Critical Evaluation of Poor Hand Hygiene During Ultrasound Scan and Its Impact on Patient Care

In healthcare, good hygiene is important as it prevents many diseases and infections (Malliarou, 2017). The issue of hand hygiene is important because approximately 10 percent of patients admitted worldwide will acquire healthcare associated infection (HAI) while in hospital (Jowitt et al., 2016). Healthcare worker’s hand are the primary medium for the transmission of pathogens from patient to patient in healthcare facilities. The skin of patients may be colonized with pathogens, and when they shed this skin, it covers the surfaces of their environment (Allegranzi & Pittet., 2009). The transmission of pathogens usually occurs when a health worker touches a patient’s environment. Despite no direct contact between the healthcare worker and the patient, transmission still occurs (Allegranzi & Pittet., 2009). In many health facilities, workers wear gloves to prevent HAI, but this is ineffective due to their improper use by health care workers and the fact that microorganisms can survive for several minutes which is sufficient for an individual to contaminate a large area (Pronovost, 2015 A lot of resources are devoted to maintaining high levels of hygiene in healthcare facilities.

However, hand hygiene is usually overlooked despite its role in the spread of diseases (Mathur, 2011). Poor hand hygiene in a health facility exposes patients, visitors and health workers and their families to diseases and infections. Simple tasks performed by healthcare workers such as checking the temperature of patients and changing their gowns can expose both the patient and the healthcare worker to harmful microorganisms (Shabot et al., 2016). To ensure good hand hygiene, it is essential for healthcare workers to scrub their hands vigorously using soap and water to ensure all microorganisms are destroyed (Widmer, 2013). The scope of the problem of hygiene in healthcare can be analysed by looking at HAI that patients suffer from when undergoing treatment in healthcare facilities (Al-Tawfiqa & Tambyahc, 2014).

In England there are approximately 100 000 cases of HAI which result in close to 5000 deaths annually (World Health Organization, 2007). HAI costs the National Health Service approximately 1 billion pounds a year and in the United States, there are 2 million cases of HAI annually at the cost of approximately 5 billion dollars. Also, 90 000 deaths are as a result of HAI (Fox et al., 2015). Evidence from studies shows that poor hand hygiene is the primary cause of HAI and to reduce infections and increase patient safety health facilities will have to encourage and maintain hand hygiene (World Health Organization, 2007). The introduction of alcohol-based hand sanitizers has had a positive impact as it has allowed healthcare staff to frequently and conveniently sanitize their hands. Despite the introduction of alcohol-based hand sanitizers adherence to hand hygiene standards remain as low as forty percent and this includes large well-resourced facilities (Longtin et al., 2011).

In many health facilities around the world understaffing is a major problem and places a heavy workload and pressure on existing staff, leaving them little time to focus on maintaining required hand hygiene standards (Ellingson et al., 2014). In some health facilities, sinks are placed in inconvenient locations which results in their limited use (Kendall et al., 2016). Also, cultural issues play a part in hand hygiene standards such as the case of Muslims who shun the use of alcohol-based hand sanitizers as alcohol is taboo in their religion (Van de Mortel et al.,2017). Management or senior staff in health facilities play a vital role in hand hygiene as they must be role models and must set an example to other staff members otherwise they will pay little attention to hygiene rules and guidelines. Health facilities have workers from different professions such as nurses, physiotherapists, radiographers, sonographer and doctors and this has a direct impact on the level of hand hygiene of each worker (Allegranzi & Pittet, 2009). This implies that individuals from different professions are trained differently with each profession placing a different emphasis on the importance of hand hygiene (Allegranzi & Pittet, 2009). The area in a health facility that individual works also influences their level of hand hygiene (Allegranzi & Pittet, 2009). Health workers who work in the intensive care unit and surgery rooms demonstrate high levels of hand hygiene due to the policies placed by their units because of the sensitive condition of patients in these areas (Allegranzi & Pittet, 2009). However, this approach is not entirely successful as HAI still occurs as health workers from less hygienic parts of the facility visit these areas. For instance, sonographers usually go to the intensive therapy units to perform bedside scans. As a result, it is essential for health facilities to ensure that all departments are subject to the same high standards of hygiene.

An important aspect of hand hygiene is the attitude and perceptions of healthcare workers towards this issue. A research conducted on the perception of healthcare workers in Malaysia raised the importance of this issue (Birks et al., 2011). The research indicated that despite extensive training and efforts by healthcare facilities to highlight the importance of hygiene to its workers, their perception of the importance of hygiene determined their level of hand hygiene (Birks et al., 2011). It is impossible to monitor every health worker at a health facility so to overcome this issue it is important for staff to be highly motivated and receive mentorship from senior staff members to ensure they continue learning and developing professionally. The attitude of health workers plays a role in their level of hygiene in a healthcare facility (Dreidi et al., 2016). A health worker with bad attitudes often careless when it comes to their duties and is more likely not to maintain the required levels of hygiene (Dreidi et al., 2016).

