Background: Healthcare-associated infections affect hundreds of millions of patients worldwide. Children have greater susceptibility to healthcare-associated infections due to the immaturity of their immune system. Contact precautions aim to promote safety, protection and prevention of contamination. Thus, the objective of this study was to verify adherence to contact precaution measures, as well as compliance to the use of personal protective equipment. Methods: This cross-sectional observational study was carried out from July to October 2019 using a checklist to evaluate health professionals’ adherence to hand hygiene procedures and the use of gloves and surgical gowns when assisting children on contact precautions. Results: A total of 941 observations were carried out in a total of 300.532 hours. Hand hygiene was performed before and after contact with the patient in 58.84% and 75.09% of the cases, respectively and a surgical gown was used in 86.40% of the cases. The use of gloves was the variable most adhered to by professionals (87.57%). Intensive care unit professionals were the care workers who most complied with the regulation regarding hand hygiene after contact with the patient (p = 0.009) and the use of the surgical gown (p < 0.001). The correct hand hygiene technique was the recommendation with least adherence. Non-compliance to the hand hygiene technique was statistically significant among intensive care unit professionals (p = 0.002). Conclusions: Adherence to hand hygiene before contact with the patient and compliance with the hand hygiene technique were neglected by most professionals. However, there was good adherence to the use of surgical gloves and gowns, as well as high compliance to the techniques of removing these items.
Hospital Infection Universal Precautions Patient Safety Pediatric Nursing Isolation of Patients Microbial Drug Resistance1. Introduction
Healthcare-associated Infections (HAIs) are understood to be any infection acquired during the care process after the patient’s admission to the hospital environment; they may manifest during hospitalization or after discharge [1] .
Children have greater susceptibility to HAI due to the immaturity of their immune system. In addition, situations of prematurity and low birth weight require invasive procedures thereby increasing risk [2] . HAIs reflect in increased complications and complexity of treatment since they increase morbidity, mortality, and child and family suffering, as well as length of hospitalization and treatment cost [3] .
As a means of preventing the transmission of multidrug-resistant microorganisms in the hospital environment, professionals use personal protective equipment (PPE) and techniques called contact precautions during the care of these patients [4] .
Contact precautions are indicated in cases of excessive wound drainage, fecal incontinence and the presence of other body fluids that are potential environment contaminators from patients infected or contaminated with multidrug-resistant microorganisms, as well as in cases of increased contamination risk. These clinical conditions carry a sufficiently high risk to call for the practical application of isolation precautions, empirical contact precautions, while waiting for a clear diagnosis. This occurs when a patient is admitted to a tertiary facility after referral from another health service because of the possibility of colonization by a multi-resistant microorganism. In these empirical cases, the same contact precaution measures used in patients infected or colonized with multidrug-resistant bacteria are adopted. The use of an isolation room is recommended with the door always being kept closed. However, if it is impossible to keep the door shut, it is important to keep the patient at least six feet away from other patients [4] .
Contact precautions, as recommended in the Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings and defined in the Regulatory Standard No. 6 approved in 1978, are one of several regulations of the Consolidation of Brazilian Labor Laws, which includes hand hygiene, and the use of gloves and surgical gowns as PPE. The objective is to promote safety, protection, and prevention of contamination among professionals and patients [5] . Above all, PPEs are indispensable for the entire team that care for patients with HAIs. When healthcare professionals do not follow the recommended protective measures while treating patients on contact precautions, they increase the risk of cross-contamination [6] . As multidrug-resistant microorganisms are the most common cause for the increase in HAIs, it is necessary to adopt strict contact precaution measures [7] .
The incidence of multi-resistant bacteria in recent decades has increased, thereby further complicating the treatment of some HAIs. In addition, there is a consensus that bacterial resistance is an important factor in increasing mortality rates of critically ill patients [8] . In view of these mortality rates, the compliancy of all health professionals to the contact precaution guidelines has become essential when caring for patients with resistant microorganisms. In doing so, they will help to avoid the spread of multi-resistant bacteria in the hospital environment and to reduce occupational risk [9] . The most common multidrug-resistant bacteria responsible for hospital infections are Staphylococcus aureus, Enterobacteria, the CESP group of bacteria (Citrobacter spp., Enterobacter spp., Serratia spp. and Providencia spp.), Enterococcus, Klebsiella pneumoniae, and Acinetobacter sp. [10] .
As cross-contamination of organisms occurs due to contaminated hands that promote the transfer of microorganisms from one surface to another, it is worth noting that around 30% of hospital infections can be prevented by hand hygiene with water and soap, 70% alcohol (gel) or by degerming solution [11] .
However, clinical audits are still needed to evaluate whether health professionals are following the contact precaution guidelines [12] . These measures support staff training and development since the use of PPEs is still a challenge due to lack of training, long working hours and inadequate concern among the professionals themselves [13] .
Given these considerations, this study aims to verify both adherence to contact precautions including compliance of the correct techniques of PPE removal in a teaching hospital specialized in children’s and women’s health.
2. Method
The methodology used was a cross-sectional observational study with a descriptive design and a quantitative analytical approach with correlation between variables. The research setting is a 201-bed teaching hospital in southeastern Brazil, which is specialized in children’s and women’s health.
