Hand Hygiene In Residential Aged Care Facilities: Critical Evaluation

Importance of Hand Hygiene in Preventing Viral Diseases

Hand hygiene is concerned with the cleanliness of hands to prevent any germs and infections from entering the body via hands. It includes washing hands with soap and water or alcohol-based sanitizer for the reduction of microorganisms on the surface of the hands (ACSQHC, 2019). With the onset of the COVID-19 pandemic, hand hygiene became an essential part of lifestyle and routine and its significance increased more than ever especially in the healthcare sector since healthcare workers work in environments where they are continuously exposed to contacting contagious viruses (Wang, et al., 2021). Residents at aged care facilities are more prone to infections of the skin, respiratory or urinary tract because most have an underlying disease, physical or psychological problems, and use devices like catheters. They are also in frequent contact with staff and other residents rendering them susceptible to catching any virus (Bennett, et al., 2018). Hand hygiene becomes important in aged care facilities as elders are more vulnerable to infectious diseases because most elders have chronic health conditions and the body’s immunity levels decrease with age (Mueller, et al., 2020). But there is a proper way of washing hands as shown in figure 1 which should be followed to ensure maximum protection from viruses. This essay is a critical evaluation of hand hygiene in residential aged care facilities in Australia. The essay will explore the meaning and importance of hand hygiene for the prevention of viral diseases. Additionally, the essay will identify and discuss the problems in practicing hand hygiene such as lack of proper compliance and the interventions that are made to improve the problem. The essay will also confer the need and process of implementing such interventions and the problems faced during the communication of interventions. Finally, the essay will evaluate the interventions to find out if they are effective and whether any further interventions are needed.

 

Figure 1 

Source: (Duda, 2020)

Practicing hand hygiene and educating the residents at aged care facilities is one of the most effective ways of fighting infections. Hygiene in hospitals and residential aged care facilities is crucial in reducing morbidities and prolonged stay at hospitals among patients and residents (Engdaw, et al., 2019). People frequently touch surfaces and unknowingly invite many germs on their hands. These germs can pass from person to person through hand-shakes and can enter the body through the eyes, nose, ears, or mouth because people generally touch these body parts a lot of times. Hand hygiene can contribute up to 50% prevention of infections if practiced effectively (WHO, 2021). Hence, hand hygiene is an important factor to consider for precautionary measures against infectious diseases.

Hand hygiene should be implemented in aged care facilities and the residents and staff should be educated about the importance and correct implementation of it. The caregivers at these facilities should be aware of the times at which they should wash their hands to avoid infections. There are 5 important moments before or after which handwashing is necessary (figure 2). These moments are before performing any medical examination (blood pressure test), before insertion of devices like nasal cannula, after insertion of a catheter, after assisting the residents in bathing, and after coming in contact with resident’s surrounding objects (Mun Global, 2020). Taking care of these things will ensure maximum protection of the residents from exposure to harmful viruses.

Problems in Practicing Hand Hygiene in Aged Care Facilities

 

Figure 2    

Source: (Mun Global, 2020)

But the problem arises when there is not enough compliance to the hand hygiene guidelines among people. Poor compliance can be because of a lack of awareness regarding hygienic practices. The most common reason for non-compliance of hand hygiene among healthcare workers is inaccessibility to sink and the attitude of “others do not do it. Why should I?” (Figure 3). It can be the same for caregivers and residents at residential aged care. This needs to be addressed by spreading awareness and letting them know the purpose behind hand washing.

 

Figure 3 

Source: (Engdaw, et al., 2019)

The reasons behind poor compliance in residential aged care facilities could be inaccessibility to sinks, handwash products causing skin damage and irritation, and a lack of knowledge regarding proper ways to wash hands and its implications. Elders are less likely to walk long distances to wash hands and the location and visibility of sinks directly impact the frequency of times people wash their hands (Deyneko, et al., 2016). Risks of skin infections also increase with age because with age there are changes in skin structure with the thinning of dermis and epidermis and fragmentation of elastic and collagen (Chambers & Vukmanovic-Stejic, 2019). Frequent handwashing can lead to skin drying and skin rash. These issues need to be addressed to ensure adherence to hand hygiene guidelines.

Interventions to solve these issues become important for promoting better hand hygiene and the reduction of viral diseases. This becomes even more significant in the present times because of the rampant global pandemic called Corona which is caused by a SARS-CoV-2 virus that adversely affects people’s respiratory tract. Hand hygiene has proved to be the most effective way of preventing viruses and residents should be encouraged to wash their hands before eating and after using the toilet as a minimum (Doherty Institute, 2018). Promoting these habits will result in the active containment of viruses in old-age homes.

Identification of barriers to hand hygiene can help implement suitable interventions that can work in many ways to improve compliance with hand hygiene. Education about hand hygiene and the right ways to wash hands can encourage people to adopt correct techniques contributing to better outcomes. Audit and feedback after implementation help in ensuring continuous compliance to rules. Reminders at specific time intervals can compel people to take action. Finding out about people’s problems with hygiene products and accessibility to sinks can encourage proper interventions in this area as well (Gould, et al., 2017). Getting the staff to actively participate in practicing and promoting hand hygiene will also help to a large extent. This shows that compliance with hand hygiene can be increased through the right interventions.

