Knowledge levels of medical students about hand hygiene

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2 ORiginAl ARticle Knowledge levels of medical students about hand hygiene Dattatreya Prabhakumar, Murali Chakravarthy 1, Shruthi Nayak 2, Rajathadri Hosur 2, Sumant Padgaonkar 2, Chidanannda Harivelam 2, Ashwin Bharadwaj 2 Consultant Anesthesiologist, Fortis Hospitals, 2 Research Fellow, Fortis Hospitals, Bannerghatta Road, 1 Department of Anesthesia, Critical Care, Pain Relief and Infection Control, Fortis Hospitals, Bangalore, Karnataka, India Address for correspondence: Dr. Murali Chakravarthy, Department of Anesthesia, Critical Care, Pain Relief and Infection Control, Fortis Hospitals, Bannerghatta Road, Bangalore, Karnataka, India. mailchakravarthy@gmail. com Access this article online Website: DOI: / Quick Response code: Abstract Introduction: Hand hygiene is one of the least expensive easy to train procedure which can sub substantially decrease hospital associated infections. Healthcare workers perhaps are the major contributors to health care associated infection by their non compliance to this simple practice. It is important that knowledge and training about this preventive measure be inculcated during the training of healthcare workers. Training of young medical students is undoubtedly an important pivot to ensure reduction in hospital associated infections. Aim: A survey regarding hand hygiene practices among medical students was conducted with an aim to find out the knowledge and practices of the students regarding hand hygiene during their interaction with patients and their routine hospital visits. Methods: An electronic survey using survey monkey was conducted in a medical college in the city of Bengaluru to assess the knowledge levels of medical students. Medical students of all the years of education were included. Full fledged doctors were excluded from participation. Results: Our results suggest that knowledge regarding hand hygiene is sub optimal among the students (40%) and the compliance is low (63%) as a consequence of non availability of hand rubs at various locations. Theoretical knowledge among the medical students was high. More than 70% knew that the gloves cannot be replacement of hand hygiene. But the other details of the procedure of hand hygiene, were not known to them. Only 44% of the respondents an swered that 10 seconds contact time with an alcohol, 29% answered it as 20 seconds, 23% an swered as 1 minute and 4% answered 3 seconds. These data suggest that the medical institu tions must taken upon themselves to train the prospective doctors in this vital, life saving simple. Conclusion: The knowledge levels of medical students about hand hygiene is far below expecta tions; the administrators should take upon themselves to include this topic in the educational curriculum. Key words: Hand hygiene, medical students, survey INTRODUCTION Health care-associated infections (HAIs) are major concern areas for health care workers. We have now reached a point where bugs are resistant to most available antibiotics and sadly there are no newer antibiotics in the pipeline. This leads us to a catch 2 situation where a smart health This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: reprints@medknow.com How to cite this article: Prabhakumar D, Chakravarthy M, Nayak S, Hosur R, Padgaonkar S, Harivelam C, et al. Knowledge levels of medical students about hand hygiene. J Nat Accred Board Hosp Healthcare Providers 2016;3: The Journal of National Accreditation Board for Hospitals & Healthcare Providers Published by Wolters Kluwer - Medknow

3 care worker would aim to effectively prevent infection rather than despair without appropriate treatment for HAIs. A simple yet effective intervention measure to prevent and reduce these infections is hand hygiene. [1,2] Poor hand hygiene has been linked to HAIs, which cause increased morbidity, mortality, and costs. [2] In developing countries, the prevalence of hand hygiene-associated infections has been found to be as high as 19%. [3] It is commonly observed that in a health care setup, nurses are the most compliant to the practice of hand hygiene; in contrast, the doctors are usually less compliant. [4] In order to improve compliance of the doctor community, medical students ought to be sensitized with aspects of infection control in medical school itself, with the hope that they understand and comply with infection-related issues when they start to practice. Medical students are trained with the intention to make them competent physicians. Similar to other health care workers, medical students are vulnerable to HAIs and occupational hazards during their training and occupation. Their knowledge, attitude, and performance in this period are a cornerstone for their performance in the future. Hand hygiene is one such critical behavior, which requires their attention, in order to prevent HIAs. Despite the importance attributed to hand hygiene in the literature, [5] physician compliance is abysmally low (range: 5 89%; average: 38.7%); [6] however, the presence of a mentor might help change attitudes toward hand hygiene practices and policies. [7] The aim of this study was to identify the level of knowledge and gaps in attitudes and practices in hand hygiene among medical students. The