Abstract
The nosocomial infection rate is high in unsterile conditions that facilitate microbial transmission. Resident and transient microbes colonize the healthcare workers’ hands, making them effective vectors of bacteria that cause nosocomial infections. In particular, patients undergoing surgery are at a greater risk of nosocomial infection because of the invasive nature of surgical procedures. Therefore, hand hygiene is an effective intervention for preventing nosocomial infection in medical-surgical units. The proposed study will compare the efficacy of chlorhexidine-based detergents over plain soaps in eradicating microbes colonizing the hands of the medical staff.
Introduction
Nosocomial infections constitute a significant threat to improved clinical outcomes of post-surgery patients. Since they are acquired within a healthcare setting, hand hygiene is indicated before and after invasive procedures. Hand washing aims to reduce microbes colonizing the hands of the clinical staff to lessen the risk of hospital-acquired infections. In busy medical-surgical clinics, maintaining routine hand hygiene is often a challenge because the units handle a large number of cases within a specific period (Hart, 2007). However, the risk of patient infection from antibiotic-resistant microbes calls for evidence-based interventions to prevent nosocomial infections (NI). This research study aims to evaluate post-surgery hand washing as an effective intervention for the control of NI in busy surgical units.
Problem Statement
The clinical staff’s hands serve as a major transmission route for hospital-acquired microbes. In a hospital setting, resident flora, such as S. aureus, occurs in the hands of up to 80% of healthcare staff (Hart, 2007). In addition, while transient flora survives for only a short time, resident flora is highly persistent with S. aureus lasting for close to two hours (Hart, 2007). Pathogens, such as S. aureus and E. coli, associated with UTIs, pneumonia, parasitemia, and surgical wounds can persist in cases of poor hand hygiene (Hart, 2007). Post-surgery patients contract these pathogens during catheter placement or removal, intubation, and bandage placement or removal. Hand washing before and after these procedures can help minimize the risk of NI and improve patient outcomes.
Review of Relevant Literature
Empirical evidence associates a lower rate of nosocomial infection to hand washing. A study by Garcia-Vazquez, Murcia-Paya, Canteras, and Gomez (2011) evaluated the risk of nosocomial infection in an ICU after the hospital adopted a hand-washing program. This prospective study compared the rate of infection before (P1) and after (P2) implementing the program. The study found a higher nosocomial infection rate of 26% in P1 compared to 16% in P2 during procedures such as central nervous catheterization.
Hart (2007) notes that hand washing constitutes an effective intervention for preventing hospital-acquired infections. She, however, recommends that hand washing alone cannot prevent nosocomial infections due to variables like “adequate staffing levels and education” (Hart, 2007, p. 46). In light of this, the appropriate hand hygiene technique depends on the task and the extent of contact with the patient. Before a surgical operation, washing hands in “warm water and antiseptic detergent” can clear resident and transient flora (Hart, 2007, p. 47). Healthcare workers irritated by antiseptic detergents, such as chlorhexidine solutions, can use plain soaps, which, however, are less effective in clearing resident flora.
Washing with a plain detergent and water, therefore, does not completely disinfect the hands. De Wandel, Maes, Labeau, Vereecken, and Blot (2010) found that hand washing without an antiseptic agent has a marginal effect of 2log10 on transient microbes. Washing with plain soaps is effective in clearing bloodstains and spores and enhances compliance. However, in clinical settings, hand disinfection is an effective technique for NI prevention. Wet hands should be dried in paper towels as they can transmit resident microbes to the patient.
A systematic review by Marimuthu and Harbarth (2014) evaluated studies examining the correlation between handwashing and methicillin-resistant S. aureus (MRSA) infection. The evidence indicated a direct association between hand hygiene and low MSRA infection rates in post-surgery patients. Increased compliance with recommended hand-washing practices by the healthcare staff was found to correlate with reduced hospital-acquired infections involving resistant pathogens. On average, the MRSA bacteremia declines by 0.02 to 0.01 per hundred patients per month when a unit attains a compliance rate of 33% (Marimuthu & Harbarth, 2014). Therefore, routine hand washing can lower the risk of infection from resistant flora residents on the clinical staff’s hands.
A multi-faceted study that entailed uninterrupted 3-year compliance with hand hygiene in a hospital found a significant decrease in MSRA bacteremia of 0.7 per 1000 patient days (Kirkland et al., 2012). The compliance rate at the teaching hospital stood at 87%, up from 40%. In this study, the MRSA infection rate in the operating room declined in response to the increase in compliance. Another study by Beggs, Shepherd, and Kerr (2008) found a 40-percent compliance rate to be the minimum threshold for preventing MSRA transmission in intensive care units. In this study, increasing compliance beyond this level was found to have an insignificant effect on the reduction of the NI rate. Therefore, the efficacy of handwashing depends on the compliance rate in surgical units.
Method
The studies reviewed have focused on hand hygiene practices, compliance, and nosocomial infection rate in hospital wards. The studies left out the hand hygiene practices in the surgical unit, which are prone to nosocomial infections due to prolonged patient contact during surgical procedures. Hand washing after surgery by medical-surgical staff is critical in preventing the transmission and bacteremia in operated patients. An effective handwashing technique should eliminate both resident and transient pathogens to reduce the risk of infection. This investigation will evaluate the efficacy of two techniques, namely, soap and water versus antiseptic and water, in preventing NIs in medical-surgical units.
