnaires. Three questionnaires were distributed in the private ward and

operating room, two questionnaires in the pediatric intensive care unit/neonatal intensive

care unit and ward, and a single questionnaire in the intensive care unit. The participants

were given one week to answer the questionnaire, but this was not followed because

many of the participants lost the questionnaires. The researchers again distributed

questionnaires to replace the lost questionnaires

After collecting all the needed information, the researchers computed the

percentage and mean of the nurses’ demographic data (age, gender, civil status,

educational attainment, designated area, and length of professional service).

Handwashing frequency was obtained by dividing the actual handwashing practices using

soap and water or waterless alcohol-based hand solution to the total required

handwashing practices observed within the hours of observation period multiplied by

100. The researchers used the Pearson Correlation to find out the correlation between the

intensity of patient care and handwashing frequency.

Data Analysis
 55

The statistical treatment used for the demographic data (age, gender, civil status,

educational attainment, designated area, and length of professional service) of the

participants was percentage and mean. The handwashing frequency in terms of the

participants’ demographic data was obtained through dividing the total actual

handwashing practices divided by the required handwashing practices multiplied by 100.

(F= AHP x100)

RHP

(Note: Please improve the formula.)

The intensity of patient care was the sum total of the type of nursing unit, nurse-

patient ratio and level of patient care. Nursing unit may be classified as a critical unit

with a point score of two, or non-critical unit with a point score of one. The nurse-patient

ratio depends on hospital protocol but in general the ideal ratio of nurse and patient is

“one is to five” in non-critical area and “one is to one” in critical areas or special areas.

The level of patient care was identified by assessing if the patient was less dependent

with a point score of zero; if the patient needs moderate assistance with a point sore of

one; and if the patient was completely dependent with a point score of two.

The relationship between the intensity of patient care and handwashing frequency

was measured using Pearson Correlation.

 56

CHAPTER IV

Presentation and Interpretation of Data

This chapter presents the data gathered in Our Lady of Mercy General Hospital.

The main objective of the study was to conduct a survey of nurses’ compliance to

handwashing guidelines. The sequence of the presentation followed the research

objectives found in Chapter I.

 57

Originally, fifteen nurses were chosen to respond in the study, three nurses from

the operating room, pediatric intensive care unit/neonatal intensive care unit, emergency

room, ward, and private ward. Two nurses were already observed in the emergency room

and two questionnaires have been distributed, but none of the nurses submitted the

questionnaires. They were not able to answer the questionnaires for the very reason that

they had many patients to attend, and they could not use their free time answering the

questionnaires because they had to do a lot of paper works. At first the area of the

intensive care unit was not included because student researchers even the clinical

instructors and head nurse are not allowed to conduct observation until the senior nursing

students were assigned in the special areas. Two nurses were observed by the senior

nursing students in the intensive care unit and two questionnaires were also distributed,

unfortunately only one nurse answered the questionnaire.

Objective 1: (Note: Please specify Objective 1. State the same objectives from

Chapter 1.)

a. Sex

Figure 3 presents the classification of the participants according to sex.

(Note: Insert Figure 3 here.)

There were eleven participants observed by the researchers, seven participants

were female and the remaining four participants were male. This also means that sixty-

four percent were female and thirty-six percent were male. There were two female

participants from the operating room, ward, and private and one female participant from
 58

the PICU/NICU. There was only one male participant in the operating room, private,

PICU/NICU, and ICU.

36%

Female

64% Male

(Note: Please label Figure 3.)

b. Civil Status

Figure 4 shows the classification of participants according to civil status.

There were eight participants who were not yet married and three participants

who were already married. This means that seventy-three percent were single and twenty-

seven percent were married. There were three single participants in the ward, two single

participants in the operating room, and one single participant in the ward, PICU/NICU,

and ICU.
 59

80%

60%
Single
40%
Marred
20%

0%
Single Married

(Note: Please label Figure 4.)

c. Age

Figure 5 presents the classification of participants according to length of

professional service.

