Impact of Hand Hygiene on Nosocomial Infections in Intensive Care Units

The importance of hand hygiene in the intensive care unit (ICU) is investigated in this study. Researchers Sutter et al. (2010) found that hand disinfection is more suitable for handling patients in ICU compared to hand-washing. The study also highlights the effectiveness of alcohol-based hand rubs in reducing nosocomial infection rates. Other studies, such as those by Maliekal et al. (2005), Andreas F. (2000), Tuladhar et al. (2015), and Hugonnet et al. (2002) have observed similar findings, emphasizing the importance of hand hygiene in preventing nosocomial infections. The purpose of this study is to investigate whether hand-washing can be replaced with alcohol-based hand rubs, which has been reported to reduce infectivity by a greater extent.

DOES THE ALCOHOL HAND RUB IS BETTER
THAN SOAP AND WATER IN REDUCING THE
INFECTION IN ICU

ABSTRACT
Hand washing is generally referred as cleaning of hands so that micro-organism and dirt
present on hands is removed. In medical field hand hygiene is directly related to administrating
medical procedures and medicines so that spread of diseases is minimised.
Aim
Major aim of this study was critically analysing that whether alcohol hand rub is better than soap
and water in reducing the infection in ICU. Regarding this, it has focused on various types of
micro-organisms that persists in ICU which can cause bacterial infections.
Design
Descriptive study design has been incorporated in the research. Along with descriptive study
quantitative study has also been taken into account .Focus has also given on the efficacy of
alcohol hand rub with soap and water in reducing infection in ICU.
Participants
Overall study has chosen most appropriate methods and techniques for getting appropriate
findings and results. In the overall study it has been stated that even after using many other
methods such as washing hands with other soaps and antiseptic detergents they were not reported
to kill all the types of germs and micro-organism which are present on hands. All the micro-
organism that are present on different parts of the body in ICU are acquired through various
sources.
Data collection
The data is collected through various methods such as conducting case control study based
survey and random sample techniques.
Data analysis
As the overall study is based on quantitative technique which has been undertaken in the
research because it is very suitable as per the research subject. Case control study will be used
which is one of the observational study used to compare the results of two almost same
procedures in an effective way.
Conclusion
The viable conditions in which all the different types of microbes survive depends upon the
structure of microbes that are generally present on hands. Based on the overall research report it

was stated that alcohol hand rub was proved to one of the most effective methods in reducing the
germ and presence of other microbes on hands. I is very important to remove all the types of
germs so that effective care services are provided in ICU.

TABLE OF CONTENTS
Title..................................................................................................................................................1
Introduction......................................................................................................................................1
Justification and Background for the research.................................................................................1
Research aim....................................................................................................................................5
Research Objectives.........................................................................................................................5
Research question............................................................................................................................5
Research Methodology....................................................................................................................6
Analysis of Data..............................................................................................................................8
Ethical consideration.......................................................................................................................8
Timescale (Gantt Chart)..................................................................................................................8
conclusion......................................................................................................................................10
references.......................................................................................................................................11

LIST OF TABLES
Table 1: Time scale for the current research...................................................................................8
Title
“To investigate whether alcohol hand rub is better than soap and water in reducing the infection
in ICU or not?”

INTRODUCTION
What?
The main aim of the proposal is to investigate the effectiveness of alcohol hand rub gel
technique in intensive care unit. Hand-washing or hand sanitation is considered as the act of
cleaning hands with the use of agents that are meant to remove oil, dirt, soil and other micro-
organism which persists on hand after different activities.
Why?
Hand-washing practice in medical profession is referred to hygienic act that is
implemented to before administrating medicines and other surgical procedures (Steinmann,
Becker, Bischoff and Steinmann, 2015). It is very necessary to sanitize hands because it helps in
preventing and minimizing infectious and non infectious diseases within hospital and outside the
hospital. The act of hand-washing is done to clean the hands which are exposed to pathogens to a
higher degree. Earlier hand-washing was done with the use of soap containing antiseptic
properties but with the advancement this tradition of hand-washing with soaps has been replaced
with the use of alcohol hand rub procedures (Gay, Mills and Airasian, 2011).
How?
The proposal will include various types of studies which will mainly focus on
investigating the effectiveness of alcohol hand-washing over soap and water. Further the
research proposal will also compare the efficiency and efficacy of alcohol hand rub procedures
with soap hand-washing in reducing different types of infection in the ICU. Lastly it will also
explore best possible solutions to reduce the existing infections in intensive care unit of the
hospital.
JUSTIFICATION AND BACKGROUND FOR THE RESEARCH
Health Care Associated Infection (HCAI) is the major cause of death and disability
worldwide. It is an issue because health care professionals are not focus on appropriate safety
and prevention of patients from such types of infection. These infection increases the rates of
different types of diseases. So, infection in ICU is one of the major issue of the current research
(WHO Guidelines on Hand Hygiene in Health Care: a Summary, 2016).
6 | P a g e

