Citing articles

LLapa-Rodríguez EO, Oliveira JKA de, Menezes MO et al. Health professionals’ adhesion to...

English/Portuguese

J Nurs UFPE online., Recife, 12(6):1578-85, June., 2018 1578

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a230841p1578-1585-2018

HEALTH PROFESSIONALS’ ADHESION TO HAND HYGIENE ADERÊNCIA DE PROFISSIONAIS DE SAÚDE À HIGIENIZAÇÃO DAS MÃOS

ADHERENCIA DE LOS PROFESIONALES DE SALUD PARA LA HIGIENE DE LAS MANOS

Eliana Ofelia LLapa-Rodríguez1, Júlian Katrin Albuquerque de Oliveira2, Max Oliveria Menezes3, Luciana de Santana Lôbo Silva4, Daniel Marques de Almeida5, David Lopes Neto6

ABSTRACT

Objective: to analyze the adhesion to hand hygiene of health professionals who provide cancer care and its correlation with the variables professional category, indication, type of conduct and used input. Method: quantitative, cross-sectional study, with a sample of 1397 observation opportunities of the five moments of hand hygiene at a cancer hospital. Data were collected by means of a form and analyzed using Graph Pad Prism 5.0. Results: the overall adherence rate was 29%, classified as undesirable or tolerable, with higher rates for nurses. There were no significant differences between adhesion and category (p<0.0001), as well as in the five moments (p<0.0001). The moment “after exposure to bodily fluids” showed higher rates, predominating the use of water/soap. Conclusion: adherence to hand hygiene was classified according to Carter’s index as tolerable, outside the recommendations advocated by the World Health Organization. Descritores: Hand Hygiene; Patient Care Team; Patient Safety; Nursing Team; Oncology Service, Hospital; Quality Control.

RESUMO

Objetivo: analisar a aderência à higienização das mãos de profissionais de saúde que prestam assistência oncológica e sua correlação com as variáveis categoria profissional, indicação, tipo de conduta e insumo utilizado. Método: estudo quantitativo, de corte transversal, com amostra de 1397 oportunidades de observação dos cinco momentos de higienização das mãos em um hospital de oncologia. Os dados foram coletados por meio de um formulário e analisados pelo Graph Pad Prism 5.0. Resultados: a taxa de aderência global foi de 29%, classificada como indesejavel ou sofrível, com maior taxa para os enfermeiros. Houve significância entre a aderência e categoria (p<0,0001), bem como nos cinco momentos (p<0.0001). Observou- se maior taxa no momento “após exposição a fluidos corpóreos”, predominando o uso da água/sabão. Conclusão: a aderência à higienização das mãos foi classificada segundo o índice de Carter como sofrível, encontrando-se fora das recomendações preconizadas pela Organização Mundial de Saúde. Descritores: Higiene das Mãos; Equipe de Assistência ao Paciente; Segurança do Paciente; Equipe de enfermagem; Serviço Hospitalar de Oncologia; Controle de Qualidade.

RESUMEN

Objetivo: analizar la adherencia a la higiene de las manos de los profesionales de salud que proporcionan cuidados del cáncer y su correlación con las variables de la categoría profesional, indicación, tipo de conducta y de entrada utilizada. Método: estudio cuantitativo de corte transversal, con una muestra de 1397 oportunidades para la observación de los cinco momentos de la higiene de las manos en un hospital de oncología. Los datos fueron recolectados por medio de un formulario, y analizados mediante Graph PAD Prism 5.0. Resultados: la tasa global de cumplimiento fue del 29%, la cual fue clasificada como indesejavel u tolerable, con tasas más altas para los enfermeros. No hubo diferencias significativas entre la adherencia y la categoría (p<0,0001), así como en los cinco momentos (p<0,0001). Se observó una mayor tasa en el momento “después de la exposición a fluidos corporales”, predominando el uso de agua/jabón. Conclusión: la adherencia a la higiene de las manos se clasifica según el índice de Carter como tolerable, encontrándose fuera de las recomendaciones recomendadas por la Organización Mundial de la salud.Descritores: La Higiene de Manos; Equipo De Atención Al Paciente; Seguridad del Paciente; Grupo de Enfermeria; Servicio de

