Scope and Definitions

**3**

• Diabetes

**Chapter 1**

*Manal Mohammad Baddour*

**1. Surgical site infections**

describes three levels of SSI [2]:

occur after surgery [1].

Introductory Chapter: Surgical

Site Infections - A Quick Glance

Surgical site infections (SSIs) are infections of the incision or organ space that

Thus, infections that occur in the wound created by an invasive surgical procedure are generally referred to as surgical site infections (SSIs). SSIs are one of the

• *Superficial incisional*, affecting the skin and subcutaneous tissue. These infections might show localized signs such as redness, pain, heat, or swelling at the

• *Deep incisional*, affecting the fascial and muscle layers. These infections can be detected by the presence of pus or an abscess, fever with tenderness of the wound, or a separation of the edges of the incision exposing the deeper tissues.

• *Organ or space infection*, which involves any part other than the incision that is opened or manipulated during the surgical procedure, for example, a joint or the peritoneum. These infections can be suspected by the drainage of pus or the formation of an abscess detected by histopathological or radiological

The endogenous bacteria on a patient's skin are believed to be the main source of pathogens that contribute to surgical site infection [3]. To help prevent SSI, preoperative surgical site skin preparation standard of care entails scrubbing or applying alcohol-based preparations containing antiseptic agents prior to incision, most commonly chlorhexidine gluconate or iodine solutions. These agents have an

Assessment of risk factors for developing SSI can be generally grouped by

excellent action against a wide range of bacteria, fungi, and viruses.

The United States Centers for Disease Control and Prevention (CDC) has developed a definition for SSI as an "infection related to an operative procedure that occurs at or near the surgical incision within 30 days of the procedure or within 90 days if prosthetic material is implanted at surgery." This CDC definition thus

most important causes of healthcare-associated infections (HCAIs).

site of the incision or by the drainage of pus.

examination or during re-operation.

patient, wound, and procedural variables.

• Very young or very old age

Patient variables that increase risk of SSI include:

### **Chapter 1**

## Introductory Chapter: Surgical Site Infections - A Quick Glance

*Manal Mohammad Baddour*

### **1. Surgical site infections**

Surgical site infections (SSIs) are infections of the incision or organ space that occur after surgery [1].

Thus, infections that occur in the wound created by an invasive surgical procedure are generally referred to as surgical site infections (SSIs). SSIs are one of the most important causes of healthcare-associated infections (HCAIs).

The United States Centers for Disease Control and Prevention (CDC) has developed a definition for SSI as an "infection related to an operative procedure that occurs at or near the surgical incision within 30 days of the procedure or within 90 days if prosthetic material is implanted at surgery." This CDC definition thus describes three levels of SSI [2]:


The endogenous bacteria on a patient's skin are believed to be the main source of pathogens that contribute to surgical site infection [3]. To help prevent SSI, preoperative surgical site skin preparation standard of care entails scrubbing or applying alcohol-based preparations containing antiseptic agents prior to incision, most commonly chlorhexidine gluconate or iodine solutions. These agents have an excellent action against a wide range of bacteria, fungi, and viruses.

Assessment of risk factors for developing SSI can be generally grouped by patient, wound, and procedural variables.

Patient variables that increase risk of SSI include:


Procedural variables that can affect the risk for SSI include factors related to preoperative skin preparation, sterilization protocols, and the surgery itself such as:


In 2016, the World Health Organization (WHO) published global guidelines for the prevention of surgical site infection which are evidence-based and present additional information in support of actions to improve practice [4]. Strong guideline recommendations by the WHO include:


**5**

*Introductory Chapter: Surgical Site Infections - A Quick Glance*

• Hair should NOT be shaved whether before surgery or in the operating room.

• Preoperative antibiotic prophylaxis should be administered before surgical

• Preoperative antibiotic prophylaxis should be administered within 120 minutes before the surgical incision, taking into consideration the half-life of the

• Surgical hand preparation can be performed by either scrubbing with a suitable antimicrobial soap and water or by using a suitable alcohol-based handrub

• Alcohol-based antiseptic solutions based on CHG for surgical site skin prepara-

• Adult patients undergoing general anesthesia with endotracheal intubation for surgical procedures should receive 80% fraction of inspired oxygen intraoperatively and, if feasible, in the immediate postoperative period for 2–6 hours.

• Preoperative antibiotic prophylaxis administration should not continue after

Actually, regarding a few of the WHO recommendations, the CDC stated that available evidence suggested uncertain trade-offs between the benefits and harms regarding

SSI rate is a percentage and is calculated as the number of SSIs divided by the

The rate of surgical site infections (SSIs) is low for most surgical procedures. However, because of the relatively large surgical volume in many hospitals, SSIs are sometimes considered the most common healthcare-associated infections [5]. SSIs are often localized to the incision site but can also extend into deeper adjacent structures [6]. Because of the presence of intraluminal bacteria, gastrointestinal procedures are among the highest risk procedures for SSI. Rates of SSI following bile duct, liver, or pancreatic surgery are as high as 10 per 100 procedures, according to data published by the National Healthcare Safety Network. Rates of SSI following colon surgery are ~5 per 100 procedures, and rates of SSI following gallbladder surgery are 0.7 per

A prevalence survey undertaken in 2006 suggested that ~8% of patients in hospitals in the UK have a healthcare-associated infection (HCAI). SSIs accounted for 14% of these infections, and nearly 5% of patients who had undergone a surgical procedure were found to have developed an SSI. However, the true prevalence is expected to be higher since many of these infections occur after the patient has been discharged from hospital and are thus underreported and underestimated [8].

In an annual report from a UK hospital in 2009, the crude SSI rate was 4.4% [9]. Some studies done in Brazil, Sweden, China, and the USA report SSI prevalence

Within the context of this book, some of the risk factors and practices associated with SSI will be displayed, and an outline of the recommendations published by several authorities shall be portrayed. Additionally, since dental procedures pose a major concern in infection control, a comprehensive report on factors related to

rates of 7.2, 5.9, 6.2, and 2.9%, respectively, after appendectomy [10].

infection control in dentistry will be presented.

tion should be used in patients undergoing surgical procedures.

such practices and that they advocated no recommendation/unresolved issue.

If absolutely necessary, hair should only be removed with a clipper.

*DOI: http://dx.doi.org/10.5772/intechopen.88496*

incision, when indicated.

before donning sterile gloves.

completion of the operation.

total number of patients.

100 procedures [7].

antibiotic.

*Surgical Infections - Some Facts*

• Immune compromised patients

• Length of preoperative stay

• Antimicrobial prophylaxis

• Duration of surgical scrub

• Preoperative hair removal

• Operating room ventilation

• Foreign matter in the surgical site

• Wound class

• Surgical techniques

• Duration of surgery

antibiotics).