It is an issue because health care professionals does not apply appropriate solution to
reduce infection in ICU. So, these infections raise the different physical and mental problems of
patients.
It is an issue now because most of the health professionals use alcohol hand rub and soap
and water for reducing infection in ICU (Sutter. Pargger and Widmer, 2010). But, they are not
assure about that what is the best solution for reducing infection. There are number of
investigation have conducted on similar subjects but no one focused on micro-organism of ICU.
So, for resolving this issue I has decided to conduct investigation on this subject.
For resolving this, problem I will shed light on various Micro-organisms that persists in
ICU. Further, focus will also give on efficacy of alcohol hand rub with soap and water in
reducing infection (ICU Infection Control and Preventive Measures, 2016). Therefore, the
current investigation will help in determining that whether alcohol hand rub is better than soap
and water in reducing the infection in ICU.A detailed research on use of alcohol hand rub in ICU
was performed because no research has been done on this issue earlier (Garner, and Favero,
2002). Prior to this research all other studies were done t analyse the the use of alcohol hand rub
in different department of hospitals but this research is basically done to analyse the impact of
alcohol hand rub in ICU (Simpson, 2014).
Background:
Hygiene in healthcare care setting is the prime requirement from all the staff members to
reduce the rate of spreading of infectious and non-infectious diseases within the hospital
(Maliekal and et.al, 2005). According to general survey conducted on reviewing the healthcare
settings in different countries the Is reported that only 38-40% of healthcare workers were
reported to comply with the hygiene conditions necessary in all hospitals and healthcare units
(Steinmann and et.al, 2015). Earlier, the individuals involved in healthcare recognised soap
hand-washing method as the most effective way of preventing the spread of germs and diseases.
However, in recent times scientific evidence have claimed that hand rub with alcohol is more
hygienic and effective in killing microbes in hospital. The antimicrobial activity of any soap or
alcohol used in hand-washing is determined by calculating the log values before and after the
process of cleaning hands. The values of log vary highly when alcohol is used for hand washing
as compared to soaps containing antiseptic activity. In many countries, both soaps and alcohol
hand rub are replaced by chlorinated lime because the reducing factor estimated by chlorinated
7 | P a g e

lime is 6.1 log10 cfu and for soap it is measured to be 3.2 log10. The use of chlorinated lime in
medical profession is considered more superior than alcohol. But due to various harmful effects
produced by chlorinated lime this cannot be suggested for hand wash for daily use (Maliekal and
et.al, 2005).
ICU is selected in primary research because it is the considered as one of the places in
hospitals which is more prone to different infections and diseases. As compared to any other
department it has highest percentage of micro-organisms which can cause further illness and
occurrence of diseases. Hence it is very necessary to maintain hand hygiene in ICU.
Background studies have estimated that even if the cost of alcohol hand rub is costly as
compared to soap hand-washing system but the efficiency, reduction in side effects and decrease
in rate of nosocomial infection cannot be overlooked as far as the health of individual is
concerned. More side effects of soap hand-washing has been discussed in this research (Maliekal
and et.al, 2005). The study states that some bacteria becomes resistant to different soaps by
altering the shape or function of the body. In such cases the antiseptic soap do not have any
effect on resident or transient bacteria even after washing the hands the removal of both the
bacterial flora is not achieved hence it is very necessary to treat the hands with alcohol so that it
reduces the growth of bacteria to a higher extent (Kriz, Gummesson and Quazi, 2013). Although
the practice of hand-washing through soap is considered as a very old practice but hand rubbing
with alcohol is effective in reducing the bacterial infection to a significant extent. (Stowell and
et.al, 2014).
RESEARCH AIM
“To investigate whether alcohol hand rub is better than soap and water in reducing the
infection in ICU or not”.
RESEARCH OBJECTIVES
 To identify various types of micro-organisms that persists in ICU which can cause
bacterial infections.
 To compare the efficacy of alcohol hand rub with soap and water in reducing infection in
ICU.
 To suggest the best solution for reducing the infection in ICU.
8 | P a g e

