Healthcare-associated Infections (HAIs) become the priority attentions of health authorities worldwide since it became the most frequent adverse event of infections in health care system . World Health Organizations defines HAIs referred to nosocomial or hospital infection as an infection occur in a patient during the process of care in a hospital or other healthcare facility which was not present or incubating at the time of admission . Emori and Gaynes said that Healthcare Associated Infections (HAIs) is defined as one in which there is no evidence of patient infection (or colonization) at the time of admission to a hospital . HAIs related to prolonged hospital stay, increased morbidity and mortality, extra financial burden, increase length of stay (LOS) and increased microbial resistance to anti microbe . The future burden of endemic HAIs is congruent to the WHO Report in 2011. According to this report, seven out of 100 hospitalized patients in developed countries and ten out of 100 hospitalized patients in developing countries will develop at least one case of HAIs . For treating some of these infections, healthcare teams make great effort to improve healthcare worker safe practices and reduce the spread of bacteria and viruses that lead to HAIs . The major types of HAIs infections are bloodstream infections (BSI), surgical-site infections (SSI), pneumonia, urinary tract infections and catheter category . The minor types of HAIs infection are respiratory and gastrointestinal illness. Respiratory symptoms of infection can be cold symptom and influenza. Gastrointestinal symptoms can be diarrhoea, vomiting or dysenteries .
Hand hygiene is regarded as the most effective means of preventing Healthcare Associated Infection . Hand hygiene also important for patient safety because hands of health care personnel frequently serve as vectors for the transmission of organisms from personnel hands to patient and are also a major reservoir for pathogens with antimicrobial resistance. For this reason, In 2005, the WHO World Alliance for Patient Safety launched a campaign, the First Global Patient Safety Challenge——Clean Care is Safer Care—aiming to improve hand hygiene in healthcare . However, despite the continuous efforts, healthcare professionals' compliance about hand hygiene guidance remains sub-optimal .
Although hand hygiene is seen as the most important method to prevent the transmission of HAIs, hand hygiene practice in reducing HAIs seems to remain poor and challenging. This study aims to assess the hand hygiene practices among health workers in order to reduce Healthcare Associated Infections. Thus, the practice of hand hygiene could be adopted by all healthcare workers to reduce the HAIs.
This is a systematic review based on PRISMA Protocol. The journal articles are searched on online databases such as ProQuest and SAGE using keywords: hand hygiene, hand washing and Healthcare Associated Infections. The downloading process was valued independently by the author. Based on just the keywords, from two online data base, 5788 articles are found. The articles are downloaded on November 2016.The author filter the selected articles using time restriction, choosing only articles published from 2006 until 2016 to make the review more updated, resulting in 390 articles. Next, the author made the exclusion criteria which are the type of source and subject. After using the abovementioned criteria, the number is reduced to 365 articles. Furthermore, author selected the title, read the abstract and full-text articles to determine 11 articles in qualitative studies. The selection process of the articles in this review presented in Figure 1.
As a result, there are 11 journal articles, 10 of them are on observational studies and 1 study is experimental interventional study. Four of the articles based on systematic review analysis and the rest article based on statistics analysis. Half of the studies in this systematic review done in American region, 2 studies in Europe region and 3 studies in Asia region which are Thailand, Saudi Arabia and Shanghai, China.
From all of the articles, only 5 articles showed positive association between implementation of hand hygiene and HAIs. The articles showed that the implementation of hand hygiene decreases the Healthcare Associated Infections significantly [3–6, 9].
Another findings in this review showed that the rest of articles shows that knowledge of HAIs and compliance of hand hygiene take more effect on reducing rates of Healthcare Associated Infections. Reviews of each article can be seen in Table 1.
Hand hygiene and HAIs
Hand hygiene is still the most powerful way to reduce the Healthcare Associated Infections rates [5,6,9,10]. Implementing hand hygiene to prevent HAIs could be done with hand washing with water alone, with soap (anti-bacterial, non-anti-bacterial soap) or with waterless hand sanitizer (alcohol based hand sanitizer, non-alcohol based hand sanitizer) . Either hand washing just with water or soap, alcohol based rub or with towel have the same potential to reduce HAIs rates, the greater result shown in hand washing with water and soap. Improved hand hygiene resulted in reduction both gastrointestinal and respiratory illness, it is found that gastrointestinal illness reduced until 31% (95% CI = 19–42%) and respiratory illness reduced until 21% (95% CI = 5–34%) . The used of non-antibacterial soap in hand washing shows the strongest protective effect on both gastrointestinal and respiratory illness . The use of anti-bacterial soap just added little benefit compared with the non-anti-bacterial. But in contrast, the use of anti-bacterial soap has shown some efficacy in both illness when compared with non-intervention group .
