Journal of Clinical Surgery and Anesthesia

Knowledge and Compliance to Hand Hygiene Among Anesthesiologists in the Operation Room in Sudan 2022

Farah Seif Aldein Ahmed Khalel^1*, Eltayeb GareebAlla Eltayeb AbdAlla², Mohamed Ali Hassabo³ and Mohamed Osman Suliman Basher⁴, Rabaa Abdelwahab Mohamed⁵ and Omyma Hassan Alamin Ahmed⁶

¹MBBS, Neelain University, 2015, SMSB, Sudan
²MBBS, Khartoum University, 2022, Sudan
³MBBS,  Neelain University, 2014, MPH, MRCP Sudan
⁴MBBS, Neelain University, 2014, MRCS, MD, Sudan
⁵Associate Prof of Anaesthesia Faculty of Medicine Omdurman Islamic University
⁶MBBS khartoum university 2001 MD SMSB 2008

*Corresponding author
Farah Seif Aldein Ahmed Khalel, Neelain University, SMSB, Sudan.

ABSTRACT
Objectives: This study aims to assess anesthesiology registrars’ knowledge and compliance with Hand hygiene strategies in the operation room and ICU in Sudan in 2022.

Materials and Methods: This was a descriptive cross-sectional study conducted among anesthesiology registrars registered in the Sudanese Council of Anaesthesia and Intensive Care. Data was collected by the researcher using a self-administered Google form questionnaire assessing knowledge about patient prevention, self-protection, alcohol-based rubbing, hand washing using soap and water, and compliance with the WHO 5 moments hand hygiene practice, then analyzed by SPSS V 28 software. 

Results:  The study included 150 anesthesiology registrars with a mean age of 31± 4 years and a female majority of 67%. Overall, the majority 88% have a fair knowledge regarding hand hygiene, 12% have poor knowledge, and 65% were compliant with all the recommended 5 moments of hand hygiene. Analysis of Factors affecting participants’ compliance with WHO 5 moments revealed that only experience was associated with the participants’ compliance. 

Conclusion: Many gaps in knowledge about hand hygiene were identified regarding patients and self-protection, and hand washing and rubbing, thus, anesthesiology registrars had poor to fair knowledge regarding hand hygiene. While  65% of them are compliant with the WHO 5 Moments hand hygiene. Compliance with the WHO 5 Moments hand hygiene was associated with participants’ experience.  

Introduction
Audits of infection prevention practices are uncommon, and not all hospitals have infection prevention and control policies that are specific to anesthetic treatment in the Operation Room (OR). Clinicians may not be aware of the necessary actions and procedures as a result [1] According to studies, anesthesia professionals engage in risky behaviors such as using multiple-dose vials for more than one patient, using gloves for airway management 100% of the time, failing to complete hand hygiene (HH) after removing gloves, and entering anesthesia cart drawers without doing HH [2-6].

A significant contributor to healthcare-associated infections (HAIs) is healthcare personnel’s inconsistent observance of simple preventative measures like hand hygiene [7,8]. Failure to follow aseptic technique guidelines as well as inefficient equipment cleaning and surgical site preparation have been linked to higher risks of surgical site infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, and other HAIs [9]. Unsafe injection practices, inappropriate reuse of needles, syringes, and single-use devices, as well as an increase in multiple-drug resistant organisms, have all been linked to a rise in emerging infections [7].

Recent studies have reported low levels of adherence to hand hygiene best practices among healthcare workers [10-12]. Poor adherence to HH was attributed to poor knowledge and perception of hand hygiene were reported to have a positive impact on adherence to hand hygiene practice [12,13]. Moreover, barriers to HH practice included the lack of posters or written policies on HH and tools such as alcohol-based hand rubs [13-16].  HH compliance was higher when risk was perceived to be higher (i.e., in the emergency and wound dressing/treatment rooms and labor wards [16]. Additionally, the profession is also thought to affect HH practice; as medical students were more likely to have better compliance [14]. while doctors had poor HH practices [16].

This study aims to report knowledge and practices of hand hygiene in the operation room and the ICU among the anesthesiology registrars registered in the Sudanese Council of Anaesthesia and Intensive Care to provide information about the anesthesiology department’s compliance with hand hygiene. The findings of the study are thought to give insight into the implementation of universal guidelines in hand hygiene practice, and the factors affecting it, thus reflecting the situation and the need for interventions that improve patient outcomes, and ensure health workers’ protection. 

