A Systematic Review on Hand Washing and Hospital Acquired Infections

This report presents a systematic review of the effectiveness of hand washing in preventing hospital-acquired infections (HAIs). It begins by introducing the prevalence and adverse consequences of HAIs, emphasizing the importance of hand hygiene as a primary prevention method. The research question, formulated using the PICO framework, explores whether hand washing among medical staff prevents HAIs. The methodology includes a search strategy using various databases and keywords, resulting in the selection of 11 relevant articles. The discussion section highlights the significance of hand hygiene in minimizing HAI prevalence and antimicrobial resistance, referencing studies that demonstrate the effectiveness of hand washing in reducing infection rates. The report also examines the challenges of healthcare professionals' adherence to hand hygiene protocols and the importance of initiatives like the WHO's Five Moments of Hand Hygiene. Several research findings are presented, including studies on multimodal strategies, automated hygiene surveillance systems, electronic monitoring systems, and the impact of multidrug-resistant bacteria. The report concludes by emphasizing the critical role of hand washing in reducing the incidence of HAIs, supported by evidence from various studies and highlighting the need for continuous training and compliance.

Running head: Hospital Associated Infections
Hospital Associated Infections
Name of the Student
Name of the University
Author Note

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Introduction
Over the past few decades, literature has been well informed of the prevalence and
adverse consequences of health-associated diseases (HAIs). The occurrence of HAIs is rising at
an unprecedented rate. The word "HAI" relates originally to all illnesses related to hospital entry
(formerly defined as nosocomial infection), which now extends to the acquisition of diseases in
continuous medical settings (e.g., long-term care, home treatment and ambulatory care).
Unanticipated complications occur through diagnosis, contributing to serious diseases and
fatalities of patients (morbidity and mortality), increase the length of medical stays and involve
additional testing and surgical procedures, causing increased expenses for the people currently
suffering from the specific illness. HAIs are viewed as an adverse outcome and are deemed a
measure of the level of health treatment, a detrimental event and a question of patient safety, as
these can be avoided by following simple measures (Shobowale, Adegunle & Onyedibe, 2016).
Hospital Acquired Infections (HAIs) are a significant safety issue for both health care providers
and patients. In consideration of morbidity, mortality, increased duration of staying at the
hospital, and the expense, attempts should be made to avoid these infections in hospitals as
safely as possible. Hand hygiene is identified as the starting point and basis of all infection
prevention systems, with healthcare workers serving as drivers and advocates of infection in
patients who are critically ill. Hand washing has been described as a preventive prevention
technique to reduce the cross-transmission of contaminants in the healthcare community. This
has been shown to decrease the occurrence of HAIs (Vermeil et al., 2019). Thus, the paper will
explore on the effectiveness of hand washing in decreasing the incidence of HAIs among patients
conducting a systematic review with the help of literatures conducted in this area.

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Research question
The research question has been formulated using the PICO framework. The PICO
process (or framework) is a mnemonic tool utilized in evidence-based practice (and especially
evidence-based medicine) to frame and address clinical or health care relevant queries. The
PICO method is often used to establish methods for the search for literature, for example in
systematic reviews (Eriksen & Frandsen, 2018). PICO stands for
P – Problem or population
I – Intervention
C – Comparison
O – Outcome
Thus, the research question formulated as “Will hand washing among medical staff prevent
hospital-acquired infections infection?”
For this paper, the following PICO elements have been considered.
Elements Examples
P (Problem/Population) Hospital Associated Infections (HAIs)
I (Intervention) Hand washing
C (Comparison) No hand washing; other solution; masks
O (Outcome) Reduced infection
Search strategy
In order to conduct this systematic review, first a research question has been developed
based on which different keywords were searched on various online databases such as PubMed,

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CINAHL and Google scholar. To make the search more specific and broaden the results, the
keywords have been searched in combination with the Boolean operators such as AND, OR,
NOT. Truncation has also been used to prevent limiting the search by only the specific words
that were entered in the database search bar. Some of the keywords that have been used to
conduct this study include “Hospital acquired Infections”, Healthcare associated Infections”,
“Hand hygiene”, “Hospital acquired Infections AND Hand hygiene”, “HAI prevention”,
“Standard Precautions”, “Alcohol hand rub”, “infection control” etc in combination of Boolean
operators and Truncation.
A total of 21 papers were found to be relevant or near the research area, however, only a
total of 11 articles have been selected for this study based on their relevance, authenticity,
conclusiveness and rigorousness. All the articles were screened by skimming through the
abstract of the papers that gave a succinct flow on the study area of the research. Articles that
were lacking a proper abstract have been excluded form the study. The articles that were
conducted after the year 2012 were included in the study to get the recent findings.
Discussion
Health-related infections are grabbing the attention of patients, insurers, governments and
regulators. It is not only due to the severity of the epidemic with regards to increased morbidity,
mortality and care expenses, but also that the most of which are readily preventable. The
scientific community has made remarkable advances on understanding of the pathophysiology
and the dissemination of multidrug-resistant infection in patient care services around the entire
world. HCAIs are diseases contracted by patients during their course of the stay at hospital
during treatment. The word HCAIs originally applied to certain infections connected with
admission to acute hospital (previously referred to as nosocomial infections), which also

