Hardy, Susan L

							                                  Hardy, Susan
Assessment of hand washing techniques in the emergency room,
  through observation and survey, as a determinant of the high
nosocomial infection rate at the Luis Vernaza general hospital in
                      Guayaquil, Ecuador.
                              Faculty Mentor: Sheri Palmer, Nursing

INTRODUCTION AND PURPOSE
Hospital acquired infections, or nosocomial infections, have been recognized by experts such as
Semmelweiss, Holmes, Nightingale, and Lister as a critical problem world wide for over 150
years. These infections greatly affect the quality of patient care provided in the hospitals. A
hospital acquired infection is defined as an infection for which there is no presence of at the time
of admission (Creedon, 2005). These infections are one of the leading causes of morbidity,
mortality and prolonged hospital stays; resulting in extra costs to patients and health services
(Panhotra, 2005). Transmission of microorganisms via the hands of health care workers is
recognized as the main route of spread. Current research studies confirm that at least one-third
of all hospital infections are preventable through proper hand hygiene (Creedon). Hand hygiene
is the simplest and most efficient action in preventing hospital acquired infections; yet the
adherence of health care workers (HCW) to the recommended guidelines is poor.

According to the 2002 annual report of the Luis Vernaza General Hospital in Guayaquil, 48,194
people were admitted to the emergency room last year. Of those having emergency surgeries,
nearly 72% contracted a nosocomial infection. Proper hand washing techniques are vital to
controlling the transmission of diseases and thus the health and healing of patients.

METHODS
In May of 2005 my mentor and I spent two weeks at the Luis Vernaza hospital in the emergency
room assessing the hand washing techniques of nurses and nurses’ assistants in the emergency
room. We decided on the emergency room because that is the entry into the hospital for pre-
surgical patients and other hospitalized patients. Assessment of the hand washing techniques
was obtained through observation and a survey.

Among the various areas of the emergency department are three holding rooms: (1) a ICU room
consisting of 25 to 30 patients waiting for beds in the hospital, (2) a room used for minor
interventions including suturing and setting of factures, and (3) a major trauma room for patients
needing cardiac resuscitation and invasive procedures prior to surgery or admission to the
intensive care unit. Each holding room contains a single sink for hand washing.

Observation entailed 12 hours in each holding room. These observations included how many
times each nurse washed her hands during one shift, the frequency of hand washing between
patients, the availability of soap and its use, and the hand drying techniques.

A survey of hand washing techniques was also given to the nurses and nurses’ aides present
during the observation time. Questions on the survey include: (1) How many times do you wash
your hands during a shift? (2) How much time do you spend washing your hands each time they
are washed? (3) Do you wash your hands with soap each time? (4) Do you wash your hands
between each patient? (5) Do you wash your hands after working with a patient with a cough?
(6) Do you wash your hands before changing a dressing?

FINDINGS
Findings from the survey of hand washing techniques provided us with a basic understanding of
35 nurses and nurse’s aides knowledge regarding the importance of hand washing and their
actual hand washing procedures. When answering how often they wash their hands during a 6-
hour shift, the responses included many varying answers such as whenever necessary and before
and after every intervention. Some of the participants answered the same questions numerically,
such as five times washing their hands, up to 20 times during a shift. Their response to how long
they spent washing their hands varied from five seconds spent all the way up to six minutes spent
washing hands. Of those surveyed everyone said they washed their hands between patients. All
but one said they used soap every time they washed their hands. All but two nurses said they
washed their hands before changing a dressing and after using gloves.

Findings from the observation were variable depending on the location of the observation. A
total of fifty hand washings were observed from 21 nursing staff members including eight
licensed nurses, and thirteen nursing aids. In the ICU waiting room one nurse’s aide washed her
hands six times, the six nurses and six nursing aides washed their hands anywhere from one to
five times per 6- hour shift. In the room used for minor interventions a nursing aide was observed
washing their hands only once per each 6-hour shift before doing wound care with a physician.
In the major trauma room, the licensed nurse washed her hand three times one day and then the
next day was not observed washing her hands at all. One nursing aide washed her hands twice
during the shift, but the rest of the nursing aides (3 aides) only washed their hands once during
the shift.

All of the nurses and nursing aides used water when washing their hands. Of those observed
washing their hands, 90% used betadine, a bacteria killing agent, to wash their hands. After
washing their hands, many methods were employed to dry their hands because no paper towels
were provided for drying. Some of these methods include: air dried, cloth towel (brought in by
the nursing staff), back of pants, hair, front or back of scrub top, lab coat or any other clothing
they were wearing.

Conclusions
A huge disparity exists between what was reported by the nursing staff on the survey and actual
observations made by the team. Part of the overall problem is probably a lack of full
understanding on the importance of proper hand hygiene, along with a large lack of resources,
such as paper towels and alcohol hand rubs, which are quick and very effective at reducing the
bacterial count on the nursing staff hands, so they do not pass it to patients. More research is
needed on this subject in Ecuador. It is possible for classes to be taught to the nurses about the
importance of hand washing and actually practicing proper hand washing techniques; these
would be enveloped by, a pre and post research study should also be conducted on infections
rates.