The mean age of the participants was 23.5. Eight participants were aged 20 to 23

years. This also means that seventy-three percent of the participants were aged 20 to 23

years. Two participants were aged 24 to 27 years old. This also means that eighteen

percent of the participants were aged 24 to 27 years old. Only one participant was 35

years old. This also means that nine percent was age 35.

18%
20-23
0% 24-27
28-31
32-35
73% 9%

(Note: Please label Figure 5.)

d. Educational Attainment
 60

Figure 6 shows the classification of participants according to educational

attainment.

All the participants finished their baccalaureate degree, but none of them holds

masteral degree because most of the participants were young and according to them a

masteral degree is expensive. This also means that eleven participants finished their

Bachelor of Science in Nursing Course.

0%

BSN

MSN

MAN

100%

(Note: Please label Figure 6.)

e. Length of Professional Service

Figure 7 presents the classification of participants according to the length of

professional service.

The mean professional service of the participants was 19.3 months. Among the

eleven nurses who participated in the study, only one has been practicing her profession

in the hospital for ninety-six months. This also means that nine point one percent of the

participants have been practicing her profession in the hospital for eight years. Another

participant has been practicing his profession for thirty-six months. This also means that

another nine percent of the participants have been practicing their profession for three
 61

years. Two out of the eleven participants have been practicing their profession from

eighteen to twenty-four months. This also means that eighteen point two percent of the

participants have been practicing their profession for one and a half to two years. Four

out of the eleven participants were practicing their profession from almost seven to

twelve months. This also means that thirty-six point four percent of the participants have

been practicing their profession for one year. The remaining three participants, who were

newly graduates, were practicing their profession for five months and less. This also

means that twenty-seven point two percent of the participants have been practicing their

profession for five months or less.

40%

30%
6 m onths
20%
7-12 m onths
10% 18-24 m onths
30- 34 m onths
0%
less than 7-12 18-24 30- 34 above 42
six months months months months
months

f. Designated Area
 62

Figure 8 shows the classification of participants according to designated area of

the hospital.

The areas which were observed by the researchers include the following: ward,

private, operating room, PICU/NICU, and intensive care unit. Originally the intensive

care unit was not included in the list because students who were not assigned to work in

the area were strictly prohibited to enter. The areas which were supposed to be observed

were emergency room and dialysis, but the nurses from the emergency room could not

find their time to answer the questionnaires and there were no available observers in the

dialysis area.

Among the eleven participants, there were three participants from the OR. This

also means that twenty-seven point two percent of the participants were assigned in the

OR. There were also three participants from the private. And this means that twenty-

seven point two percent of the participants were assigned in the private. Out of the eleven

participants, two participants were from the ward. This also means that eighteen point

two percent of the participants were assigned in the ward. Another two participants were

from the PICU/NICU. This also means that another eighteen point two percent of the

participants were assigned in the PICU/NICU. The remaining participant was from the

ICU. This also means that only nine point one percent of the participants was assigned in

the ICU.

Objective 2: (Please insert Objective 2.)

 63

Table 1 presents the summary of the participants’ handwashing frequency,

duration, and technique in terms of their demographic data (age, sex, civil status,

educational attainment, length of professional service, and area of responsibility).

Based on the findings of the study, all the participants did not comply in terms of

handwashing duration and technique because the maximum duration reached was only 14

seconds without completing the nine steps of proper handwashing. The handwashing

frequency was obtained according to their age, sex, civil status, educational attainment,

length of professional service, and area of responsibility.

In terms of their age, participants whose age ranged from 24 to 27 years old got

the highest handwashing frequency of 150 with a total duration of 8 seconds. Those who

got the second highest score of 33, with a total duration of 14 seconds, were ages 28 to 31

years old. This showed that older nurse-participants were not compliant to handwashing

frequency but they did wash their hands longer than the young ones. Those who got the

lowest score of 28 with a duration of 8 seconds were the youngest in the group, their ages

ranged from 20 to 23 years old.

Male participants were more compliant to handwashing frequency compared to

female participants because they received the total score of 100 with a total duration of

nine seconds while the female participants received only 26 with the same duration as the

male. This result supports the study of Fortuno (2005) that more male nurses were

washing their hands frequently than female nurses.