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encompasses infections acquired in a number of environments where patients access health
services (e.g. long-term services, family medicine facilities, home treatment, and inpatient care).
HCAIs are diseases that occur for the first time 48 hours or more after hospitalization or within
30 days after accessing health care. Many findings suggest the adverse conditions that most often
arise in hospitalized patients include severe medication reactions, HCAIs and surgical
complications. The most effective, easiest and cheapest way of minimizing HAI prevalence and
the dissemination of antimicrobial resistance is proper hand hygiene. Several research have
shown that hand washing eliminates practically the carrying of MRSA that is inevitably carried
out by the HCPs employed in ICUs. A decline in MRSA levels was observed to follow an
improvement in the compliance with hand washing. Many controlled studies have demonstrated
substantial decreases in infection-related findings by following proper hand hygiene
techniques including in areas with a high infection risk in seriously sick patients. A number of
research shows that basic infection prevention procedures, such as alcohol-based hand rubbing,
may help deter HCAIs and save lives and reduce morbidity and decrease the expense of health
care. Routine awareness programs for workers in the health sector will lead to improving their
washing habits to deter infection spread. The WHO has established recommendations to improve
the tradition of hand washing between the Member States (Bhagawati 2018).
Evidences have shown that the incidence of HAIs can only decrease if proper hand
washing protocols are followed. However, significant number of evidences have shown that
healthcare professionals does not always abide by the rules, despite of their awareness about the
same. tHealthcare staff are exposed to bacterial and other microbial colonised interactive items.
There are two microbial floras in the hands: permanent and transient. In areas such as the
Intensive Care Unit (ICU), the highest levels for hand colonization will result in contamination

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in critical treatment areas which involve inanimate objects. It has been recommended that if
proper hand hygiene processes are strictly practiced by health care staff, a substantial 15–30 per
cent decrease of hospital-associated infections may result; nevertheless, observational results
indicate that hand hygiene enforcement levels constitute around 50 per cent of patient
opportunities. The elevated levels of nosocomial infections indicate the effect of non-adherence
to hand hygiene on the part of healthcare staff. It is driven by the absence of development
measures of healthcare organizations. Successful approaches aimed at enhancing hand hygiene
will involve hand washing and gloves preparation and instruction. The World Health
Organisation (WHO) has established an evidence-based hand hygiene initiative named the Five
Moments of Hand Hygiene, which applies to hand washing before contacting a patient,
conducting an aseptic or sterile operation, possible access to body fluids, contacting a patient,
and touching a patient's setting. The link of hand hygiene and avoidance of HAIs has long been
recognized (if not necessarily generally accepted) since a long time. The difficulty in healthcare
environments is to obtain and ensure strong compliance across several groups of staff working
with patients and their community (Sickbert-Bennett et al., 2016). Healthcare-associated
infections (HAIs) cause significant concern for the protection and efficiency of healthcare
worldwide. The World Health Organization (WHO) established the International Partnership for
Patient Protection in October 2004. The HAIs were described as a critical concern and were
selected as the subject of the first Global Patient Care Challenge. Hand hygiene was established
as a key component of this approach because it is a clear, systematic, cost-effective method
centered on solid scientific evidence. Weak compliance by healthcare professionals, regardless
of the services accessible, is a major barrier.

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Research findings
The study by Shobowale, Adegunle and Onyedibe (2016) Hand hygiene is described as
a prevention management technique that prevents the cross-transmission of pathogens in the
health community. The prevalence of nosocomial infections has been shown to be reduced.
Suitable hand hygiene methods have been shown to decrease the levels of pathogens of the
urinary, respiratory and skin tract. Recent hand hygiene activities require the use of lotions or
rubs based on alcohol.
The study by Chavali, Menon & Shukla, (2014) has used Multimodal strategies to
improve the conformity of all health care personnel with hand hygiene (HH) over the past 1 year.
This cross-sectional observational research was performed at the end of the training year in the
surgical ICU to determine commitment to HH among nurses and allied health care staff. After 1
year of intensive multimodal action to enhance enforcement with HH, they have found an overall
rate of compliance as 78%. It ensures that consistent success and HH enforcement will be
assured by continuing preparation. Clinical evaluation is a commonly employed, reliably
reproducible form of tracking compliance.
The study by Boyce et al. (2019) was conducted to determine the impacts of an
Automated Hygiene Manual Surveillance System (AHHMS) and other Manual Hygiene and
Infections (HAIs) approaches. The levels of compliance with handhygiene produced by direct
observation were significantly higher than those of the AHHMS. The implementation of
AHHMS without external exercises did not result in a considerable increase in the standard of
hand hygiene. The introduction of many supplementary techniques has resulted in a statistically

