Effectiveness Of Hand Hygiene Procedures In Reducing Nosocomial Infections Among Healthcare Workers

Background

The objective of this assignment is to facilitate the process of gaining a sound understanding on the ways that should be adopted to retrieve high quality reliable articles that are related to the PICO question “Does hand hygiene procedure among healthcare workers reduce rates of nosocomial infections in hospitals?” The literature search was primarily conducted during the month of April, 2018.

Hospital acquired infections are found to affect millions of patients worldwide annually. Such infections, more commonly known as nosocomial infections are found to result in serious illness, which in turn increase the length of hospital stays, and induce long-term disability among the patient. This further adds to high cost for the patients and their families, thereby contributing to a additional huge financial burden on the entire health-care system, which might often result in loss of life, if untreated (Lewis et al., 2013). These infections are found to be a direct manifestation of a plethora of factors that are related to processes and systems of appropriate care provision, as well as human behaviour, which is often conditioned by political, education, and economic constraints on the healthcare systems and the concerned countries. Beliefs and societal norms are also found to exert an effect on the overall health and wellbeing of the patients (Dancer, 2014). However, most infections are preventable, with the implementation of appropriate infection control practices, most common of which is hand hygiene (Cornejo-Juárez et al., 2015). Prevalence rates of nosocomial infections that are acquired in ICUs generally vary from 9-37% across hospitals in Europe and the USA. This has often been correlated with crude mortality rates that ranges from 12%-80% (World Health Organisation, 2009). Moreover, there is a lack of adequate infection control measures in most healthcare settings due to several unfavourable factors such as, poor hygiene, poor sanitation, understaffing, shortage of equipments, overcrowding, and inadequate structures, all of which are attributed to restrain in financial resources. Furthermore, high prevalence of malnutrition and other chronic diseases in developing countries greatly increase the risks of acquiring infections.

Appropriate hand hygiene has been identified as one of the primary control strategies that effectively prevents the outbreak of infections, across healthcare settings.  Hand hygiene can be defined as the method, which destroys or removes several microorganisms from the hands. There is mounting evidence to establish the fact that hand hygiene is an essential measure that can prevent spread of harmful pathogens (Salama et al., 2013).  Hand hygiene programs have been found effective in reducing infections in hospitals owing to the fact that these programs contain exhaustive information on the procedures that should be implemented by healthcare professionals for removing common pathogens from their hands, thereby eliminating chances of contaminating patient body, equipments and surgical sites (Morens & Fauci, 2013).  Hand washing procedures generally involve the process of cleaning hands for removing all kinds of soil, microorganisms and dirt with the use of soap and water.

Hand Hygiene as an Effective Control Strategy

Hand washing have been found effective in preventing the spread of several communicable diseases such as, cholera and diarrhea, which are generally transmitted through the fecal-oral routes (Allegranzi et al., 2013). Patients admitted to hospitals are found to be more susceptible to acquiring respiratory infections such as, common cold or influenza, upon failure of the healthcare workers to wash their hands before caring for the patients (Luangasanatip et al., 2015). Thus, the main objective of this literature search was to identify articles that would help in determining the effectiveness of hand hygiene procedures in reducing the rates of nosocomial infections among patients. This resulted in the formulation of the PICO question that is given below:

“Does hand hygiene procedure among healthcare workers reduce rates of nosocomial infections in hospitals?”

P (Population/Problem)	Nosocomial infection
I (intervention/indicator)	Hand hygiene practices
C (comparison)	No hand hygiene practices
O (outcome of interest)	Reduced infection rates

Table 1- PICO framework

The primary aim of the literature search was identification and extraction of high quality, and reliable evidences in the form of research articles that were related to the PICO question, given above. Therefore, a set of inclusion and exclusion criteria were formulated with the aim of facilitating the selection of articles that would be included, and eliminated from the search, respectively. Inclusion criteria contain the characteristics that prospective articles must have had to be included in the search. On the other hand, exclusion criteria refer to characteristics that disqualified or eliminated prospective articles from inclusion in the literature search.