• Choice of preoperative skin preparation

• Sterilization of instruments and environment

• Skin antisepsis protocol

• Wound contamination

• Colonized or infected remote body site

Procedural variables that can affect the risk for SSI include factors related to preoperative skin preparation, sterilization protocols, and the surgery itself such as:

In 2016, the World Health Organization (WHO) published global guidelines for the prevention of surgical site infection which are evidence-based and present

• Patients with documented nasal carriage of *Staphylococcus aureus* should be decolonized by intranasal applications of mupirocin 2% ointment with or

• Mechanical bowel preparation alone should NOT be used in adult patients undergoing elective colorectal surgery (without the administration of oral

additional information in support of actions to improve practice [4]. Strong guideline recommendations by the WHO include:

without chlorhexidine gluconate (CHG) body wash.

• Smoking

• Steroid use

• Obesity

• Malnutrition

**4**


Actually, regarding a few of the WHO recommendations, the CDC stated that available evidence suggested uncertain trade-offs between the benefits and harms regarding such practices and that they advocated no recommendation/unresolved issue.

SSI rate is a percentage and is calculated as the number of SSIs divided by the total number of patients.

The rate of surgical site infections (SSIs) is low for most surgical procedures. However, because of the relatively large surgical volume in many hospitals, SSIs are sometimes considered the most common healthcare-associated infections [5]. SSIs are often localized to the incision site but can also extend into deeper adjacent structures [6].

Because of the presence of intraluminal bacteria, gastrointestinal procedures are among the highest risk procedures for SSI. Rates of SSI following bile duct, liver, or pancreatic surgery are as high as 10 per 100 procedures, according to data published by the National Healthcare Safety Network. Rates of SSI following colon surgery are ~5 per 100 procedures, and rates of SSI following gallbladder surgery are 0.7 per 100 procedures [7].

A prevalence survey undertaken in 2006 suggested that ~8% of patients in hospitals in the UK have a healthcare-associated infection (HCAI). SSIs accounted for 14% of these infections, and nearly 5% of patients who had undergone a surgical procedure were found to have developed an SSI. However, the true prevalence is expected to be higher since many of these infections occur after the patient has been discharged from hospital and are thus underreported and underestimated [8].

In an annual report from a UK hospital in 2009, the crude SSI rate was 4.4% [9]. Some studies done in Brazil, Sweden, China, and the USA report SSI prevalence rates of 7.2, 5.9, 6.2, and 2.9%, respectively, after appendectomy [10].

Within the context of this book, some of the risk factors and practices associated with SSI will be displayed, and an outline of the recommendations published by several authorities shall be portrayed. Additionally, since dental procedures pose a major concern in infection control, a comprehensive report on factors related to infection control in dentistry will be presented.

*Surgical Infections - Some Facts*

### **Author details**

Manal Mohammad Baddour Alexandria University, Alexandria, Egypt

\*Address all correspondence to: manal.baddour@alexmed.edu.eg

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**7**

pdf

2009;**37**:783

*Introductory Chapter: Surgical Site Infections - A Quick Glance*

Treatment of Surgical Site Infection. London: RCOG Press; 2008. NICE Clinical Guidelines, No. 74. ISBN-13:

[9] Surgical Site Infection Surveillance (SSIS) for General Surgery. Wexford General Hospital Surgical Site Infection (SSI) data report; Annual report; 2009

[10] Rosenthal VD, Richtmann R, Singh S, et al. Surgical site infections, International Nosocomial Infection Control Consortium (INICC) report, data summary of 30 countries, 2005-2010. Infection Control and Hospital Epidemiology. 2013;**34**:597-

604. DOI: 10.1086/670626

978-1-904752-69-1

*DOI: http://dx.doi.org/10.5772/intechopen.88496*

[1] National Healthcare Safety Network,

Centers for Disease Control and Prevention. Surgical site infection (SSI) event. 2017. Available from: http://www.cdc.gov/nhsn/pdfs/ pscmanual/9pscssicurrent.pdf [Accessed: 25 January 2017]

[2] Health Protection Agency.

Surveillance of Surgical Site Infection in England: October 1997–September 2005. London: Health Protection

[3] Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. American Journal of Infection Control.

[4] WHO global guidelines for the prevention of surgical site infection. 2016. Available from: https://www.who.

[5] Lewis SS, Moehring RW, Chen LF, et al. Assessing the relative burden of hospital-acquired infections in a network of community hospitals. Infection Control and Hospital Epidemiology. 2013;**34**:1229

[6] CDC/NHSN Protocol Corrections, Clarification, and Additions. April 2013. Available from: http://www.cdc.gov/ nhsn/PDFs/pscManual/9pscSSIcurrent.

[7] Edwards JR, Peterson KD, Mu Y, et al. National Healthcare Safety Network (NHSN) report: Data summary for 2006 through 2008, issued December 2009. American Journal of Infection Control.

[8] National Collaborating Centre for Women's and Children's Health (UK). Surgical Site Infection, Prevention and

int/gpsc/SSI-outline.pdf?ua=1

**References**

Agency; 2006

1999;**27**:97-132

*Introductory Chapter: Surgical Site Infections - A Quick Glance DOI: http://dx.doi.org/10.5772/intechopen.88496*

### **References**

*Surgical Infections - Some Facts*

**6**

**Author details**

Manal Mohammad Baddour

Alexandria University, Alexandria, Egypt

provided the original work is properly cited.

\*Address all correspondence to: manal.baddour@alexmed.edu.eg

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

[1] National Healthcare Safety Network, Centers for Disease Control and Prevention. Surgical site infection (SSI) event. 2017. Available from: http://www.cdc.gov/nhsn/pdfs/ pscmanual/9pscssicurrent.pdf [Accessed: 25 January 2017]

[2] Health Protection Agency. Surveillance of Surgical Site Infection in England: October 1997–September 2005. London: Health Protection Agency; 2006

[3] Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. American Journal of Infection Control. 1999;**27**:97-132

[4] WHO global guidelines for the prevention of surgical site infection. 2016. Available from: https://www.who. int/gpsc/SSI-outline.pdf?ua=1

[5] Lewis SS, Moehring RW, Chen LF, et al. Assessing the relative burden of hospital-acquired infections in a network of community hospitals. Infection Control and Hospital Epidemiology. 2013;**34**:1229

[6] CDC/NHSN Protocol Corrections, Clarification, and Additions. April 2013. Available from: http://www.cdc.gov/ nhsn/PDFs/pscManual/9pscSSIcurrent. pdf

[7] Edwards JR, Peterson KD, Mu Y, et al. National Healthcare Safety Network (NHSN) report: Data summary for 2006 through 2008, issued December 2009. American Journal of Infection Control. 2009;**37**:783

[8] National Collaborating Centre for Women's and Children's Health (UK). Surgical Site Infection, Prevention and Treatment of Surgical Site Infection. London: RCOG Press; 2008. NICE Clinical Guidelines, No. 74. ISBN-13: 978-1-904752-69-1

[9] Surgical Site Infection Surveillance (SSIS) for General Surgery. Wexford General Hospital Surgical Site Infection (SSI) data report; Annual report; 2009

[10] Rosenthal VD, Richtmann R, Singh S, et al. Surgical site infections, International Nosocomial Infection Control Consortium (INICC) report, data summary of 30 countries, 2005-2010. Infection Control and Hospital Epidemiology. 2013;**34**:597- 604. DOI: 10.1086/670626

**9**

microenvironment effects.

