Assessment of Hand Hygiene Knowledge among Residents and Nursing staffs at Nobel Medical College Teaching Hospital ,

Introduction: Hand hygiene is a very simple and cost-effective procedure to prevent cross-transmission of microorganisms. The compliance of residents and nursing staffs with hand hygiene guidelines seems to be vital in preventing disease transmission among patients. The objective of the study was to assess the knowledge of residents and nursing staffs with regard to hand hygiene. 
Material and Methods: This was an institution based descriptive cross-sectional study conducted among 55 respondents (29 nursing staffs and 26 resident doctors) of department of paediatrics, Nobel Medical College in Biratnagar, Nepal. Knowledge was assessed using WHO hand hygiene questionnaire for health care workers. Chi square test was used to compare the percentage of correct responses between resident doctors and nursing staffs. A p value of <0.05 was considered significant. 
Results: Among 26 resident doctors and 29 nursing staffs who participated in the study, 30.7% of resident doctors and 55.1% of nursing staffs had received formal training in hand hygiene in the last three years. Only 9% of participants (5 out of 55) had good knowledge regarding hand hygiene. 
Conclusions: The knowledge regarding hand hygiene is limited among the study population. The study recommends the need for emphasizing hand hygiene component in the preservice as well as in-service training programs of doctors and nurses.  


Introduction
H and hygiene is a general term that applies to either hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis 1 .Hand hygiene is a simple measure to prevent crosstransmission of microorganisms and to reduce the incidence of health care associated infections 2,3 .Health Care Professionals (HCPs) hands become progressively colonized with commensal fl ora as well as with potential pathogens during patient care 4 .Hand hygiene is one of the fi ve key initiatives set out by the World Alliance for Global Patient Safety Challenges 5 .
Despite the relative simplicity of this procedure, compliance with hand hygiene among HCPs is as low as 40% 2,6,7 .To address this problem, continuous eff orts are being made to identify eff ective and sustainable strategies.One ofsuch eff orts is the introduction of an evidence-based concept of "My fi ve moments for hand hygiene" by World Health Organization.These fi ve moments that call for the use of hand hygiene include the moment before touching a patient, before performing aseptic and clean procedures, after being at risk of exposure to body fl uids, after touching a patient, and after touching patient's surroundings.This concept has been aptly used to improve understanding, training, monitoring, and reporting hand hygiene among HCPs 2 .
Nurses and resident doctors constitute the largest percentage of the HCPs.Because they spend more time with patients than any other HCPs, their compliance with hand washing guidelines seems to be vital in preventing the disease transmission among patients.
In Asian countries like Nepal, there is a paucity of studies exploring this subject, although the prevalence of health care associated infections is high in this region; especially medical and nursing staff s , knowledge of standard precautions is rarely studied 8,9,10 .The observation of hand hygiene by residents has been reported to be weak 11,12 .Therefore, it is essential to investigate health professionals' knowledge regarding hand washing so that appropriate strategies can be developed to promote hand washing compliance 13,14 .The objective of the study was to assess the knowledge of residents and nursing staff s with regard to hand hygiene.

Materials and Methods
This cross-sectional study was conducted in Department of Paediatrics, Nobel Medical College Teaching Hospital (NMCTH), one of the biggest teaching hospitals in eastern part of Nepal.The hospital currently had 911 beds of its own at full function.It serves the patients from various communities of Nepal and adjoining Bihar state of India.The study was conducted in a period of one month from May to June 2018.Ethical clearance was obtained from the Ethical Review Committee of Nobel Medical College.Resident doctors and nursing staff s were explained the content and nature of the study.Verbal consent was obtained from 26 resident doctors and 29 nursing staff s who volunteered to participate.Knowledge was assessed using WHO hand hygiene questionnaire for health care workers.This questionnaire included 25 dichotomous "yes" or "no" questions; and "true" or "false" questions.One mark was given for each correct response so that maximum score for knowledge was 25.A score of more than 75% was considered good, 50-74% moderate, and less than 50% was taken as poor.Data was analysed using SPSS 16 version software.Descriptive statistics was used to calculate percentages for each of the responses given.Chi square test was used to compare the percentage of correct responses between resident doctors and nursing staff s.A p-value less than 0.05 was considered signifi cant.

