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Clinical Investigations in Critical Care |

Hand Washing and Use of Gloves While Managing Patients Receiving Mechanical Ventilation in the ICU* FREE TO VIEW

Mohamad Khatib, PhD; Ghassan Jamaleddine, MD, FCCP; Afif Abdallah, RN; Youssef Ibrahim, RN
Author and Funding Information

*From the Department of Anesthesiology (Dr. Khatib and Nurses Abdallah and Ibrahim), Division of Inhalation Therapy, and the Department of Medicine (Dr. Jamaleddine), School of Medicine, American University of Beirut, Beirut, Lebanon.

Correspondence to: Mohamad Khatib, PhD, Department of Anesthesiology, PO Box 113-6044, Beirut, Lebanon; e-mail: mk05@aub.edu.lb



Chest. 1999;116(1):172-175. doi:10.1378/chest.116.1.172
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Study objective: To evaluate the effectiveness of warning labels permanently attached to mechanical ventilators in improving the practice of hand washing and use of gloves by respiratory care practitioners (RCPs) in the ICU.

Design: The study consisted of two 4-week periods. Daily observations of hand washing and use of gloves by RCPs were made over four 1-h observation periods. Prior to the first 4-week period, the importance of hand washing and use of gloves was presented to all staff. At the end of the first period, “Wash Hands Use Gloves” labels were permanently placed on all ventilators in the ICU. The RCPs were not aware they were being observed for hand washing and use of gloves in either period.

Measurements and results: The total number of encounters between the RCPs and patients as well as the rates of hand washing and use of gloves were obtained during the study. The rates of hand washing and use of gloves were significantly higher during the second period when labels were attached to the ventilators, as compared to the rates during the first period: hand washing, 92% vs 46% (p < 0.05); use of gloves, 92% vs 43% (p < 0.05), respectively. During the first period, the rates of pre-encounter hand washing (78%, 48%, 27%, and 29% in weeks 1 through 4, respectively) and the use of gloves (56%, 37%, 32%, and 45% in weeks 1 through 4, respectively) were primarily declining. This was not observed during the second period of the study (94%, 88%, 95%, and 92% in weeks 1 through 4, respectively) for the rates of pre-encounter hand washing and the use of gloves.

Conclusions: Simple measures such as the placement of warning labels on mechanical ventilators can significantly improve hand washing and use of gloves by RCPs in the ICU.

Figures in this Article

Abbreviation: RCP = respiratory care practitioner

Patients receiving mechanical ventilation in the ICU are at high risk of getting a hospital-acquired infection or ventilator-associated pneumonia. These patients are frequently subjected to invasive therapy, such as tracheal suctioning, bronchodilation, and manipulation of the ventilator or endotracheal tube. Therefore, the likelihood of contamination and cross-infection is increased. Pathogens causing nosocomial pneumonia, such as Gram-negative bacilli and Staphylococcus aureus, are ubiquitous in hospitals, especially in ICUs.1The transmission of these microorganisms to patients frequently occurs via the hands of health-care workers that become contaminated or transiently colonized with the microorganisms.2These infections are a major cause of mortality and morbidity, as well as of prolongation of hospitalization and increases in hospitalization costs.3 Thus, prevention of hospital-acquired infections has become an important aspect of intensive-care practice.

An effective hand-washing technique is the cornerstone of effective infection control and remains unchallenged as the most effective means of preventing hospital-acquired infections. The practice of hand washing is well known to reduce the spread of infection, yet the compliance of health-care professionals, including those in the high-risk area of intensive care, is usually unsatisfactory and occasionally very poor.4

In this study, we intended to evaluate the effectiveness of permanently placing warning labels on mechanical ventilators in improving the practices of hand washing and the use of surgical gloves by RCPs in the ICU.

Patients

All patients receiving mechanical ventilation in the ICU participated in the study. This study was approved by the institutional review board, and a consent form was waived.