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significant improvement of 85 per cent in hand hygiene results. It was found that the introduction
of the AHHMS, when coupled with a variety of complementary techniques as part of the
multimodal system, resulted in dramatically improved hand hygiene efficiency.
Often healthcare facilities may not agree with the requirements for hand hygiene. The
study by Srigley et al (2015) have thus carried out a comprehensive analysis, which tests the
utility in enhancing hand hygiene or decreasing the occurrence of healthcare-related infections
(HCAI) with Electronic and visual monitoring systems (EMS and VMS). Several papers were
included in the Following Report, which included laboratory experiments and quasi-
experimental research. However, the EMS / VMS were not suggested due to insufficient study
papers and sufficient data. The paper suggests the usage of suitable and more comprehensive test
formats including control arms and established system-independent hand-hygiene activities in
potential experiments on hand hygiene.
The research by Cornejo-Juárez et al. (2015) attempted to examine the prevalence of
HAIs as well as determine microbiological and antibiotic tolerance profiles of pathogens
responsible for triggering HAIs along with the impact on death-related multi-drug-resistant
bacteria. The researchers used 5-year longitudinal systematic HAI analysis in admitted ICU
patients to perform this report. The prevalence of MDR bacteria was found to raise problems for
health care practitioners as the treatment solutions were not adequate. Patients admitted to the
ICU due to persistent disease were also found to be at higher risk due to MDR-HAI which had an
adverse mortality impact.
Nasution et al. (2019) have performed an extensive analytical study using a random
sampling method. To assess the effectiveness of the hand washing procedure relative to hand
rubs in order to remove microorganisms in nurses 'hands at the Sumatra Utara University

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Hospital. For this report, 16 nurses were registered. Two classes were involved; the first party
used hand washing with soap while the second group used hand rub. The swabs were obtained
from all sets of hands before and after they had washed their hands. In addition, the swabs have
been sent directly to the Sumatra Utara University Microbiology Laboratory to classify the
bacteria that colonize the hand. There were no major variations in the usage of hand washing as
opposed to hand rub in the reduction of the total bacterial colony on the hands. The average
overall colony reduced by the usage of the hand washing system is 59.5 per cent and by the use
of the hand rub is 47.2 per cent. The study thus indicates, hand washing is important to reduce
the risk of developing HAIs irrespective of the method followed to wash hand, whether using
alcohol based hand rub or liquid hand soaps. Thus, healthcare professionals including nurses
must strictly follow hand hygiene to reduce the risk of HAIs.
However, on the contrary, the study by McLaws (2015) have highlighted the fact that
although, the argument that improved attention to hand hygiene contributes to the reduction in
the amount of health-related diseases, good hand hygiene alone cannot impact formidable threats
such as age, immunosuppression, and admission to the intensive care system.. If hand hygiene
measures are performed at the same time as other regular or specific prevention approaches,
there is a tendency for such overlapping approaches to undermine the impact of the hand hygiene
programme. The result could be an overestimation of the system of hand hygiene, because the
purpose of the procedure or research controls the effects of potential confounders. Certain
epidemiological concepts that could also have an effect on the results of the hand hygiene system
entail failing to recognize an error in calculating the quality of the hand hygiene plan and an
error in evaluating implementation. Many epidemiological failures in hand hygiene projects
aimed at minimizing HAIs are inevitable and are not readily managed.

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Conclusion
The most effective, easiest and cheapest way of minimizing HAI prevalence and the
dissemination of antimicrobial resistance is proper hand hygiene. Several research have shown
that hand washing eradicates practically the carrying of MRSA that is inevitably carried out by
the HCPs employed in ICUs and other health settings. A decline in MRSA levels has been
observed to follow an improvement in the compliance with hand washing. Patients who are
subjected to peripheral catheters and to Parenteral nutrition, surgery and urinary catheters in
highly-resourced healthcare environments are at elevated risk for HAI. Hand hygiene is
generally connected to infection control without disclosing any other preventive measures
relevant to this high risk exposure. However, hand hygiene alone does not substantially prevent
the effect of formidable risk factors, including the admission to the ICU, acquisition of HAI at an
older age and duration of stay longer than normal, and the fourfold rise in the incidence of
infection in patients.

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