**Chapter 2**

Infections

classification, guidelines

**1. Introduction**

*Hadir Okasha*

**Abstract**

Risk Factors and Key Principles

Surgical site infections are one of the most important causes of healthcareassociated infections (HCAIs). They are associated with morbidity and possibly in part as a factor in associated postoperative mortality if present. Thus, it is important to recognize different SSIs and that they can vary from trivial wounds to a life-threatening condition. There are multiple risk factors contributing to the development of SSIs and guidelines to combat and decrease the possibility of the

Infections occurring in the wound of an invasive surgical procedure are generally referred to as surgical site infections (SSIs), and they continue to be a common complication of surgical procedures despite advances in infection control practices. This infection is a result of several factors that if combined would increase the risk of SSI together with the fact that the population is aging with longer average life expectancy meaning that not only the number of operations are likely to increase but also the SSI risk index for an aging population will be higher. Other clinical outcomes of SSIs include poor scars that are cosmetically unacceptable, such as those that are spreading, hypertrophic, or keloid; persistent pain and itching; and restriction of movement, particularly when over joints and have a significant impact on emotional well-being. Given already the high economic cost of surgery, SSI will only burden the health

system by increasing hospital stay, antibiotic intake, and other associated cost. In this chapter we will briefly go through the pathogenesis and risk factors for

Most surgical wounds are contaminated by bacteria, yet infection will only develop in minority. As in the majority, innate host defenses will efficiently eliminate contaminants at the surgical site. This is besides other factors that interplay to give rise to a SSI including the inoculum of bacteria and its virulence and adjuvant

SSI and guidelines to decrease their incidence.

**2. Local events occurring on surgical incision**

occurrence of such events through proper implementation.

**Keywords:** surgical site infections, hospital associated infections, criteria,

for Prevention of Surgical Site

### **Chapter 2**

## Risk Factors and Key Principles for Prevention of Surgical Site Infections

*Hadir Okasha*

### **Abstract**

Surgical site infections are one of the most important causes of healthcareassociated infections (HCAIs). They are associated with morbidity and possibly in part as a factor in associated postoperative mortality if present. Thus, it is important to recognize different SSIs and that they can vary from trivial wounds to a life-threatening condition. There are multiple risk factors contributing to the development of SSIs and guidelines to combat and decrease the possibility of the occurrence of such events through proper implementation.

**Keywords:** surgical site infections, hospital associated infections, criteria, classification, guidelines

### **1. Introduction**

Infections occurring in the wound of an invasive surgical procedure are generally referred to as surgical site infections (SSIs), and they continue to be a common complication of surgical procedures despite advances in infection control practices.

This infection is a result of several factors that if combined would increase the risk of SSI together with the fact that the population is aging with longer average life expectancy meaning that not only the number of operations are likely to increase but also the SSI risk index for an aging population will be higher. Other clinical outcomes of SSIs include poor scars that are cosmetically unacceptable, such as those that are spreading, hypertrophic, or keloid; persistent pain and itching; and restriction of movement, particularly when over joints and have a significant impact on emotional well-being.

Given already the high economic cost of surgery, SSI will only burden the health system by increasing hospital stay, antibiotic intake, and other associated cost.

In this chapter we will briefly go through the pathogenesis and risk factors for SSI and guidelines to decrease their incidence.

### **2. Local events occurring on surgical incision**

Most surgical wounds are contaminated by bacteria, yet infection will only develop in minority. As in the majority, innate host defenses will efficiently eliminate contaminants at the surgical site. This is besides other factors that interplay to give rise to a SSI including the inoculum of bacteria and its virulence and adjuvant microenvironment effects.

### *Surgical Infections - Some Facts*

So what happens with the creation of the surgical incision through the skin and into subcutaneous tissues?


### **3. Risk factors**

Despite of efficient decontamination and antisepsis, bacteria may still enter the wound from the OR environment or instruments or surgical staff or from patients skin. The largest inoculum of bacteria was found to occur with operations involving a body structure heavily colonized by bacteria (bowel). Substantial numbers of bacteria are also present in the stomach of older patients who have hypo- or achlorhydria. Significant concentrations of bacteria are encountered in the biliary tract when patients are over 70 years of age or have obstructive jaundice, common bile duct stones, or acute cholecystitis [3]. Procedures involving the female genital tract will encounter 106 –107 bacteria/mL. Procedures that enter into the oropharynx, lung, or urinary tract will have significant contaminants depending upon the duration and types of disease that are responsible for the operation. Notably, SSIs are generally the consequence of intraoperative contamination and seldom result from bacterial contamination from distant blood-borne seeding of the wound site during the postoperative period.

The larger the inoculum of bacterial contamination, the greater the probability of infection as the outcome. There are other factors that make a given bacterial inoculum to result in infection in a patient, while a similar inoculum of contamination in other patients has no such outcome. These are the local environment of the surgical site and the integrity of host defense of the patient. These factors include but not limited to surgical site hematoma, necrotic tissue from overuse of electrocautery, the presence of foreign bodies (e.g., sutures,

**11**

gangrene.

*Risk Factors and Key Principles for Prevention of Surgical Site Infections*

particularly braided silk and other permanent braided suture materials) in the surgical site, dead space management, and manner of handling soft tissue and organs are all contributors to SSI. These are technical issues that are generally not covered in published guidelines but are of great significance in the prevention of

Another determinant contributing to SSI is the virulence of the bacterial contaminant. The more virulent the bacterial contaminant, the greater the probability of infection. Coagulase-positive staphylococci require a smaller inoculum than the coagulase-negative species. Virulent strains of *Clostridium perfringens* or group A streptococci require only a small inoculum to cause severe necrotizing infection. *Bacteroides fragilis* and other Bacteroides species are ordinarily organisms of minimal virulence as solitary pathogens, but when combined with other oxygen-consuming organisms, they will result in microbial synergism and cause very significant infection following operations of the colon or female genital tract [5]. The virulence of the bacteria represents an intrinsic variable influenced by the surgery site and bacteria colonizing the patient and cannot easily be controlled by

Another factor to consider is the integrity of host defenses as acquired impairment of host responses is objectively related to increased rates of SSI, as in the case of chronic illnesses, malnutrition, hyperglycemia, and conditions associated with prolonged intake of corticosteroids and other infection at locations remote from the

Thus it is important to collect data on different types of risk factors in order to analyze SSI outcomes, to identify high-risk patients, and to control for differences in the patient level risk; this is done through surveillance. Important data to be collected for all patients are at least age; sex; type of surgical procedure, whether elective or emergency surgery; the American Society of Anesthesiologists (ASA) score; timing and choice of antimicrobial prophylaxis; duration of the operation;

SSI can be classified according to the degree of microbiological contagion; this classification system is an adaptation of the American College of Surgeons wound

**Clean-contaminated**: These are operative wounds that involve the respiratory, alimentary, genital, or urinary tracts but under controlled conditions and without unusual contamination. This category includes operations involving the biliary

**Clean**: An operative wound in which no infection and no inflammation is encountered, and the respiratory, alimentary, genital, or uninfected urinary tracts

**Contaminated**: These include, besides open, fresh, accidental wounds, operations with major breaks in sterile technique as in open cardiac massage or spillage from the gastrointestinal tract and incisions in acute inflamed tissues, including necrotic tissue without evidence of purulent drainage as dry

**Dirty or infected**: This includes wounds with retained devitalized tissue and those with existing clinical infection or visceral perforation. In this group, it is suggested that the organisms causing postoperative infection were present in the

*DOI: http://dx.doi.org/10.5772/intechopen.85284*

infection [4].

preventive strategies.

and wound contamination class [6].

