Summary
Introduction: Hand hygiene is one of the most effective infection control measures to prevent the spread of healthcare-associated infections (HCAI). Water, soap, paper towel and hand disinfectant must be available and adequate in terms of effective hand hygiene. The adequacy of hand hygiene products or keeping water-soap and paper towel is still a problem for many developing countries like Turkey. In this multicenter study, we analyzed the adequacy in number and availability of hand hygiene products.
Materials and Methods: This study was performed in all intensive care units (ICUs) of 41 hospitals (27 tertiary-care educational, 10 state and four private hospitals) from 22 cities located in seven geographical regions of Turkey. We analyzed water, soap, paper towel and alcohol-based hand disinfectant adequacy on four different days, two of which were in summer during the vacation time (August, 27th and 31st 2016) and two in autumn (October, 12th and 15th 2016).
Results: The total number of ICUs and intensive care beds in 41 participating centers were 214 and 2357, respectively. Overall, there was no soap in 3-11% of sinks and no paper towel in 10-18% of sinks while there was no alcohol-based hand disinfectant in 1-4.7% of hand disinfectant units on the observation days. When we compared the number of sinks with soap and/or paper towel on weekdays vs. weekends, there was no significant difference in summer. However, on autumn weekdays, the number of sinks with soap and paper towel was significantly lower on weekend days (p<0.0001, p<0.0001) while the number of hand disinfectant units with alcohol-based disinfectant was significantly higher (p<0.0001).
Conclusion: There should be adequate and accessible hand hygiene materials for effective hand hygiene. In this study, we found that soap and paper towels were inadequate on the observation days in 3-11% and 10-18% of units, respectively. Attention should be paid on soap and paper towel supply at weekends as well.
Introduction
The frequency of hand washing or alcohol-based hand disinfectant use is affected by the availability of hand hygiene products[2, 4-6]. Water, soap, paper towel and hand disinfectants must be available and adequate for effective hand hygiene. The adequacy of hand hygiene products and/or keeping adequate water, soap and paper towel is still a problem for developing countries like Turkey. In this multicenter study, it was aimed to analyze the adequacy and availability of hand hygiene products in intensive care units (ICUs) in Turkey.
Methods
The total number of ICUs and intensive care beds were 214 and 2377, respectively. Medical ICUs were the majority of the ICUs in the participating centers (number of medical ICUs: 142, number of surgical ICUs: 49 and general (non-spesific) ICUs: 23).
The planned study was announced in the Infectious Diseases and Clinical Microbiology Specialty Society of Turkey mail communication group and all sites that accepted the invitation were included in the study. Study contributors from each site collected the data in a standard form by visits to ICUs in their center on the study dates. We analyzed via these forms the adequacy of water, soap, paper towel and alcohol-based hand disinfectant on four different days [two of which were in summer during the vacation time (August 27 and 31, 2016) and two others in autumn (October 12 and 15, 2016)]. All participants sent their data on Excel and Word formatted forms via e-mail.
Statistical Analysis
There was no need for patient consent or approval of the ethics committee since no personal or medical information about the patients was used.
Statistical analysis was performed via SPSS 24.0 package program. A chi-square test was used for comparison of the number of sinks with water and/or paper towel on week days vs. weekends in summer and autumn. A p value of less than 0.05 was considered statistically significant.
Results
When we compared the number of sinks with soap and/or paper towel on weekdays vs. weekends, there was no significant difference in summer (Table 1). However, on autumn weekdays, the number of sinks with soap and paper towel was significantly lower on weekend days (p<0.0001, p<0.0001). There was no significant difference in the number of units with alcohol-based disinfectant between summer weekdays vs. weekend. However, the number of units with alcohol-based hand disinfectant was significantly higher (p<0.0001) on weekend days in autumn (Table 1, 2).
Discussion
In a study performed at Ege University Hospital in 2004, hand hygiene compliance rates in nurses and doctors were 3.9% and 3.2%, respectively[9]. Studies suggest that hand hygiene compliance rates increased during the last decade. In another study from a tertiary-care university hospital in Istanbul, the rate of hand hygiene compliance was 37% (nurses, 41.4%, and doctors, 31.9%) in 2013[10]. Hand hygiene observation is being performed mandatorily by the enforcement of the Turkish Ministry of Health since 2014. In 2016, hand hygiene compliance rates were 70% and 48.6% for nurses and doctors, respectively in Ege University ICUs[11]. In an educational research hospital, between 2012 and 2015, the rate of compliance with hand hygiene increased from 45.3% to 60% for doctors and from 53.5% to 68.5% for nurses[12]. Nevertheless, despite these increased compliance with hand hygiene during nearly one decade of time, hand hygiene compliance could still not be achieved in about 20-50% of healthcare personnel.
The causes of non-compliance with hand hygiene were investigated in several studies; lack of soap, paper towels, hand washing materials, accessible alcohol-based hand rubs and sinks that are inconveniently located or shortage of sinks were the most common reasons[2, 4-6, 13]. Karabey et al.[13] also reported that lack of alcohol-based antiseptics and/or paper towels, inadequate hand washing technique, reduced hand hygiene when wearing gloves, lack of foot pedal bins, inappropriate nursing technique, and unnecessary contact with the patient's environment were among the causes of poor hand hygiene compliance. In a study investigating the factors affecting hand hygiene compliance in Ege University Hospital among 214 healthcare workers (129 nurses, 26 medical doctors and 59 auxiliary healthcare workers), the most common causes of non compliance were reported to be irritation from alcohol-based hand disinfectants and liquid soap (63.1%) followed by lack of paper towel (53.3%)[5]. As an evidence of the above studies, in our study; soap and paper towels were absent in 2.9-17.1% of the overall sample while soap and paper towels were less available particularly at the weekends. The relatively less availability of paper towels at the weekends suggests possible problems in provision.
In their study performed in Rwanda, a Sub-Saharan African country, Holmen et al.[14] reported that a 32.1% decrease was observed in hand hygiene compliance between 2015 and 2016 while availability of alcohol-based disinfectants in patient rooms also decreased from 100% in 2015 to 79.5% in 2016 (p<0.01). The reduction in alcohol-based hand disinfectants was found to be associated with lower hand hygiene compliance rates. In a multi-center study in the United States, it was reported that increased sinks-to-bed ratio had no effect on improved hand hygiene rates in all units. Hand hygiene rates were slightly increased in the ICUs, but this increase was not statistically significant[15]. In a study by Kaplan and McGuckin[16], nurses" hand hygiene rates were better in ICUs with a higher ratio of sinks-to-beds (1:1) than in those with a lower ratio (1:4) (76% vs. 51%). However, in our study, we did not analyze the distribution of sinks and alcohol-based disinfectant dispensers per ICU bed.
Our study has several limitations. Although this study included data from 41 centers from all the seven regions of Turkey, it does not represent the whole country. We could not analyze the association of the adequacy and availability of hand hygiene products with hand hygiene compliance as well as patient outcomes (HCAI or mortality rates)[17]. Despite these disadvantages, to our knowledge, this is the largest detailed dataset related to the problem.
Conclusion
Ethics
Ethics Committee Approval and Informed Consent: There was no need for patient consent or approval of the ethics committee since no personal or medical information about the patients was used.
Peer-review: Externally and internally peer-reviewed.
Authorship Contributions
Surgical and Medical Practices: A.U., Concept: All authors, Design: All authors, Data Collection or Processing: All authors, Analysis or Interpretation: All authors, Literature Search: All authors, Writing: All authors.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.