Oncología En Hospital; Control de Calidad. 1RN, PhD (Postdoc), Federal University of Sergipe/FUFES, Aracaju (SE), Brazil. E-mail: elianaofelia@gmail.com ORCID iD: http://orcid.org/0000-0002-2117-6051 2RN,Master, University of Tiradentes/UNIT. Aracaju (SE), Brazil. E-mail: julian.nespih@gmail.com ORCID iD: http://orcid.org/0000-0002-1041-7964; 3Nursing Especialist, University of Tiradentes/UNIT, Aracaju (SE), Brazil. E-mail: maxoliver19@hotmail.com ORCID iD: http://lattes.cnpq.br/5850995998660034; 4Nursing Especialist, Estacio Faculty of Sergipe/ FASE. Aracaju (SE), Brazil. E-mail: lucys_lobo@yahoo.com.br ORCID iD: http://orcid.org/0000-0002-8424-1551; 5RN, Federal University of Sergipe/UFS, Aracaju (SE), Brazil. E-mail: danielmarques.enfermagem@gmail.com ORCID iD: http://orcid.org/0000-0002- 3322-1892; 6RN, PhD, Federal University of Amazonas/PPGENF/UFAM. Manaus (AM), Brazil. E-mail: davidnetto@ufam.edu.br ORCID iD: http://orcid.org/0000-0002-0677-0853

ORIGINAL ARTICLE

LLapa-Rodríguez EO, Oliveira JKA de, Menezes MO et al. Health professionals’ adhesion to...

English/Portuguese

J Nurs UFPE online., Recife, 12(6):1578-85, June., 2018 1579

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a230841p1578-1585-2018

Hand hygiene (HH) is a simple action, with

significant impact and proven efficacy in the

prevention of healthcare-related infections

(HCRI), being considered an excellent

indicator of quality for patient safety.1

The World Health Organization (WHO)

estimates that, worldwide, HCRI affect one

every ten patients, and its their incidence is

more frequent in developing countries.