Wounds are divided into four classes:

are not involved and are primarily closed.

tract, vagina, appendix, and oropharynx.

operative field before the operation.

**4. Important classifications**

classification scheme [7].

surgical.

### *Risk Factors and Key Principles for Prevention of Surgical Site Infections DOI: http://dx.doi.org/10.5772/intechopen.85284*

*Surgical Infections - Some Facts*

into subcutaneous tissues?

tory process.

phagocytes.

against infection [1, 2].

–107

**3. Risk factors**

will encounter 106

the postoperative period.

So what happens with the creation of the surgical incision through the skin and

**A.** First, of course, there will be platelet and coagulation factor activation as part of hemostasis mechanisms, and this also marks the beginning of the inflamma-

**B.** Mast cells and complement proteins are activated, and bradykinin is produced from its precursors. The net effect of these factors is the production of nonspecific chemoattractant signals and chemokine signals that "draw" variable

**C.** Also we get vasodilation and increased local blood flow at the site of the incision. Yet blood flow slows down in preparation for margination of

**D.** So we have increased vascular permeability and local vasodilation leading to edema fluid and increased space between endothelial cells, i.e., permeability,

**E.** The increased vascular permeability provides phagocytic access to the injured soft tissue, while edema provides aqueous conduits for the navigation of these

**F.** Thus, this inflammatory process occurring at the site of injury is crucial for mobilization of phagocytes instantly into the incisional wound before significant intraoperative contamination occurs giving the patient an advantage

Despite of efficient decontamination and antisepsis, bacteria may still enter the wound from the OR environment or instruments or surgical staff or from patients skin. The largest inoculum of bacteria was found to occur with operations involving a body structure heavily colonized by bacteria (bowel). Substantial numbers of bacteria are also present in the stomach of older patients who have hypo- or achlorhydria. Significant concentrations of bacteria are encountered in the biliary tract when patients are over 70 years of age or have obstructive jaundice, common bile duct stones, or acute cholecystitis [3]. Procedures involving the female genital tract

lung, or urinary tract will have significant contaminants depending upon the duration and types of disease that are responsible for the operation. Notably, SSIs are generally the consequence of intraoperative contamination and seldom result from bacterial contamination from distant blood-borne seeding of the wound site during

The larger the inoculum of bacterial contamination, the greater the probability of infection as the outcome. There are other factors that make a given bacterial inoculum to result in infection in a patient, while a similar inoculum of contamination in other patients has no such outcome. These are the local environment of the surgical site and the integrity of host defense of the patient. These factors include but not limited to surgical site hematoma, necrotic tissue from overuse of electrocautery, the presence of foreign bodies (e.g., sutures,

bacteria/mL. Procedures that enter into the oropharynx,

phagocytes through the normally condensed extracellular tissues.

leukocyte populations into the area of incision.

giving phagocytic access to the incised damaged tissue.

**10**

particularly braided silk and other permanent braided suture materials) in the surgical site, dead space management, and manner of handling soft tissue and organs are all contributors to SSI. These are technical issues that are generally not covered in published guidelines but are of great significance in the prevention of infection [4].

Another determinant contributing to SSI is the virulence of the bacterial contaminant. The more virulent the bacterial contaminant, the greater the probability of infection. Coagulase-positive staphylococci require a smaller inoculum than the coagulase-negative species. Virulent strains of *Clostridium perfringens* or group A streptococci require only a small inoculum to cause severe necrotizing infection. *Bacteroides fragilis* and other Bacteroides species are ordinarily organisms of minimal virulence as solitary pathogens, but when combined with other oxygen-consuming organisms, they will result in microbial synergism and cause very significant infection following operations of the colon or female genital tract [5]. The virulence of the bacteria represents an intrinsic variable influenced by the surgery site and bacteria colonizing the patient and cannot easily be controlled by preventive strategies.

Another factor to consider is the integrity of host defenses as acquired impairment of host responses is objectively related to increased rates of SSI, as in the case of chronic illnesses, malnutrition, hyperglycemia, and conditions associated with prolonged intake of corticosteroids and other infection at locations remote from the surgical.

Thus it is important to collect data on different types of risk factors in order to analyze SSI outcomes, to identify high-risk patients, and to control for differences in the patient level risk; this is done through surveillance. Important data to be collected for all patients are at least age; sex; type of surgical procedure, whether elective or emergency surgery; the American Society of Anesthesiologists (ASA) score; timing and choice of antimicrobial prophylaxis; duration of the operation; and wound contamination class [6].

### **4. Important classifications**

SSI can be classified according to the degree of microbiological contagion; this classification system is an adaptation of the American College of Surgeons wound classification scheme [7].

Wounds are divided into four classes:

**Clean**: An operative wound in which no infection and no inflammation is encountered, and the respiratory, alimentary, genital, or uninfected urinary tracts are not involved and are primarily closed.

**Clean-contaminated**: These are operative wounds that involve the respiratory, alimentary, genital, or urinary tracts but under controlled conditions and without unusual contamination. This category includes operations involving the biliary tract, vagina, appendix, and oropharynx.

**Contaminated**: These include, besides open, fresh, accidental wounds, operations with major breaks in sterile technique as in open cardiac massage or spillage from the gastrointestinal tract and incisions in acute inflamed tissues, including necrotic tissue without evidence of purulent drainage as dry gangrene.

**Dirty or infected**: This includes wounds with retained devitalized tissue and those with existing clinical infection or visceral perforation. In this group, it is suggested that the organisms causing postoperative infection were present in the operative field before the operation.