Materials and Methods 
This was a descriptive cross-sectional institutional-based study. The study was conducted in Sudan, Council of Anaesthesia and Intensive Care among anesthesiology registrars registered in the Sudanese Council of Anaesthesia and Intensive Care. The study sample was calculated using the formula:

n= N/(1+N*MOE²)
n= Sample size 
N= Total population (250)
MOE= margin of error (0.05)
The sample size was estimated to be 152

Convenient non-probability sampling was used to access the studied population. 

Data was collected by the principal researcher using a predesigned data collection sheet in the form of a self-administered Google form.

The questionnaire contains three sections:

• Section one is about participants’ characteristics (age, gender, and experience).
• Section two is about participants’ knowledge of hand hygiene
• Section three is about participants’ practice of hand hygiene using the WHO ‘5 Moments of hand hygiene’ which has been launched in 2009 in an attempt to reduce the burden of healthcare-associated infections. 

Data was cleaned and entered into a Microsoft Excel data sheet and was analyzed using SPSS version 28 software. Categorical data was represented in the form of frequencies and proportions. The chi-square test was used as a test of significance for qualitative data. Continuous data was represented as mean and standard deviation. ANOVA test was used as a test of significance for quantitative data. MS Excel and MS Word were used to obtain various types of graphs such as bar diagrams. P value (Probability that the result is true) of <0.05 was considered statistically significant after assuming all the rules of statistical tests and level of confidence. Data was represented after analysis in the form of uni-variable tables, cross tabulation (bi-variable tables), figures, and narrative illustrations.

knowledge was scored by giving the correct answer a score of 1 and the wrong answer a score of 0. Total scores were calculated and transformed into percentages; percentages from 0 to 50 were considered poor knowledge, percentages from 50 to 80 were considered fair knowledge, and percentages from 80 to 100 were considered good knowledge. 

Compliance was scored by giving adherence to the recommended practice a score of 1, and non-adherence to the recommended practice a score of 0, total scores were calculated; a score of 5 was considered as compliant to the WHO 5 moments of hand hygiene, a score of less than 5 was considered as non-compliant to the WHO 5 moments of hand hygiene.  

Results
The study included 150 anesthesiology registrars registered in the Sudanese Council of Anaesthesia and Intensive Care. The mean age of participants was 31± 4 years and a female majority of 67%. More than half of them have 2 to 5 years of experience (table 1). 

Knowledge of patients prevention among participants was assessed, the majority have known that hand hygiene prevents the transmission of germs to the patient before touching the patient 95%, Immediately after the risk of body fluid exposure 89%, and Immediately before clean/aseptic procedure 91%, however, only 16% knew that hand hygiene can prevent transmission of germs to the patient after exposure to immediate surroundings of the patient (table 2).

Regarding knowledge of self-protection, the majority have known that hand hygiene prevents the transmission of germs to the health worker after touching the patient 95%, Immediately after the risk of body fluid exposure 96%, and after exposure to immediate surroundings of the patient 94%, however, only 22% knew that hand hygiene can’t prevent transmission of germs to the health worker after exposure to immediate surroundings of the patient (table 2).

Upon assessing knowledge of hand washing and rubbing, participants have known that rubbing is more rapid than washing 71%, and the minimal time needed for alcohol-based hand rub to kill most germs on your hands is 20 seconds 72%. Nevertheless, 24% knew that Hand rubbing does not cause skin dryness more than hand washing, 52% knew that Hand rubbing is not more effective against germs than hand washing, and 32% knew that there is no recommendation that Hand washing and hand rubbing are to be performed in sequence (table 2).

Regarding the appropriate hand hygiene method, participants identified that rubbing is recommended Before palpation of the abdomen 58%, Before giving an injection 53%, After making a patient’s bed 34%, Before giving a spinal anesthetic 20%, Before epidural insertion 20%, and Before central venous catheterization 21%. And washing After emptying a bedpan 75%, after visible exposure to blood 75%, Before general anesthesia induction 58%, Before attempting nerve block 79%, Before canulation 43%, and Before arterial line insertion 67% (table 2).

Overall, the majority 88% have a fair knowledge regarding hand hygiene, and 12% have poor knowledge (figure 1).

Regarding participants’ practice of the WHO 5 Moments hand hygiene, hand hygiene was least done Before touching a patient 77%, otherwise, the majority reported doing hand hygiene Before clean/aseptic procedures 91%, After bodily fluid exposure/risk 99%, After touching a patient 93, and After touching patient surroundings 89% (table 3). Overall 65% were compliant with all the recommended 5 moments of hand hygiene (figure 2).