Married participants were more compliant with handwashing frequency than

those who were still single. The handwashing frequency of married participants reached
 64

83 with a total duration of 9 seconds, while the single participants’ handwashing

frequency was 23 and with a duration of 8 seconds.

In terms of their educational attainment, all the participants were able to finish

their baccalaureate degree. Their handwashing frequency was only 55 and the total

handwashing duration was only 9 seconds.

Participants who practiced their profession from 18 to 24 months, whose score

was 100 with a duration of 7 seconds, were more compliant with handwashing frequency

than those who practiced their profession for almost 54 months and above, whose score

was only 33 and with a duration of 14 seconds. The participants who served in the

hospital for 30 to 48 months had the lowest score of 25 with a duration of 8 seconds.

These findings did not support the theory of Fortuno (2005) that “compliance is the

power exerted by an individual to control over his acts based on past learning and

working experiences”.

Participants who were assigned in the PICU/NICU were the most compliant with

handwashing frequency for they earned the highest score of 106 with a duration of 8

seconds. There were only two participants in this area. This proves that they were honest

with their answers that they consistently washed their hands before and after handling

patients because their patients were children and newborns, who are more susceptible to

infections than older patients. The lowest score was from the ward, which was only 11

and a with duration of 6 seconds though they had an equal number of participants with

the PICU/NICU.
 65

In general, the findings revealed that most male both single and married nurses,

whose ages ranged from 21 to 26 years, and with a professional service of five months to

36 months were more compliant with handwashing frequency to female married nurses,

whose ages ranged from 23 to 35 years old, with a length of professional service of 24

months to 96 months.

(Note: Please improve the table on the next page.)

Demographi Total number of Total Frequen Average Techniq

c data required number cy Duratio ue

66
handwashing of actual n

pratices handwashing

ID- incorrectly done pratices

Age in years

20-23 46 13 28 8 ID

24-27 12 18 150 seconds ID

28-31 0 0 0 8

32-35 6 2 33 seconds ID

Total=64 Total=33 0

14

seconds
Sex

Male 22 22 100 9 ID

Female 42 11 26 seconds ID

Total=64 Total=33 9

seconds

Civil status

Single 40 13 33 8 ID

Married 24 20 83 seconds ID

Total=64 Total=33 9

seconds

Educational

attainment

BSN 64 33 52 9 ID

MSN 0 0 0 seconds

MAN 0 0 0

Total=64 Total=33
 67

Objective 3: (Note: Please insert Objective 3 here.)

Figure 9 presents the reasons for compliance of participants to handwashing

guidelines.

There were ten participants who expressed that the primary reason why they were

able to comply with handwashing was to “prevent transfer of microorganisms from one

patient to another and lessen the risk for acquiring nosocomial infections”. This also

means that ninety-one percent of the participants expressed that the primary reason why

they were able to comply with handwashing was to “prevent transfer of microorganisms

from one patient to another and lessen the risk for acquiring nosocomial infections”. Only

one of the participants answered “to maintain the sterility of our own workplace”. This

also means that only nine percent of the participants answered “to maintain the sterility of

our own workplace”. Apparently the only participant who answered in a different way

was from the operating room because it is the responsibility of an OR nurse to maintain

sterility and prevent microbial contamination, although it should be practiced in any area

of the hospital. This finding showed that the nurses were aware of their role as healthcare

providers that their duty was to maintain optimal health and preserve life and not to be a

cause in acquiring nosocomial infections.

 68

prevent
100%
nosocomial
80% infections
maintain
60%
91% sterility
40%

20%
9%
0%

Figure 10 shows the reasons of the participants for non-compliance to

handwashing guidelines.

