A multicentric survey of the practice of hand hygiene in haemodialysis units: factors affecting compliance

M. Dolores Arenas1,3,4, José Sánchez-Payá2, Guillermina Barril5, Juan García-Valdecasas6, Jose Luis Gorriz7, Antonio Soriano3, Andres Antolin8, José Lacueva9, Sergio García11, Ana Sirvent4, Mario Espinosa12 and Manuel Angoso10

1 Hospital Perpetuo Socorro, Alicante, 2 Unidad de Control de Infecciones y Epidemiología de Hospital de Alicante, 3 Haemodialysis Unit, Elda, 4 Haemodialysis Unit, Elche, 5 Hospital de la Princesa, Madrid, 7 Hospital Clínico, Granada, 6 Hospital Dr Peset, 8 Cediat-Aldaia, 9 Cediat-Turia and 10 Clinica Virgen del Consuelo Valencia, 11 Hospital de Poniente, Almeria and 12 Hospital Reina Sofía, Córdoba, Spain

Correspondence and offprint requests to: M. Dolores Arenas, Jiménez Plaza, Dr Gomez Uua, IS 03013, Alicante (Spain). Email: arenasd{at}perpetuosocorro.nehos.com



   Abstract
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Background. This study intended to investigate the degree of compliance with hand hygiene and use of gloves by health workers in haemodialysis (HD) units, and the factors that influenced adherence to hand hygiene protocols.

Methods. During the month of November 2003, one person observed the health care staff in each of nine different dialysis units, during 495 randomly distributed 30 min observation periods that covered all steps of a haemodialysis session (connection, dialysis and disconnection). The observers noted the number of potential opportunities to implement standard precautions and the number of occasions on which the precautions were actually taken. Adherence to standard precautions was evaluated, analysing the influence of the following variables: the patient-to-nurse ratio, the number of HD shifts scheduled per day, acute HD units vs chronic, whether or not infectious patients were isolated and in-house vs contract cleaning personnel.

Results. There were a total of 977 opportunities to wear gloves for, and to wash the hands following, a patient-oriented activity, and 1902 opportunities to wash hands before such an activity. Gloves were actually used on 92.9% of these occasions. Hands were washed only 35.6% of the time after patient contact, and only 13.8% of the time before patient contact. Poor adherence to hand washing was associated with the number of shifts per HD unit per day and with higher patient-to-nurse ratios. In the acute HD units, there was greater adherence to standard precautions than in the chronic units, although there too it was substandard. The personnel's knowledge of patients’ infectious status did not modify their adherence to hand hygiene practices. A higher patient-to-nurse ratio independently influenced hand washing both before and after patient contact.

Conclusions. The overall adherence of health care workers to recommended hand washing practices is low. Whether or not programmes promoting higher hand hygiene standards and the potential use of alcohol-based hand cleansers will improve hand hygiene practices in HD units requires further investigation.

Keywords: haemodialysis; hand hygiene; hepatitis C prevention; standard universal precautions



   Introduction
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Blood-borne infections have been one of the most important problems in haemodialysis (HD) units. Until the mid 1970s, the most frequent viral infection acquired in HD was hepatitis B (HBV). After the introduction of anti-hepatitis B vaccination, patient segregation and the use of dedicated HD machines for hepatitis B-positive patients, hepatitis C virus (HCV) infection came to prevail in this population [1].

The incidence and prevalence of this infection have decreased in Spain and the rest of Europe during the past few years [2,3]; and they seem to continue in their downward trend [4], although with sporadic HCV outbreaks in some HD units [5]. The annual incidence of HCV infection in chronic HD patients has been reported to be between 0.5 and 11.1% [3,4]. In Spain, a range of isolation measures, such as the clustering of HCV-positive patients in a defined sector of the HD unit, have been adopted. A multicentre Spanish study of HCV in dialysis showed that with emphasis on isolation measures, a decrease in the prevalence of HCV came about [3]. However, it should be emphasized that, irrespective of whether or not patients are isolated, there is general agreement that standard precautions should be reinforced [6].

In 1999, we demonstrated that, in a Spanish HD unit, the application of such precautions is frequently suboptimal [7]; however, this problem probably is not limited to a particular HD unit.

Recently, the Spanish Society of Nephrology published guidelines on HD-associated viral infections, emphasizing the need for the personnel of HD units to adhere to standard precautions [8]. The aim of our present study was to evaluate the extent of compliance with standard precautions by HD personnel in several HD units, and to assess the factors that influence optimal adherence to hand hygiene.