Inclusion criteria	Exclusion criteria
Studies published in English	Abstracts
RCTs, systematic reviews, observational studies, cohort studies, case-control study, and controlled trials	Unpublished manuscripts
Studies that focused on hand hygiene procedures on adults, infants and children	Articles published in foreign languages
Articles published on or after 2013	Articles published before 2013
Studies that were conducted across hospitals or other healthcare settings	Clinical guidelines
The following outcomes were considered: reduced nosocomial infections, lower length of hospitalization, reduced mortality, reduced surgical site infection, improved wellbeing,	Studies conducted on animal models

Table 2: Inclusion and exclusion criteria for the literature search

The literature search was limited to journal articles that were published in English language. Furthermore, since all articles were required to contain the four elements, as identified by the PICO framework, five years was selected as the time frame for retrieval of articles. All articles that addressed the elements identified by the PICO question, related to rates of infection, upon implementation of effective hand hygiene procedures were extracted from the database. Studies that described the use of hand hygiene or hand washing process in infants, children or adult patients, admitted to hospitals were included, in addition to studies that focused on forming a correlation with hand washing procedure and surgical site infections among patients. Owing to the fact that the PICO question focused on patients, studies that were conducted in the form of trials on animal models were excluded from the literature search. Even, studies that addressed the PICO questions, but were published before five years were excluded, to make the literature search more comprehensive and succinct. Initially, the literature search was based on retrieving randomised controlled trails (RCTs) and systematic reviews, due to the fact that these two kinds of studies are considered higher hierarchial levels of evidences. However, owing to the fact that less number of systematic reviews and RCTs published after the aforementioned date were available, observational studies were later on included in the search strategy. However, clinical reports, guidelines from health organization on hand hygiene practices, narrative literature reviews were not included in the literature search, since they are considered as secondary sources of research (Greenhalgh, 2014). However, qualitative studies were included since they are exploratory in nature and allow for gaining a deeper understanding of the phenomenon or process being investigated.

Objective of the Literature Search

Hybrid Discovery (HyDi) search engine

The Hybrid Discovery (HyDi) search engine was used for extracting full text articles that contained appropriate combinations of the keywords used for the research. A pilot search was conducted for identifying articles that contained the keywords namely, “hygiene”, “hand washing”, “hand hygiene”, “infection control”, “infection”, “hospital acquired”, “nosocomial”, “nurses”, “healthcare workers”, “professionals”, “disinfection”, and “cross infection”. All of the aforementioned key terms were combined with the use of boolean operators AND and OR. The operator AND helped in narrowing down the hits to those articles that contained the search items. On the other hand, OR operator broadened the search by forming a connection between synonyms. The search scope was limited to electronic journal articles that were published from 2013-2018, full-text, peer reviewed articles.

Truncations were used to broaden the search, with the aim of including different word spellings and endings. Quotation marks allowed searching for specific phrases and terms, as given as an input in the database. When the HyDi was searched with “hand washing” term, in addition to “infection” and “hospital acquired”, 3122 articles were retrieved. Upon replacing “hand washing” with “hand hygiene”, a total of 4879 articles could be extracted. Combination of search terms such as “hand hygiene” AND “infection control” AND “nosocomial” yielded 3407 hits. Furthermore, 1700 hits were obtained on replacing “hand hygiene” with “hand washing”. Another combination of the search terms was used, in the form of “hand hygiene” AND “infection rates”, which gave a total of 11301 hits. 

Name of the database	Keywords used	Filters used	Number of hits
Hybrid Discovery (HyDi)	“hand washing” AND “infection” AND “hospital acquired”	1. Full text online 2. Peer reviewed 3. Articles 4. Year: 2013-2018	3122
	“hand hygiene” AND “infection rates”	1. Full text online 2. Peer reviewed 3. Articles 4. Year: 2013-2018	11301
	“hand hygiene” AND “infection” AND “hospital acquired”	1. Full text online 2. Peer reviewed 3. Articles 4. Year: 2013-2018	4879
	“hand hygiene” AND “infection control” AND “nosocomial”	1. Full text online 2. Peer reviewed 3. Articles 4. Year: 2013-2018	3407
	“hand washing” AND “infection control” AND “nosocomial”	1. Full text online 2. Peer reviewed 3. Articles 4. Year: 2013-2018	1700

