Indian Pediatr 2015;52: 382-383
Hand Washing Practices in Neonatal Intensive
B Vishnu Bhat and B Adhisivam
From the Department of Neonatology, JIPMER,
ne-third of the annual 4 million neonatal deaths
occurring worldwide are associated with infections [1,2]. In countries
with high neonatal mortality (>45 per 1000 births), 50% of these deaths
are attributed to infections . India contributes to one-fifth of the
total live births and 27% of global newborn mortality . Essential
maternal and newborn care interventions such as clean delivery, hygienic
cord care, thermal care and breastfeeding can reduce infection-related
neonatal deaths by 20–50% [4,5]. Simultaneously, it is prudent to
escalate all measures to decrease health care-associated infections
(HCAI) or ‘nosocomial’ infections. Proper hand washing by personnel
handling neonates is a simple and effective intervention to prevent
HCAI. However, it requires staff accountability and behavioral change.
Strict adherence to hand hygiene practices in neonatal intensive care
unit (NICU) has the potential to reduce the duration of hospital stay,
long-term morbidity, emergence of multi-resistant organisms, cost of
medical care and unnecessary deaths associated with HCAI. The rationale
for hand washing is to reduce transient and resident micro-flora, and
there is substantial evidence for the same. Better adherence to hand
hygiene guidelines and policies has been shown to reduce the HCAI rate
by as much as 40% [6,7].
The basic requirements for reducing HCAI in NICU
would include continuous water supply, soap, elbow- or foot-operated
taps, strict hand washing, avoiding overcrowding, acceptable
nurse-to-patient ratio, sufficient disposables, rational antibiotic
policy, and good housekeeping and asepsis routines. One should wash
hands for at least 2 minutes following the six steps of hand washing
allotting at least 20 seconds for each step. The six steps should cover
the following in sequence: palms and fingers and web spaces, back of
hands, fingers and knuckles, thumbs, finger tips and wrists and forearm
upto elbow . A hand rub may not be a substitute for hand washing
before entering the NICU. The "My 5 Moments for Hand Hygiene" approach
outlines the key moments which are applicable to the NICU setting also.
This approach recommends hand washing before touching a patient, before
clean/aseptic procedures, after body fluid exposure/risk, after touching
a patient, and after touching patient surroundings . Annual global
campaign by WHO "Save lives: clean your hands" also emphasizes the need
to improve and sustain hand hygiene practices of health-care workers at
the right time, and in the right way, to help reduce the spread of
potentially life-threatening HCAI.
In a video surveillance audit of hand washing
practices in a 26-bedded level III Neonatal Intensive Care Unit (NICU)
from Gujarat, reported in this issue of Indian Pediatrics, the
authors observed that among 1081 video recordings, 403 (37.3%) were
excellent, 521 (48.2%) were acceptable and 157 (14.5%) were unacceptable
. About one in seven hand washing procedure was unacceptable, and
these unacceptable procedures were more common during night hours and
among parents . Though this descriptive data appears preliminary, it
probably reflects the state of hand hygiene compliance in most of the
NICUs across the country, and calls for similar audits in all health
care settings. It is to be noted that despite the fact that the
participants were aware of the video surveillance, the compliance was
not 100%. In case, the same video recordings had been done without the
participants’ knowledge, we would probably get the true picture.
Moreover, the video recordings can be shared with all the participants
as a feedback, and this could in fact serve as a good training tool to
enhance the compliance for strict hand hygiene in NICU. In the long run,
even a dummy camera at the site of hand washing can make most of the
healthcare workers adhere to strict hand hygiene. This report also
reiterates the importance of ensuring good hand hygiene practices among
all caregivers, especially parents. The limitations of the study, as
stated by the authors, were: short duration, not observing health care
personnel behavior change after the initial hand wash and not
correlating the healthcare-associated infections during the study
Hand hygiene is indispensable for ensuring neonatal
safety and should occur in a timely and effective manner in NICU. Low
compliance with hand hygiene and poor antisepsis at birth and in the
first week of life can increase the risk of deadly but preventable
infections. Hand hygiene in NICU can be improved by removing the
barriers and actively promoting compliance. Enhancing compliance can be
achieved by training of personnel, provision of appropriate hand wash
facilities, placing hand-rub dispensers at the appropriate sites, and by
physicians setting a good example for others. It will be better if NICU
personnel develop obsessive compulsion for frequent hand washing rather
than frequently chasing nosocomial bugs with newer antibiotics.
Funding: None; Competing interests: None
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