Knowledge, attitudes and practices on hand hygiene among ICU staff in Anuradhapura Teaching hospital

lntroduction : Hand hygiene practices of health care workers has been shown to be an effective measure in preventing hospital acquired infections. Methodology : We carried out a study to assess the knowledge, attitudes, practices and satisfaction of facilities available to health care workers in the intensive care units with regard to hand hygiene in the Anuradhapura Teaching hospital using a self ad mi niste red q uestion nai re. Results : Our study showed that majority of respondents (72.5%) had moderate knowledge of hand hygiene. Knowledge on the correct use of hand washing and alcohol hand rubs was not consistent. When the attitudes were assessed for each individual respondents 47S% had good attitudes whereas a majority (62.5%l wasseento have poor hand hygiene practices. The level of satisfaction among the health care workers regarding the facilities available for hand hygiene was poor (55%). Conclusion : Hand hygiene knowledge attitudes and practices among ICU staff in Anuradhapura Teaching hospital was moderate to poor. Our study highlights the urgent need for introducing measures to increase the knowledge, attitudes, practices and facilities available for hand hygiene in the lCUs in Anuradhapura Teaching Hospital, which may play a very important role in increasing hand hygiene compliance among the ICU staff and reducing cross transmission of infections among the ICU patlents.


Introduction
Hospital acquired infections (HAls) are infections acquired in hospitol by o potient who was odmitted for a reason other than that infection'. HAls are one of the important public health problems in many countries throughout the world. A WHO study, have also shown that the highest prevalence of nosocomial infections occurs in intensive care units and in acute surgical and orthopaed ic wards'.
HAIs results in higher morbidity, mortality, and additional costs. lt is well recognized that the risk of transmission of pathogens when providing medical care and the incidence of HAls can be kept low through appropriate standardized prevention procedures. However, it has been welldocumented that the level of compliance with the use of proven HAI measures by healthcare workers (HCWs) has been disappointing'. In order to overcome this problem it is vital to implement and practice prevention and control strategies with demonstrated value consistently and rigorously. Among the different strategies, the adherence to guidelines for disinfection is an essential ingredient for activities aimed at preventingthe HAls.
The importance of hands in the transmission of hospital infections has been well demonstratedn, and can be minimized with appropriate hand hygieneu'''''t. However, compllance with handwashing, ls frequently suboptimal. ln the Sri Lankan theatre settings a study demonstrated that only 60% of the doctors performed appropriate hand washing before entering the theatre'. Non compliance with hand washing may be due to a variety of reasons, including: lack of appropriate facilities for hand washing, high staff-to-patient ratios, insufficient knowledge and attitudes of the stafl and allergies to hand washing products. Therefore it is important to address these issue in hospital i nfection control. Ethical clearance for the study was obtained from the Anuradhapura Teaching hospital, where the studywas conducted.

Self administered questionnaire
The questionnaire will consist of five parts; demographic information, assessment of knowledge, attitudes, practices and facilities available for hand hygiene. Knowledge will be assessed using 8 questions which included muitiple choice questions with single answers as well as yes (true)/ No (false) answers. Attitudes will be measured using 1-0 statements and the respondents were given the option to select on a 1 to 7 point scale between strongly agree and strongly disagree, out of which the first two responses are taken as positive responses (strongly agree) and the rest taken as negative responses. Similarly practices and satisfaction with facilities available were assessed in the same method.
Overall knowledge attitudes practices and satisfaction with facilities were assessed for each individual using a scoring system (1 for correct knowledge, good attitudes, correct practices, and satisfaction,0 for incorrect knowledge, poor attitudes, incorrect practices and dissatisfaction with the availability of facilities for hand hygiene).
The average of the score for each category (knowledge, attitudes, practices, satisfaction) was used for calculating the percentage of each category; A percentage of 75% for knowledge, satisfaction with the facilities available or 7O% for attitudes and practices was considered as good, 50% -74% for knowledge and satisfaction of facilities or 50% -69% for attitudes and practices was considerd as moderate while less than 50% was considered as poor. obtaining the percentage of correct responses for knowledge, good attitudes, and correct practices, and satisfaction with availability of facilities Data was analysed using EXEL software.

Resu lt
There was a total of 40 volunteers from the NICU (n=2), PICU (n=9), MICU (n=11")and SICU (n=18)of Anuradhapura Teachlng Hospital. Of these respondents 8 (20%) were doctors while 30 (75%) were nursing staff. Majority of the volunteers were female (n=31,77 .5%). Most of the participants had 2-5 years work experience (57.5%). Only 45% of the study population had received formal training on hand hygiene within the past 3 years while some had never received a ny forma I tra i n ing. (Ta blel)  Knowledge on the correct use of hand washing and alcohol hand rubs was not consistant. While majority (80%) correctly said that hand rubbing was more rapid than washing, they believed it causes skin dryness (55%), and that rubbing should be followed by hand washing in routine practice(60%). Only 35% knew that hand rubbing for 20seconds was recommended to remove most germs from their hands. From our study the respondents had poor knowledge on the situations where hand rubbing can be used as an alternative to hand washing. However the knowledge on the factors that contribute to hand colonization was good as more than 90% respondents said that wearing jewellery, damaged skin, artificial fingernails should be avoided. (Table 3) 1. Which of the folloring is the main rqlte of cross-transnission of potentially harmful germs between patients in a health care facility ?
Health workers hands when not clean 2. What is the most frequent source of germs responsible for health care    Regarding the attitude towards others hand hygiene, 62.5% disagreed that they felt frustrated when others omit hand hygeie n, andT5Yo disagreed that they are reluctant to ask others to engage in hand hygiene. Only 35% were of the attitude that newly qualified staff were not properly instructed on hand hygiene methods. Half of the respondents believed that adhering to hand hygiene practices is easy in the current ICU setup. (Table 4)     It was interesting to note that although hand rub was satisfactorily available the respondents were not aware of the situations that hand rub can be used in place of hand washing. As hand washing takes up about one minute and requires a sink with running water, soap/ antiseptic as compared to hand rubbing which takes only 20 seconds, it is important to make the health care workers knowledgeable on the appropriate use of hand rubbing and to encourage its use further to improve compliance.
Similar to studies reported from other developing countries, the health care workers in our lCUs were not satisfied with the facilities available for hand hygiene. Therefore we need to address this lssue and improve facilities such as improving the availability of soap/antiseptics, paper/cloth for drying hands and gloves. Further it is essential to conduct hand hygiene training programmes for the ICU staff members.
Our study has several drawbacks which need to be considered when interpreting this data. Data was collected by using a self administered questionnaire, which allows the respondent to check others responses or discuss the answers as well as document the expected response rather than the health care workers own practice or attitudes. This can be overcome by incorporating an observational study which will enable the investigator to observe the actual hand hygiene practices among these health care workers.
However it is not easy to conduct such a study currently due to the high work load and time restra i ns.
ln conclusion our study highlights the urgent need for introduclng measures inorder to increase the knowledge, attitudes, practices and facilities available for hand hygiene in the lCUs in Anuradhapura Teaching Hospital, which may play a very important role in increasing hand hygiene compliance among the ICU staff and reducing cross tra nsm ission of infections a mong the ICU patients.