   Methods
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Design and subjects
The degree of compliance with some basic standard precautions (hand washing or hand hygiene and wearing of gloves) by health workers was monitored in nine Spanish HD units (Table 3). All of the units had written guidelines for the prevention and control of infectious diseases. During the previous 2 years, there had been no HBV or HCV infections in the units selected for this study.


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Table 3. Characteristics of the dialysis units

 

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Table 1. Periods of observation

 

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Table 2. Activities performed by the staff of the HD unit and definition of when universal precautions must be adhered to

 
We identified those activities of health care personnel in the unit that required the application of the standard precautions recommended by the Centers for Disease Control and Prevention (CDC) [9].

The activities that required precautions in a HD unit and the types of precautions required were determined jointly by the dialysis unit nurses, nephrologists and the hospital epidemiologist. Before the study, comprehensive workshops were held for the observers and all involved investigators, including the epidemiologist, in which methods of data collection were reviewed in detail.

For 1 month (November 2003), observers (usually nephrologists) were assigned to each of the units being monitored to observe the activities of the unit's staff who did not know that they were under observation. We planned 24 observations for each step of the HD procedure—connection, dialysis and disconnection—during a period of four 6 day weeks. A total of 495 randomly distributed observation periods were scheduled, depending on the personnel and shifts of the HD units. The randomization was based on a table of random numbers (Table 1).

The observation periods were 30 min long and covered all the steps of HD and all scheduled HD shifts.

Variables
The activities that required the implementation of hand hygiene and use of sterile gloves were: connection and disconnection of the patient to and from the machine; care and handling of the puncture site; manipulation of the blood line during the dialysis; retrieval of disposable HD material and cleaning of the dialysis room (Table 2).

In order to identify factors that might influence the adherence to standard precautions, we analysed the following variables in the degree of compliance with hand hygiene and use of gloves: (i) the patient-to-nurse ratio; (ii) the scheduled number of dialysis shifts per day; (iii) the acute HD units vs chronic HD units; (iv) the isolation of infectious patients; and (v) hospital vs external cleaning personnel.

Centres
The observers evaluated the total number of potential opportunities to implement standard precautions and the number of occasions when they were actually implemented.

Adherence to hand hygiene, use of gloves, etc., was quantified as percentage adherence (the denominator was the total number of potential situations calling for standard precautions, and the numerator the actual number of times precautionary measures were implemented). The observers recorded these events according to a pre-established protocol.

Statistical analysis
To describe the percentage of adherence in all the periods of observation and for each of the activities, we used the mean and SDs. The Student t-test was used to compare the differences between the means of two groups, and analysis of variance (ANOVA) was used to compare three or more groups. We performed a multivariate ANOVA to search for more than one variable among the statistically significant variables identified in bivariate analysis. A P<0.05 was considered as statistically significant.



   Results
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
There were 1902 opportunities to wash hands and wear gloves before a patient-oriented activity and 977 after. The degrees to which standard precautions were employed by the personnel is show in Tables 4–7GoGoGo.


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Table 4. Percentages of compliance of staff with precautionary measures (means±SD)

 

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Table 5. Staff compliance with precautionary measures during connection

 

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Table 6. Staff compliance with precautionary measures during disconnection

 

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Table 7. Staff compliance with precautionary measures during puncture site dressing

 
Patient-to-nurse ratio
In general, poor adherence to hand washing was associated with higher patient-to-nurse ratios (P<0.001). No significant association was observed between the ratio and the use of gloves (Tables 5–7GoGo).

Number of shifts per day
The staff of HD units with three scheduled shifts of dialysis per day were less conscientious about hand washing than the staff of units running one or two shifts, but they did not show a significant difference in the use of gloves (Tables 5–7GoGo).

Acute HD units
A total of 45 observations (9.1%) were made in the acute HD units. Hand washing following connection or disconnection of patients, wound dressing and manipulating patients’ blood lines was significantly more frequent in the acute HD units than in the chronic units (P<0.001). No significant differences were observed in the use of gloves during the HD procedure between the different types of units (Tables 5–7GoGo).