To warrant maximum compliance to hand hygiene, education can prove to be a great tool. Educating the residents and caregivers at residential aged care facilities about the risks of infections from poor hand hygiene, how bacteria travel from hand to body, the effectiveness of washing hands regularly, and the positive impact of hand hygiene on their health can be beneficial for ensuring adherence to hand hygiene guidelines (Yang, et al., 2019). Raising awareness through teaching will improve hand hygiene behaviours among residents.

Interventions to Improve Compliance with Hand Hygiene

The care providers at aged care homes should be provided with adequate knowledge about the right way of practicing hand hygiene. Government guidelines advocate for care providers to wash their hands at 5 important moments that are: before touching the residents or doing their routine health check-up, after touching the resident or anything in his surrounding environment like bed-linen, after a procedure in which there has been a body substance exposure (NHMRC, 2019). This will ensure that they do not knowingly or unknowingly expose the older adults to any viruses.

Intervention for preventing any skin infection or rash among the residents is also important since their skin is more sensitive. Many factors can lead to dermatitis such as preservatives or fragrances in ABHR, washing hands regularly that may contribute to skin drying, using hot water to wash hands, use of low-quality paper towels, or not using enough moisturizers (Hand Hygiene Australia, 2022). This can be avoided by providing the residents with hand rubs, soaps, or paper towels according to their specific needs and preferences (NHMRC, 2019). There should be the availability of moisturizers at all times to prevent skin drying. This will ensure the elimination of skin problem risks and maximum compliance to hand washing throughout the day.

One more intervention can be setting reminders for the residents at specific time intervals to remind them of washing hands if they forget. These reminders can be vibration, bells, light sound, or even human announcements (before eating, after using washrooms, or after doing some activity that included touching surfaces of things) to gently remind them to wash or sanitize their hands. Data shows that there has been a significantly positive effect of voice reminders on handwashing (figure 4). The graph shows how at first without voice reminders the compliance to hand hygiene was low and it increased drastically after using reminders. Then again when reminders were turned off, there was a drop in handwash compliance which again increased after turning them back on. This proves the effectiveness of reminders in improving compliance with hand hygiene.

 

Figure 4 

Source: (Hermann, 2019)

Another intervention would be to improve the accessibility of hygiene products. If these products are within reach and there is little to no effort required to reach and use them, then hand hygiene practices will be more disciplined. Sinks or ABHR should be conveniently situated at places that are easily accessible and there should be no shortage of sinks. This is a proven way to implement effective hand hygiene in healthcare or aged care centres.

Creating a culture that encourages a positive attitude towards hand hygiene will also help to a great extent. This has to be done at all levels of management at the facility for maximum benefits. This type of culture can be created through promotion of hygienic packaging for products that are used in the facility, installation of systems that provide for limited touch, providing better accessibility to sinks, keeping all the places within and surrounding the facility clean and hygienic, making a strategy for the long-term and ensuring procurement of hygiene equipment is cost-efficient (Veridia, 2021). The creation of culture will contribute to the creation of hygienic values among all the residents, staff, and management of the facility and will have a long-term positive effect.

Barriers to Hand Hygiene and Suitable Interventions

Feedback is another intervention that should be implemented to evaluate how much adherence there has been to the guidelines for hand hygiene. It is believed to motivate people to keep up with good hygiene practices but research and survey show that feedback does not have an impact on hand hygiene behaviours (Scherer, et al., 2019). But the importance of feedback should not be completely ignored. Implementing technological and automatic ways of recording and evaluating hand hygiene behaviour regularly can help in comparing the actual performance to the set standards, finding deviations, identifying reasons for those deviations, and then finally making a strategy to eradicate the root cause of the deviation (Theißen, 2019).  

Implementing the interventions is not enough, it needs to be made sure whether the interventions are working and are having a decent impact on hand hygiene compliance or not. Various evaluation methods are used to measure compliance to hand hygiene guidelines. These evaluation methods help improve hand hygiene compliance since people tend to be more disciplined when they are being monitored. Studies have shown a visible difference in compliance before and after observation and monitoring (Lenglet, et al., 2019). Hence, it can be said that evaluation is necessary for hand hygiene compliance at aged care facilities.

Monitoring can be done through various direct or indirect methods. Observation is a direct method wherein a trained observer is appointed to first calculate all the opportunities (appropriate times for handwashing) and then observe how much these opportunities are being utilized by people to assess compliance. This method can be very useful in the way that it provides directly observed data and is done by a professional observer. However, it requires the facility to hire the right observer who is trained and experienced enough to do this and is willing to work long hours. One more problem with this method is that it is subjected to the observer’s own biases that can negatively impact the credibility of the data collected (Masroor, et al., 2017). The indirect method is to measure the hygiene product usage across a specified period. This is done by measuring how much the product (paper towels, hand rubs, and soap) has been used and then this data is used to estimate the number of hygiene events that took place. It is a cost-effective method and does not require any trained observer which is why it is free from any biases but observing the quantity of products is not a clear indicator of whether all the handwashing events happened at appropriate times or not (Masroor, et al., 2017). Both of these methods are cost-saving and can be adopted in facilities with limited resources and can help in improving obedience to hand hygiene.