Differences in the frequency and timing of hand hygiene practice may account for the stronger reductions rates of the gastrointestinal illnesses than the respiratory illnesses. This difference probably happens because hand hygiene practices directly after coughing or sneezing may not be as consistent or as frequent as hand hygiene practices directly after defecation .
Hand hygiene and its compliance
Hand hygiene compliance still remains challenging despite the numerous guidelines has been published. Factors from the health workers such as skin-irritating soap, hard soap, lack of awareness of the importance of hand hygiene, forgetfulness and heavy workload has been attributed to health workers lack of compliance reason. Studies show that health workers only wash their hands only when it necessary, not always when hands are more likely to be heavily contaminated and the technique is still remain poor . Another factor is the hand sanitizer accessibility. Increased accessibility of alcohol-based hand rubs has been associated with significantly higher rates of hand hygiene practice . Major advantages of alcohol-based hand rubbing are that less time is required for hand washing compared to traditional hand washing with soap, and hand hygiene product dispensers can be distributed widely throughout the health care environment without the need for sinks and paper towel or hand-drying equipment . Other approaches method like dispensing an existing product, individual dispensers carried by health workers and placing dispensers in more prominent positions can be added as a way to improve the hand washing practice .
Majority of the health care professional had a very high degree of awareness about the effectiveness of hand hygiene against Healthcare Associated Infection . But in hand washing practices, more women (75%) than men (58%) washed their hands, suggesting gender difference  and between the health workers, nurse achieved higher compliance than physician which nurses achieved higher hand hygiene compliance (93%) than physicians (78%) . Another study showed that nurses were generally better than physicians particularly in hand hygiene, perhaps because nursing job is more patient oriented and compliance demanding meanwhile physician considered play important roles as opinion leaders, decision makers, and role models in clinical environment .
Hand hygiene intervention and monitoring
The need of hand hygiene intervention are important to improve the compliance of hand hygiene practice especially for physicians . A series of interventions began in late 2006, and by 2008, explicit interventions were implemented across the medical centre and no new interventions were added since then . Organizational factors such as staff engagement, commitment of the department heads, and leadership were perceived to be significant in promoting hand hygiene practices . Reward incentives from organizational leader both financial and non-financial for the workers who complete the level of compliance can be added to improve the compliance of hand hygiene . An electronic learning module and a training video that provided hand hygiene education for all staff which accessible through the hospital intranet can also be implemented . Making a series of awareness-raising posters and screen savers, writing stories in medical centre publications and local news outlets, and using direct communications with staff about expectations and progress towards goals can be done as an effort to improve quality of hand hygiene practice by marketing staffs .
Monitoring hand hygiene practices and providing feedback appear to be important components of more successful hand hygiene programs. Methods to monitor hand hygiene include direct observation by anonymous observers, self-reporting, measuring or monitoring product usage, and non-direct observation by electronic monitoring system . Routine hand hygiene audits on all units, and continued surveillance for Healthcare Associated Infections which were published on an intranet site available to all staff, and reported to executive leadership, clinical leaders and board members can be a direct methods to measure and monitor the compliance of health workers . Electronic monitoring in hand hygiene compliance show promising result with automatic data gathering, data analysis and real-time feedback reporting .
This systematic review shows that implementation hand hygiene practice is needed for reducing HAIs. Hand hygiene is proven to reduce gastrointestinal illness and respiratory illness better than other HAIS infection. This review also suggest more research is needed to be conducted to measure the effect of hand hygiene and HAIs rates not only for gastrointestinal illness and respiratory illness but also for other HAIs like Ventilator Related Pneumonia (VAP), Urinary Tract Infection related catheter, central line associated bloodstream infection and least is Methicillin Resistant Staphylococcus Aureus (MRSA) infection.
Even though the awareness of Healthcare Associated Infections among healthcare workers is good, the compliance of hand hygiene practice is still lacking and needed to be enhanced. Monitoring of compliance, direct or non-direct observation, and support from management are strongly recommended to improve it.