The participants were also asked why they were not able to comply with

handwashing for most of the time, thirty-seven percent of the participants honestly

answered that most of the time they were really unable to wash their hands or even clean

them with alcohol because there were too many patients to attend to and that most of the

relatives of the patients were very demanding. Majority of these participants were from

the private. The researchers were that aware of this scenario because they witnessed how

the participants provide nursing care to their patients and that they handled the same

patients. During the time when the researchers were still completing their duty hours in

Our Lady of Mercy General Hospital, staff nurses often asked the help of Nursing

students (with the guidance of their Clinical Instructors) in performing other nursing

activities to diminish their workload.

 69

About thirty-six percent of the participants insisted that they were indeed washing

their hands. They also added that there was no reason for them not to comply with

handwashing guidelines because it was a strict regulation in their area to consistently

wash their hands. These participants were all from the PICU/NICU, and OR

There were twenty-seven percent of the participants who reasoned that liquid soap

and water was not available. They used alcohol as an alternative to soap and water. These

participants were mostly from the ward. In the OR, nurses and even doctors were having

a hard time in scrubbing their hands due to the absence of water. They used mineral water

to wash their hands, which was definitely not sufficient because this could result to

improper handwashing and scrubbing and might lead to compromised sterility of the

area.

None of the participants answered that no sink was available. Through the

observation it was found out that sinks were accessible in all areas of the hospital. This

finding is not congruent with the study of Fortuno (2005) and Gomez (2004) that

inaccessible sink is one of the reasons why nurses do not comply with handwashing

guidelines.

The participants were asked if handwashing guidelines or protocols were readily

accessible in their unit and only one of them answered negatively. This also means that

only nine percent of them answered negatively. This participant was from the intensive

care unit. Majority of the participants answered positively. This also means that ninety-

one percent of the participants answered positively. Through further investigations made

by the researchers, not all areas of the hospital had handwashing guidelines or protocols
 70

and the only areas where handwashing guidelines were accessible was in the

PICU/NICU, and OR.

The participants were also asked if seminars and updates were regularly done in

their hospital. Only two replied yes and it was usually done semi-annually. The rest

answered negatively. This also means that eighteen percent of them answered yes and

eighty-two percent of them answered no. The researchers again made further

investigations and it was found out from the nurses who worked in Our Lady of Mercy

General Hospital for about 5 years, no seminars and updates were done in the hospital.

Objective 4 : (Please insert Objective 4.)

Table 2 presents the Intensity of Patient Care (Type of Unit, Nurse-patient Ratio,

and Level of Patient Care), and Handwashing Frequency in each Area of Observation.

The intensity of patient care was the sum total of the type of nursing unit, nurse

patient ratio and level of patient care.

Using the Pearson Correlation, the score obtained was +.54. There was a

moderate or average positive correlation between the intensity of patient care and

handwashing frequency. This also means that the higher the intensity of patient care, the

higher the handwashing frequency; the lower the handwashing frequency, the lower the

intensity of patient care. The intensity of patient care activity was associated with

handwashing frequency but this was not valuable because only thirty-three percent of the

participants from the special areas complied with handwashing frequency. These findings

were consistent with the study of Fortuno (2004) that high intensity of patient care was

associated with low compliance to handwashing frequency.

 71

(Note: Please improve the table on the next page.)

Area Type of Nurse- Level Intensity of Handwashin

of unit patient of patient g frequency

Observation ratio patient care

care (total)
Ward 1 2 1 4 11
Private 1 2 1 4 33
OR 2 0 2 4 43
PICU/NICU 2 0 2 4 106
ICU 2 2 2 6 100

Objective 5

Figure 11 shows the nurses’ use of soap and water or waterless alcohol-based

hand solution.