RESEARCH QUESTION
1. Does the alcohol hand rub is more effective as compare to soap and water in reducing the
infection in ICU?
RESEARCH DESIGN
The overall research is based on collecting data from primary sources. The data which is
being used is by qualitative method. The research method, collection of data and data analysis
procedure has been described below. Research philosophy: For the current investigation positivism research paradigm will be
used because it will help in getting most appropriate solution of research problem by
focusing on research objectives (Steinmann, Becker, Bischoff and Steinmann, 2015).
Along with this, it will play important role in in-depth analysis about the various types of
micro-organisms that persists in ICU. It will help in attaining aim and objectives in
appropriate way. Research approach: Deductive research approach will be applied as it will help in
developing a new theory on the basis of hypothesis testing (Stowell and et.al, 2014). It
will move towards the specific to general way. So, at first it will focus on the major
objectives of the current study. Afterwards it will develop a new theory on the current
research subject. So, theory will be based on the current research subject which focuses
on whether alcohol hand rub is better than soap and water in reducing the infection in
ICU.
 Research design: Descriptive research design will be appropriate for determining that
whether alcohol hand rub is better than soap and water in reducing the infection in ICU.
It will be suitable for the current investigation because it will help in determining
different infections which persist in ICU. Along with this, it will provide a subjective
support to understand research problem and getting suitable solution to resolve it in
effective way (Eggers and et.al, 2015). One of the main reason due to which this
descriptive design is appropriate for the research is that through this it is possible to
provide description of the topic being selected. Further, it will allow in accomplishing
overall aim and objectives of the study.
RESEARCH METHODOLOGY
9 | P a g e

Research methods: Quantitative strategy will help in accomplishing whole investigation in
appropriate manner. quantitative research techniques will play important role in understanding
different types of infection in ICU. Along with this, it will help in comparing efficacy of alcohol
hand rub with soap and water in reducing infection in ICU (Kriz, Gummesson and Quazi, 2013).
As the objective of the research proposal is to investigate and compare two methods it is
preferable to use case control study which will successfully complete the study. Case control
study is a type of observational study rather than experimental study. In this study two groups
will be selected to compare the results. One will be the group where participants will be allowed
to use hand-washing with alcohol and soap and the other group will not be allowed to wash their
hands with any solutions.
1. Data collection: According to the aim and objectives of the current investigation I needs to
collect data on various types of micro-organisms that persists in ICU which can cause bacterial
infections. Along with this, it is very necessary to obtain information about role and efficiency of
alcohol hand rub, soap and water in reducing infection in ICU. For collecting all these
information, use of only primary data collection methods will be best suitable. In which primary
data collection will be collected by different health care professionals (Gay, Mills and Airasian,
2011). A team for collection of data will be hired which will help in comparing the results also.
2. Participants: As per case control studies health care professionals are considered as research
universe. For selecting sample random number sampling method will be preferred. Use of
selected 20 respondents which will represent the characteristics of whole research universe
(Garner and Scott, 2013). So, sample size for the current investigation will be 20. It will be
appropriate because it provides equal chance to each and every patients to select in a sample.
Similarly it reduces the sampling error also which augments the overall reliability and validity of
the data.
3. Analysis of Data: Quantitative research techniques for conducting whole investigation
will be used. So, for analysing statistical data the best possible method will be statistical
analysis methods. Statistical analysis will help in analysing subjective content relevant to
the infection in ICU (Kundrapu and et.al, 2014). It will be appropriate for resolving
research problem and attaining aim and objectives in effective manner. Statistical
analysis will include different graphs, charts, figures and diagrams for analysing collected
facts and figures. These will help in analysing information and conducting in-depth
10 | P a g e