The isolation of infectious patients
Altogether, 418 observations were made in HD units of specific isolation measures applied to hepatitis C and hepatitis B patients who were assigned their own room and dedicated personnel and dialysis machines (305 in rooms of patients who were HCV and HBV negative and 113 in rooms of patients who were HCV and/or HBV positive). There were 75 observations made of personnel specifically allocated to hepatitis C-positive patients clustered in a defined section of the HD unit. No significant differences were observed in the use of gloves or in hand washing in the HD rooms of infectious and non-infectious patients. The HD units without isolation displayed poor adherence to standard precautions (Tables 5–7GoGo). Personnel were not observed to cross over between the positive and negative areas.

HD and outside cleaning personnel
Of the observations made on cleaning personnel, 80.5% were of outside cleaners and 19.5% of internal HD unit cleaning staff. The outside cleaners used gloves significantly more frequently (91.6±23.2) than the in-house cleaning staff (50.5±44.2) (P<0.01), and no differences were found in hand washing after room cleaning (22.7±38.5 outside cleaners vs 17.4±36.9 unit-based cleaners, P = 0.62)

Changing gloves
The activities found to have a higher inclusion of changing gloves between patients were: connection (89.1%), disconnection (80.6%) and puncture site dressing (88.5%). The activities that were accomplished with a lower compliance with this measure were: disposal of waste material (56.2%) and cleaning of the HD unit (76.9%) (Tables 5–7GoGo).

Centres
Significant differences between individual centres were found in hand washing: before (mean of the nine centres±SD; range) (22.2±38.03; 1.5–96.2) (P<0.001) and after (37.5±36.5; 0.0–100.0) (P<0.001) connection; before (16.0±31.1; 0.0–83.3) and after (31.9±39.9; 0.0–88.3) (P<0.001) disconnection; and before (11.4±27.3; 0.0–68.9) and after (38.7±38.8; 2.2–100.0) (P<0.001) dressing the wound. There were significant differences between centres in changing gloves between patients to disconnect (92.6±19.6; 69.2–100.0) (P<0.01) and after wound dressing (93.8±20.8; 52.9–100) (P<0.01).

Multivariate analysis
Table 8 shows the results of the multivariate analyses for the various factors that influence adherence to hand hygiene measures. A higher patient-to-nurse ratio was an independent factor affecting hand washing before and after an activity.


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Table 8. Multivariate analysis

 
A larger number of shifts per day was associated with lower rates of glove use and fewer glove changes between patients to disconnect. In the acute HD units, there was better hand hygiene after but not before the activity. The treatment of patients in non-isolation wards was less likely to be associated with hand washing following any activity. There were differences between various centres in the rates of changing gloves after treatment and in hand washing following the three activities (connection, disconnection and dialysis) as well as in hand washing prior to connection.



   Discussion
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
A number of observers have suggested that nosocomial cross-infection from an HCV-infected patient to other patients dialysed simultaneously in the same ward is the principal mode of the transmission of HCV in HD [6,10]. It is likely that most of the patient-to-patient transmissions occur, either directly or indirectly, through contaminated surfaces. Unfortunately, this is the most difficult pathway to document and control.

Standard hygienic precautions include the use of gloves and hand washing whenever a patient is touched or equipment (blood pressure, cuffs, clamps, scissors) is shared between patients, medication or supplies are prepared, and surfaces and items are cleaned or disinfected. We only analysed glove use and hand washing [9].

Although there is a clear requirement and an obligation to adhere to standard precautions, these measures were poorly observed by some staff. In agreement with the results of other studies [7,11], our investigation shows a poor degree of adherence to the recommended practices of hand hygiene among health care personnel. It is therefore not surprising that significant amounts of ‘invisible’ blood were detected by chemical tests on various surfaces or items [12].

We found that gloves were used on between 82.1 and 97% of the occasions where they could appropriately have been used. This is probably associated with the personnel's concern for the possible transmission of pathogenic viruses by patients. In contrast, personnel tend to disregard their own role in transmitting infections to patients. As in other studies [13], hand washing enjoyed a lower compliance (the averages ranged between 15.52% after disposal of material and 67.6% after wound dressing). The study was not designed to analyse health workers’ adherence to proper hand washing technique but mainly to determine if it was done when it was supposed to be done. A second objective of this study might have been to include an analysis of hand washing techniques, although this would have added significantly to the complexity of collecting data; and this is a limitation of our study. Wearing gloves may represent a barrier to compliance with hand hygiene due to the belief of some health workers that wearing gloves makes hand washing unnecessary. Hand washing is recommended after glove removal because hands could get contaminated during glove removal or as a result of broken gloves.

