Hand Washing: How to Wash Your Hands Properly

In health care facilities, hand hygiene is critical among health care practitioners because it facilitates the realization of the goal of fighting germs and consequently, the reduction of infection rates that are associated with hand hygiene. Maintaining hand hygiene among workers in healthcare facilities can be achieved by either hand washing or hand rubbing, with the latter being the most effective means of fighting germs. Unlike hand washing that only facilitates the destruction of bacteria and germs, hand rubbing also results in the killing of viruses. Therefore, in the oncology department, hand hygiene among care providers becomes crucial because it reduces the rates of nosocomial infections among cancer patients. Hence, this paper will explore the standards of hand hygiene in health care facilities and the relationship between hand hygiene and health care associated infections. Additionally, it will cover the interventions used to improve hand hygiene compliance in patient care. The purpose of the paper is to establish the superiority of hand rubbing over hand washing as a hand hygiene measure in the oncology department.

PICOT Question 

In healthcare, PICOT questions are specially formulated in a manner that allows them to be researchable and answerable. Well written PICOT questions enhance the flow of the research process as the collection of data and evaluation of the evidence is straight forward. Also, they allow a researcher to establish the research population, intervention, comparison, outcome and time (Riva et al., 2012). The PICOT question for this research is, “How can health care practitioners in the oncology department (P) use alcohol-based solutions (I) instead of soap and water (C) to boost hand hygiene and reduce the rates of nosocomial infections among their patients (O) within two to three hours (T)?” (World Health Organization, 2012). The said topic is critical to nursing because it will provide information on the best hand hygiene techniques that nurses across various health care departments can employ to better hand hygiene and reduce infection rates among patients (Mathur, 2011).

Literature Review 

The literature review for this paper was conducted using Google Scholar, The Joint Commission, Jstor and Elsevier to obtain relevant information from articles covering different aspects of the PICOT question. The articles used were published between 2013 and 2018. The following keywords and Boolean search phrases were used. They include hand washing or hand rubbing , hand hygiene, control, bacteria, virus, health care workers, hand hygiene compliance, oncology, and hand washing technique. On completion of the review of the five current studies, I discovered three key themes that were apparent in the literature related to my PICOT question including; standards for hand hygiene in health care settings, the relationship between hand hygiene and healthcare-associated infections and interventions to improve hand hygiene in patient care. A summary of the studies I reviewed is included as Appendix A. 

Standard of Hand Hygiene in Health Care Settings 

Hand hygiene in health care settings has been a matter of concern across generations. During the 19 th Century, scientists in the pharmacy and obstetrics fields established that the hands of clinicians carry pathogenic organisms that are likely to be transmitted from one patient to another, leading to the subsequent development of infection. During the 20 th Century, evidence on the risk of pathogen transmission among patients from health care workers was mounting (McLaws, 2015). So, after the publication of hand hygiene guidelines in healthcare settings by the Centers for Disease Control and Prevention (CDC) in 2002, the World Health Organization (WHO) also published guidelines for the same in 2009 and hand hygiene studies addressing controversial issues continue to be published (Ellingson et al., 2014).

According to Boyce (2013), in the past, the Joint Commission, expected hospitals to achieve at least 90% of health care hand hygiene compliance as outlined by the CDC. Regardless, despite the recorded increasing levels of hand hygiene in health care facilities, many hospitals, as of 2013, had not achieved the 90% compliance level, forcing the Joint Commission to reword their hand hygiene standard and require that hospitals work towards improving compliance.

The Relationship between Hand Hygiene and Health Care-associated infection 

For over a century and a half, the association between improved hand hygiene and reduced Healthcare Associated Infectrions (HIAs) has been recorded in various settings, making hand hygiene a foundational component of programs that seek to prevent and control infections (Ellingson et al., 2014). Health-care associated infections result in mortality and morbidity within health care institutions and hand hygiene among health care practitioners is considered an appropriate preventive measure (Gould et al., 2018). Musu et al. (2017) second the claim above as they establish that HAIs result in disability, morbidity, and reduced life quality, all of which are factors that contribute to high mortality rates and increased costs of health systems. Moreover, they indicate that the hands of health care workers (HCWs) are common microorganism carriers. Thus, this results in the association of poor hand hygiene practices with poor clinical conditions within health care facilities. 

Additionally, Boyce (2013) points out that studies have been published indicating that improved hand hygiene results in the reduction of HAIs. Also, based on the findings of a new modeling study, hand hygiene compared with screening asymptomatic individuals and contact precautions is considered to potentially have the most significant effect in the reduction of the transmission of the multidrug-resistant organisms. Additionally , McClaws (2015) determines that the relationship between hand hygiene and HAIs is more complicated than it is often presented. He explains that high hand hygiene alone cannot impact specified healthcare-associated infections caused by risk factors like immunosuppression and old age. Thus, to reduce HAIs within care facilities, hand hygiene must be coupled with other special or routine preventive measures. 