The cause of negative attitudes of healthcare workers is mainly due to displeasure caused by their working environments such as long working hours or an unreasonable workload. Negative attitudes can be prevented by management and senior staff members communicating with workers to gain knowledge of the challenges they face and to find solutions to this challenge. Health facilities have few private rooms for patients and open ward designs, and semi-private rooms make reducing HAI and improving hygiene difficult (Stichler 2013). Poor hand hygiene can be prevented through tools and methods such as automated observation, volume-based observation and direct observations (Ellingson et al. 2014). However, throughout the world, there are no national standards, rules or laws for hand hygiene in health facilities. A government program that includes measurement and feedback from patients will be an effective method improving the national level hand hygiene (Bhat et al. 2015).

The case A patient complained through Patient Advised and Liaison Service (PALS) of the trust about her experience in the ultrasound department. She was experiencing post-menopausal bleeding and was referred to the ultrasound department by her general practitioner (GP). Prior to the scan the sonographer informed her that the scan would be performed both trans-abdominally and trans-vaginally to evaluate the lining of the uterus and the ovaries in greater detail. She gave her consent to the procedures. However, according to the patient, the sonographer did not carry out hand hygiene before performing the transvaginal scan. While she could not challenge this at the time of the scan, this made her uncomfortable throughout the scan which resulted in her loss of confidence in the sonographer and the system at large. She also mentioned she had both trans-abdominal and transvaginal scans in the past in this trust and other trusts during which the sonographers observed all the necessary hygiene in each of the scans and wondered why things had changed. She was concerned that health service users would potentially be exposed to infection if the infection control policy of the trust is not adhered to by the staff. The department however, has not been able to verify if the information in this complaint is entirely true.

Discussion A critical evaluation of the case will require an in-depth analysis of the procedures and methodology used by the sonographer. The patient was suffering post-menopausal bleeding and determining the cause the sonographer decided to perform both trans-abdominally and transvaginal scan as recommended by departmental and BMUS guidelines. The complainant did not mention if the sonographer observed hand hygiene before the initial trans-abdominal scan. The major issue in this case arises from the lack of hand hygiene before the transvaginal scan. Understandably, with transvaginal ultrasonography, there is higher possibility of cross-contamination involving microorganisms which increases the risk of disease or infection to the patient (Buescher et al., 2016). So it is not surprising that the patient was more concerned about the hand hygiene prior to the transvaginal scan. To prevent the spread of disease and infection in a medical facility, it is essential for medical staff to wash and cover themselves and to use sterilized or disinfected equipment (Allegranzi & Pittet, 2009). The sonographer may have displayed negligence and a disregard for the safety of the patient by providing the least amount of protection or safety. In this case, hand sanitization was vital as the sonographer could have easily transferred bacteria or a virus to the outer layer of the gloves which would have come into direct contact with the patient.

The vagina is a sensitive organ which is extremely susceptible to diseases and infection, and the sonographer should have taken extra care when performing a transvaginal scan. The low hygiene standards expose the sonographer to the risk of disease and infection which can quickly spread throughout the health facility as the sonographer is exposed to sick individuals with weak immune systems (Mathur, 2011). The event had negative psychological and emotional impact on the patient. The patient was already suffering from post-menopausal bleeding which is a serious condition which put her in distress. She gave her consent and placed her trust in the sonographer because the sonographer was a professional who was assisting her. During the transvaginal scan, the patient experienced psychological distress as she was put in a helpless position while being exposed to a procedure that was potentially harmful to her. As a result, the patient lost trust in the medical facility and the safety of medical procedures.

The fact that she had knowledge of trans-abdominally and transvaginal scans as she had undergone the procedures in the past will make restoring her faith difficult. The long-term impact of the case on the patient is that she may be unwilling to give her consent to medical procedures in the future and may seek less effective methods of treatment and put her health at risk. The case will also make other women who use the medical facility less willing to give their consent to gynaecological scans especially transvaginal scans out of the fear that they may be exposed to the risk of disease and infection. The community that the health facility serves will be less willing to use its services as the low levels of hygiene and patient are highly discouraging.