Automated systems can be installed at the facility to evaluate performance without human efforts. These automated systems can be used to electronically monitor the use of sinks and hand rubs. This will provide precise quantitative data and cost will only be included in the installation and repair of the systems. The electronic system can also be used to set reminders for hand washing and for providing feedback data. Studies have shown a significant increase in hand hygiene compliance when feedback and reminder systems are used together (Hayashi, et al., 2016). Embedded reminder systems have shown an increase of 97% in compliance and a decrease of 90% in cross-contamination (Lorenzi, 2021). This shows the relevance of automated systems in improving hand hygiene at facilities.

Importance of Staff Participation in Promoting Hand Hygiene

Auditing is used to evaluate the effectiveness of hand hygiene programs. The Australian Commission on Safety and Quality in Healthcare provides facilities with an auditing tool called HHCApp which can be used to audit hand hygiene compliance with the 5 moments guidelines (ACSQHC, 2021). Currently, this tool is recommended for facilities with great staff/resident activities for recording and auditing a higher number of moments in a short period. As per studies, groups, where auditing and feedback are used, show less compliance (50%) than groups where incentives are used as an intervention (78%) but the compliance here was more sustainable than any other intervention’s compliance (figure 5). Therefore, auditing can be used to increase the compliance of residents and staff in aged care facilities.

 

Figure 5 

Source: (Moghnieh, et al., 2017)

Australian government’s Hand hygiene Initiative that advocates for strategic interventions and auditing in accordance with the 5-moment hand hygiene has been effective in improving hand hygiene compliance in healthcare workers. Since, its inception in 2009, the participation and compliance for hand hygiene in healthcare facilities has only increased which shows how much effective it is for controlling infections through hand hygiene (figure 6). This compliance has been consistently increasing even after the 2020 audit in which the compliance for National Hand Hygiene reached 88.2% (figure 7). This proves that the government of Australia is dedicated to improving the hand hygiene of the country to prevent infectious diseases and their Hand Hygiene Initiative can help aged care facilities to implement significant changes for hand hygiene.

 

Figure 6 

Source: (Grayson, et al., 2018)

 

Figure 7 

Source: (AIHW, 2022)

One more technology-oriented method for the evaluation of compliance is video-surveillance systems. This can be done through the installation of cameras at places near the sink and hand rubs to monitor the hand hygiene behaviour among the residents and staff (Mckay, et al., 2020). This method can be beneficial because of the objectivity in observation but it can be a little expensive. Also, cameras should only be installed with the prior permission of everyone to avoid a breach of privacy. This technology in aged care facilities can improve real-time data collection and can compel the residents to improve their hygiene behaviour.

Conclusion

To conclude, hand hygiene means keeping the hands clean and free from foreign germs and bacteria. It is done through handwashing with the help of soap and water or alcohol-based hand rubs. Hand hygiene is important because it is said to be the backbone for preventing infectious diseases and it became all the more important after the onset of global pandemic Corona. Older adults are more vulnerable to infections which is why hand hygiene has to be followed in residential aged-care facilities properly.

In this regard, the government of Australia has implemented the Hand Hygiene Initiative that aims to improve hand hygiene in healthcare facilities. In aged-care facilities, the staff has to follow the 5 moments approach for handwashing at appropriate times. These moments include times before and after coming in contact with the residents or their environmental things.

Conclusion

However, there are many hurdles in ensuring proper compliance to hand hygiene guidelines. These include lack of knowledge of the importance and proper ways of handwashing among residents and staff at facilities, faraway placement of sinks and ABHR, the negative impact of frequent handwashing on the skin of the older adults, and undisciplined behaviour of people towards hand hygiene.

These barriers can be solved with the right interventions such as education programs to raise awareness towards hand hygiene, providing the residents with products that meet their specific preferences and do not harm their skin, correct placement of sinks that will make them accessible by everyone, installation of reminder systems to remind people of handwashing at appropriate times, and implementing a monitoring/feedback system to ensure that everyone is following the correct hygiene behaviour.

The interventions have to be measured regularly. This helps in continuous compliance and positive behaviour towards hand hygiene. Evaluation can be done through direct monitoring (hiring a trained observer who will calculate the opportunities for handwashing and will monitor residents’ behaviour according to that) and indirect monitoring through measurement of the quantity of hygiene products. This can also be done through a video surveillance system through the placement of cameras near sinks and hand rubs. Another way is auditing for which tools are provided by ACSQHC but it is recommended to be used in facilities with more staff/resident interactions to collect and audit more data in lesser time. Auditing has proved to result in sustainable compliance. All this shows that the problems with hand hygiene can be solved through the right interventions and those interventions can be evaluated through various techniques for improving compliance to hand hygiene.

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