Participants
A convenient sample of 20 study subjects will be drawn from the medical-surgical staff, i.e., surgeons and nurses. All health care workers in this unit will be eligible to participate voluntarily while controlling for variables such as gender, age, and race.
Design
The study will use a prospective case-control approach. The participants will be randomly sampled into the control and experimental groups of 10 each. The independent variables will be plain soap and water (condition 1) and antiseptic detergent and water (condition 2) while the dependent variables will be the bacteremia level and incidence of bacteria in lab cultures.
Procedure
The study will take place in a medical-surgical unit in a hospital setting. The current nosocomial infections at the surgical unit will serve as the baseline rate. The participants in the control group will be required to wash their hands with plain soap and warm water after each surgical procedure for three months. The experimental group will be subjected to handwashing with an antiseptic detergent (chlorhexidine) and warm water for the same period. Parasitemia levels and lab cultures will determine the prevalence of nosocomial infections in post-surgery patients. The results help determine the efficacy of each technique in removing resident pathogens colonizing the subjects’ hands.
Data Analysis
The study will involve a between-condition comparison of the NI prevalence. Data analysis will involve ANOVA to determine the significance of the correlation between the independent and dependent variables. We predict that the prevalence of NI in the experimental group (chlorhexidine-based detergent and warm water) will be lower than that in the control group (plain soap and warm water) during the study period. Chlorhexidine-based detergents are more effective in the removal of resident microbes than plain soaps. Therefore, the nosocomial infection rate will decline in the experimental group and increase or remain unchanged in the control group.
Nosocomial infection rates will be monitored throughout the study period. Post-surgery parasitemia levels and positive lab cultures will indicate the nosocomial infection rate for each condition. We predict that parasitemia levels in patients recovering from surgery will be higher in condition 1 than in condition 2. High parasitemia levels will manifest as NI episodes in patients recovering from surgery. We also predict that condition 1 will have a higher incidence of positive clinical cultures than condition 2, indicating that handwashing with soap and water has little effect on resident flora decolonization. A compliance rate of 100% is expected for the duration of the study.
Discussion and Findings
Hand washing aims to reduce bacterial colonization on the hands of the medical staff. It is indicated before and after clinical situations, including surgical procedures, to reduce nosocomial infection rates. However, the efficacy of handwashing depends on the disinfectant used. The proposed study aims to compare the efficacy of plain soap versus antiseptic detergent (chlorhexidine) to lower microbial colonization.
The invasive nature of surgical procedures coupled with the prolonged patient contact makes the hands of clinical staff vectors of microbes associated with NI. S. aureus has been found to colonize the hands of up to 80% of clinical staff (De Wandel et al., 2010). The resistant subtype, i.e., MRSA, poses a threat to the patient clinical outcomes. An effective handwashing technique can help decrease the bacterial load colonizing the hands.
Hart (2007) established that a medicated soap clears skin microbes effectively reducing NI transmission. Chlorhexidine-based soaps are indicated as effective hand disinfectants. The study will corroborate the use of chlorhexidine in hand washing after a surgical procedure. It will test the hypothesis that chlorhexidine-based soaps are more effective hand disinfectants than plain soaps in clinical settings. Therefore, its findings will have implications for NI prevention in surgical units. Further research should compare chlorhexidine-based detergents with alcohol-based rubs common in hospital wards.
Conclusion
Hand hygiene, a clinical routine, can help reduce the risk of NI and improve patient outcomes. The study will examine the efficacy of two hands-washing agents in removing bacteria colonizing the hands of medical-surgical staff. The infection rates determined by the parasitemia levels in post-surgery patients and positive lab cultures will indicate the efficacy of the respective condition. It is hypothesized that lower nosocomial infection rates will accompany the use of chlorhexidine-based detergents to wash hands after a surgical procedure.
References
Beggs, C., Shepherd, S., & Kerr, K. (2008). Increasing the Frequency of Hand Washing by Healthcare Workers does not Lead to Commensurate Reductions in Staphylococcal Infection in a Hospital Ward. BMC Infective Diseases, 8(1), 114-121.
De Wandel, D., Maes, L., Labeau, S., Vereecken, C., & Blot, C. (2010). Behavioral Determinants of Hand Hygiene Compliance in Intensive Care Units. American Journal of Critical Care, 19(3), 230-239.
Garcia-Vazquez, E., Murcia-Paya, J., Canteras, M., & Gomez, J. (2011). Influence of a Hygiene Promotion Programme on Infection Control in an Intensive-care Unit. Clinical Microbial Infection, 17(1), 894–900.
Hart, S. (2007). Using an Aseptic Technique to Reduce the Risk of Infection. Nursing Standard, 21(4), 43-48.
Kirkland, B., Homa, A., Lasky, R., Ptak, J., Taylor, E., & Splaine, M. (2012). Impact of a Hospital-wide Hand Hygiene Initiative on Healthcare-associated Infections: Results of an Interrupted Time Series. BMJ Quality Safety, 21(12), 1019–1026.
Marimuthu, K., & Harbarth, S. (2014). Screening for Methicillin-resistant Staphylococcus aureus: All Doors Closed?. Current Opinions in Infective Diseases, 27(4), 356–362.