### **5. What are surgical site infection criteria?**

According to the CDC [7], SSI is classified into:


### **5.1 Superficial surgical site infection**

Infection occurring within 30 days after any operative procedure and only the skin and subcutaneous tissue are involved must be associated with at least one of the following:


### **5.2 Deep incisional SSI**

Infection involves deep soft tissues of the incision as fascial and muscle layers and occurs within 30 or 90 days after the operative procedure and must be associated with at least one of the following:


### **5.3 Organ/space SSI**

It involves any part of the body deeper than the fascial/muscle layers, that is opened or manipulated during the operative procedure, and infection occurs within 30 or 90 days after the operation and must be associated with at least one of the following:


**13**

*Risk Factors and Key Principles for Prevention of Surgical Site Infections*

**A.** In late 2016, the World Health Organization (WHO) provided guidelines offering ways to stop surgical infections including evidence-based recommendations, addressing the increasing burden of healthcare-associated infections on both patients and healthcare systems. They are suitable for any country and can be

**B.** In May 2017, the Centers for Disease Control and Prevention's (CDC) Healthcare Infection Control Practices Advisory Committee (HICPAC) published its Guideline for the Prevention of Surgical Site Infection, 2017, in the journal JAMA Surgery. Which also included evidence-based recommendations for the

**C.** The Association of periOperative Registered Nurses (AORN) has published the 2018 Guidelines for Perioperative Practice with five updated guidelines, as well as a completely new guideline that addresses team communication. Guidelines for Perioperative Practice, published each January, is a collection of 32 guidelines that provide evidence-based recommendations to deliver safe perioperative patient care and achieve workplace safety. The AORN's Guidelines for Perioperative Practice is divided into five main topic areas: Aseptic Practice, Equipment and Product Safety, Patient and Work Safety, Patient Care, and Sterilization and

It is considered a good practice to advice patients to bathe or shower (full body) prior to surgery, with either plain soap or an antimicrobial soap on at least the night

ii.For patients undergoing cardiothoracic and orthopedic surgery with known nasal carriage of *S. aureus*, decolonization with mupirocin 2% ointment with or without CHG body wash for the prevention infection in nasal carriers is

iii.Administer preoperative surgical antibiotic prophylaxis (SAP) prior to the surgical incision when indicated (based on the type of operation, published clinical practice guidelines and while considering the half-life of the antibiotic, such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made). Topical antimicrobial agents

iv.As for postoperative antimicrobial prophylaxis in clean and clean-contaminated procedures, there is no need for additional antimicrobial prophylaxis doses after the surgical incision is closed in the operating room, even in the

v.Hair removal in patients undergoing any surgical procedure should either not be removed or, if necessary, should be removed with a clipper, since

shaving is discouraged, whether preoperatively or in the OR.

should not be applied to the surgical incision.

*DOI: http://dx.doi.org/10.5772/intechopen.85284*

**6. SSI prevention guideline**

locally adapted [8].

prevention of SSIs [9].

Disinfection [10].

before the operative day.

recommended.

presence of a drain.

**7. Key recommendations in guidelines**

i.Preoperative bathing

### **6. SSI prevention guideline**

*Surgical Infections - Some Facts*

1.Superficial

3.Organ/space

**5.1 Superficial surgical site infection**

2.Deep

the following:

**5.2 Deep incisional SSI**

**5.3 Organ/space SSI**

ated with at least one of the following:

**5. What are surgical site infection criteria?**

According to the CDC [7], SSI is classified into:

Infection occurring within 30 days after any operative procedure and only the skin and subcutaneous tissue are involved must be associated with at least one of

• Purulent drainage from the superficial incision, with or without culture testing

• At least one of the following signs or symptoms: pain or tenderness, localized swelling, erythema, or heat and superficial incision deliberately opened by a surgeon

Infection involves deep soft tissues of the incision as fascial and muscle layers and occurs within 30 or 90 days after the operative procedure and must be associ-

• Purulent drainage from the incision but not from the organ or space involved

• Dehiscence or deliberate opening or aspiration by the surgeon from the deep incision when the patient has at least one of the following: fever greater than 100.4°F,

• An abscess or other evidence of infection involving the deep incision that is detected

It involves any part of the body deeper than the fascial/muscle layers, that is opened

• Abscess or other evidence of infection involving the deep incision that is found during examination of incision, reoperation, or pathologic or radiologic exam

or manipulated during the operative procedure, and infection occurs within 30 or 90 days after the operation and must be associated with at least one of the following:

• Purulent drainage from a drain that is placed into the organ/space

• Organisms identified from fluid or tissue in the organ/space

• Isolated organisms from an aseptically obtained specimen

• Isolated organisms from an aseptically obtained specimen

localized pain, or edema, unless culture is negative

during anatomical or histopathologic exam or imaging

• Diagnosis of a superficial incisional SSI by the involved clinician

**12**


### **7. Key recommendations in guidelines**

i.Preoperative bathing

It is considered a good practice to advice patients to bathe or shower (full body) prior to surgery, with either plain soap or an antimicrobial soap on at least the night before the operative day.


However no randomized controlled trials evaluated methods to achieve and maintain normothermia and identified the lower limit of normothermia or the optimal timing and duration of normothermia for the prevention of SSI.


**15**

with limited resources.

*Risk Factors and Key Principles for Prevention of Surgical Site Infections*

timely dissemination of these data to those who need it" [11].

implementation is meant to overcome these obstacles [13, 14].

**9. Guideline implementation in reality**

ineffective team communication as a common cause of adverse events," and that "Understanding the evidence supporting strategies to strengthen team communication is critical for teams to successfully implement all AORN

An effective infection prevention and control (IPC) program must not only apply measures and guidelines to avoid infections but should also monitor the outcome through surveillance. Which is defined as "the ongoing, systematic collection, analysis, interpretation and evaluation of health data closely integrated with the

It is important that guidelines can be adapted with relative flexibility to suit different clinical situation in the context of availability of resources, training, and according to economic feasibility. Thus, the local situation in any institute would influence applicability and will therefore have a significant impact on implementing a certain guideline. Nonetheless, this does not negate the importance of having guidelines based on best evidence [12]. Rather, it emphasizes the extent to which evidence obtained in a specific setting is generally valid or applicable to

Thus implementation of evidence-based guidelines is a challenge in many healthcare settings, and it is not often easy to evaluate application and consistency of performance in clinical practice. It has been stated that it takes approximately 5 years for any given guidelines to be accepted and adopted into routine clinical practice and often not fully followed [12, 13]. This is because of the multifactorial nature of implementing these guidelines, where implementation is influenced by the patient, healthcare providers, institutional facilities, and management; yet

That is why guidelines take relatively a long time to implement using different tools to bypass these problems, for example, not only vigorous and continuous education aiming to train individuals but also to change believes and misconceptions reflected on certain behaviors that have become second nature, especially if the recommendation requires infrastructure or a device that is not available or the practice opposes the cultural norms of a specific setting/group. Implementation tools that increase guideline acceptability and accessibility must use a variety of user-friendly formats directed to deliver the knowledge to all those involved in the issue including patients and different groups of HCWs among different settings [14]. Also as most of the suggested guidelines are not subjected to rigorous economic evaluation, it is important to keep this point in focus alongside with effectiveness during implementation, by using surveillance feedback which provide guidance to staff and decision-makers to lever support for the appropriate allocation of resources and efforts, helping clinicians in selecting the best available evidence-based options in healthcare organizations

*DOI: http://dx.doi.org/10.5772/intechopen.85284*

**8. Surveillance**

other situations.

guidelines for safe perioperative care."

ineffective team communication as a common cause of adverse events," and that "Understanding the evidence supporting strategies to strengthen team communication is critical for teams to successfully implement all AORN guidelines for safe perioperative care."