Approximately 19,000 health units, in 177

countries, support HH through health

campaigns, such as Save lives: clean your

hands.2

Historical facts mark the path of including

HH at health services, particularly regarding

the observation made in 1847 by the

physician Ignaz Philipp Semmelweis, which

related the reduction of parutients’ mortality

to health professionals using chlorine solution

for previous hand hygiene.3,4 In this

perspective, in 1854, during the Crimean

War, Florence Nightingale reduced the

mortality rates by adopting preventive

measures of washing professionals’ hands and

hygiene of patients and wards.4

In the biological field, the skin is colonized

by bacteria and fungi that heterogeneously

occupy different areas of the human body,

highlighting the hands of health professionals,

with an estimated concentration between 104

and 106 Colony Forming Units per cm2.4 Thus,

in order to reduce the microbial load and

prevent its transmission, sanitizing the hands

with soap and water or antiseptic becomes

essential, by means of degermation, simply

wash and antisepsis, applied to health care

practice,4-5 since hand hygiene prevents

cross-transmission of microorganisms present

in resident and transient microbiota.3

Even with the achievement of evidence

about the benefits of HH over time, the

professionals' adherence to this practice is

still incipient and in disagreement with the

guidelines recommended by the World Health

Organization, which may be expanding the

incidence of HCRI and, consequently, the

increase in mortality of children and adults,

and the elevation of health costs.1,3,6

In the United Uunidos of America, a study

conducted in 183 hospitals with 11,282

patients found that 4.0% of them presented

one or more healthcare-associated infections,

especially pneumonia (21.8%), infection of

the surgical site (21.8%) and gastrointestinal

tract (17.1%).7

In Brazil, in 2010, given the

epidemiological data on healthcare-

associated infections, the National

Epidemiological Surveillance Agency (Anvisa –

Agência Nacional de Vigilância

Epidemiológica) deployed the surveillance

system for primary bloodstream infections

associated with central venous catheter as a

starting point for subsequent release, in

2013, of the National Program for Prevention

and Control of HCRI, especially, in

compliance with the strategic action of hand

hygiene. 8

In contrast to the WHO recommendation

about the importance of handwashing in

health services, factors like time for

handwashing, lack of infrastructure and

inputs, skin irritation and inadequate human

resources dimensioning are considered

barriers to an effective accession to HH.9

Moreover, there is the weakness identified in

the formation process of health professionals,

ufavorable to the safety culture in healthcare

practices.10

The WHO, by considering HCRI a global

public health problem, in 2004, launched the

World Alliance for Patient Safety, whose Goal

5 - Reduce the risk of healthcare-associated

infections aims at increasing the quality of

health services. The following year, linked to

this alliance, the First Global Patient Safety

Challenge was created, with the theme Clean

Care is Safer Care, with the purpose of

preventing the transmission of pathogens

through hand hygiene promotion and

catalyzing global commitments and actions

for preventing and reducing infections.11

Contextualizing, in Brazil, regarding the

international scenario to reduce nosocomial

infections, the first initiatives related to

global challenges were implemented in 2007

by means of Multimodal Strategy to Improve

Hand Hygiene at Health Services11,

consolidated in 2013 with the launch of the

Patient Safety Plan at Public Services, which

introduced actions in risk management and

the five moments essential to HH.12

In this perspective, the Brazilian Ministry

of Health started to require the incorporation

of essential components to control HCRI,

considering the need for adhesion to HH as a

measure that prevents cross-transmission of

microorganisms. Not unlike that reality,

cancer services stand out due to their type of

clientele, with significant vulnerability to

pathogens13-14, bearing in mind that, in these

services, patients are submitted to multiple

diagnostic and therapeutic interventions that

prolong their stay in the hospital

environment.15 The exposure to biological

hazards, the presence of neutropenia,

radiotherapeutic treatment, use of

INTRODUCTION

LLapa-Rodríguez EO, Oliveira JKA de, Menezes MO et al. Health professionals’ adhesion to...

English/Portuguese

J Nurs UFPE online., Recife, 12(6):1578-85, June., 2018 1580

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a230841p1578-1585-2018

immunosuppressive drugs and antibiotics,

manipulation of catheters and surgical

procedures increase the risk for infections,

which demand a greater assistance by the

healthcare professional.16

In this respect, a national survey

conducted with 70,662 oncological patients

identified an overall rate of 8.24% of HCRI,

and the most affected topographies were

surgical site (26.11%), blood stream (24.11%)

and respiratory tract (18.50%). The same

study showed rates of lethality and mortality

associated with infection of 23.86% and

1.37%, respectively15, which demonstrates the

magnitude of the problem.

● To analyze the adhesion to hand hygiene

by professionals who provide cancer care and

its correlation with the variables professional

category, indication, type of conduct and

used input.

Quantitative, cross-sectional study, carried

out in the department of adult and pediatric

oncology of a reference hospital of Aracaju,

state of Sergipe, northeastern region of

Brazil.

The research sites were oncological units

that offer specialized and high-complexity

services for definitive diagnosis and

treatment of patients with neoplasms. The

hospital offers a multidisciplinary team

composed by physicians, nurses, nursing

technicians/assistants, physiotherapists,

dieticians, speech therapists, laboratory

technicians, social workers, and

psychologists. The physical structure of the

hospital unit consists of 39 beds; of these, 21

constitute the adult ward and 18 the

pediatric ward.

Regarding the infrastructure and

equipment necessary to perform the HH, in

the collection period, the pediatric unit had

an external sink in the nursing station, with

liquid soap and paper towel; the isolation bed

had a sink, a dispenser of alcohol-gel and

liquid soap and other wards had a dispenser

of alcohol-gel. The adult unit had two

external sinks with liquid soap dispensers and

paper towel, one in the corridor and the

other in the nursing station, the insulations

had sinks and dispensers of liquid soap.