analysis on the current subject. It will help in making comparison between alcohol hand
rub and soap. Overall quantitative analysis will play important role in examining
collected information of survey and getting solution for research question.
4. Reliability and Validity: It is one of the most important consideration which should be
taken into account so that we are able to derive valid findings and results related to the
study. Case control study will be chosen for conducting primary research because it is the
observational study that will help in comparing results of two different findings in most
appropriate way. It is also necessary to check the reliability of data to ensure error free
data is produced. For retaining validity and reliability most effective observational study
is selected.
ETHICAL CONSIDERATION
In the present research investigator will face some ethical issues where one of them is
approval from hospital committee as data has to be collected from health care professionals and
due to this reason it is not easy to obtain data easily. Further, the data is confidential due to
which it is not provided for the purpose of research. Research study will apply the primary
investigation for the current investigation. So, safety and security of personal information of each
and very participants is one of the major ethical issue. So, for resolving this issue I need to assure
about the use of only those information which will be required for completing the current
investigation in effective manner. It will help completing whole investigation with consideration
of research ethics.
PRACTICAL CONSIDERATION
Gantt chart has been added in the appendix so that times required to complete the
research proposal is identified. It is usually based on the person who is conducting the research
and can be changed accordingly. The cost which is needed to conduct the research will include
the following
 Cost for conducting the overall research.
 Cost used in printing and binding of papers
 Cost related for individuals hired for data collection
 Cost of purchasing SPSS
11 | P a g e

 Cost related to travelling and transportation.
There are many other issues which are generally encountered while conducting various
research.
 Difficulty in developing assurance to all the patients that the data which they are giving
will be maintained and safeguarded.
 Problems in analysing data due to different sample size.
 Incomplete and irregular answers to all the questions based on surveys
Cost estimationAccording to the cost estimations the overall was completed in £180. The
amount was allocated to different sources such as internet accessibility, transport and other
aspects (Kundrapu and et.al, 2014). Used different types of transportation services in order to
complete the ongoing research successfully. It helped in conducting various surveys, face to face
interviews and self-monitoring so that the research is completed in time. The expense of printing
and binding of two copies have also been included in the overall cost.
CONCLUSION
The current research study has proposed an investigation on whether alcohol hand rub is
better than soap and water in reducing the infection in ICU or not. Regarding this, it has focused
on the primary data collection method and regarding this I have chosen case control study survey
of health professionals of different health and institutions. Overall, study has suggested different
methods for determining appropriate findings of the research question. The study analysed the
use of different hand washing methods so that it is able to compare the results and efficiency of
alcohol hand-washing. The report revealed that although many other methods consistently
decreased the ratio of presence of all the micro-organism but hand-washing methods with
alcohol was one of the most effective methods which can significantly reduce down the number
of all types of microbes such as bacteria, virus and pathogens. Lastly the study also included that
even though other methods were also effective in killing the ratio germs but this method is
generally used by all the healthcare professionals in intensive care units and other surgical
theatres. Lastly the research proposal also included various ethical and practical considerations
that are faced by individuals who are conducting various studies and researches.
12 | P a g e

