The Impact of Hand Hygiene on Healthcare Associated Infections

This report examines the critical role of hand hygiene in preventing healthcare-associated infections (HAIs). It begins by defining HAIs and hand hygiene, followed by a PICO question to guide a literature review. The search strategy encompasses databases like NCBI, Google Scholar, and PubMed, using keywords such as "Healthcare-associated infections" and "Hand Washing." The rationale for selecting hand hygiene highlights the significant global impact of HAIs, emphasizing the importance of interventions, particularly in ICUs. A critical appraisal of a chosen article, "A systematic review on the effectiveness of interventions to improve hand hygiene compliance of nurses in the hospital setting" is conducted using the CASP tool. The review assesses the quality of included studies, the reasonableness of combining results, and the overall findings, concluding that multimodal techniques show stronger results. The report recommends following WHO guidelines for hand hygiene implementation, emphasizing the importance of a coordinated national approach, and highlights the benefits of interventions outweighing the costs. It stresses the need for ongoing efforts to improve hand hygiene practices and reduce the spread of pathogens.

Running head: HAND HYGIENE - CASP
Hand Hygiene - CASP
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Introduction
Health Associated Infection (HAIs) is those diseases which a patient receives during
his/her stay in the hospital for receiving treatment for his medical condition. According to the
literature, HAIs are preventable (Allegranzi et al., 2011). Modern-day healthcare system utilizes
different healthcare methods and devices to treat the patient and recover him/her from their
medical condition (Allegranzi et al., 2011). Though, the main path for the transmission of the
HAIs is through the improper way of using the healthcare devices and inappropriately delivering
treatment. The main reason for the death and injury to the patient in different countries is HAI,
and it leads to a significant rise in the health care costs annually. Hand-mediated transmission is
another leading reason for the transfer of HAI in hospitals (Allegranzi et al., 2011). Though
different literature has proved that hand hygiene is a significant way of reducing the rate of HAI.
Effective hand hygiene intervention is a crucial way of preventing the hospital staff from getting
pathogens that may cause serious infections (Sickbert et al., 2016).
Various research articles have proved that hand hygiene is a vital tool in stopping the
transmission of healthcare-associated infections among patients. Many experiments have shown
that hand-washing effectively eradicates the transfer of (Methicillin-resistant Staphylococcus
aureus) MRSA that happens inevitably in the hands of healthcare professionals in ICU. The
improvement in hand-washing showed a reduction in MRSA levels. Thus, this article will help in
defining what HAI and Hand-hygiene are, develop a PICO question and based on that will
conduct a literature review. By choosing one article, a critical analysis will be done using the
CASP tool.

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PICO
 P - Health care-associated infections (HAI)
 I – Hand Washing
 C - No hand washing, or other solutions, alcohol based hand rub
 O – Decrease in the rate of HAI
Is hand hygiene a successful way to decrease the incidence of hospital-related infections by
healthcare workers?
Search Strategy
To gather information regarding the effectiveness of hand hygiene in the reduction of
hospital-associated infections, a systematic review has been conducted. A systemic review is
described as an effective way of assessing the answer to a research topic by collecting evidence
from peer-reviewed evidence that fits the pre-specified requirement of inclusion and exclusion.
All peer-reviewed information shown in this article is collected from different academic sources
as NCBI, Google Scholar, Cinahl, PubMed, and Medline. There are specific keywords that
helped in the finding of the relevant articles such as Healthcare-associated infections (HAI) and
Hand Washing. Articles chosen are –
1. Gould, D. J., Moralejo, D., Drey, N., Chudleigh, J. H., & Taljaard, M. (2017). Interventions
to improve hand hygiene compliance in patient care. Cochrane database of systematic
reviews, (9).
2. Haque, A., Guo, M., Alahi, A., Yeung, S., Luo, Z., Rege, A., ... & Platchek, T. (2017).
Towards vision-based smart hospitals: A system for tracking and monitoring hand hygiene
compliance. arXiv preprint arXiv:1708.00163.

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3. Jones, D., Martello, M., Biron, A., & Lavoie‐Tremblay, M. (2017). A systematic review on
the effectiveness of interventions to improve hand hygiene compliance of nurses in the
hospital setting. Journal of Nursing Scholarship, 49(2), 143-152.
4. Levchenko, O. I., Pong, S. M., & Fernie, G. R. (2017). U.S. Patent No. 9,836,950.
Washington, DC: U.S. Patent and Trademark Office.
5. Sickbert-Bennett, E. E., DiBiase, L. M., Willis, T. M. S., Wolak, E. S., Weber, D. J., &
Rutala, W. A. (2016). Reduction of healthcare-associated infections by exceeding high
compliance with hand hygiene practices. Emerging infectious diseases, 22(9), 1628.
Rationale for selecting hand hygiene
The impact of HAI can be seen on 100 million people worldwide annually. Such
infections lead to more critical a disease, leading to long-duration stays in the hospitals, prompt
long-term disabilities, increasing healthcare costs, the financial impact on the family members
causing a financial burden on the healthcare system and eventually lead to the death of the
patient. Especially in the ICUs, the usage of different healthcare instruments such as the central
venous catheter or urinary catheter is one of the significant risk characteristics for getting HCAI.
The infections occurring due to the healthcare instruments have a high economic impact, for
instance, methicillin-resistant Staphylococcus aureus (MRSA) causes catheter-related
bloodstream infection may lead to a cost similar to or may exceed US$ 38000 per episode. The
healthcare-associated pathogens spread through direct and indirect contact, droplets, air and a
typical mode of transport.
The following articles were chosen because the articles discuss different interventions
which can help in enhancing the hand hygiene compliance in various healthcare settings (Gould,
Moralejo, Drey, Chudleigh & Taljaard, 2017). Another article by Haque et al. (2017) discussed a