### **8. Surveillance**

*Surgical Infections - Some Facts*

reducing SSI.

vi.Performing surgical site skin preparation using an alcohol-based antiseptic

vii.Surgical hand preparation to be performed by scrubbing with either a suitable antimicrobial soap and water or using a suitable alcohol-based handrub

maintained for all patients, in the OR and during the surgical procedure for

However no randomized controlled trials evaluated methods to achieve and maintain normothermia and identified the lower limit of normothermia or the optimal

ix.Sterile drapes and gowns, either disposable or reusable woven drapes and gowns, must be used during surgical operations for the purpose of preventing SSI. On the other hand, the use of plastic adhesive incise drapes for prevent-

x.Wound protector devices were considered in clean-contaminated, contaminated, and dirty abdominal surgical procedures for the purpose of reducing

xi.Irrigation of incisional wound using saline before closure for preventing SSI was neither recommended for or against as no enough evidence were present for justification. However the use of an aqueous PVP-I solution for the irrigation of incisional wound before closure in clean and clean-contaminated wounds for the purpose of preventing SSI was recommended. While antibiotic incisional wound irrigation was recommended against, CDC considers intraoperative irrigation of deep or subcutaneous tissues with aqueous iodophor solution for the prevention of SSI but stated that for contaminated or dirty

xii.Antimicrobial triclosan-coated sutures for the purpose of reducing the risk of

xiii.Perioperative glycemic control implementation using blood glucose target levels less than 200 mg/dL in patients with and without diabetes is

xiv.Regarding postoperative phase, there are fewer recommendations identified across the guidelines in relation to wound care. For example, the WHO (2016) guidelines states: "The panel suggests not using any type of advanced dressing over a standard dressing on primarily closed surgical wounds for

xv.Team communication: AORN's Guidelines are the first evidence-based guideline to tackle the issue of effective communication in the perioperative environment which is essential for accurate transfer of patient information. The Editor in chief of AORN's Guidelines for Perioperative Practice stated that "Every AORN guideline recommends team involvement and shared communication with all stakeholders on the perioperative team, yet research still identifies

viii.Normothermia (i.e., a perioperative normal body temperature) to be

solution is recommended unless contraindicated.

timing and duration of normothermia for the prevention of SSI.

abdominal procedures, it is not necessary.

SSI, independent of the type of surgery, were suggested.

before donning sterile gloves.

ing SSI was discouraged.

the rate of SSI.

recommended.

the purpose of preventing SSI."

**14**

An effective infection prevention and control (IPC) program must not only apply measures and guidelines to avoid infections but should also monitor the outcome through surveillance. Which is defined as "the ongoing, systematic collection, analysis, interpretation and evaluation of health data closely integrated with the timely dissemination of these data to those who need it" [11].

### **9. Guideline implementation in reality**

It is important that guidelines can be adapted with relative flexibility to suit different clinical situation in the context of availability of resources, training, and according to economic feasibility. Thus, the local situation in any institute would influence applicability and will therefore have a significant impact on implementing a certain guideline. Nonetheless, this does not negate the importance of having guidelines based on best evidence [12]. Rather, it emphasizes the extent to which evidence obtained in a specific setting is generally valid or applicable to other situations.

Thus implementation of evidence-based guidelines is a challenge in many healthcare settings, and it is not often easy to evaluate application and consistency of performance in clinical practice. It has been stated that it takes approximately 5 years for any given guidelines to be accepted and adopted into routine clinical practice and often not fully followed [12, 13]. This is because of the multifactorial nature of implementing these guidelines, where implementation is influenced by the patient, healthcare providers, institutional facilities, and management; yet implementation is meant to overcome these obstacles [13, 14].

That is why guidelines take relatively a long time to implement using different tools to bypass these problems, for example, not only vigorous and continuous education aiming to train individuals but also to change believes and misconceptions reflected on certain behaviors that have become second nature, especially if the recommendation requires infrastructure or a device that is not available or the practice opposes the cultural norms of a specific setting/group. Implementation tools that increase guideline acceptability and accessibility must use a variety of user-friendly formats directed to deliver the knowledge to all those involved in the issue including patients and different groups of HCWs among different settings [14]. Also as most of the suggested guidelines are not subjected to rigorous economic evaluation, it is important to keep this point in focus alongside with effectiveness during implementation, by using surveillance feedback which provide guidance to staff and decision-makers to lever support for the appropriate allocation of resources and efforts, helping clinicians in selecting the best available evidence-based options in healthcare organizations with limited resources.

*Surgical Infections - Some Facts*

### **Author details**

Hadir Okasha Medical Microbiology and Immunology, Faculty of Medicine, Alexandria University, Egypt

\*Address all correspondence to: shellm@gvsu.edu

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**17**

*Risk Factors and Key Principles for Prevention of Surgical Site Infections*

[10] Association of Perioperative Registered Nurses (AORN) Guidelines for Perioperative Practice, 2018 Edition:

[11] CDC/NHSN surveillance definitions for specific types of infections. Atlanta (GA): Centers for Disease Control and Prevention; 2017. Retrieved from https://www.cdc.gov/nhsn/pdfs/ pscmanual/17ps cnosinfdef\_current.pdf

[12] Grol R, Grimshaw J. From best evidence to best practice: Effective implementation of change in patients' care. Lancet. 2003;**362**(9391):1225-1230. DOI: 10.1016/S0140-6736(03)14546-1

[13] Grimshaw J, Thomas RE,

Maclennan G, Fraser C, Ramsay CR, Vale L, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technology Assessment. 2004;**8**(6):1-72

[14] Gagliardi AR, Brouwers MC. Do guidelines offer implementation advice to target users? A systematic review of guideline applicability. BMJ Open. 2015;**5**:e007047. DOI: 10.1136/

bmjopen-2014-007047

www.aornstandards.org/

*DOI: http://dx.doi.org/10.5772/intechopen.85284*

[1] Robson MC, Krizek TJ, Heggers JP. Biology of surgical infection. Current Problems in Surgery. 1973;**10**(3):1-62

[2] Heggers JP. Assessing and controlling wound infection. Clinics in Plastic

[3] Onderdonk AB, Bartlett JG, Louie T, et al. Microbial synergy in experimental intra-abdominal abscess. Infection and

[4] Fry DE. Prevention of infection at the surgical site. Surgical Infections. 2017;**18**(4). DOI: 10.1089/sur.2017.099

[5] Polk HC Jr, Miles AA. Enhancement of bacterial infection by ferric iron: Kinetics, mechanisms, and surgical significance. Surgery. 1971;**70**:71-77

[6] Protocol for Surgical Site Infection Surveillance with a Focus on Settings with Limited Resources. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. https://www.who. int/infection-prevention/tools/surgical/

SSI-surveillance-protocol.pdf

[7] Centers for Disease control and prevention. Procedureassociated Module. SSI. Surgical Site Infection (SSI). Retrieved from: https://www.cdc.gov/nhsn/pdfs/ pscmanual/9pscssicurrent.pdf

bcf0-1a3d1fcc7b87/doc.pdf

jamasurg.2017.0904

[8] Global guidelines for the prevention of surgical site infection, second edition. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. Retrieved from: https://www.medbox. org/preview/5c35b992-bb40-4beb-

[9] Berríos-Torres SI et al. Centers for disease control and prevention guideline for the prevention of surgical site infection. JAMA Surgery (Published online May 3, 2017). 2017. DOI: 10.1001/

Surgery. 2003;**30**:25-35

**References**

Immunity. 1976;**13**:22-26

*Risk Factors and Key Principles for Prevention of Surgical Site Infections DOI: http://dx.doi.org/10.5772/intechopen.85284*

### **References**

*Surgical Infections - Some Facts*

**16**

**Author details**

University, Egypt

Hadir Okasha

provided the original work is properly cited.