REFERENCES
Books and journals
Creswell, J. W. (2013) Research design: Qualitative, quantitative, and mixed methods
approaches. London: Sage publications.
Eggers, M., Eickmann, M., Kowalski, K., Zorn, J and Reimer, K. (2015) Povidone-iodine hand
wash and hand rub products demonstrated excellent in vitro virucidal efficacy against
Ebola virus and modified vaccinia virus Ankara, the new European test virus for enveloped
viruses. BMC infectious diseases. 15(1). p.1.
Garner, J. and Favero, M.S., (2002). CDC guideline for hand-washing and hospital
environmental control. BMJ 7. pp.231-43.Simpson, R. (2014) Handbook of Research
Methods and Applications in Spatially Integrated Social Science. Cheltenham: Edward
Elgar.
Garner, R. and Scott, G. M. (2013) Doing qualitative research: designs, methods, and
techniques. New York: Pearson Education.
Gay, L. R., Mills, G. E. and Airasian, P. W. (2011) Educational research: Competencies for
analysis and applications. New York: Pearson Education.
Kriz, A., Gummesson, E. and Quazi, A. (2013) Methodology meets culture: Relational and
Guanxi-oriented research in China. International Journal of Cross Cultural Management,
14: 3-5.
Kundrapu, S., Sunkesula, V., Jury, I. and Donskey, C.J. (2014) A randomized trial of soap and
water hand wash versus alcohol hand rub for removal of Clostridium difficile spores from
hands of patients. Infection Control & Hospital Epidemiology. 35(02). pp.204-206.
Maliekal. M. and et.al., (2005). Comparison of traditional hand-wash with alcoholic hand rub in
ICU setup. Lancet 191(96). pp. 2120-2125.
Simpson, R. (2014) Handbook of Research Methods and Applications in Spatially Integrated
Social Science. Cheltenham: Edward Elgar.
Steinmann, J., Becker, B., Bischoff, B. and Steinmann, E. (2015) Alcohol hand rub or soap and
water for removal of norovirus from hands–the debate continues. Journal of Hospital
Infection. 91(4). pp.371-372.
Stowell, J. D., Forlin-Passoni, D., Radford, K., Bate, S.L., Dollard, S.C., Bialek, S.R., Cannon,
M.J and Schmid, D.S. (2014) Cytomegalovirus survival and transferability and the
effectiveness of common hand-washing agents against cytomegalovirus on live human
hands. Applied and environmental microbiology. 80(2). pp.455-461.
Sutter. T., Pargger. H. and Widmer A.F., (2010). Hand hygiene in the intensive care unit.
PubMed. 38(8). pp. 299-305
13 | P a g e

APPENDIX
TIME SCALE (GANTT CHART)
The current research subject requires in-depth investigation on different aspects of the
current subject, so, it will take time and require time scale can be presented by Gantt chart which
includes different activities and duration (Creswell, 2013). Gantt chart for the current
investigation is as follows:
Table 1: Time scale for the current research
Key activity / Weeks 1 2 3 4 5 6 7 8 9 1
0
1
1
1
2
1
3
1
4
1
5 16
Review of background and
rational of the current subject
Literature review on infection
in ICU
Research methodology
Data collection using primary
data collection methods
Sampling technique
Data analysis using most
appropriate methods
Interpretation of findings and
results
Submission of Draft and
making necessary changes
Final submission of report
14 | P a g e

Appendices
Appendix 1: Letter to the Nurse Manager
Dear Madam,
My name is Jabir and I am a final year nursing student at University of West London. In order to
successfully complete the course, I have to conduct a primary research and the topic I have
selected is: Effectiveness of Alcoholic hand rub with soap and water in reducing the infection in
ICU . The design of the proposed research is quantitative study . I believe that this study will be
helpful in nurturing nurses knowledge on hand hygiene and its benefits in reducing infection.
Participants required: The plan is to recruit 20 participants ( 20 nurses from ICU ward in control
group ).
Intervention and data collection: Assessment of the knowledge of infection control, the
frequency of hand washing and their knowledge and experience regarding use of alcoholic hand
rub. This Information will be obtained through research questionnaires and close ended
interviews.
Before participating in the study, informed consent will be sought from the participants. This
study is accepted and approved by the research module leader of University of West London
(UWL). Also, the ethical approval was obtained from the ethical committee of UWL.
I am also hopeful that this study will aid in corroborating the earlier research findings on the
efficacy of alcoholic hand rub. Please contact me at [e-mail] if you require any
additional details on the study
Regards,
Jasbir kaur
15 | P a g e

Appendix 2: Participant information sheet
Dear Participant,
I am nursing student from University of West London. I have to conduct a study among nurses
in ICU ward in this hospital in order to evaluate the efficacy of alcoholic hand rub in reducing
transmission of infection.
For the purpose of conducting this study, I require 30 participants nurses who are allocated in
ICU ward . Participants will also be subject to microscopic test of hands in order to identify the
bacterial load.
You are free to decide whether to participate in this study or not. You will not be coerced or
influenced to participate in the study and it is completely your discretion. Since it is voluntary,
you will be asked to sign the written consent to be a part of this study. This study is approved by
the ethical committee of research and by the module leader of the University of West London.
Your participation and the data collected from you will be kept confidential all the time and will
only be used for legitimate requirements of this research.
Should you require any details further, do not hesitate to contact me
Researcher name:
Jasbir Kaur
Mail: [e-mail]
Phone no: xxxx
16 | P a g e