The sample constitution considered the

observation opportunities of the five

moments of HH recommended by WHO

(before the contact with the patient, before

aseptic procedure, after body fluids, after

contact with the patient and after touching

the patient vicinity), carried out by

multidisciplinary teams of the selected units,

and the sample size calculation used the

criteria described in the HH manual

recommended by WHO. In addition, to ensure

the representativeness of the participants,

200 HH procedures should be observed for

each work shift, totaling 1200 opportunities

for both oncological units selected (adult and

pediatric), however, the present study

recorded 1397 actions involving the HH

procedure.5

Data collection occurred from December

2014 to December 2015, in three work shifts

(morning, afternoon and evening), by means

of non-participatory observation. The used

instrument the note form 34 of the Technical

Reference Manual for Hand Hygiene. There

was a previous training for both observers and

recorders of data regarding the recommended

five moments, as well as to the proper

completion of the search form. To fulfill this

purpose, the training material provided by

WHO was used.5

Methodologically, the observers remained

at each unit for two hours and during the

period of greater implementation of

activities. For this, a previous immersion was

performed at each unit, identifying the

routines and periods of increased activity in

each shift. The observers were positioned at

strategic points of the wards, without

disrupting the activities of the unit to observe

and record the opportunities for HH and the

type of action performed.

The professionals were randomly observed

in pre-defined moments according to the

research schedule, being the actions recorded

only when the professional had availability

and access to all supplies and materials

necessary for hand hygiene.

Data analysis used descriptive ana analytic

statistics, using Graph Pad Prism 5.0

software. For descriptive analysis, we

performed calculations of frequency and for

the analytical test, chi-squared (X²),

considering significant difference when p-

value<0.05. Furthermore, we used the

formula for calculating the adhesion

recommended by WHO, as follows:

Adherence (%) = Performed

actions/Opportunities X 100.

To determine the degree of conformity of

the evaluated process (hand washing), the

positivity index proposed by Carter was used,

which allows determining the conformity of

care practice in terms of quality, where:

100% of positivity represents a desirable

METHOD

OBJECTIVE

LLapa-Rodríguez EO, Oliveira JKA de, Menezes MO et al. Health professionals’ adhesion to...

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J Nurs UFPE online., Recife, 12(6):1578-85, June., 2018 1581

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a230841p1578-1585-2018

assistance; 90 to 99% adequate assistance; 80

to 89% a safe handling; 70 to 79% a borderline

assistance and less than 70% an undesirable or

tolerable assistance.17

The research protocol was approved by the

Research Ethics Committee of the Federal

University of Sergipe, CAAE n.

24183113.2.0000.5546.

There were recorded 1397 observations

involving hand hygiene, 780 (56%) in the

pediatric oncological unit and 617 (44%) in

the adult oncological unit. Among the actions

performed by professionals, 587 performed by

nursing technicians/assistants (42%); 339 by

nurses (24%); 242 by physicians (17%); 137 by

physiotherapists (10%) and 131 (7%) by other

health professionals (laboratory technicians,

nutrition technicias, nutritionists, social

assistants and psychologists).

The overall adhesion rate to the procedure

among the observed professionals was 29%

(407 actions), classified as an undesirable and

tolerable assistance. The highest rate (38%)

was for the category of nurses, with 129

actions and the lowest rate (10%) for the

category other professionals (nine actions),

there was a statistical difference between

the different categories (p <0.0001) regarding

adhesion to this procedure (Table 1).

Table 1. Adherence to hand hygiene among health care workers, stratified by professional category. Aracaju (SE), Brazil, 2015.

Professional category Hand hygiene adherence rate(%) p-value <0,0001*

Nurse 38 Physioterapist 36 Nurse assistant 30 Doctor 18

Others 10

*Statistically significant differences. Chi-square test was used to assess them.

Regarding the choice of conduct and input

for hand hygiene by professionals, of the 407

actions, 344 (85%) used soap and water, 63

actions (15%) used alcohol-gel, with a higher

proportion in medical category - 11 (25%) and

the use of soap and water in the category

physiotherapists - 45 (92%), without statistical

difference (p = 0.0995) between the

categories regarding used of hand hygiene

used (Table 2).