Experiment Protocol

The study consisted of two 4-week periods. Before the initiation of the first 4-week period, all RCPs received in-service instructions on appropriate hand-washing techniques and the use of gloves when caring for mechanically ventilated patients. The in-service program consisted of formal lectures and demonstrations of techniques. An oral and written request was delivered to all RCPs, asking that they use gloves and appropriate hand-washing techniques whenever encountering mechanically ventilated patients in the ICU during all shifts.

For the following 4-week period, daily observations of hand washing and use of gloves by RCPs were made during four 1-h observation periods. Observation periods were randomly selected during the day. However, the periods were equally divided among the day and night shifts. Throughout the study, RCPs were not aware that they were being observed for hand washing and use of gloves. Encounters with patients were only considered when patients were receiving mechanical ventilation in the ICU.

At the end of the first period, “Wash Hands Use Gloves” labels were permanently placed on all ventilators (Fig 1 ). RCPs were reminded about the policy requiring hand washing and use of gloves, but they were given no feedback regarding the outcomes of the first 4-week period. Then the second 4-week period commenced. The same protocol regarding observations and data collection was applied during both 4-week periods.

Data Collection and Analysis

The number of total encounters per week was determined throughout the study. The frequency of hand washing and use of gloves prior to and following each encounter with a patient was obtained during the 1-h observation periods. Data collection was performed by nursing staff who had no direct work-related influence on the RCPs.

The frequency of hand washing and use of gloves were compared prior to and following encounters with patients. Data obtained during the first 4-week period of the study were compared among the 4 weeks. A similar analysis was performed during the second 4-week period. Finally, data from the first 4-week period were compared to data from the second 4-week period.

Statistical Analysis

The χ2 test was utilized for statistical analysis. Statistical significance was considered at the 0.05 level.

The First 4-Week Period

A total of 537 encounters with mechanically ventilated patients were observed during the first period (Table 1 ). The highest percentages for pre-encounter and postencounter hand washing were obtained during the first week. During the second week, the pre-encounter hand-washing rate significantly dropped in comparison to the first week (p < 0.05), but it remained significantly higher than the pre-encounter hand-washing rates during the third and fourth weeks (p < 0.05). There were no significant differences in postencounter hand-washing rates among the second, third, and fourth weeks. Throughout the entire first period, the postencounter hand-washing rate was significantly higher than the pre-encounter hand-washing rate (p > 0.05).

Similarly, using gloves before patient encounters was highest during the first week of the study and dropped significantly in the following 3 weeks. After encounters with patients, all gloves were removed before approaching another patient or exiting the ICU.

The Second 4-Week Period

A total of 543 encounters with mechanically ventilated patients were observed during the second study period (Table 2 ). The pre-encounter and postencounter hand-washing rates did not change significantly through the 4 weeks of the second study period. Also, there were virtually no differences between the pre-encounter and the postencounter hand-washing rates during any of the 4 weeks in the second study period.

Similarly, no changes in the pre-encounter rates for use of gloves were observed throughout the second phase of the study. Following encounters with patients, all gloves were removed before approaching another patient or exiting the ICU.

The First vs the Second 4-Week Period

The pre-encounter and postencounter rates for hand washing and use of gloves were significantly higher during the second period (after labels were attached to the ventilators) than during the first period: hand washing, 92% vs 46% (p < 0.05); use of gloves, 92% vs 43% (p < 0.05), respectively. During the first period, the rates of hand washing (78%, 48%, 27%, and 29% in weeks 1 through 4, respectively) and use of gloves (56%, 37%, 32%, and 45% in weeks 1 through 4, respectively) were basically declining over time; this decline was not observed during the second period (after the Wash Hands Use Gloves labels were permanently placed on the ventilators), as identical rates of 94%, 88%, 95%, and 92% for weeks 1 through 4, respectively, were noted for pre-encounter hand washing and use of gloves.

Our findings suggest that simple measures such as the placement of reminding labels on mechanical ventilators can significantly increase the frequency of hand washing and use of gloves by RCPs in the ICU. This should help in minimizing and limiting the transmission of pathogens via health caregivers and thus improve infection control in hospitals.