Appendix 3:
Title of Project: Quantitative descriptive study (MSc final project) on effectiveness of alcoholic
hand rub with soap and water in reducing the infection in ICU.
Name of Lead Investigators: Jasbir Kaur
Tick the boxes if appropriate.
1. I confirm that I have read and understand the information sheet dated.....................
(Version ............) for the above study and have had the opportunity to ask questions.
2. I understand that my response may be recorded.
3. I understand that my participation is voluntary and that I am free to withdraw at any time
without giving any reason.
4. I agree to take part in the above study.
Name of participant 11.05.2016 Signature
Name of person taking consent 11.05.2016 Signature
(If different from researcher) 11.05.2016 Signature
17 | P a g e

Appendix 4: Research protocol
Purpose – The purpose of the proposed study is to analyze the effectiveness of alcoholic hand
rub with soap and water in reducing the infection in ICU.
Samples, Participants: The proposed study is intending to recruit 30 nurses who are working in
ICU.
Recruitment of sample: Random number sampling method will be used to recruit participants.
The nurses who are working in the ICU department hospital in London will be included .
Participants will also be subject to microscopic examination in order to identify the presence of
bacterial and other infectious agents in their hands. The criteria of personal characteristics of
each age cohorts will be considered while selecting the participants.
Data collection: Questionnaires and interview (close ended). The questions will focus on three
parts, Attitudes of participants regarding hand hygiene, use of alcoholic hand gel and any
negative consequences of the alcoholic hand gel over soap and water. Each part will contain 10
questions. The questions will be constructed by literature review and consultation with the
experts. The questionnaire will be validated by the help of pilot study and consultation with the
panel of experts in the field of Infection control. The subgroup of the population will be included
in the pilot study. 10% population of the actual sample size will be included in the pilot test. The
responses of the participants following the pilot study will be analysed in order to assess the
understanding of the question. Any question that has been misunderstood or may present
ambiguity will be modified. The time taken by the respondents will be assessed.
Data analysis: SPSS (Ztest, Ttest, ANOVA test).
Ethical compliance: This study is approved by the ethical committee of research and by the
module leader of the University of West London. The participants’ data will be kept confidential
all the time and will only be used for legitimate requirements of this research.
18 | P a g e

Author and year Journal Types of study Purpose Key findings
Gunter. K.,
Harald. L. and
Petra. Gastmeier
(2009)
Deutsches
Arzteblatt
International
Literature based
study
Purpose of the
study is to
investigate hand-
washing as
essential tool fro
prevention of
nosocomial
infection in ICU
Hand disinfection
is more suitable
for handling
patients in ICU as
compared to
hand-washing.
Maliekal. M. and
et.al., (2005)
IJCCM Observational
study.
To study
nosocomial
infection rate in
intensive care
unit.
Hand-washing
with alcohol is
more effective as
compared to other
agents.
Andreas. F. W.,
(2000)
Oxford Journals Observational
study.
The aim is study
whether alcohol
hand rub can be
replaced with
hand-washing.
It can be replaced
because it is
found to kill more
micro-organism.
Tuladhar. E. and
et.al., (2015)
The Journal of
hospital infection
Observational
study
To evaluate the
efficacy of
alcohol and
disinfectant
against human
enteric and
respiratory virus.
Alcohol has been
reported to reduce
the infectivity by
to a greater
extent.
Hugonnet. S. and
et.al., (2002)
Arch Intern Med. Observational
study surveys and
To assess the
effectiveness of
Compliance for
alcohol hand
19 | P a g e

campaigns an intervention to
promote hand
hygiene.
rubbing increased
from 38.4% to
54.5%
20 | P a g e

APPENDIX : OBSERVATION SHEET
21 | P a g e

22 | P a g e

23 | P a g e

24 | P a g e