Recommendations for Practice After analyzing the literature that is related to the case, I learned that poor hand hygiene has a significant impact on patient care. Also, I learned that health care professionals could pose a threat to the health patients by not upholding high hygiene standards. The case I presented exposes the psychological impact the lack of hand hygiene can have on a patient and their attitude towards healthcare. A recommendation I can use from my literature review that can put into practice is the use of tools and methods that can be used to monitor hand hygiene adherence in a health facility. An effective method that can be used universally is direct observation where healthcare workers are monitored to ensure they maintain the required hygiene standards (Ellingson et al., 2014). Automated monitoring of hand hygiene involves devices that record the use of hand hygiene dispensers by staff members and their movements, especially when entering a patient’s room (Polgreen et al., 2010). As such, this system is effective for large healthcare facilities where active monitoring of healthcare staff would be difficult (Polgreen et al., 2010).

An additional method of monitoring and measuring hand hygiene adherence is volume-based measurement which involves measuring the amount of soap or hand sanitizer used by a health facility as hand hygiene is an accurate measure of the level of hygiene in a health facility (Jeanes, 2003). The use of video recording to analyze hand hygiene in a facility is a highly effective and cost friendly method (Reynier et al., 2016). The use of these monitoring and evaluation methods could have easily prevented the issue of poor hand hygiene presented in my case. It could have as well verified if what the patient said was entirely true. A recommendation I have derived from the analysis of the literature review relating to my case is the use of the five rules of hand hygiene which were created by the World Health Organization (Landers et al., 2012). The rules of hand hygiene state that before and after a healthcare worker touches a patient, they must sanitize their hands (World Health Organization, 2018). When a healthcare worker wants to clean a patient or change their clothes they must sanitize their hands (World Health Organization, 2018). Upon exposure to the body fluids of a patient, a healthcare worker must sanitize their hands. Lastly, when the health worker touches the surroundings of a patient they must sanitize their hands (World Health Organization, 2018).

The rules of hand hygiene have proven an effective strategy in promoting hand hygiene in healthcare facilities especially in third world countries with healthcare facilities that have limited resource. Another recommendation that is vital to the case will be to introduce and practice patient empowerment as a tool for hand hygiene. The empowerment of patients involves giving them a platform and encouraging them to speak out when healthcare workers do not sanitize their hands (Lastinger et al., 2017). As such, this would have prevented the exposure of the patient in my case to the risk of disease and infection. Also it is highly recommendable for sinks which are meant for hand-washing be situated very close to the entrance of procedure room to enable the sonographer and other healthcare workers easily access these sinks.

Evidently, good hygiene is important as it prevents many diseases and infections. Evidence from studies shows that poor hand hygiene is the primary cause of HAI and to reduce infections and increase patient safety health facilities will have to promote and improve hand hygiene. Alcohol-based hand sanitizers has allowed healthcare staff to frequently and conveniently sanitize their hands but despite its introduction adherence to hand hygiene standards remain as low as forty percent even well-resourced facilities. A major issue with the case arises from the poor hand hygiene before the transvaginal scan. Preventing the spread of disease and infection in a medical facility is important and is essential for medical staff to wash and cover themselves and to sterilize or disinfect equipment. The sonographer displayed negligence and a disregard for the safety of the patient by providing the least amount of protection or safety. In this case, carrying out hand hygiene was vital as the sonographer could have easily transferred bacteria or a virus to the outer layer of the gloves which would have come into direct contact with the patient. Microorganisms can survive for several minutes, and in this case, the patient could have easily contracted a sexually transmitted disease due to the negligence of the sonographer as the vagina is a sensitive organ which is extremely susceptible to diseases and infection.

The event had negative psychological and emotional impact on the patient who was suffering from the serious condition and was put in a helpless position while being exposed to a procedure that was potentially harmful to her health. The lasting impact of the case on the patient is that she may be unwilling to give her consent to medical procedures in the future and may seek less effective methods of treatment. The case will also make other women who use the medical facility less willing to give their consent to trans-abdominally and transvaginal scans out of the fear that they may pose a risk to their health. To improve hand hygiene in the healthcare field, it is essential to introduce measures such as monitoring hand hygiene adherence and the rules of hand hygiene presented by the World Health Organization