Analysis of Factors affecting participants’ compliance with WHO 5 moments revealed that only experience was associated with the participants’ compliance; compliance was 38% in less than 2 years of experience, 62% in 2 to 5 years of experience, and 81% in more than 5 years of experience (p-value 0.002). Compliance was higher in females vs. males (66% vs. 63%) and fair vs poor (66% vs. 61%) however without statistical significance (table 4).

Discussion
A major cause of healthcare-associated infections (HAIs) is the lack of consistent compliance by healthcare workers with basic prevention techniques such as hand hygiene [7,8]. To assess anesthesiologist knowledge, and compliance with Hand hygiene strategies, this study included 150 anesthesiology registrars registered in the Sudanese Council of Anaesthesia and Intensive Care with a mean age of 31± 4 years, a female majority of 67% and  2 to 5 years of experience 51%.  

Anesthesiology registrars’ compliance with hand hygiene guidelines is an important measure for healthcare-associated infection prevention [17]. The present study revealed that the majority of anesthesiology registrars have fair knowledge regarding hand hygiene, and few have poor knowledge, however, non have shown good knowledge regarding hand hygiene. This is explained by the gaps in participants’ knowledge identified in many aspects such as patients prevention; only 16% knew that hand hygiene can prevent transmission of germs to the patient after exposure to immediate surroundings of the patient, and self-protection; only 22% knew that hand hygiene can’t prevent transmission of germs to the health worker after exposure to immediate surroundings of the patient. Similarly, Patrick et al. reported that One or more knowledge deficits were identified among health workers in their multicenter study [17].

Knowledge gaps regarding hand washing and rubbing and their appropriate uses were also identified in the present studies, many participants thought that rubbing is more effective than hand washing and few participants identified appropriate when to use rubbing (aseptic procedures) such as spinal anesthetic, epidural insertion, and central venous catheterization compared to those identified when to use hand washing (sterile procedures). Similarly, Sreejith et al. found that medical and nursing students had more knowledge gaps regarding rubbing use than hand washing, despite nursing students showing better knowledge than medical students this knowledge gap existed overall [18]. 

Two-thirds were compliant with all the recommended 5 moments of hand. Based on the WHO 5 Moments of hand hygiene, hand hygiene was least done Before touching a patient, otherwise, the majority reported doing hand hygiene Before clean/aseptic procedures, After bodily fluid exposure/risk, after touching a patient, and after touching patient surroundings. This is ways better than what was reported in Nigeria by Onyedibe et al in which the compliance rate was 31%, however, similarly hand hygiene was least applied before touching the patient [14]. another study in Nigeria reported a compliance rate of 30% [15]. Also, in Ghana, Care-related Hand Hygiene compliance among doctors and nurses in this large West African hospital was found to be low [16].  Furthermore, upon assessing the adhesion to the different aspects of hand hygiene in the ICU, it was found that there were low levels of adherence to best hygiene practices [10].

In this study participants’ experience was the only factor significantly affecting their compliance with hand hygiene practice; the more experience the higher the compliance. Despite that difference between males and females was reported but it didn’t reach statistical significance. Similarly, it was reported that females had higher hand hygiene compliance compared to males [15]. Hand hygiene compliance was also found to be higher among participants with fair vs poor knowledge, however without statistical significance. Similarly, commonly identified barriers to Hand Hygiene were limited resources and lack of knowledge on appropriate times to perform Hand Hygiene [13].

Conclusion
Anesthesiology registrars had poor to fair knowledge regarding hand hygiene. Many gaps in knowledge about hand hygiene were identified regarding patients and self-protection, and hand washing and rubbing. Two-thirds of anesthesiology registrars were compliant with the WHO 5 Moments hand hygiene which was affected by their experience.  Interventions such as lectures and courses in infection control could be done to improve participants’ knowledge. Additionally, promotion for compliance with hand hygiene practices should be designed and introduced in all service centers.
 
Declaration 
The authors declare no conflict of interest.  

Ethical approval for conducting this research was obtained from the ethical committee of the Sudanease Medical Specializations Board (SMSB)

Raw data are available upon request from the corresponding author 

All authors contributed to formulating the research idea, designing the study, collecting data, data anaslysis, and writing this manuscript. 
This research was not funded by any funding agencies in the public, commercial, or not-for-profit sector.

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