Eastern Mediterranean Health Journal | Past issues | Volume 12, 2006 | Volume 12, issue 6 | Personal hygiene and safety of governmental hospital staff in Shiraz, Islamic Republic of Iran

Personal hygiene and safety of governmental hospital staff in Shiraz, Islamic Republic of Iran

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M. Askarian,1 A. Khalooee1 and N.N. Emroodi2

ABSTRACT Complying with infection control standards is essential to prevent nosocomial infections. We aimed to determine health workers’ hygiene practices and compliance with recommended instructions for personal hygiene among staff in all 30 hospitals affiliated to Shiraz University of Medical Sciences. The results showed that physicians and nurses were less compliant with personal hygiene practices than cleaners. Availability of protective measures was better in teaching hospitals than non-teaching hospitals as were vaccination rates among staff (hepatitis B and tetanus/diphtheria) with physicians scoring highest. Measures are needed to improve health workers’ compliance.

L’hygiène personnelle et la sécurité du personnel des hôpitaux publics à Chiraz (République islamique d’Iran)

RÉSUMÉ Le respect des normes de lutte contre les infections est essentiel pour la prévention des infections nosocomiales. Notre objectif était de déterminer les pratiques d’hygiène des agents de santé et le respect par ces derniers des prescriptions d’hygiène personnelle parmi le personnel de l’ensemble des 30 hôpitaux rattachés à l’Université des Sciences médicales de Chiraz. Les résultats ont montré que les médecins et les infirmières respectaient moins l’hygiène personnelle que les agents de nettoyage. La disponibilité de mesures de protection était meilleure dans les hôpitaux universitaires que dans les hôpitaux non universitaires, tout comme les taux de vaccination parmi le personnel (hépatite B et tétanos/diphtérie), les médecins ayant le score le plus élevé. Des mesures sont nécessaires pour améliorer le respect de ces normes par les agents de santé.

1Department of Community Medicine, Shiraz Medical School, Shiraz, Islamic Republic of Iran (Correspondence to M. Askarian: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).
2Department of Community Medicine, Kerman Medical School, Kerman, Islamic Republic of Iran.
Received: 30/03/04; accepted: 04/04/05
EMHJ, 2006, 12(6): 768-774 


Introduction

Nosocomial infections have been recognized for 150 years but they remain a hazard to both health workers and patients [1].

In the Islamic Republic of Iran there is increased awareness of the importance of hospital-acquired infections and the need to allocate more financial resources to infection control programmes [2–4]. However, there are no regular infection control teaching or surveillance programmes in the country. There have only been a series of lectures and workshops that the Department of Community Medicine of the Shiraz University have undertaken on different areas of infection control at the province and national levels which are now being expanded throughout the country.

The incidence of human immunodeficiency virus (HIV) infection in the Islamic Republic of Iran is increasing, especially among intravenous drug abusers [5]. The incidence of hepatitis B infection ranges between 1.75% and 5.0% and that of hepatitis C between 0.2% and 1.5% in different parts of the country [6]. These data indicate the necessity for local studies about the noso-comial infection control standards [7].

Many studies have been carried out throughout the world [8–10] about nosocomial infection that indicate a lack of attention to nosocomial infection control standards in different countries. We aimed to study the personal hygiene practices of heath care workers (HCWs) and the staff safety measures in place in all government teaching and non-teaching hospitals in Fars province. Our objective was to identify areas of negligence which could lead to transmission of noscomial infections.

Methods

This study was carried out with the cooperation of Central Committee of Nosocomial Infection of Fars province. All hospitals (13 teaching and 17 non-teaching) government hospitals affiliated to Shiraz University of Medical Sciences were included in the study which was conducted from April to the end of June 2001. Data were collected through 2 checklists, which were prepared with the reference to established guidelines [11,12]. The checklists were piloted tested in 3 different hospitals by trained nurses to detect any misunderstandings and problems and modified accordingly. The checklists are shown in Tables 1 and 2. These checklists were completed for all health care workers (HCWs) in all wards and services of the selected hospitals. This included 2134 doctors, 8986 nurses and 1236 hospital cleaners. A total of 30 trainee infection control nurses were trained in a 3-day workshop on how to observe HCWs and complete the checklists with consistency: they then completed 10 068 checklists. Data were missing for 2288 staff members because they were absent on the days of observation. As a quality check, the Central Committee of Nosocomial Infection Prevention rechecked 20% of the checklists in all hospital wards and services. If there was a more than 10% difference between Committee reports and data recorded by the trainee nurses, they were retrained and they completed the checklists accompanied by one of the researchers the next time.