results may help explore the effectiveness of hand hygiene training modules for undergraduate medical students and thus, help improve existing training programs and enhance good hand hygiene practices in the future while they practice medicine. MATERIALS AND METHODS This cross-sectional study was conducted from November 2015 to December The study participants included students in the first, second, third, and final year undergraduate and postgraduate medical students at Bangalore Medical College, Bengaluru, Karnataka, India. The survey questions were sent using the Internet-based survey instrument, survey monkey [Annexure 1]. A total of 300 survey forms were sent and 221 medical students responded. The questionnaire tested their knowledge and practices regarding hand hygiene routinely followed by them during patient care and visits to the hospital. The reasons for poor compliance at the individual and institutional levels were also assessed. Statistical methods The information obtained from the questionnaires was entered and analyzed using Microsoft Excel. The analysis was performed Table 1: The results in terms of descriptive statistics, and associations between variables were tested using Chi-square test. The values were mentioned as mean ± standard deviation (SD). RESULTS About 66% of the students responded to the survey. The results of the study can be seen in Table 1. The students belonged to the first, second, third, and final year undergraduate and postgraduate years in medical school. First year undergraduates had no exposure to patients or patient care. Second year and third year undergraduates had about h of patient exposure. Final year students had about h of exposure to patients on a daily basis. Postgraduate students had the maximum exposure to patients. Among the 221 students: - 53% were female respondents and 47% male. - Only 40% of the respondents had received any kind of formal training in hand hygiene and almost every respondent agreed that medical students need to trained in hand hygiene. - 63% of the respondents routinely used alcohol-based hand rub in their clinical rotations and patient care. - 75% of the respondents correctly answered that gloves were not a substitute for hand hygiene. - 44% of the respondents answered that 10 s contact time with an alcohol-based hand rub was essential to kill most germs, 29% answered it to be 20 s, 23% answered it to be1 min, and 4% answered it to be 3 s. - 48% of the respondents answered that 3 ml was the minimum amount of alcohol-based hand rub essential to kill all germs, 30% answered it to be 5 ml, 19% answered 1 ml, and 3% answered it to be 15 ml. - 69% of the respondents felt that the patient visitors had no access to alcohol-based hand rubs. - A majority of the respondents answered that the hands had to be dry before care. DISCUSSION Result Male:Female 117:84 Trained in hand hygiene? Y/N 88:133 Have used alcohol for hand hygiene Y/N 55:33 Gloves are not replacements for hand hygiene Y/N 165:56 Time taken for hand hygiene is 10 s Y/N 96:125 Amount of alcohol required for hand hygiene is 3 ml Y/N 108:113 Visitors have access to hand hygiene Y/N 152:69 An Internet-based survey was conducted among medical students. The response was more than 60%. It was heartening to know that the theoretical knowledge level of the medical The Journal of National Accreditation Board for Hospitals & Healthcare Providers Jan-Jun 2016 Vol 3 Issue 1 28

4 students was adequate but teaching and training in the process of hand hygiene was lacking. It is extremely important for all health care workers to know the accurate process and method of hand hygiene. It may be inferred that if hand hygiene is not taught in the curriculum of medical students, other aspects of infection control, appropriate antibiotic use, sterilization, disinfection, isolation precautions, personal protective equipment, and protection from sharp injuries may also not be known to them. This survey exemplifies the lack of teaching about infection-related parameters in medical schools in India. Based on this observation, it is high time that educationalists include these topics for medical students in the third year of their education so that when they commence their clinical postings, they know the appropriate processes. In developed countries, HAIs concern 5 15% of patients and 9 37% of patients admitted in intensive care units. [8,9] Patients can be exposed to a variety of exogenous microorganisms from other patients, health care personnel, or visitors. The patient s endogenous flora and contaminated inanimate environmental surfaces or objects also add to the risk of developing hospital-associated infections. [10] The established indications for hand hygiene have been summarized in guidelines published by the Centers for Disease Control and Prevention (CDC), [11] which call for hand washing (a) before performing invasive procedures; (b) before taking care of particularly susceptible patients; (c) before and after touching wounds, whether surgical, traumatic, or associated with an invasive device; (d) after situations during which microbial contamination of hands is likely to occur; (e) after touching inanimate sources that are likely to be contaminated with virulent or epidemiologically important microorganisms; (f) after taking care