Table 2. Adherence to hand hygiene among health care workers, stratified by type of hand hygiene behavior and cleaning agent used. Aracaju (SE), Brazil, 2015.

Categoria Profissional Nº of HH actions

HH with alcohol gel HH with soap and water

n % n %

Nurse 129 17 13% 112 87% Doctor 44 11 25% 33 75%

Physioterapist 49 04 08% 45 92% Technician/Auxiliary 176 28 16% 148 84%

Others 09 03 33% 06 67% Total 407 63 15% 344 85%

HH: hand hygiene

Regarding the five moments for HH, the

largest adhesion of professionals was at the

time “after exposure to bodily fluids” and the

lowest at “after environments near the

patient”. The adhesion to the recommended

moments of HH was classified as undesirable

or tolerable; there was statistically significant

difference between the moments indicated

for HH and adhesion to the procedure

(p<0.0001) (Table 3).

Table 3. Adherence to hand hygiene among health care workers, according to the five moments. Aracaju (SE), Brazil, 2015.

Indicated moments for HH HH adherence rate (%) p-value < 0.0001*

1- before touching a patient 29 2- before clean/aseptic procedure 30 3- after body fluid exposure risk 41 4- after touching a patient 33 5- after touching patient surroundings 15

RESULTS

LLapa-Rodríguez EO, Oliveira JKA de, Menezes MO et al. Health professionals’ adhesion to...

English/Portuguese

J Nurs UFPE online., Recife, 12(6):1578-85, June., 2018 1582

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a230841p1578-1585-2018

Hand hygiene is the most effective

procedure to prevent and control assistance-

related infection.4 This practice should be

valued in the oncological services,

considering the immunodepression presented

by patients treated in this unit, as well as the

impact on morbidity and mortality.13

The data analysis allowed identitfying an

unwanted assistance, and consequent low

adherence to HH regarding the positivity

rate. There was a similar situation at a

teaching hospital in Paraná that presented an

adhesion rate of 26.5%.19 In consonance with

these studies, a North American university

hospital found rates between 23.5% and

27.1%, demonstrating that the variation in

rates of adherence was influenced by the

climate of the region.19

Studies on structural conditions mention

that low rates of professionals’ adhesion to

HH could be related to the unavailability of

inputs (alcohol-gel, soap, detergent and

paper towel), as well as lack of knowedlege

on recommendations, dermatological

allergies and lack of infrastructure, as the

main ones.18,20 Nevertheless, this justification

is different from this study, once the

observed professionals had total availability

of inputs, as well as this study did not

evaluate other factors and working

conditions.

Regarding the choice of conduct and inputs

for HH, the results indicate low compliance

with the practice of using alcohol gel,

corroborating surveys conducted in the

southeast and south regions of Brazil, which

showed, respectively, adhesion rates of 6.3%

and 12.5% for the use of alcohol gel and

water and soap. These results show that this

group of professionals preferred soap and

water as the best option for controlling

HCRI.3,18 In contrast, a study at a university

hospital in Turkey showed that 65% of the

nurses had preference for alcoholic antiseptic

solutions.21

Regarding the use of products for HH,

friction with alcohol gel 70% presents greater

effectiveness when compared to the use of

common or antiseptic soaps, considering as

positive points the short time for hygiene, the

input availability at the time of the

assistance, no need for special infrastructure

and good tolerability of the skin.4,20,22

As for the challenge proposed by the WHO

for adherence to HH practice in the five

moments, this study identified a higher rate

of adhesion after contact with body fluids,

which shows that health professionals often

perform hand hygiene as a form of selfcare,

which was also evidenced in other studies.18,23

Also regarding indication, according to

classification of five times, the touch on the

surfaces near the patient showed the lowest

rate found, a worrisome facwhich is

worrisome, considering the risk of

contamination and the possibility of

uncontrolled facilitator of dissemination of

microorganisms in the hospital environment.