We observed that hand washing was significantly lower when the number of patients attended by nurses was higher, and when there were more shifts per day. One of the factors that can contribute to non-compliance is time limitation—staff having to work in a hurry because shifts follow each other closely and because the timetable has to be strictly adhered to. Other studies have shown the patient-to-nurse ratio to be an independent risk factor for bloodstream infections [14,15]. Other self-reported reasons for poor adherence with hand hygiene were: hand washing agents cause irritation and dryness, sinks are inconveniently located or absent, lack of soap or paper towels, high workload and under staffing, interference with patient care and the low risk of acquiring infection from patients. Others factors that may influence the degree of compliance with hand hygiene are the physicians’ specialities and the health workers’ beliefs and perceptions [16].

In acute units, the compliance was higher than in chronic units, but these units also have a smaller patient-to-nurse ratio, generally two to one; and this could contribute to higher compliance.

Our study showed that the activities performed by nursing assistants or cleaning personnel (preparation of dialysis material, preparation of the machine, disposal of material and cleaning of the room) enjoyed lower compliance than the activities performed by nurses (puncture and connection, disconnection, wound dressing and manipulating the patient's blood lines). These observations have been noted in other studies, which reported that nursing assistants contributed to poor adherence more than nurses [15].

The use of universal standard precautions was not very different between the nurses assigned to the hepatitis B and C patients and the nurses caring for non-infectious patients. Both displayed the same low adherence to standard precautions.

In contrast, the outside cleaning personnel showed a higher degree of compliance than those of the in-house cleaning services, probably because the outside cleaners received precise instructions or because the clinics’ own cleaning personnel had become more relaxed.

Since October 2002, the CDC [17] has changed the concept of hand washing to hand hygiene, and the Centers provide specific recommendations that are designed to promote improved hand hygiene. For generations, hand washing with soap and water has been considered a measure of personal hygiene, but now, if hands are not visibly soiled, the routine use of an alcohol-based hand rub to decontaminate hands is regarded as sufficient [18]. Alcohol-based hand rubs provide the following benefits: they require less time, cleanse more effectively than standard hand washing with soap, are more accessible than sinks, reduce bacterial counts on hands and improve skin condition, all of which could favour the use of this method [13,18].

Although all the HD units had written standard precautions guidelines, which were distributed to their personnel and were known by them, the degree of compliance was low. In our study, there were differences between centres in the degree of compliance with some of the universal precautions, probably due to differences in the awareness of personnel. If we are to improve hand hygiene habits and successfully promote them in our personnel, we will need to increase educational and motivational programmes, utilize routine monitoring and feedback by independent observers and introduce new hand cleansing agents.

The isolation of HCV-infected patients in independent rooms has been shown to be effective in controlling this infection [19], but major reductions in HCV transmission in HD have also been observed after strict enforcement of standard precautions [9]. However, this issue raises economic as well as logistic problems; and the CDC do not recommend the isolation of HCV-infected patients in HD units [9]. On the other hand, recent studies suggest other possible sources of HCV infection: patients with long-standing abnormal liver function tests (whose aetiology is unknown after exclusion of all known causes of liver disease) may have intrahepatic and peripheral blood mononuclear cells and HCV RNA in the absence of anti-HCV antibodies and of serum HCV RNA [20]. Therefore, it is difficult to know which criteria should be used to separate patients and to identify highly infectious patients. The questions that remain are: should we invest our resources in isolating infected patients, or should we instead allocate resources to the ongoing education of personnel regarding the importance of systematic application of standard precautions?

The low prevalence of HCV infection in our units, the isolation of infectious patients and the use of dedicated areas for seropositive patients could be responsible for the decrease in the transmission of HCV infection observed in our HD units. This could explain the low incidence of HCV, despite the poor adherence to standard precautions.

In conclusion, although the CDC and Spanish Society of Nephrology (SEN) guidelines have been adopted by the vast majority of HD centres, the adherence of health care workers to recommended hand washing practices has remained low. This poor adherence is influenced by the numbers of patients and shifts attended by the nurses. In the acute HD units, adherence is higher than in chronic HD units, although it is still substandard. The behaviour of health workers was not modified by their awareness of patients’ infectious status. To improve hand hygiene and successfully promote it among HD personnel, we will need to increase educational and motivational programmes, implement routine monitoring and feedback by independent observers and introduce the use of alcohol-based hand rubs.