Table 3: Hybrid Discovery (HyDi) search hits

Several articles retrieved upon use of the search terms in various combinations, were irrelevant. Filters were also used to ensure that the obtained hits matched the inclusion criteria for the search, as stated above. An exhaustive analysis of the retrieved articles was conducted to evaluate those that were potentially relevant to the pre-formulated PICO question. Following removal of the duplicate articles, and those that did not have full-text availability, a total of 45 articles could be extracted that matched the PICO question. Of these articles, 24 were observational studies, five were systematic reviews, 13 RCTs, and three qualitative studies.

PubMed

The second literature search was undertaken via using PubMed database. According to Lu (2011), with the ease of access to internet, the amount of available biomedical literature under the electronic format is on the rise. As a matter of fact, as highlighted in previous work (please refer to figure 3), the overall size of the bibliome has increased exponentially during the past few years. As per the published reports till 2010, there are more than 20-million citations indexed via PubMed (Lu, 2011). This is the reason why the researcher has chosen PubMed as one of the principal electronic database for the search of the relevant yet authentic literary articles. PubMed is a part of NCBI’s Entrez retrieval system that provides access to more than 38 databases. Moreover, at present PubMed includes abstracts and citations from over 5000 life science journals centring biomedical articles since 1948 (Lu, 2011). Another reason for chosing PubMed as one of the electronic data base for the search of the literary articles is, PubMed is regarded as the primary tool for retrieving biomedical literature (Lu, 2011).

Inclusion and Exclusion Criteria

Through the electronic database of PubMed, the Medical Subject Headings (MeSH) database was selected. MeSH is one of the 38 databases which PubMed provides access. Lu (2011) is of the opinion that MeSH database is a rich repository of biomedical journals and hence best suited for answering the PICO question of this research. Although PubMed-MeSH bestows, a broad yet updated search interface, it has become more challenging for the users to identify the relevant information at once. Due to this, the users are frequently overwhelmed by the lost list of search results. Lu (2011) stated that nearly one-third of the PubMed queries procure more than 100 citations. So in order to refine the search more specific, the researcher here has used few keywords which fall in scope with the PICO question of the research. “Hand Hygiene” was recognised as a MeSH term and is defined as “practices involved in preventing the transmission of disease by hand”. The first combination of keywords that was used for the MeSH search include “hand hygiene” AND “hospital acquired infection” [Mesh]. This failed to include any relevant search results with the last five years. Then second combination of term used for Mesh search includes: “Hand Disinfection “[MESH] “Cross infection” and these yielded 157 results. The number 157 is huge and hence in order to refine the number of search further specific MeSH terms were used for the search of the literary articles and this include “Hand Disinfection “[MESH] “hospital acquired infection” which yielded 5 hits within last five years. Since five articles is extremely limited further keyword modification was done and the keyword combination of ((Hand Disinfection) Nurse) AND “Hand Disinfection”[Mesh] yielded 43 hits. Apart from the MeSH keyword search, a generic key word search in the PubMed database was also. The keyword search of hygiene” AND “hospital acquired infection” yielded 22 hits within last five years of research (2013 to 2018).

Databases	Keywords	Number of Hits (after filters)	Filters used
PubMed	hygiene” AND “hospital acquired infection”	22	1. Search within 5 years (2013 to 2018) 2. Human trials 3. Full text availability 4.Language: English
PubMED using MeSH terms	Hand Disinfection “[MESH] “Cross infection”	157
“Hand Disinfection “[MESH] “hospital acquired infection”	5
((Hand Disinfection) Nurse) AND “Hand Disinfection”[Mesh]	43

Table 4: Search results from PubMed

Source: Created by author

 Throughout the entire search, “AND” is used as a BOOLEAN operator. According to McGowan et al. (2016), using “AND” as a Boolean operator helps to narrow down the results and signifies the data base that all search terms must be reflected within the generate hits. Out of all the published articles that were retrieved from PubMed database search, the duplicates were removed and only 32 articles were found to be unique via examining the title of the study. Then these 32 articles were again screened via reading their abstract and only 13 articles coincided with the scope of the PICO question.  Out of the 13 articles, 3 articles coincided with the research articles retrieved from Hydi Advanced search and thus 10 articles were considered to be unique. Of the selected articles included 4 qualitative survey based study, 2 included observational study, 2 systematic review and 2 quantitative study.

