Abstract

A significant number of patients acquired health care associated infections worldwide, and this has devastating effect on both the patient and the health system. Although they disseminated easily between patients through health-care workers contaminated hands, they are preventable infections. Hand hygiene including hand washing and alcohol based hand rub is the most effective method of prevention. We aimed, in this study, to evaluate the effect of educational activity in improving participants' knowledge about infection control. Ninety seven recent medical graduates with a mean age of 23.8 years attended workshop that included both lectures and practical sessions regarding various aspects of infection control. Hand hygiene was practiced in one station according to WHO guidelines, and was emphasized in all stations as a fundamental pre-requisite. WHO’s “Hand Hygiene Knowledge Questionnaire” was used to assess the knowledge both before and after the educational session. Data was analyzed using SPSS statistics version 22, and McNemar test was used to compare participant's knowledge pre and post session. The majority (61.9%) of them did not receive formal training in hand hygiene. The knowledge about hand hygiene improved considerably after the workshop, this is reflected by a significant p value (< 0.05) in 12 out of 24 knowledge related items tested (50%). Adding more clinical scenarios to stress on the practice of infection control measures contributed well to the effectiveness of the workshop in improving the knowledge. In conclusion, conduction of educational sessions that include simulated activity can be very useful to bridge the knowledge gap, as well as carrying out continuous feedback and analysis of outcome to improve the quality of educational activity.

1. Introduction

About 15 % of hospitalized patients suffer from healthcare associated infection (HCAI) ¹ furthermore, 26,250 deaths can be directly related to this type of infection ². In 2002 there was roughly 1.7 million of hospital acquired infections according to national nosocomial infections surveillance ³. Blood stream associated infection increased the length of stay in surgical intensive care unit from 30 to 54 days and average of $ 40 000 extra cost per survivor ⁴. Hand hygiene is the most effective measure in prevention of dissemination of infectious diseases ⁵ and reduction of nosocomial infection ⁶. Regarding financial benefit of hand hygiene, every 1 USD paid out for hand hygiene promotion might result in US$ 23.7 benefit ⁷, on another hand 1% rise in hand hygiene compliance would save US$ 39,650 annually ⁸.

Hand hygiene includes hand washing with medicated soap and alcohol based hand rub, both contains antiseptic ingredients that are able to kill microorganisms. Hand washing is usually used when hands are visibly dirty. Alcohol based hand rub is considered to be highly effective, fast and cause less dryness in compare to washing, using only 2 to 3 ml of solution that contains 75%- 85% alcohol for 20 to 30 second is enough to kill the transient flora and prevent its transmission. Health care providers should perform hand hygiene at the five moments as recommended by WHO and also whenever they move between health care zone and patient zone ^{9, 10, 11}.

Application of infection control measures lead to a significant reduction in MRSA bacteremia in acute hospitals ¹². Moreover, an increase in hand hygiene per patients using both soap and alcoholic hand rub had major effect in reduction of both MRSA and Colistridium difficile infection in some hospitals by nearly 50% ¹³. One of the factors that reduce hand hygiene is lack of knowledge of hand hygiene guidelines, unawareness about risk of transmission of infection between patients and inability to detect moments of hand hygiene during patients care ¹⁴. Health care associated infections have bad consequences such as prolongation of hospital stay; prolong disability, financial burden on both the health system and the patient and increase resistance to drugs. Furthermore, it can result in emotional stress to the patients and their families ¹⁵.

Transmission of health care associated infection (HCAI) can occur through various methods but the spread through healthcare workers' contaminated hands is by far the most common way. Those organisms can survive for several minutes, so omission, inadequate hand hygiene or use of wrong agents can result in transmission of organisms between healthcare workers and patients. Regarding hand hygiene improvement, WHO designed tools and strategies including regular educational sessions on the importance of hand hygiene and the correct technique based on the five moments of hygiene ¹⁵. The best way is through active education with demonstration of the right techniques and observation of the practice ¹⁶. Moreover, continuous monitoring of hand hygiene knowledge and practice is needed ¹⁵. Many studies found that hand hygiene knowledge among medical students is inadequate and a structured educational program is required ^{17, 18}. More researches are needed to determine the specific effect of each component of those strategies in reduction of HCAI, so that the most effective one can be used in low resource area ¹⁹.

The aim of this study was to evaluate the effect of the educational session in improvement of knowledge about hand hygiene among recent medical graduates.

2. Methods

An infection control workshop including hand hygiene section was conducted once in October 2017. The workshop program included didactic lectures describing the burden of HCAI; standard precautions; concepts of basic disinfection and sterilization and post exposure prophylaxis for healthcare providers. These were followed by practical stations demonstrating and discussing: 1) hand hygiene technique and application in the right context; 2) implementation of urinary catheter bundles; 3) implementation of central venous catheter bundles and 4) prevention of surgical site infection.

Ninety-seven recent medical graduates participated in this workshop. Hand hygiene was practiced in one station according to WHO guidelines, and was emphasized in all station as a fundamental pre-requisite.

The knowledge about hand hygiene for each participant was assessed using WHO’s “Hand Hygiene Knowledge Questionnaire”, both before and after the educational session.

Data was analyzed using SPSS statistics version 22 and McNemar test was used to compare students' knowledge about hand hygiene before and after the educational intervention.

The proposal of this study was approved by Soba Center for Audit and Research (SCAR).

3. Results

The participants were 97 recent medical graduates, with mean age of 23.8 years old. 87 (89.7%) were female and only 10 (10.3%) were male. Of them 61.9% did not received formal training in hand hygiene in the last three years while only 43.3% claimed that they use alcohol based hand rub routinely. Table 1 and Table 2 show the percentage of the participates choosing a particular answer for each item of the questionnaire which were filled before or after undertaking the educational session, in addition to the p values for each item.