Of these hospital beds, 49 are designated for gynecology and obstetrics and 152 beds are assigned to pediatrics. Of the pediatric beds, 55 are on children’s wards and 97 are in intensive care units (ICUs). Of the ICU beds, 39 are designated for general pediatrics, 23 for pediatric cardiology, 16 for neonatology, and 19 for neonatal intermediate care. The service is intended for users of the public healthcare system, various health insurance companies and healthcare providers. It is important to highlight that 16 patients on average are hospitalized per month on contact precautions.
Every day from July 1st to October 31st 2019, the Hospital Infection Control Commission (HICC) provided the locations of patients on contact precautions aged between 0 and 12 years old. These included children infected or contaminated by carbapenems-resistant Pseudomonas spp. and Acinetobacter spp., vancomycin-resistant Enterococcus spp., carbapenemase-producing or carbapenem-resistant gram-negative bacteria, microorganisms resistant to all classes of antimicrobials and other bacteria with a multidrug-resistant profile as defined by the HICC, such as multidrug-resistant Staphylococcus sp.
All professionals who treated patients on contact precautions during the period of the observations were included as the study population. The information related to the adherence of health professionals to contact precaution guidelines was collected through observations in the three work shifts (morning, afternoon, and night), both on the wards and in ICUs.
A practical tool adapted from the Manual for Reasoned Observers: “The World Health Organization Multimodal Hand Hygiene Improvement Strategy” was used for the observations. The manual was translated by Sátia Marine [Brasília: Pan American Health Organization; Brazilian Health Surveillance Agency (ANVISA)]. The instrument is composed of identification data such as city, institution, and name of the observer, date, and duration of the session, working shift, hospital unit (ward or ICU) and professional category [14] . The following variables were observed: hand hygiene before and after patient care, use of gloves and of surgical gown. Compliance was also assessed on the correct hand washing techniques, PPE, and removal of gloves and surgical gown. If any of the variables were not marked in the instrument, they were excluded at the end of the analysis.
Prior to observations, a 40-minute on-the-job training session was provided by the HICC nurse to seven third-year nursing students of the São José do Rio Preto Medical School (FAMERP) undergraduate nursing course, who participated in data collection with a checklist being presented during training. A pilot test was carried out for a month before the start of data collection so that the results could be compared with those of the instructor and any doubts could be discussed. The instructor and observers communicated during the entire data collection process. The observers were instructed to start a stopwatch when the healthcare professional started hand hygiene before beginning patient care and stop it at the end of hand hygiene after contact with the patient. If the professional did not perform hand hygiene before contacting the patient, the stopwatch was started when care began and stopped only after removing the PPE. It is believed that the use of a stopwatch is relevant in checking the duration of the observation of professionals.
Compliance with the technique of using a surgical gown was considered when it was removed inside out after removing the gloves without contact with the external region of the gown. The correct technique for using gloves was observed when they were removed before the surgical gown, first removing one of the gloves by turning it inside out and then the second glove covering the first, without any contact of the hands on the external surfaces of the gloves. The hand hygiene technique, both with soap and water and with alcohol solution, was considered compliant when performed following the five steps established by the health institution of the study. These are: 1) apply the product to the hands and rub them; 2) rub the palm of the right hand against the back of the left hand and vice versa; 3) rub the spaces between the fingers; 4) rub the thumbs; 5) rub the fingers and nails of one hand against the palm of the opposite hand and rinse the soap with water. Hand hygiene was considered adequate when performed both before having contact with the patient and immediately after providing care.
Information, such as registration, culture and antibiogram tests related to each patient observed were retrieved from the electronic medical records. Data were recorded on a form specifically designed by the author. Variables recorded included identification data (service code and medical records of each patient), hospitalization unit, bed number, name, gender, age, and city of origin. The reason for hospitalization was also identified in the patient’s medical record as was the length of hospitalization. The medical specialty that attended the patient, the International Classification of Diseases (ICD) 10 and results of exams (clinical specimens and antibiogram) were also recorded.
This project was approved by the Ethics Committee of the Medicine School in São José do Rio Preto (approval number 3.277.936).
Statistical Methods
Descriptive and inferential statistics were used to analyze data. Data were tabulated in Excel and are expressed in absolute and relative numbers. Regarding inferential statistics, the analysis of independence and prediction of the variables used the Mann-Whitney U test. Analyses used the SPSS software version 23 in the Microsoft Excel program version 2016.
3. Results
A total of 941 observations were made over 300.53 hours. The average time of observation was 19.16 minutes (SD ± 14.8), ranging from five minutes to 3 hours distributed across shifts: morning (29.88%), afternoon (38.50%) and night (31. 62%) (Table 1). It is noteworthy that 147 (15.62%) observations were made on wards and 794 (84.38%) in the ICU.
Registered nurses were the healthcare professionals most observed in 8730.05 minutes (48.41%) of observations recorded. Subsequently, in decreasing order of observation, were licensed practical nurses and nursing assistants (4469.05 minutes; 24.78%), physical therapists (3228.13 minutes; 17.90%), physicians (1499.72 minutes; 8.32%), speech therapists (44 minutes; 0.24%), biomedical professionals (31 minutes; 0.17%) and radiologists (30 minutes; 0.17%).
Distribution of the time spent on observations by shift. São José do Rio Preto. 2023
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