Thirty-seven percent of the participants washed their hands incorrectly using soap

and water after nursing intervention. Eighteen percent washed their hands incorrectly

using soap and water before and after nursing intervention. Nine percent used waterless
 72

alcohol-based hand solution in cleaning his hands incorrectly before and after nursing

intervention. Eighteen percent used both water and soap and waterless alcohol-based

hand solution in cleaning their hands incorrectly before nursing intervention. Another

eighteen percent used both water and soap and waterless alcohol-based hand solution in

cleaning their hands incorrectly before and after nursing interventions. These findings

shows that majority of the nurses are using soap and water in cleaning their hands and

that all of them did not comply with the ideal handwashing duration.

soap & w ater

B&A intervention

soap & w ater A

18% 18% intervention

WABHS B&A
intervention

18% both soap &

w ater & WABHS
37%
9% B&A intervention
both soap &
w ater B
intervention

B- before A- after WABHS- waterless alcohol-based hand solution

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CHAPTER V

Summary, Conclusions, and Recommendations

Summary of Findings

The summary of the findings of this study are as follows:

1. Most of the participants were female, single, ages 20 to 23 years old, and with

a length of professional service of seven months to 12 months.

2. The findings of the study revealed that most male both single and married

nurses, whose ages range from 21 to 26 years old, and with a professional

service of five months to 36 months were more compliant in terms of

handwashing frequency than female married nurses, whose ages range from

23 to 35 years, with a length of professional service of 24 months to 96

months.

3. The major reason why nurses cannot consistently wash their hands was that

they were too busy attending the needs of their patients. And the major reason

why they should consistently wash their hands was to prevent transfer of

microorganisms from patient to another.

4. There was a moderate or average positive correlation between the intensity of

patient care and handwashing frequency. This also means that the higher the

intensity of patient care, the higher the handwashing frequency; the lower the

handwashing frequency, the lower the intensity of patient care.

5. Nurses prefer the use of soap and water to clean their hands. Alcohol is the

most preferred alternative to soap and water.

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Conclusions

Based on the findings of the study, the following conclusions were drawn:

1. The major reason why nurses cannot consistently wash their hands was

that they were too busy attending the needs of their patients. The major

reason why they should consistently wash their hands was to prevent

transfer of microorganisms from patient to another.

2. There was a moderate or average positive correlation between the intensity

of patient care and handwashing frequency. This also means that the

higher the intensity of patient care, the higher the handwashing frequency;

the lower the handwashing frequency, the lower the intensity of patient

care.

3. Nurses prefer the use of soap and water to clean their hands. Alcohol is the

most preferred alternative to soap and water.

(Note: Please revise your conclusions. Conclusions should not be a repetition of your

findings. Conclusions must be based on the findings.)

Recommendations

Based on the conclusions of the study, the following recommendations are given:

1. Nurses should strictly follow the proper handwashing guidelines to prevent

the spread of hospital acquired infections. .

2. Tertiary hospitals should strictly follow the ideal nurse-patent ratio which is

one is to four in non-special units, and one is to one in special units so that

nurses will be able to consistently wash their hands.

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3. Future researchers are urged to develop handwashing assessment tools and

observational checklists in assessing other healthcare providers like nursing

assistants, midwives, physical therapists, radio therapists, and medical

technologists.

4. Researchers are encouraged to develop an intervention program applicable for

young children. It is better to teach them proper handwashing techniques as

early as possible because they were more susceptible to infections.

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BIBLIOGRAPHY

Books

Burton, Gwendolyn R. and Paul G. Engelkirk. 2000. Microbiology. Philadelphia:

Lippincott Williams and Wilkins, Inc.

Kozier, Barbara.,et.al. 2004. Fundamentals of Nursing. Philippines: Pearson Education

South Asia PTELTD.

Pillitteri, Adele. 1992. Maternal and Child Health Nursing. Philadelphia: J. B.

Lippincott Company.

Polit, Denise F. and Cheryl T. Beck. 2003. Nursing Research: Principles and Methods.
Philadelphia: Lippincott Williams and Wilkins, Inc.

Reyala, Jean P. et.al.2000. Community Health Nursing Services in the Philippines.

Manila: Community Health Nursing Section, National League of Philippine
Government Nurses, Inc,

Sevilla, Consuelo G., et. al. 1992. Research Methods. Manila: Rex Printing Company,
Inc.

Researches/Internet Articles

Barrs, Amy W. Handwashing: Breaking the Chain of Infection. Available:

http://en.wikipedia.org. Retrieved January 15, 2007.

Case, Christine L. Handwashing. Available: http://www.accessexcellence.org. Retrieved

January 15, 2007.

