Hardy, Susan L
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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.