Interventions to Improve Hand Hygiene in Health Care Facilities 

The increased need to improve hand hygiene among health care practitioners has led to the establishment of interventions to enhance hand hygiene. Among the interventions suggested by Ellingson et al. (2014) is the application of existing hand hygiene guidelines like those provided by the CDC, and also ensuring that clarification is sought from updated copies of the same. Secondly, interventions to improve hand hygiene can be based on the principle of efficacy versus virus since studies show that alcohol-based hand rubs (ABHRs) efficiently destroy bacteria. Boyce (2013) proposes the use of alcohol-based hand rubs as investigations have established the 70% ethanol formulations meet ASTM and EN 1500 efficacy standards. Also, Gould et al. (2018) propose the use of performance feedback to enhance hand hygiene as well as education to increase compliance with the same. Moreover, the authors also claim that the close placement of ABHRs near patient contact points is likely to impact hand hygiene positively. Finally, Musu et al. (2017) emphasize on periodic checks on the knowledge of proper hand hygiene among health care practitioners to establish the gaps thereof and fill them through training with the aim of improving the HAI prevention compliance standards.

Preliminary Conclusions 

From the evidence gathered, it is possible that hand rubbing may be considered a better method of improving hand hygiene in health care facilities compared to hand washing. The evidence from previous research conducted shows that alcohol-based hand cleaning solutions have increased capabilities of killing germs and pathogens.

Summary 

Hand hygiene is critical to the prevention of HAIs in health care facilities. Research on the effects of hand hygiene in preventing HAIs in oncology departments can only be facilitated through the establishment of well-written PICOT questions that promote the adequate flow of the research process (Riva et al., 2012). Therefore, standards of hygiene among healthcare practitioners are established to facilitate the reduction of pathogen transmission rates among patients through the hands of their health care providers (McLaws, 2015). The institutions that enable the establishment of the said standards are CDC and WHO, which are also involved in the establishment of interventions to improve hand hygiene (Ellingson et al., 2014). Moreover, it is essential to understand that poor hand hygiene results in the reduced quality of patient life (Musu et al., 2017) and alcohol-based hand rubs are deemed the most effective solutions for proper hand hygiene among healthcare professionals (Gould et al., 2018; Boyce, 2013).

References 

Boyce, J. M. (2013). Update on hand hygiene.  American journal of infection control ,  41 (5), S94-S96. Retrieved from https://www.ajicjournal.org/article/S0196-6553(13)00016-3/fulltext 

Ellingson, K., Haas, J. P., Aiello, A. E., Kusek, L., Maragakis, L. L., Olmsted, R. N., ... & VanAmringe, M. (2014). Strategies to prevent healthcare-associated infections through hand hygiene.  Infection Control & Hospital Epidemiology ,  35 (8), 937-960. Retrieved from https://www.jstor.org/stable/10.1086/677145 

Gould, D., Moralejo, D., Drey, N., Chudleigh, J., & Taljaard, M. (2018). Interventions to improve hand hygiene compliance in patient care: Reflections on three systematic reviews for the Cochrane Collaboration 2007–2017.  Journal of Infection Prevention ,  19 (3), 108-113. Retrieved from http://openaccess.city.ac.uk/20266/1/Gould_et_al-2017-Cochrane_Database_of_Systematic_Reviews.pdf 

Mathur, P. (2011). Hand hygiene: back to the basics of infection control.  The Indian journal of medical research ,  134 (5), 611. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3249958/ 

McLaws, M. L. (2015). The relationship between hand hygiene and healthcare-associated infection: it’s complicated.  Infection and drug resistance ,  8 , 7. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4319644/ 

Musu, M., Lai, A., Mereu, N. M., Galletta, M., Campagna, M., Tidore, M., ... & Mura, P. (2017). Assessing hand hygiene compliance among healthcare workers in six Intensive Care Units.  Journal of preventive medicine and hygiene ,  58 (3), E231. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5668933/ 

Riva, J. J., Malik, K. M., Burnie, S. J., Endicott, A. R., & Busse, J. W. (2012). What is your research question? An introduction to the PICOT format for clinicians.  The Journal of the Canadian Chiropractic Association ,  56 (3), 167. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3430448/ 

World Health Organization. (2012). Recommendations for management of common childhood conditions: evidence for technical update of pocket book recommendations: newborn conditions, dysentery, pneumonia, oxygen use and delivery, common causes of fever, severe acute malnutrition and supportive care. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK138330/ 