Dellinger, Patchen E. 2006. Nosocomial Infection: Discussion. Available:

http://www.medscape.com. Retrieved January 15, 2007.

Fortuno, Carolina. 2005. An Intervention Program to Improve Nurses’

Compliance to Handwashing Guidelines in a Tertiary Hospital in Manila.

Fucanan, Terrie B. 2006. Handwashing-the hottest thing in Health Care. Available:

http://www.manilatimes.net. Retrieved January 15, 2007.

Garner, Julia S., et.al. 1985. Guideline for Handwashing and Hospital Environmental
Control. Available: http://vm.cfsan.fda.gov/~comm/lacf-phs.html. Retrieved
January 15, 2007.

Lautenbach, Ebbing. Practices to Improve Handwashing. Available:

http://vm.cfsan.fda.gov/comm//acf-phs.html. Retrieved January 15, 2007.
 77

Pittet, Didier. Imposing Adherence to Hand Hygiene Practice: A Multidisciplinary

Approach. Available: http://www.cdc.gov/ncidod/eid/vol7no2/pittet.htm.
Retrieved January 15, 2007.

Zanni, Guido R. Good Hand Hygiene Includes More than Hands. Available:
http://www.pharmacytimes.om. Retrieved January 15, 2007.

http://www.answers.com. Nosocomial Infection. Retrieved January 15, 2007.

http://www.cybervitamins.com. Retrieved January 15, 2007

http://www.mb.com.ph. 2003. Captain Safeguard, Germ Patrol Campaign for

Frequent Handwashing. Retrieved February 20, 2007.

http://www.kcprofessional.com. Breaking the Chain of Infection.

Retrieved January 15, 2007.

http://complab.nymc.edu/Curriculum/ComPrevMed/NosoomialInfections.htm.
Nosocomial Infections and Infection Control in the Hospital. Retrieved
January 15.2007.

http://www.vrtua.org Handwashing. Retrieved January 15, 2007.

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Appendix A

Communication Letter for the Chief Nurse

January 15, 2007

(Name of Chief Nurse)

Chief Nurse
Our Lady of Mercy General Hospital

Dear Mrs. Villanueva:

We, the BSN III students of (name of college), would like to ask your permission

to conduct a study in your hospital. The study will entail the nurses’ compliance to

handwashing guidelines. Data gathering will be done through written questionnaires, and

observational checklists. This study aims to assess the degree of compliance of nurses

with regard to handwashing.

We look forward to your support. Thank you very much and God Bless!

Truly yours,

(4 spaces)

(Insert name of the group leader.)

Noted by:

(Dean’s Name)
Dean

(Thesis Adviser’s or Clinical Instructor’s Name)

Clinical Instructor
Appendix B
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Handwashing Assessment Tool

(Note: Please improve your Appendix B.)

Code

Code No.

PART I. Respondent’s Demographic Data

Name:(Optional)
________________________________________________________________
Age in Years:
_____________________________________________________________________
Length of service/professional experience (in years)
________________________________
Gender: ( ) Male ( ) Female
Civil Status: ( ) Single ( ) Married ( ) Separated ( ) Widow/widower
Educational Attainment: ( ) BSN ( ) MAN/MS/MA ( ) Ph D
Area of
Assignment:_____________________________________________________________
__
PART II BASIC INFORMATION
1. How important is handwashing for you?
( ) not so important ( ) important ( ) very important
2. Are handwashing guidelines available and easily accessible in your unit?
( ) yes ( ) no
3. Is handwashing seminar/update regularly made in your hospital? ( )yes ( )no
If yes how frequent?
( ) monthly ( ) quarterly ( ) semi-annually ( ) annually
(If you need more space for question #4-6, please use the back of this sheet)
4. Write your reasons why handwashing should be consistently done in your place of
work?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_____
5. Write your reasons why at times washing your hands in your place is not
consistently done? Write the factors that will influence your decision to
consistently wash your hands in your place of work?
____________________________________________________________________
____________________________________________________________________
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____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
______
81