\*Address all correspondence to: shellm@gvsu.edu

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Medical Microbiology and Immunology, Faculty of Medicine, Alexandria

[1] Robson MC, Krizek TJ, Heggers JP. Biology of surgical infection. Current Problems in Surgery. 1973;**10**(3):1-62

[2] Heggers JP. Assessing and controlling wound infection. Clinics in Plastic Surgery. 2003;**30**:25-35

[3] Onderdonk AB, Bartlett JG, Louie T, et al. Microbial synergy in experimental intra-abdominal abscess. Infection and Immunity. 1976;**13**:22-26

[4] Fry DE. Prevention of infection at the surgical site. Surgical Infections. 2017;**18**(4). DOI: 10.1089/sur.2017.099

[5] Polk HC Jr, Miles AA. Enhancement of bacterial infection by ferric iron: Kinetics, mechanisms, and surgical significance. Surgery. 1971;**70**:71-77

[6] Protocol for Surgical Site Infection Surveillance with a Focus on Settings with Limited Resources. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. https://www.who. int/infection-prevention/tools/surgical/ SSI-surveillance-protocol.pdf

[7] Centers for Disease control and prevention. Procedureassociated Module. SSI. Surgical Site Infection (SSI). Retrieved from: https://www.cdc.gov/nhsn/pdfs/ pscmanual/9pscssicurrent.pdf

[8] Global guidelines for the prevention of surgical site infection, second edition. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. Retrieved from: https://www.medbox. org/preview/5c35b992-bb40-4bebbcf0-1a3d1fcc7b87/doc.pdf

[9] Berríos-Torres SI et al. Centers for disease control and prevention guideline for the prevention of surgical site infection. JAMA Surgery (Published online May 3, 2017). 2017. DOI: 10.1001/ jamasurg.2017.0904

[10] Association of Perioperative Registered Nurses (AORN) Guidelines for Perioperative Practice, 2018 Edition: www.aornstandards.org/

[11] CDC/NHSN surveillance definitions for specific types of infections. Atlanta (GA): Centers for Disease Control and Prevention; 2017. Retrieved from https://www.cdc.gov/nhsn/pdfs/ pscmanual/17ps cnosinfdef\_current.pdf

[12] Grol R, Grimshaw J. From best evidence to best practice: Effective implementation of change in patients' care. Lancet. 2003;**362**(9391):1225-1230. DOI: 10.1016/S0140-6736(03)14546-1

[13] Grimshaw J, Thomas RE, Maclennan G, Fraser C, Ramsay CR, Vale L, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technology Assessment. 2004;**8**(6):1-72

[14] Gagliardi AR, Brouwers MC. Do guidelines offer implementation advice to target users? A systematic review of guideline applicability. BMJ Open. 2015;**5**:e007047. DOI: 10.1136/ bmjopen-2014-007047

**19**

Section 2

Nursing Staff

Contribution

Section 2

Nursing Staff Contribution

**21**

nurses

the hospital infection rates.

**Chapter 3**

Care Units

*Esmail Khodadadi*

**Abstract**

Investigating the Factors Affecting

Background: Hospital infections are known as one of the most important risk factors in healthcare units, and the hand hygiene is the first step in controlling these infections. Considering the importance of hand hygiene in reducing hospital infections, especially in intensive care units (ICUs), this study aimed to determine the factors affecting the compliance of hand hygiene among the ICU nurses in educational hospitals of Tabriz in Iran. Methods: This descriptive cross-sectional study was performed on 200 nurses working in ICU of educational hospitals in Tabriz. Sampling method determined the sample size and a 29-item researchermade tool helped to collect data on demographic characteristics of nurses and organizational factors as self-report. The software SPSS 21 was used for descriptive analysis and statistics. Results: The results of this study showed that majority of nurses' viewpoint as an individual was affirmative by indicating: "positive effects of hand hygiene on reducing the incidence of hospital infections"; "skin irritation from repeated hand washes"; and "wearing gloves instead of using hygiene solution". The nurses' viewpoint on the organizational factors, distinguished: "working in ICU with simultaneous care of several patients"; "the type of hand washing solution used in the hospital"; "the availability of hand washing solutions at all times"; "the correct sink location"; "continuing education and retrain for ICU nurses"; "caring for isolated patients"; and "administrative support and their encouragement is effective for hand hygiene compliance". Conclusions: The results of this study showed that the level of hand hygiene compliance among the healthcare personnel who work in ICU, are associated with several personal and organizational factors. These results can facilitate institutional application of more effective hand hygiene procedures in ICU by specialized nurses and reduce

**Keywords:** hand hygiene, personal and organizational factors, intensive care units,

the Hand Hygiene Compliance

from the Viewpoints of Iranian

Nurses Who Work in Intensive

### **Chapter 3**

Investigating the Factors Affecting the Hand Hygiene Compliance from the Viewpoints of Iranian Nurses Who Work in Intensive Care Units

*Esmail Khodadadi*

### **Abstract**

Background: Hospital infections are known as one of the most important risk factors in healthcare units, and the hand hygiene is the first step in controlling these infections. Considering the importance of hand hygiene in reducing hospital infections, especially in intensive care units (ICUs), this study aimed to determine the factors affecting the compliance of hand hygiene among the ICU nurses in educational hospitals of Tabriz in Iran. Methods: This descriptive cross-sectional study was performed on 200 nurses working in ICU of educational hospitals in Tabriz. Sampling method determined the sample size and a 29-item researchermade tool helped to collect data on demographic characteristics of nurses and organizational factors as self-report. The software SPSS 21 was used for descriptive analysis and statistics. Results: The results of this study showed that majority of nurses' viewpoint as an individual was affirmative by indicating: "positive effects of hand hygiene on reducing the incidence of hospital infections"; "skin irritation from repeated hand washes"; and "wearing gloves instead of using hygiene solution". The nurses' viewpoint on the organizational factors, distinguished: "working in ICU with simultaneous care of several patients"; "the type of hand washing solution used in the hospital"; "the availability of hand washing solutions at all times"; "the correct sink location"; "continuing education and retrain for ICU nurses"; "caring for isolated patients"; and "administrative support and their encouragement is effective for hand hygiene compliance". Conclusions: The results of this study showed that the level of hand hygiene compliance among the healthcare personnel who work in ICU, are associated with several personal and organizational factors. These results can facilitate institutional application of more effective hand hygiene procedures in ICU by specialized nurses and reduce the hospital infection rates.