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tracking system to track all the healthcare staff members, patients, and visitors and understand
the source of infections. The researchers visualize a smart hospital that can increase efficiency
and performance and improve care for patients with lower expenditure. In this paper, they
suggested a vision-based, non-intrusive tracking system to track the activity of people in the
hospital. The article by Jones, Martello, Biron & Lavoie‐Tremblay (2017) presented a systemic
review to recognize different interventions that enhance hand hygiene compliance (HHC),
especially among the nurses. HCW adherence to suggested hand hygiene procedures was
recorded as variable, with average baseline levels varying from 5% to 89% and an overall
average of 38.7% (WHO, 2016).
Critical Appraisal using CASP:
The article chosen for critical appraisal is –
Jones, D., Martello, M., Biron, A., & Lavoie‐Tremblay, M. (2017). A systematic review on the
effectiveness of interventions to improve hand hygiene compliance of nurses in the
hospital setting. Journal of Nursing Scholarship, 49(2), 143-152.
CASP tool will be used to appraise this article (CASP, 2020).
 Did the review address a clearly focused question?
Yes, the review properly answers the PICO question. The objective of this systematic review
is to recognise approaches explicitly between all of the nurses which enhance hand hygiene
compliance (HHC).
 Did the authors look for the right type of papers?
Indeed, the investigators picked only those articles that were restricted to interrupted time
series (ITS), randomized controlled trials (RCTs), and controlled before and after studies

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(CBAs) that explored intervention capacity to improve HHC in intensive healthcare
organizations.
 Do you think all the important, relevant studies were included?
Indeed, the researchers shortlisted some articles that were restricted to interrupted time series
(ITS), randomized controlled trials (RCTs) and controlled before and after studies (CBAs)
that investigated mediation effectiveness to improve HHC in acute healthcare organizations.
The Cochrane Effective Practice and Organization of Care Committee (EPOC) has
introduced guidelines for the features of the study design.
 Did the review’s authors do enough to assess quality of the included studies?
Yes, the review’s authors do enough to assess quality of the included studies. Criteria for
EPOC prejudice assessment for RCTs and ITS research have been used to evaluate the
internal and external quality of the chosen research. Bias analysis for RCTs was based on
various parameters: determination of random sequence and distribution concealment,
screening of subjects and investigators, analysis of covariance through baseline effect and
community characteristics measures, cross-contamination among test and study classes,
selective reporting, and resolving researchers ' missing results or attrition levels. The
subsequent factors were assessed for the evaluation of prejudice for ITS test designs: monitor
for other changes taking place alongside intervention, coherence of impact interpretation with
the intervention stage, discussing the intervention influence on the collection of data,
concealment of assignments, addressing incomplete data and disclosing selective outcomes.
 If the results of the review have been combined, was it reasonable to do so?
Yes, it was reasonable for the authors to combine the results of the articles chosen for the
review. The Statement of Preferred Reporting Items for Systematic Reviews and Meta-

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Analyses (PRISMA) was used as a standard for investigating systematic reviews and
research meta-analyses. All the authors independently confirmed the accuracy of the data for
inconsistencies.
 What are the overall results of the review?
413 articles were chosen for the review. But after the inclusion and exclusion criteria, 6
articles were finally used for this review. Two research examined single-component
programs, such as hand hygiene education or training; basic safeguards and epidemiology
were often linked to specific training sessions. One article merged education with responses
in the manner of assessments and presented outcomes on a poster whereas another paper
contrasted education in combination with motivational interviewing along with education.
Another paper assessed the effect of feedback and electronic reminders on HHC. Another
paper involved multidimensional approaches along with a mixture of measures like academic
training, responses, notifications, product availability, incentive adding, transparency, setting
goals, and unit leaders participation.
 How precise are the results?
The results of the review were found to be consistent with the results of the Gould et al.
(2010) and Luangasanatip et al. (2015) on interventions to improve HHC among HCWs.
Single-component approaches were shown to enhance HHC, however, in addition to setting
goals, reward opportunities and transparency, evidence showed permanent and stronger
results for multimodal techniques. Future research, however, continues to be needed to tackle
low HHC levels among nurses and other HCWs.
 Can the results be applied to the local population?
Yes, the results of the review can be applied to the local population.