Several areas of knowledge probed for by the questionnaire were found to be significantly affected by the session. Out of a total of 24 knowledge related items tested for using the questionnaire, 12 (50%) were significantly affected by the educational session (p < 0.05). The significant effects of the workshop were found to be in the knowledge about the main route of transmission of germ between patients, prevention of germ transmission to the patient by hand disinfection after exposure to the immediate patient's surrounding and immediately before a clean aseptic procedure, prevention of germ transmission to the health-care workers by hand disinfection immediately after a risk of body fluid exposure and before a clean aseptic procedure, hand rubbing is more rapid for hand cleaning than hand washing, hand washing and hand rubbing are not recommended to be performed in sequence, minimal time required to kill most germs on hands, type of hand hygiene method required before giving an injection and after making a patient bed and most common healthcare associated infection. All data listed in (Table 1 and Table 2).

4. Discussion

Several studies were conducted to illustrate the effect of education workshop on improvement of the knowledge level. Bush‐Knapp ME et al, reported a significant effect of workshop on knowledge about health care associate infection and antimicrobial resistance among members who attend the session ²⁰, similar results were found in double-blind randomized control trial done by Cheng GY et al, they found that training education including supervised practice is more effective than no training in raising the awareness and performance of evidence based searching among clinicians ²¹. We aimed in this study to assess the effect of simulation education session on improvement of knowledge about hand hygiene among recent medical graduates.

The majority of participants (61.9%) did not receive proper training and only 43.3% used alcohol based hand rub in routine manner, unlike study conducted by Modi PD et al, among medical students in India which showed that although 57% of them did not get any formal training, a significant portion of 71.9% responded that they use alcohol based hand rub routinely ²². We wonder if the higher use of alcohol rub is related to cultural factors. We noticed that some healthcare providers use alcohol rub after they finish their medical task only. This may represent self-centered practice to protect themselves. The percentage of participants who knew that unclean health care workers hands is a main route of transmission of germ between patients increased from 43.3% to 56.7% after the session, with significant improvement of their knowledge (P= 0.005). While only 27% of medical students in study done in India knew that fact ²².

We found a significant impact of workshop on enhancement of medical graduate's knowledge about prevention of germ transmission to the patient by hand disinfection after exposure to immediate patient's surroundings (P =0.043), before a clean aseptic procedure (P= 0.009), prevention of germ transmission to the health-care worker by hand disinfection immediately after a risk of body fluid exposure (P =0.008) and also before a clean aseptic procedure (P =0.041). All these components were demonstrated in the educational program by scenarios and asking participant to tackle specific tasks.

Strong association between conduction of education session and improvement of knowledge was also found in related to the awareness about advantage of hand rubbing as faster method of disinfection in compare to hand washing (P= 0.0001) as only 20 seconds needed to kill most of germs on hands (P= 0.001). And the fact that they are not necessary to be done in sequence (P= 0.001). In study done by Modi PD et al, among medical students only 36.1 % were aware of the time required to kill the germs ²². Furthermore ,before the workshop 62.1% of participants responded that hand washing is required before giving an injection but this corrected after the session with 61.3% reported that hand rubbing is the preferred method (P= 0.001). Similarly a significant impact was obvious in knowledge about using of rubbing after making patient's bed (P=0.016). Many studies illustrated that education sessions are recommended to improve the practice of health care workers and students; including clear instruction that hand hygiene is easiest and most effective method to decrease HCAI, ^{23, 24, 25}.

It worth noting that the proportion of medical graduate who knew that catheter associated UTI is most common health-care associate infection considerably increased from 41.6% before to 58.4% after the session with p value of 0.0001. Moreover, a significant impact was seen on participant's knowledge level about handling of collecting bags for patients with urinary catheter (P= 0.024). A study done in Cambodia among health-care workers by Conducting lectures and practice on hand hygiene, resulted in significant reduction of HCAI after one year or more of hand hygiene compliance, mainly among health workers of general, surgical and infection department ²⁶.

On another hand although there was increase in number of medical graduate who became aware about use of hand disinfection immediately after exposure to body fluid to prevent cross transmission between the patients and after touching patients and their surroundings to prevent transmission to health-care workers, there was no significant effect on the knowledge (P> 0.05) while there was declining in number of participants after the session who reported about most common source of germs responsible for HCAI, advantages of hand rubbing as more effective and causes less dryness than hand washing and using of hand washing as method of disinfection after removing of examination gloves. The effect of educational intervention on knowledge about previous items was also found to be insignificant (P> 0.05). A randomized control trial done by Jansson et al, among critical care nurse with repeated assessment of knowledge and adherence to hand hygiene guidelines after single simulation education session showed that it had no effect on their knowledge about hand hygiene ²⁷.

We conducted a similar workshop in September 2017 among health care workers, using same content of the lectures. In the practical sessions we demonstrated the technical components of hand hygiene. Assessing the outcome reflected insignificant effect of the educational session on the participant's knowledge level in almost all tested items. In this session we revised the practical stations by adding more scenarios reflecting the context of clinical practice. It is interesting to see that knowledge about hand hygiene among recent medical graduate improved considerably. This is reflected by a significant p value in 12 out of 24 items tested (50%). Feedback and analysis of outcome of educational activity is a very helpful tool in improving educational activity.

5. Conclusion

Hand hygiene is most effective method to decrease the number of patients who develop nosocomial infections, and bridging knowledge gap related to hand hygiene is essential to achieve adequate practice. Conduction of educational sessions that include simulated activity can be very useful in improving the knowledge level and continuous assessment and analysis of the outcome is needed to improve the quality of the sessions itself.

References