The data were entered into software specifically developed for the study by the first author. Data analysis was done using this software. In yes/no questions, the proportion of positive answers was calculated and multiplied by 100, giving scores between 0 to 100. The results were analysed according to job (doctor, nurse and hospital cleaner). Scores of 80–100, 61–79 and ≤ 60 were considered: good, fair and poor respectively.

Results

Distribution of scores for personal hygiene practices according to job and type of hospital is shown in Table 3. For personal hygiene practices, fewer physicians had good scores (10%) than nurses (32.2%) and hospital cleaners (56.7%). In fact the majority of doctors (67.7%) and nurses (64.6%) achieved a fair score. Nurses in teaching hospitals scored higher than those in non-teaching hospitals. As regards the availability of/access to protective measures for HCWs, physicians and nurses were better provided for or immunized than hospital cleaners where 70% of hospital cleaners in all hospitals did not have sufficient protective measures in place (Table 4). The mean (standard deviation) of personal hygiene scores for physicians in teaching hospitals was 69 (11.0), in non-teaching hospitals it was 69 (12.8) and all hospitals it was 69 (11.9). The scores for nurses in teaching, non-teaching and all hospitals were 79 (10.7), 75 (8.6) and 77 (9.6) respectively and for hospital cleaners in teaching, non-teaching and all hospitals the scores were 18 (3.4), 78 (10.6) and 79 (11.2) respectively.

The mean (standard deviation) scores of vaccination and access to protective measures were 73 (19.6), 75 (72.0), 74 (22.8) for physicians, and 70 (62.0), 67 (15.0) and 68 (20.0) for nurses and 51 (43.8), 34 (29.0), and 43 (29.5) for hospital cleaners for all wards of teaching, non-teaching and all hospitals respectively.

Discussion

Nosocomial infection control is important for 3 main reasons: 1) to prevent spread of infections from patients to HCWs and vice versa, 2) to prevent bacterial resistance and 3) to avoid waste of financial resources [13,14]. Transmission of nosocomial infections in hospitals can occur in 3 ways: patient to patient, patient to HCW and HCW to patients [15]. A major reason for transmission of microorganisms is because of lack of personal hygiene in HCWs, especially improper hand washing, disposal of sharp instruments and use of personal protective devices, such as gloves and masks [16–21]. Hence we looked at the personal hygiene practices of HCWs and their vaccination status and access to protective measures in Fars government hospitals.

Considering personal hygiene practices, only 10% of physicians in all hospitals achieved a good score with more doctors in non-teaching hospitals scoring better. Teaching hospitals are where medical students acquire scientific and clinical knowledge and practices. If examples set by doctors in such hospitals are unsatisfactory, this may lead to improper practices among the students who are the future doctors.

As shown in Table 3, the personal hygiene practices of nurses and hospital cleaners in teaching hospitals were better than in non-teaching ones. More importantly, more cleaners had good scores than both nurses and doctors (Table 3). This was wholly unexpected because physicians and nurses should have greater knowledge about the dangers of nosocomial infection and would therefore be expected to have the higher scores. However, other studies have shown that physicians, compared to nurses, are less likely to follow personal hygiene regulations [22]. Another study showed that physicians in all categories neglected hand washing before, after and between patient physical examination [23].

Research has indicated that it is necessary to supply enough resources (liquid soap, paper towels, gloves, masks, etc.) to encourage HCWs to comply with hygiene standards [24]. Furthermore, instructions about infection control should be given according to job category and level of knowledge. Review of personal hygiene practices and standards annually and encouraging feedback from HCWs are also recommended [24].

As regards immunization and access to protective measures, teaching hospitals scored better than non-teaching hospitals. In this regard less than half of HCWs achieved good scores indicating lack of adequate protection, and hospital cleaners were the least well protected (Table 4). Among 2125 surgeons in England, 38%–50% were not vaccinated against hepatitis B [25].

It would appear from our study that HCWs and patients in our hospitals are at risk to acquire nosocomial infections

because of non-adherence of HCWs to infection control standards. This may lead to high mortality and morbidity rates as well as increasing the financial costs. Therefore, future education about infection control issues must be focused on HCWs and stress the need to improve the facilities to allow adherence to infection control policies. Finally, other studies are recommended to elucidate the reasons for non-compliance with infection control measures and the level of knowledge, attitude and practice regarding infection control isolation precautions.