References

1. (Havard Leeds) Allegranzi, B. and Pittet, D. 2009. Role of hand hygiene in healthcare-associated infection prevention. Journal of Hospital Infection, 73(1), pp. 305-315.
2. Al-Tawfiqa, J. & Tambyahc, P., 2014. Healthcare-associated infections (HAI) Perspectives. Journal of Infection and Public Health, 7(1), pp. 339-244.
3. Arnstein, F., 1997. Catalogue of Human Error. British Journal of Anaesthesia, 79(1), pp. 645-656.
4. Atalabi, O. M. et al., 2012. Transvaginal ultrasonography: a survey of the acceptability and its predictors among a native African women population. International Journal of Women's Health, 4(1), pp. 1-6.
5. Bhat, L. et al., 2015. Hand-Washing and public health. Economic & Political Weekly, 48(1), pp. 19-22.
6. Birks, M., Coyle, M., Porter, J. & Mills, J., 2011. Perceptions of hand hygiene amongst healthcare workers in Sibu, East Malaysia. International Journal of Infection Control, 8(11), pp. 11-13.
7. Buescher, D. L. et al., 2016. Disinfection of transvaginal ultrasound probes in a clinical setting: comparative performance of automated and manual reprocessing methods. Ultrasound Obstet Gynecol, 47(1), p. 646–651.
8. DiSaia, P. J. et al., 2017. Clinical Gynecologic Oncology E-Book. 9 ed. s.l.:Elsevier.
9. Dreidi, M., Alrimawi, I., Saifan, A. & Batiha, A.-M., 2016. Hand Hygiene Knowledge, Practices and Attitudes among Nurses and Physicians. Health, 8(1), pp. 456-462.
10. Ellingson, C. et al., 2014. Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene. Infection Control and Hospital Epidemiology., 35(8), pp. 937-960.
11. Fox, C. et al., 2015. Use of a Patient Hand Hygiene Protocol to Reduce Hospital-Acquired Infections and Improve Uses' Hand Washing. American Journal of Critical, 24(3), pp. 216-225.
12. Jeanes, A., 2003. Improving hand hygiene compliance. Best practice Infection control, 99(7), pp. 47-49.
13. Jowitt, D. et al., 2016. The impact of the Hand Hygiene New Zealand programme on hand hygiene practices in New Zealand’s public hospitals. The New Zealand Medical Journal, pp. 67-77.
14. Kendall, A. et al., 2016. Point of care hand hygiene—where’s the rub? A survey of US and Canadian healthcare workers’ knowledge, attitudes, and practices. American Journal of Infection Control, 44(1), pp. 1095-1101.
15. Landers, T., Abusalem, S., Coty, M.-B. & Bingham, J., 2012. Patient-centered hand hygiene: The next step in infection prevention. American Journal of Infection Control, 40(1), pp. 511-517.
16. Lastinger, A., Gomez, K., Manegold, E. & Khakoo, R., 2017. Use of a patient empowerment tool for hand hygiene. American Journal of Infection Control, 45(1), pp. 824-829.
17. Longtin, Y. et al., 2011. Hand Hygiene. The New England Journal of Medicine, 364(1), pp. 24-28. Malliarou, M., 2017. Hand Hygiene of Nurses and Patient Safety. International Journal of Nursing & Clinical Practices, Volume 4, p. 217.
18. Mathur, P., 2011. Hand hygiene: Back to the basics of infection control. Indian Journal of Medical Research, 134(5), p. 611–620.
19. Pickering, A., Boehm, A., Mwanjali, M. & Davis, J., 2010. Efficacy of Waterless Hand Hygiene Compared with Handwashing with Soap: A Field Study in Dar es Salaam, Tanzania. The American Society of Tropical Medicine and Hygiene, 82(2), p. 270–278.
20. Pinto, A. et al., 2013. Sources of error in emergency ultrasonography. Critical Ultrasound Journal, 5(1), pp. 1-18. Polgreen, P. et al., 2010. Method for Automated Monitoring of Hand Hygiene Adherence without Radio-Frequency Identification. Infection Control & Hospital Epidemiology, 31(12), pp. 1294-1297.
21. Pronovost, P., 2015. Sustaining and Spreading Improvement in Hand Hygiene Compliance. Journal on Quality and Patient Safety, 41(1), pp. 1-25.
22. Reynier, P. et al., 2016. Hand Hygiene Analyzed by Video Recording. Journal of Nursing & Care, 5(2), pp. 1-5.
23. Shabot, M. et al., 2016. Sustaining Improvement in Hand Hygiene and Health Care-Associated Infections. Journal on Quality and Patient Safety, 42(1), pp. 1-17.
24. Stichler, J., 2013. Healthcare-Associated Infections: The Nursing Perspective. Sage Journals, 7(1), pp. 8-12.
25. Van de Mortel, T., Ng, W. & Shaban, R., 2017. Healthcare professionals’ hand hygiene knowledge and beliefs in the United Arab Emirates. Journal of Infection Prevention, 18(3), pp. 1-29.
26. Widmer, A., 2013. Surgical hand hygiene: scrub or rub?. Journal of Hospital Infection, 83(1), pp. S35-S39. World Health Organization, 2007. Improved Hand Hygiene to Prevent Health Care-Associated Infections. s.l.:World Health Organization Press.
27. World Health Organization, 2018. Five moments for hand hygiene. [Online] Available at: http://www.who.int/gpsc/tools/Five_moments/en