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 Were all important outcomes considered?
Yes, all the important outcomes have been considered. Though, the review also concluded
that the single-component approaches were shown to enhance HHC, however, in addition to
setting goals, reward opportunities and transparency, evidence showed permanent and
stronger results for multimodal techniques.
 Are the benefits worth the harms and costs?
Yes, the benefits or the interventions are worth the harms and costs.
Recommendation
WHO has set guidelines regarding the hand hygiene for the healthcare staff members by
conducting a systematic assessment of peer-reviewed literature related to the hand hygiene in the
healthcare system and explicit suggestions have been provided to enhance the practices and
decrease the spread of pathogens to patients and HCWs (WHO, 2016). The guide offers steps to
implement the interventions and required resources to guarantee that each factor of the
multimodal approach can be integrated into the current infection control and safety programmes
(WHO, 2016). The five steps to successfully implement the strategy are –
1. The organization must stay prepared. This means that the healthcare system should
always keep the necessary resources prepared and should also have a leadership program.
2. A systematic assessment of the hand hygiene procedure, understanding, expertise and
accessible facilities should be carried out by the healthcare system.
3. The third step is to begin the plan of reform – such as the use of alcohol-based hand
rubbing, rehabilitation, and education for workers.
4. Next step is to assess the effectiveness of the program.

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5. The final step is to devise an immediate plan of action and review cycle. The main aim is
to integrate hand hygiene into the hospital community as a cornerstone.
Conclusion
Patients are still being harmed, even after receiving treatment due to undependable
arrangements and approaches that contrast against hand hygiene approaches. As part of ongoing
global efforts to ensure that no person is intellectually harmed by failure to comply with hygiene
requirements, national coordinated interventions (in several instances campaigns) should be
considered to promote and sustain improvements in the hygiene of hands, concentrate the
problem on national issues and ensure that guidelines concerning hand hygiene are successfully
implemented. Researchers demonstrate that taking into consideration the many exclusions
affiliated with campaigning, targeted, well-executed mass media health campaigns are likely to
have some effects on health knowledge, beliefs, attitudes and behaviour. The existence of
guidelines does not improve compliance with hand hygiene per se. Consequently, the additional
incentive given by a centrally coordinated campaign or system, with some form of supervision
and assessment, priorities and legislation, has been shown to provide a powerful contribution to
local adoption. To raise awareness of the issue in particular and uplift it to a scale of
preeminence that may not be discovered in the lack of a nationally coordinated activity. For hand
hygiene improvements to be successful within an integrated security and infection control
agenda, approaches at the national level should be considered.

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References
Allegranzi, B., Nejad, S. B., Combescure, C., Graafmans, W., Attar, H., Donaldson, L., & Pittet,
D. (2011). Burden of endemic health-care-associated infection in developing countries:
systematic review and meta-analysis. The Lancet, 377(9761), 228-241.
CASP. (2020). CASP Checklists - CASP - Critical Appraisal Skills Programme. Retrieved 12
January 2020, from https://casp-uk.net/casp-tools-checklists/
Gould, D. J., Moralejo, D., Drey, N., Chudleigh, J. H., & Taljaard, M. (2017). Interventions to
improve hand hygiene compliance in patient care. Cochrane database of systematic
reviews, (9).
Haque, A., Guo, M., Alahi, A., Yeung, S., Luo, Z., Rege, A., ... & Platchek, T. (2017). Towards
vision-based smart hospitals: A system for tracking and monitoring hand hygiene
compliance. arXiv preprint arXiv:1708.00163.
Jones, D., Martello, M., Biron, A., & Lavoie‐Tremblay, M. (2017). A systematic review on the
effectiveness of interventions to improve hand hygiene compliance of nurses in the
hospital setting. Journal of Nursing Scholarship, 49(2), 143-152.
Levchenko, O. I., Pong, S. M., & Fernie, G. R. (2017). U.S. Patent No. 9,836,950. Washington,
DC: U.S. Patent and Trademark Office.
Mehta, Y., Gupta, A., Todi, S., Myatra, S. N., Samaddar, D. P., Patil, V., ... & Ramasubban, S.
(2014). Guidelines for prevention of hospital acquired infections. Indian journal of

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critical care medicine: peer-reviewed, official publication of Indian Society of Critical
Care Medicine, 18(3), 149.
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.
Sickbert-Bennett, E. E., DiBiase, L. M., Willis, T. M. S., Wolak, E. S., Weber, D. J., & Rutala,
W. A. (2016). Reduction of healthcare-associated infections by exceeding high
compliance with hand hygiene practices. Emerging infectious diseases, 22(9), 1628.
Toney-Butler, T. J., & Carver, N. (2018). Hand, Washing (Hand Hygiene). In StatPearls
[Internet]. StatPearls Publishing.
World Health Organization. (2016). WHO guidelines on hand hygiene in health care. First
Global Patient Safety Challenge. Clean Care is Safer Care. Geneva: WHO; 2009.