Results
A total of 55 partici pants were enrolled in the study.Among the respondent 26 (47.3%) were resident doctors and 29 (52.7%) were nursing staff s.Their demographic profi les are depicted in Table 1.Within resident doctors, 76.9% were male and all nursing staff s were female.
Less than one-thirds (30.7%) of resident doctors and majority (55.1%) of nursing staff s had received inservice training in hand hygiene in the last three years.
Knowledge regarding diff erent aspects of hand hygiene among the respondents is presented in Table 2 that reveals 92.3% of residents and 86.2% of nursing staff s answered correctly for the main route of cross transmission of harmful germs between patients in health care facility.About two-fi fth (42.3%) of residents and about one-thirds (31.0%) of nursing staff s knew about the most frequent source of germs responsible for health care associated infections.Regarding hand hygiene activities preventing transmission of germs to the patient, residents and nursing staff s had similar awareness with respect to practice like immediately after a risk of body fl uid exposure, before touching a patient, after exposure to the immediate surroundings of a patient and immediately before a clean/aseptic procedure.Regarding hand hygiene actions preventing transmission of germs to health care worker, higher awareness was seen among nursing staff s with respect to practice like immediately after a risk of body fl uid exposure but the diff erence was not statistically signifi cant.Nursing staff s had more knowledge on hand hygiene practices like after exposure to the immediate surroundings of a patient (82.8%) and immediately before a clean/aseptic procedure (27.6%).
Table 2 also reveals knowledge on hand rub and hand washing with soap and water.Eighty eight percent of resident doctors correctly stated that hand rubbing is more rapid for hand cleansing whereas, 62.1% of nursing staff s correctly stated about hand rubbing causing skin dryness more than hand washing.Eighty fi ve percent of resident doctors agreed that hand rubbing is not more eff ective than hand washing.Most (80.8%) of resident doctors were correct about hand washing and hand rubbing not being done in sequence.Majority (65.4%) of residents and 20.7% of nursing staff s had answered Almost all (92.0%) of doctors knew that hand washing should be done after visible exposure to blood.Nursing students were more aware that wearing jewellery (93.1%), damaged skin (100%), and artifi cial fi ngernails (96.6%) would be associated with increased likelihood of colonization of hands with harmful germs.Almost all (92.3%) of resident doctors were aware that regular use of hand cream would not increase the colonization of germs.
The knowledge on most frequent source of germs responsible for health care associated infections and hand hygiene actions preventing transmission of germs to the patient did not diff er signifi cantly between residents and nursing staff s, whereas the knowledge on the minimal time needed for alcohol-based hand rub to kill most germs on hands, things to be avoided which has high chance of colonization of germs diff ered signifi cantly between residents and nursing staff s (Table 2).

Discussion
Hand hygiene is simple tool in preventing the transmission of nosocomial infections as the hands of health care workers are the most common mode of transmission of pathogens to patients 15 .
In our study, analysis of the responses showed that health care workers had moderate knowledge on hand hygiene, simi lar to fi ndings of the study conducted in Sri Lanka fi ndings 16 .Though this was a positive fi nding, major gaps in the knowledge were identifi ed which should be addressed during the future training sessions.Nursing staff s had more knowledge compared to medical students; this may be probably due to hand hygiene related training that they have received.They also spend more time in the wards and have more chance of practicing hand hygiene.Resident doctors knew more about the time and the facts about hand rub and hand washing.They read more about the scientifi c aspects rather than practicing hand hygiene.They might not be spending more time in the wards which might be the reason for being not aware of hand hygiene aspects during diff erent clinical procedures.For instance they were not aware that hand hygiene is to be practiced before patient contact and after contact with patient surroundings.Another fi nding in our study was that 65.4% of the resident doctors and 20.4% of the nursing staff s knew the minimal time required for alcohol based hand rubs to kill the germs on hands.
In our study 30.7% of resident doctors and 55.1% of nursing staff s had formal training on hand hygiene which is very less compared to study done in Raichur by Nair et al in which 74% medical and 95% nursing students had formal training 17 .In our study 47% of resident doctors and only 52% nursing staff s regularly used alcohol based hand rub compared to 58% students in a study done in ESIC college Gulbarga by Vinod et al 18 .Most of the doctors and nursing staff s knew the main route of cross transmission of harmful germs in hospitals compared to study done in Sri Lanka by Ariyaratne et.al. in which 73% of students had answered it correctly. 19ess than 50% of resident doctors in our study knew about most frequent source of germs responsible for health care associated infections compared to 94% of students in a study done by Arthi et.al. in Puducherry 20 .The knowledge about hand hygiene actions preventing transmission to patients and also to health worker was more among nursing staff s which is comparable to study done in Raichur by Nair et.al. 17 Sixty fi ve percent of resident doctors knew the minimal time needed for alcohol-based hand rub to kill most germs on hands compared to 15% in a study done by Arthi et.al. in Puducherry 20 .In our study, resident doctors had good knowledge about hand rubbing, hand washing and its uses in diff erent situations.In contrast nursing staff s were more knowledgeable about the things associated with colonization of hand with harmful germs.

Conclusions
Knowledge on hand hygiene was moderate among resident doctors and nurses.Inspite of receiving training on hand hygiene, emphasis on hand hygiene in the curriculum of medical students, residents and nurses needs to be given in order to improve student's knowledge about the same.

Limitations
The results obtained may not truly refl ect knowledge of hand hygiene in the population because of the cross sectional study design, institution based study and small sample size.

Table 1 :
Sex and In-service Training Distribution of the Respondents

Table 2 :
Knowledge of the Respondents regarding Diff erent Aspects of Hand Hygiene (n=55)

to be avoided, as they are associated with increased likelihood of colonization of hands with harmful germs are
minimal time needed for alcohol based hand rub to kill germs on hand.About 88% of resident doctors and 76.0% of nursing staff s knew that hand washing to be done after emptying bed pan.