Appendix A 

Citation	Type of Study  Design Type  Framework/Theory	Setting	Key Concepts/Variables	Findings	Hierarchy of Evidence Level
Ellingson, K., Haas, J. P., Aiello, A. E., Kusek, L., Maragakis, L. L., Olmsted, R. N., ... & VanAmringe, M. (2014). Strategies to prevent healthcare-associated infections through hand hygiene.  Infection Control & Hospital Epidemiology ,  35 (8), 937-960. Retrieved from https://www.jstor.org/stable/10.1086/677145	Type of Study: Systematic Review and Observational Study  Design Type : Meta-analytic and review based  Framework/Theory : N/A	The findings in the study are a compilation of the documented guidance for prevention of HAIs from various expert organizations.	Concepts : Healthcare-associated infections and hand hygiene  Independent Variable: Hand hygiene  Dependent Variable : Healthcare-associated infections  Controlled Variable : N/A	There is an increasing concern on the association of hand hygiene and HAIs.  There are strategies that can be used to measure hand hygiene adherence.  There are strategies to prevent HAI through hand hygiene  Current hand hygiene strategies can be improved based on recommendations made.	Level V
Boyce, J. M. (2013). Update on hand hygiene.  American journal of infection control ,  41 (5), S94-S96. Retrieved from https://www.ajicjournal.org/article/S0196-6553(13)00016-3/fulltext	Type of Study: Systematic Review and Observational Study  Design Type: Meta-analytic and review based  Framework/Theory: N/A	The information provided is based on the findings and conclusions of other researchers.	Concepts: Hand hygiene  Independent Variable: N/A  Dependent Variable: Hand Hygiene  Controlled Variable: N/A	There are various methods that can be used in the assessment of the efficacy of the products used for hand hygiene.  Research has resulted in the improvement of hand hygiene products.  There are measures that can be taken to monitor hand hygiene	Level I or II
McLaws, M. L. (2015). The relationship between hand hygiene and healthcare-associated infection: it’s complicated.  Infection and drug resistance ,  8 , 7. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4319644/	Type of Study: Qualitative Study  Design Type:  Retrospective  Framework/Theory: N/A	The information compiled is obtained from the analysis of previously conducted research	Concepts: Hand hygiene and healthcare-associated infections  Independent Variable: Hand hygiene  Dependent Variable: Healthcare-associated infections  Controlled Variable:  N/A	There are standards that govern hand hygiene in health care facilities.  There epidemiological principles and pitfalls of hand hygiene research which indicate that the use of B-A design has the advantage of having a high probability of sufficient numbers of HAIs in the entire before- and the entire after-period to establish a statistical difference.  After 2 years, hand hygiene compliance increased from 43.6% (6,431/14,740 moments) to 67.8% (106, 851/157,708) ( P <0.001)	Level III
Gould, D., Moralejo, D., Drey, N., Chudleigh, J., & Taljaard, M. (2018). Interventions to improve hand hygiene compliance in patient care: Reflections on three systematic reviews for the Cochrane Collaboration 2007–2017.  Journal of Infection Prevention ,  19 (3), 108-113. Retrieved from http://openaccess.city.ac.uk/20266/1/Gould_et_al-2017-Cochrane_Database_of_Systematic_Reviews.pdf	Type of Study:  Randomized trials, non-randomised trials and interrupted time series analyses (ITS) Design Type:  Retrospective  Framework/Theory: N/A	Involved the collection of electronic sources from Cochrane Register of Controlled Trials, PubMed, Embase, and CINAHL	Concepts:  Hand hygiene compliance and patient care  Independent Variable: Hand hygiene compliance  Dependent Variable: Patient care  Controlled Variable: N/a	Multimodal interventions that include some but not all strategies recommended in the WHO guidelines may slightly improve hand hygiene compliance (five studies; 56 centers) and may slightly reduce infection rates (three studies; 34 centers), low certainty of evidence for both outcomes.  Multimodal interventions that include all strategies recommended in the WHO guidelines may slightly reduce colonization rates (one study; 167centers; low certainty of evidence). It is unclear whether the intervention improves hand hygiene compliance (five studies; 184 centers) or reduces infection (two studies; 16 centers) because the certainty of this evidence is very low  Multimodal interventions that contain all strategies recommended in the WHO guidelines plus additional strategies may slightly improve hand hygiene compliance (six studies; 15 centers; low certainty of evidence). It is unclear whether this intervention reduces infection rates (one study; one center; very low confidence of evidence).	Level IV
Musu, M., Lai, A., Mereu, N. M., Galletta, M., Campagna, M., Tidore, M., ... & Mura, P. (2017). Assessing hand hygiene compliance among healthcare workers in six Intensive Care Units.  Journal of preventive medicine and hygiene ,  58 (3), E231. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5668933/	Type of Study:  Qualitative and Perspective observation  Design Type:  Retrospective  Framework/Theory: N/A	The study was conducted in 6 ICUs. In each ICU, the adherence by health care workers to both hand hygiene practices and standard precautions was assessed, as well as the presence of procedures and written protocols.	Concepts : ICUs, hand hygiene compliance and  health care workers  Independent Variable: Health care workers  Dependent Variable: Hand hygiene compliance  Controlled Variable: N/A	In all the involved ICUs, 73 of 142 required protocols and procedures were available.  9 of 79 were available for a general measure of risk control, 12 of 15 for hand hygiene, and 24 of 48 for standard precautions and isolation measures  The results showed highly variable levels of adherence to the best hygiene practices in all the ICUs involved in the study, with compliance rates ranging from 3% to 100%, and 73 of 142 required protocols were available at the study time.	Level II