Dialysis units should re-evaluate their compliance with dialysis centre precautions, and where necessary improve the precautions to be taken in the care of all patients. Determining if programmes to promote hand hygiene and the use of alcohol-based hand rubs can improve hand hygiene in HD units will require further investigation.



   Acknowledgments
 
We are grateful to Thomas Stoyle, MBBS, FRCS, LMSSA for his valuable assistance in translating this text.

Conflict of interest statment. None declared.



   References
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Tong MJ, El-Farra NS, Reikes AR, Co RL. Clinical outcomes after transfusion-associated hepatitis C. N Engl J Med 1995; 332: 1463–1466[Abstract/Free Full Text]
  2. Jadoul M, Poignet JL, Geddes C et al; HCV Collaborative Group. The changing epidemiology of hepatitis C virus (HCV) infection in haemodialysis: European multicentre study. Nephrol Dial Transplant 2004; 19: 904–909[Abstract/Free Full Text]
  3. Barril G, Traver JA. Decrease in the hepatitis C virus (HCV) prevalence in hemodialysis patients in Spain: effect of time, initiating HCV prevalence studies and adoption of isolation measures. Antiviral Res 2003; 60: 129–134[CrossRef][ISI][Medline]
  4. Espinosa M, Martin-Malo A, Ojeda R et al. Marked reduction in the prevalence of hepatitis C virus infection in hemodialysis patients: causes and consequences. Am J Kidney Dis 2004; 43: 685–689[CrossRef][ISI][Medline]
  5. Ansaldi F, Bruzzone B, de Florentiis D et al. An outbreak of hepatitis C virus in a haemodialysis unit: molecular evidence of patient-to-patient transmission. Ann Ig 2003; 15: 685–691[Medline]
  6. Arenas MD, Sanchez-Paya J. Standard precautions in haemodialysis: the gap between theory and practice. Nephrol Dial Transplant 1999; 14: 823–825[Free Full Text]
  7. Arenas MD, Sánchez-Payá J, González C, Rivera F, Antolín A. Audit on the degree of application of universal precautions in a haemodialysis unit. Nephrol Dial Transplant 1999; 14: 1001–1003[Abstract]
  8. Barril G, Gonzalez Parra E, Alcazar R et al. Guías sobre enfermedades víricas en hemodiálisis. Nefrologia 2004; 24 [Suppl 2]: 43–66[Medline]
  9. Centers for Disease Control and Prevention. Update: universal precautions for prevention of transmission of human immunodeficiency virus (HIV), hepatitis B virus and their bloodborne pathogens in heath-care settings. MMWR 1988; 37: 377–382, 387–388
  10. Jadoul M, Cornu C, Van Ypersele C et al. Incidence and risk factors for hepatitis C seroconversion in hemodialysis: a prospective study. Kidney Int 1993; 44: 1322–1326[ISI][Medline]
  11. Pittet D, Mourouga P, Perneger TV, Members of the Infection Control Program. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999; 17: 53–80
  12. Caramelo C, de Sequera P, Lopez MD, Ortiz A. Hand-borne mechanisms of dissemination of hepatitis C virus in dialysis units: basis for new addenda to the present preventive strategies. Clin Nephrol 1999; 51: 59–60[ISI][Medline]
  13. Voss A, Windmer AF. No time for handwashing? Handwashing versus alcoholic rub: can we afford 100% compliance? Infect Control Hosp Epidemiol 1997; 18: 205–208[ISI][Medline]
  14. Petrosillo N, Gilli P, Serraino D et al. Prevalence of infected patients and understaffing have a role in hepatitis C virus transmission in dialysis. Am J Kidney Dis 2001; 37: 1004–1010[ISI][Medline]
  15. Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol 2000; 21: 381–386[ISI][Medline]
  16. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004; 141: 1–8[Abstract/Free Full Text]
  17. Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care setting. MMWR 2002; 51 (RR16): 1–44
  18. Doebbeling BN, Stanley GL, Sheetz CT et al. Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. N Engl J Med 1992; 327: 88–93[Abstract]
  19. Arenas MD, Gonzalez C, Enríquez R et al. Eficacia del aislamiento de pacientes anti-VHC positivos en hemodiálisis. Nefrología 1995; 24: 141–147
  20. Castillo I, Pardo M, Bartolome J et al. Occult hepatitis C virus infection in patients in whom the aetiology of persistently abnormal results of liver-function tests is unknown. J Infect Dis 2004; 189: 7–14[ISI][Medline]
Received for publication: 2. 7.04
Accepted in revised form: 17.12.04





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