of an infected patient or one who is likely to be colonized with microorganisms of special clinical or epidemiological significance; and (g) between contacts with different patients in high-risk units. Ensuring compliance with hand hygiene is a daunting task. In spite of various initiatives such as the World Health Organization s (WHO) Five Moments for Hand Hygiene [12] the compliance with hand hygiene is low among physicians and other health care workers. [6,13] Interventions and the presence of a mentor are known to improve hand hygiene practices. [7] Pitted et al. [14] monitored the overall compliance with hand hygiene during routine patient care in a teaching hospital in Geneva, Switzerland, before and during the implementation of a hand hygiene campaign from December 1994 to December Compliance improved progressively from 48% in 1994 to 66% in 1997 with a reduction in nosocomial infections and methicillin-resistant Staphylococcus aureus transmission. Apart from the hand hygiene education, promotion of bedside antiseptic hand rubs contributed to the increase in compliance. Similar results were found in Argentina when educational initiative to promote hand hygiene was introduced between September 2000 and May [15] The most common reason for non compliance was receiving patient care as priority over the procedure of hand hygiene. Irritation of the skin due to the hand rub and forgetfulness were quoted as other reasons among healthcare workers. [16] Apart from educational initiatives to improve compliance to hand hygiene, other factors that could help improve compliance include available low irritating hand hygiene agents, information of current nosocomial infection rate, and easily accessed hand hygiene supplies. [16] Our study has shown that even though a majority had not received any training regarding hand hygiene, 62.6% routinely used hand rubs. 24.9% believed that glove use obviated the need for hand hygiene. There are numerous initiatives that are undertaken on a war footing to improve compliance with hand hygiene. My Five Moments for Hand Hygiene have identified when it is critical for hand hygiene to be performed. My Five Moments for Hand Hygiene describes fundamental reference points for health care workers in a time-space framework and designates the moments when hand hygiene is required to effectively interrupt microbial transmission during the care sequence. These include before touching a patient, before a procedure, after a procedure or body fluid exposure, after touching a patient, and after touching a patient s surroundings. [17,18] There are four components [19-23] of an effective hand hygiene training and teaching program. Glove use is a mandatory part of a hand hygiene program as proper glove use is linked to effective hand hygiene. These include 1. Clinical staff, including new hires and trainees, understand the key elements of hand hygiene practice (demonstrate knowledge) 2. Clinical staff, including new hires and trainees, use appropriate techniques when cleansing their hands (demonstrate competence) 3. Alcohol-based hand rub and gloves are available at the point of care (enable staff) 4. Hand hygiene is performed at the right time and in the right way and gloves are used appropriately as recommended by the CDC s standard precautions (verify competency, monitor compliance, and provide feedback). Teaching and promoting hand hygiene should be a continuous process. There are numerous educational materials available such as posters, PowerPoint slides, videos, and self-assessment programs to help percolate knowledge about hand hygiene. [24] Hospitals should be encouraged to provide alcohol-based hand rub at the entrances to chambers and offices, lifts and wards, and at the foot end of the patient bed in order to encourage visitors and patient caregivers to perform hand hygiene and aid in the prevention of the transmission of infection to patients. 29 The Journal of National Accreditation Board for Hospitals & Healthcare Providers Jan-Jun 2016 Vol 3 Issue 1

5 We have shown that the increase in the utilization of alcohol for hand hygiene and tissue paper pulls were inversely proportional to the HAI rate. [25] While mobile technology has improved our daily lives on many levels, it has profoundly raised the quality of life for many. Health care is an area that has embraced mobile technology, and while it is still in the infancy of adoption of this technology, it is already making profound improvements for many. iscrub [26] is a free application available in the Apple app store, which helps enter electronically on whether a health care worker has performed hand hygiene. iscrub does not measure all of the Five Hand Hygiene Moments of Opportunity of WHO. Hand Hygiene Australia has created a similar application HHCApp, which is accessible via any mobile device. Hand hygiene compliance data collected through direct observation according to Five Hand Hygiene Moments of Opportunity of WHO can be entered in real time and uploaded to the secure database and analyzed. [27] In our study, 48% replied that a minimum of 3 ml alcohol-based hand rub was essential for killing germs, 30% replied it to be 5 ml, 19% replied it to be 1 ml, and 3% felt that 15 ml was required. In our study, 44% replied a contact time of 10 s was essential to kill most