However, in contrast, a study performed at

an intensive therapy unit, Rio Grande do Sul,

for this same indication, identified 49.1%

rate, greater than the one presented in this

study.23 In this respect, attention is called to

the fact that it shows that the professional is

aware of the risks related to contact with

blood and body fluids, different from the

attention given when it refers to the relative

risk to the surfaces near the patient,

emphasizing that the risk of infection is only

perceived when observed the imminent

danger involving biological material

potentially contaminated.

In relation to the professional categories

observed, all presented a rate of adherence

to HH lower than recommended by WHO,

highlighting the medical categories’ lowest

rates and the nurses with the highest rate. In

line with these findings, outcomes of a

Brazilian Child-Mother Hospital presented

rates of 39%, 27%, 33% and 23% for nurses,

nursing technicians, physiotherapists and

physicians, respectively.24 Nevertheless, the

southern region of the country showed

discordant results, with a higher rate among

physiotherapists (53.5%) and lower for the

nursing technicians/assistants (29.8%).23

The rate of adherence to hand hygiene by

healthcare professionals is outside of the

recommendations proposed by the WHO and

classified as undesirable or tolerable. The

main input used by professionals to perform

the HH procedure is the combination of soap

and water at the expense of alcohol-gel.

Among the five moments recommended,

the most used was the indication after

exposure to biological material, reflecting the

professionals’ concern with their safety. The

presented results alert the fragility presented

during the care provided to cancer patients in

the observed units.

In this context, there is need to develop

strategies for actions of service education

that ensure a safe and quality care. On the

other hand, one expects a proactive role by

CONCLUSION

DISCUSSION

LLapa-Rodríguez EO, Oliveira JKA de, Menezes MO et al. Health professionals’ adhesion to...

English/Portuguese

J Nurs UFPE online., Recife, 12(6):1578-85, June., 2018 1583

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a230841p1578-1585-2018

the teams of hospital infection control, in

order to provide the basic inputs for the

completion of the HH procedure, as well as

monitor and disseminate the adhesion by

health professionals to hand hygiene, since

this conduct represents a weakness in the

target institution of this study.

The evidence of a higher rate of adherence

to the HH by nurses, even below the

recommendations, is a positive factor,

considering that these professionals develop

their activities at health services with various

possibilities of contacts with different

patients, which makes collaborative agents in

change of culture concerning the patient

safety for incorporation of HH, as indicated

by the WHO.

Despite being a simple procedure, the

adhesion to the HH is still a challenge for the

managers of health services. Therefore, it is

necessary to build managerial strategies that

stimulate the participation of the

multiprofessional healthcare team in building

a safety culture that guarantees a risk-free

assistance.

Finally, we hope that this study stimulates

reflection on the importance of hand hygiene

and deployment of multimodal strategy,

especially in oncological services. This study

examined the professionals’ adhesion to the

HH, awakening to the need for other studies

that seek to assess the potential barriers for

large adhesion to the HH and coping with the

problems related to healthcare-related

infections.

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Acessibilidade da estrutura física hospitalar

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Anna Nery. 2013;17(2):220-6. Doi:

10.1590/S1414-81452013000200003

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care without avoidable infections The critical

role of infection prevention and control.

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REFERENCES

LLapa-Rodríguez EO, Oliveira JKA de, Menezes MO et al. Health professionals’ adhesion to...

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ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a230841p1578-1585-2018

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LLapa-Rodríguez EO, Oliveira JKA de, Menezes MO et al. Health professionals’ adhesion to...

English/Portuguese

J Nurs UFPE online., Recife, 12(6):1578-85, June., 2018 1585

ISSN: 1981-8963 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a230841p1578-1585-2018

Submission: 2017/11/14 Accepted: 2018/04/23 Publishing: 2018/06/01

Corresponding Address

Eliana Ofelia LLapa-Rodríguez Departamento de Enfermagem Rua Cláudio Batista, s/n Bairro Cidade Nova

CEP: 49060-108 − Aracaju (SE), Brazil

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