Person-to-person transmission of pathogenic organisms in the ICU has been emphasized by researchers.2,5For this reason, the routine practice of hand washing and use of gloves has been advocated to help prevent cross-contamination.6Adequate hand washing is an effective way of removing transient bacteria from the hands.7Guidelines for preventing the transmission of bacteria and viruses in health-care facilities have long been established,8but compliance is often poor.9 Efforts have been made to improve the compliance rate.10

Wurtz et al11reported a slight improvement of hand-washing compliance following the installation of three hand-washing machines in the surgical ICU. However, when an outbreak of methicillin-resistant S aureus occurred in the ICU, cultures obtained from the hand-washing machines were positive for methicillin-resistant Staphylococcus epidermidis, Achromobacter spp, and Streptococcus viridans. Another study by Kelleghan et al12 reported that the creation of a nosocomial prevention team and infection-control programs (involving regular team meetings) can significantly reduce endemic rates of nosocomial ventilator-associated pneumonia. They observed a 57% reduction in ventilator-associated pneumonia through continuous quality-improvement methods and multidisciplinary interventions. The recommendation of a multidisciplinary team approach for the control of infection in health-care facilities is a plausible idea. However, the creation of such a team and establishing the lines of communication for all health-care providers within an institution need continuous follow-up and surveillance, and they might not be easy tasks to accomplish in large institutions.

A study by van de Mortel and Heyman13 investigated the hypotheses that the subject’s profession would not influence, and performance feedback would not increase, the incidence of hand washing. They reported that 69% of registered nurses, 57% of physiotherapists, 41% of medical residents, and 35% of radiographers washed their hands after handling the patient. They observed a trend toward an increased frequency in hand washing in all groups after performance feedback. In the current study, we limited our observation to RCPs. The practice in our ICU is that all patient issues related to respiratory care, such as manipulation of mechanical ventilators, arterial blood punctures, and endotracheal tube management, are handled by RCPs. Similar to the results of the van de Mortel and Heyman study13 is the significant increase in hand-washing rates following our placement of warning labels on the mechanical ventilators.

In this study, we have shown that a simple, economical, and brief intervention, such as the placement of a permanent label on a mechanical ventilator, can significantly improve the practice of hand washing and use of gloves in the ICU. This should theoretically reduce the rate of nosocomial infection and minimize the costs related to ICU hospitalization.

Figure Jump LinkFigure 1. The “WASH HANDS USE GLOVES” label permanently attached to a mechanical ventilator.Grahic Jump Location
Table Graphic Jump Location
Table 1. Rates of Pre-encounter and Postencounter Hand Washing and Use of Gloves During the First 4-Week Period
Table Graphic Jump Location
Table 2. Rates of Pre-encounter and Postencounter Hand Washing and Use of Gloves During the Second 4-Week Period After the Placement of the Wash Hands Use Gloves Labels
Weinstein, RA, Nathan, C, Gruensfelder, R (1980) Endemic aminoglucoside resistance in gram-negative bacilli: epidemiology and mechanisms.J Infect Dis141,338-345. [PubMed] [CrossRef]
 
Daschner, FD The transmission of infections in hospitals by staff carriers: methods of prevention and control.Infect Control1985;6,97-99. [PubMed]
 
Martone WJ, Jarvis WR, Culver DH, et al. Incidence and nature of endemic and epidemic nosocomial infections. 3rd ed. Boston, MA: Little, Brown and Co., 1993; 577–596.
 
Sproat, LJ, Inglis, TJ A multicenter study of hand hygiene practice in intensive care units.J Hosp Infect1994;26,137-148. [PubMed]
 
Adams, BG, Marrie, TJ Hand carriage of aerobic Gram-negative rods by health care personnel.J Hyg (Lond)1982;89,23-31. [PubMed]
 
Klein, BS, Perloff, WH, Magi, DG, et al Reduction of nosocomial infection during pediatric intensive care by protective isolation.N Engl J Med1989;320,1714-1721. [PubMed]
 
Sprunt, K, Redman, W, Leidy, G Antibacterial effectiveness of routine hand washing.Pediatrics1973;52,264-271. [PubMed]
 
Centers for Disease Control and Prevention. Guideline for prevention of nosocomial pneumonia. Respir Care 1994; 39:1191–1236.
 