germs on their hands, 29% replied it to be 20 s, 23% replied it to me 1 min, and 4% replied it to be 3 s. CDC guidelines show a minimum of 3 ml alcohol-based hand rub with a contact time of 15 s with the hands being dry. [28] A shorter application time in hand disinfection without any reduction of efficacy is easier to comply with. The required time will be shorter, which can have a positive effect on the unknowing attitude of health care workers toward performing a hand disinfection procedure. [29,30] In our study, 25% replied that the use of gloves replaced hand hygiene. The use of gloves does not completely protect against contamination of the hands. Doebbeling et al. [31] put different microorganisms on gloved hands; they were able to isolate the same microorganisms on the skin after removal of the gloves that were placed on the gloved hands. Therefore, hand hygiene is necessary even after the use of gloves. [32] CONCLUSION Hand hygiene is one of the easiest, fastest, and cheapest strategies to reduce hospital-associated infections and the spread of antimicrobial resistance. The study has shown a lack of quality training and compliance regarding hand hygiene among medical students. Hence, it should be given a higher priority in the medical curriculum by conducting training sessions more frequently and encouraging them to follow correct hand hygiene practices at the undergraduate level itself to inculcate a patient safety culture among the future doctors. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. REFERENCES 1. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000;356: Conly JM, Hill S, Ross J, Lertzman J, Louie TJ. Handwashing practices in an intensive care unit: The effects of an educational program and its relationship to infection rates. Am J Infect Control 1989;17: Trampuz A, Widmer AF. Hand hygiene: A frequently missed lifesaving opportunity during patient care. Mayo Clin Proc 2004;79: WHO: The Burden of health care-associated infection worldwide. A summary. Available from: summary_ _en.pdf. [Last accessed on 5. Public Health Ontario, Just Clean Your Hands Your 4 Moments for Hand Hygiene, Public Health Ontario, Ontario Agency for Health Protection and Promotion, World Health Organization. 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6 train, monitor and report hand hygiene. J Hosp Infect 2007;67: Pittet D, Dharan S, Touveneau S, Sauvan V, Perneger TV. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Intern Med 1999;159: Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/ Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 2002;51:1-45, quiz CE Widmer AE, Dangel M. Alcohol-based handrub: Evaluation of technique and microbiological efficacy with international infection control professionals. Infect Control Hosp Epidemiol 2004;25: Hugonnet S, Perneger TV, Pittet D. Alcohol-based handrub improves compliance with hand hygiene in intensive care units. Arch Intern Med 2002;162: WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary. World Health Organization; Available from: [Last accessed on 24. Available from: [Last accessed on 25. Chakravarthy M, Adhikary R, Gokul B, Pushparaj L. Hospital acquired infection is inversely related to utilization of isopropyl alcohol and tissue paper pulls A prospective observational study. J Assoc Physicians India 2011;59: Hlady CS, Severson MA, Segre AM, Polgreen PM. A mobile handheld computing application for recording hand hygiene observations. Infect Control Hosp Epidemiol 2010;31: Available from: hhcappwho.aspx. [Last accessed on 28. Kampf G, Hollingsworth A. Comprehensive bactericidal activity of an ethanol-based hand gel in 15 seconds. Ann Clin Microbiol Antimicrob 2008;7: Pittet D. Improving adherence to hand hygiene practice: A multidisciplinary approach. Emerg Infect Dis 2001;7: Voss A, Widmer AF. No time for handwashing!? Handwashing versus alcoholic rub: Can we afford 100% compliance? Infect Control Hosp Epidemiol 1997;18: Doebbeling BN, Pfaller MA, Houston AK, Wenzel RP. Removal of nosocomial pathogens from the contaminated glove. Implications for glove reuse and handwashing. Ann Intern Med 1988;109: Janota J, Šebková S, Višňovská M, Kudláčková J, Hamplová D, Zach J. Hand hygiene with alcohol hand rub and gloves reduces the incidence of late onset sepsis in preterm neonates. Acta Paediatr 2014;103: Annexure 1: The Questionnaire 1. Gender 2. Age in years 3. Which year of medicine are you currently studying? 4. Does the use of gloves replace hand hygiene? Yes/No 5. Have you received formal training in hand hygiene? Yes/No 6. Do you think it is necessary for medical students to be trained in hand hygiene? Yes/No 7. Do you routinely use an alcohol hand rub for hand hygiene? Yes/No 8. What is the minimal time needed for alcohol-based hand rub to kill most germs on your hands? 3 s/10 s/1 min/20 s 9. What is the minimum amount of alcohol-based hand rub to kill most germs on your hands? 1 ml/3 ml/5 ml/15 ml 10. Which of the following statements are true? Hands have to be dry before care/your hand should be dripping with alcohol/you can dry hands with a towel after using the hand rub 11. Are alcohol-based hand rubs easily available to patient visitors and attendants? Yes/No 31 The Journal of National Accreditation Board for Hospitals & Healthcare Providers Jan-Jun 2016 Vol 3 Issue 1