Acknowledgements

This survey was funded by Shiraz University of Medical Sciences (No. 80-1259). We would like to thank the Central Committee of Nosocomial Infection Prevention of Fars Province and all the infection control nurses of the province for their cooperation; without their help this study could not be performed. We would also like to thank Dr Elaine L. Larson and Dr Faten Salti for their review of this manuscript and their valuable comments.

References

  1. Chandra PN, Milind K. Lapses in measures recommended for preventing hospital acquired infection. Journal of hospital infection, 2001, 47:218–22.
  2. Askarian M, Gooran NR. National nosocomial infection surveillance system based study in Iran: additional hospital stay attributable to nosocomial infections. American journal of infection control, 2003, 31:465–8.
  3. Askarian M et al. Incidence of urinary tract and blood stream infections in Ghotbeddin Burn Center, Shiraz 2000–2001. Burns, 2003, 29:455–9.
  4. Askarian M et al. Infection rate and outcome of female burn patients in Shiraz, Iran. American journal of infection control, 2004, 33:23–6.
  5. Hatami H, Mohraz M. Acquired immunodeficiency syndrome (AIDS). In: Azizi F, Janghorbani M, Hatami H, eds. Epidemiology and control of common disorders in Iran. Tehran, Eshtyagh, 2001:589.
  6. Malekzadeh R. Viral hepatitis. In: Azizi F, Janghorbani M, Hatami H, eds. Epidemiology and control of common disorders in Iran. Tehran, Eshtyagh, 2001:717–8.
  7. Holodnick CL, Barkauskas V. Reducing percutaneous injuries in the OR by educational methods. Association of operating room nurses, 2000, 72:461–4.
  8. Kim JM et al. Multicenter surveillance study for nosocomial infections in major hospitals in Korea. Nosocomial Infection Surveillance Committee of the Korean Society for Nosocomial Infection Control. American journal of infection control, 2000, 28:454–8.
  9. Friedman C, Chenoweth C. A survey of infection control professional staffing patterns at University Health System Consortium Institutions. American journal of infection control, 1998, 26:239–44.
  10. Puro V et al. Risk of exposure to bloodborne infection for Italian health workers, by job category and work area. Infection control and hospital epidemiology, 2001, 22:206–10.
  11. Garner JS. Hospital Infection Control Practices Advisory Committee. Guidelines for isolation precautions in hospitals. Infection control and hospital epidemiology, 1996, 17:53–80.
  12. Bolyard EA et al. Guidelines for infection control in health personnel, 1998. American journal of infection control, 1998, 26:289–354.
  13. Girou E. Controlling nosocomial infection, everyone is concerned. Archives of dermatology, 2000, 136:785–6.
  14. Center for Disease Control and Prevention. Public health focus: surveillance, prevention, and control of nosocomial infections. Mortality and morbidity weekly report, 1992, 41(42):783–7.
  15. Universal precautions guidelines for primary health centers in Indonesia (http://www.initiativesinc.com/docs/upguide.PDF, accessed 8 March 2006).
  16. Larson EL. APIC Guidelines for hand washing and hand antisepsis in health settings. American journal of infection control, 1995, 23:251–69.
  17. Rea E, Upshur R. Semmelweis revisited: the ethics of infection prevention among health workers. Canadian medical association journal, 2001, 164(10):1447–8.
  18. McCleary J, Caldero K, Adams T. Guarded fistula needle reduces needlestick injuries in hemodialysis. Nephrology news & issues, 2002, 16(6):66–70, 72.
  19. Adegboye AA et al. The epidemiology of needlestick and sharp instrument accidents in a Nigerian hospital. Infection control and hospital epidemiology, 1994, 15:27–31.
  20. Beltrami EM et al. Risk and management of blood-borne infections in health workers. Clinical microbiology reviews, 2000, 13:385–407.
  21. Smoot EC. Practical precautions for avoiding sharp injuries and blood exposure. Plastic and reconstructive surgery, 1998, 101:528–34.
  22. Pittet D et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet, 2000, 356:1307–12.
  23. Daniels IR, Rees BI. Hand washing: simple, but effective. Annals of the Royal College of Surgeons of England, 1999, 81:117–8.
  24. Naikoba S, Hayward A. The effectiveness of interventions aimed at increasing hand washing in health workers: a systematic review. Journal of hospital infection, 2001 47:173–80.
  25. Barie P et al. Assessment of hepatitis B virus immunization status among North American surgeons. Archives of surgery, 1994, 129:27–31.