Albert, RK, Condie, F Hand-washing patterns in medical intensive care units.N Engl J Med1981;304,146-147. [PubMed]
 
Garner, JS, Simmons, BP Guideline for hand washing and environmental control.Infect Control1986;7,231-242. [PubMed]
 
Wurtz, R, Moye, G, Jovanovic, B Hand washing machines, hand washing compliance, and potential for cross-contamination.Am J Infect Control1994;22,228-230. [PubMed]
 
Kelleghan, SI, Salemi, C, Padilla, S, et al An effective continuous quality improvement approach to the prevention of ventilator-associated pneumonia.Am J Infect Control1993;21,322-330. [PubMed]
 
van de Mortel, T, Heyman, L Performance feedback increases the incidence of handwashing by staff following patient contact in intensive care.Aust Crit Care1995;8,8-13
 

Figures

Figure Jump LinkFigure 1. The “WASH HANDS USE GLOVES” label permanently attached to a mechanical ventilator.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Rates of Pre-encounter and Postencounter Hand Washing and Use of Gloves During the First 4-Week Period
Table Graphic Jump Location
Table 2. Rates of Pre-encounter and Postencounter Hand Washing and Use of Gloves During the Second 4-Week Period After the Placement of the Wash Hands Use Gloves Labels

References

Weinstein, RA, Nathan, C, Gruensfelder, R (1980) Endemic aminoglucoside resistance in gram-negative bacilli: epidemiology and mechanisms.J Infect Dis141,338-345. [PubMed] [CrossRef]
 
Daschner, FD The transmission of infections in hospitals by staff carriers: methods of prevention and control.Infect Control1985;6,97-99. [PubMed]
 
Martone WJ, Jarvis WR, Culver DH, et al. Incidence and nature of endemic and epidemic nosocomial infections. 3rd ed. Boston, MA: Little, Brown and Co., 1993; 577–596.
 
Sproat, LJ, Inglis, TJ A multicenter study of hand hygiene practice in intensive care units.J Hosp Infect1994;26,137-148. [PubMed]
 
Adams, BG, Marrie, TJ Hand carriage of aerobic Gram-negative rods by health care personnel.J Hyg (Lond)1982;89,23-31. [PubMed]
 
Klein, BS, Perloff, WH, Magi, DG, et al Reduction of nosocomial infection during pediatric intensive care by protective isolation.N Engl J Med1989;320,1714-1721. [PubMed]
 
Sprunt, K, Redman, W, Leidy, G Antibacterial effectiveness of routine hand washing.Pediatrics1973;52,264-271. [PubMed]
 
Centers for Disease Control and Prevention. Guideline for prevention of nosocomial pneumonia. Respir Care 1994; 39:1191–1236.
 
Albert, RK, Condie, F Hand-washing patterns in medical intensive care units.N Engl J Med1981;304,146-147. [PubMed]
 
Garner, JS, Simmons, BP Guideline for hand washing and environmental control.Infect Control1986;7,231-242. [PubMed]
 
Wurtz, R, Moye, G, Jovanovic, B Hand washing machines, hand washing compliance, and potential for cross-contamination.Am J Infect Control1994;22,228-230. [PubMed]
 
Kelleghan, SI, Salemi, C, Padilla, S, et al An effective continuous quality improvement approach to the prevention of ventilator-associated pneumonia.Am J Infect Control1993;21,322-330. [PubMed]
 
van de Mortel, T, Heyman, L Performance feedback increases the incidence of handwashing by staff following patient contact in intensive care.Aust Crit Care1995;8,8-13
 
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