Search Strategy and Results

The second database which was selected for the search of the literary article was Google Scholar. The initial search of the broad key words revealed huge search results with 17,100 hits. In order to narrow down the search Boolean operators and more specific keywords were used. A detailed illustrations of the keywords and Boolean operators used along with the generated hits are highlighted below in Table 5

Name of the data base	Keywords used	Filters Used	Number of hits
Google Scholar	“Hand hygiene” AND “hospital acquired infection” AND “role of nurse”	Year: 2013 to 2018 Sorted by: relevance	9
	“hospital acquired infection” AND “prevention” AND “role of nurse”	16
	“infection control” AND “hand hygiene” AND “role of nurse” AND “hospital setting”	12
	“Hospital acquired infection” AND “hand disinfection” AND “nurse”	140

Table 5: The search results obtained from Google Scholar

Source: Created by author

The article relevance was considered according to the tiles of the articles and the abstract of the articles. Since Google scholar search via relevance, the relevant articles were reflected on the first page of the search. Scrolling down further, the articles which are retrieved were beyond the scope of the PICO questions. So as the relevancy of the search, in regards to the stringent keywords and abstract scrutiny and removal of duplicates only 15 articles were found to unique.

Following the electronic database search, Snowball technique is used in order to increase the horizon of the search. According to Aveyard (2014), although electronic resources are updated in a periodic manner, it is crucial to use alternative methods. The reason behind this is electronic databases are not always exhaustive and few literary articles might get skipped from the results. Via taking this analysis into consideration, after selection of the final literary articles from the electronic database, the final selected articles were read and reviewed for further short list. As a routine of the reading process, the list of references of each literary article was scanned and any important yet additional articles which considered to the relevant to the scope of the PICO questions were further sourced and analysed. This particular approach is known as Snowball technique. As per the reports pf Greenhalgh and Peacock (2005), this extended search assists in searching unidentified literature. Furthermore, it also helps in avoiding the database and keyword bias (Bettany-Saltikov 2012). The literature search was terminated when the references arising from the searchers were found to be duplicate and no new literature was identified further. Given (2008) is of the opinion that, this particular stage when no new data is being retrieved from the literature search, it is considered as “data saturation” and is considered to be ideal for further discontinuation of the research in order to achieve a rounded perspective. Via Snowball techniques, 10 unique research articles was identified further which coincided the selected time-filter of the research (last 5 years).

Database and Keywords Used

Conclusion

Thus from the above detailed illustrations of the search of the literary articles from the electronic database, it can be summarized that search of the literary articles from the electronic database is a time consuming work and requires proper selection of keywords, Boolean operators along with proper scrutiny of the abstract of the research. The first database which was chosen for the search of the literary article was Hydi Advanced search. for the Hydi search, it was initially found to be complication as it has numerous filters. However, since Hydi is one of the most preferred search engine among the other databases, it can consider to searching of the database. The search of the literary articles through Hydi revealed 45 unique search results. After Hydi the second database which was considered for the search was PubMed. The generation of the MeSH keywords and subsequent PubMed search help in the generation of the relevant articles which fell under the scope of the study. Incorporation of the specific filters, removal of the duplicate search results and scrutiny of the abstract generated 10 unique articles. These articles have a combination of both qualitative study, quantitative study and observational study. Finally the last database that was used was Google Scholar. However, in order to reduce the hits Boolean operators were used. The final articles which were retrieved from the Google Scholar via providing filter of last five years were 15 unique articles. Following search of the all the three databases, Snowball technique was used in order search more relevant articles which might have left out. The utilization of snowball technique lead to the further elucidation of the 10 unique articles which were published during the last five years.

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