**Keywords:** hand hygiene, personal and organizational factors, intensive care units, nurses

### **1. Introduction**

Currently, the World Health Organization (WHO) has reported hospital infections as a serious global issue leading to prolonged hospitalization, ineffective treatments, increased costs, and high mortality [1, 2]. Hospital infections mostly occur in ICUs at 10–80% rates, and patients in these units are 5–7 times more likely to develop infections when compared to other units [3–5]. In fact, patients in the ICU units are more at risk for injuries due to the lack of full consciousness and weaker immunity [6, 7].

However, about 50% of hospital infections are caused by the hands of personnel [8]. Evidence suggests that wearing gloves reduces the risk of pathogen transmission to the patients by the healthcare staff. The World Health Organization has also emphasized the use of gloves when it comes to contact with body fluids and secretions or when necessary for meeting the precautionary requirements [1, 9]. In addition, studies have shown that hand hygiene role is not well known and an average of hand washings rate is usually less than 50% among nurses, so the majority of them wear gloves in order to protect themselves [6, 10, 11].

Other study findings show that healthcare personnel express various barriers for poor hand hygiene such as skin irritation, lack of hygiene products, negative view of patients when nurses wear gloves, forgetfulness, ignoring instructions, lack of time, high workload, personnel shortage, and lack of scientific evidence on hand hygiene reducing hospital infections [12–14]. On the other hand, evidence suggests that hand hygiene among the healthcare personnel is influenced by religion and culture [15]; attitude and awareness [16]; and personal and organizational factors [17]. The results of some studies have shown that personal factors such as age, gender, education, and the organizational factors include management style, work environment, and education are important factors among the healthcare personnel [17–19].

A review of the studies shows that the acceptance of hand hygiene among nurses is low [20, 21], and some studies have reported a direct correlation between hand hygiene rate among the nurses and medical staffs in ICU units and a statistical high rate of hospital infections [22–24]. Considering the importance of hand hygiene in reducing hospital infections, especially in ICUs, the review of previous studies show that the factors affecting the hand hygiene compliance on reduction of infection among hospitalized patients have not been explored among the Iranian ICU nurses; therefore, the present study aimed to investigate the factors affecting the compliance of hand hygiene among ICU nurses in several hospitals in Tabriz, Iran.

### **2. Materials and methods**

This cross-sectional descriptive study was conducted in 2015, in Tabriz, Iran by targeting ICU nurses who worked in teaching hospitals. A total of 200 ICU nurses participated in this study by self-reporting a researcher-made 29-item questionnaire. There were two parts in the questionnaire for assessing nurses' demographic characteristics such as age, gender, and marital status. On the second part of the questionnaire, nurses were asked about personal (eight items) and organizational (21 items) factors. The scoring was based on the Likert scale from "very effective = 5" to "without effect = 1". The content validity of the questionnaire was established by several nursing professors from the Tabriz University of Medical Sciences. The reliability of the questionnaire was performed by a test-retest method, and the correlation coefficient of items was calculated to be 78%.

Information about the overall goals of the study was provided for all participants, and a written informed consent was signed by each participant. Voluntary

**23**

**Table 1.**

*Investigating the Factors Affecting the Hand Hygiene Compliance from the Viewpoints of Iranian…*

participation and maximum confidentiality were emphasized. The informed consent and the study implementation were approved by the Ethics Committee of Tabriz University of Medical Sciences (No. 5/2079). The questionnaires were provided to ICU nurses, and completed questionnaires were collected. Descriptive statistics (percentage and frequency, mean, and standard deviation) were used to

The demographic results of this study shown in **Table 1** consist of 200 ICU nurses from Tabriz hospitals in Iran. Majority of nurses were female, married, held an undergraduate degree, and their mean age was 33.9 ± 3.4. Most of them were working in various shifts and reported attending hand hygiene workshops.

Participating nurses agreed with the personal factors such as "positive effects of hand hygiene on reducing the incidence of hospital infections, hand injuries due to the use of washing solutions, high workload and lack of time, firm belief about the effect of hand washing, and wearing of gloves instead of hand hygiene" were effective factors in hands hygiene and identified items "mental disturbances, the preference of satisfying the patient's needs for hand hygiene, and the gender of nurses (male or female)" were ineffective or low for hands hygiene compliance (**Table 2**). The findings of this study showed that majority of nurses had considered organizational factors including ICU employment, simultaneous care of several patients, type of hand washing solution, availability of hand washing solutions, presence and location of sinks in ICU, offering continuing education programs, emergency care for patients, care for isolated patients, and organizational support to be influential in hand washing behavior. Other organizational factors included short-term care such as vital signs control, sufficient amount of paper napkins, impacts of higher skill senior nurses on junior nurses, head nurse continuous

**Demographic characteristics of nurses, N = 200 Number/percent** Gender Female 135 (67.5)

Marital status Married 129 (64.5)

Academic level Bachelor's degree 173 (86.5)

Work shift Fix 47 (23.5)

Organizational position Head nurse 16 (8)

Hand hygiene educated experiences Yes 141 (70.5)

Age (year) 33.9 ± 3.4 Work history (year) 9.38 ± 4.42

*Demographic characteristics of study participants.*

Male 65 (32.5)

Single 71 (35.5)

Master's degree 27 (13.5)

Circulate 153 (76.5)

Practitioner 184 (92)

No 59 (29.5)

*DOI: http://dx.doi.org/10.5772/intechopen.81561*

**3. Results**

analyze the data using SPSS 21 statistical software.

*Investigating the Factors Affecting the Hand Hygiene Compliance from the Viewpoints of Iranian… DOI: http://dx.doi.org/10.5772/intechopen.81561*

participation and maximum confidentiality were emphasized. The informed consent and the study implementation were approved by the Ethics Committee of Tabriz University of Medical Sciences (No. 5/2079). The questionnaires were provided to ICU nurses, and completed questionnaires were collected. Descriptive statistics (percentage and frequency, mean, and standard deviation) were used to analyze the data using SPSS 21 statistical software.

### **3. Results**

*Surgical Infections - Some Facts*

Currently, the World Health Organization (WHO) has reported hospital infections as a serious global issue leading to prolonged hospitalization, ineffective treatments, increased costs, and high mortality [1, 2]. Hospital infections mostly occur in ICUs at 10–80% rates, and patients in these units are 5–7 times more likely to develop infections when compared to other units [3–5]. In fact, patients in the ICU units are more at risk for injuries due to the lack of full consciousness and weaker immunity [6, 7].

However, about 50% of hospital infections are caused by the hands of personnel [8]. Evidence suggests that wearing gloves reduces the risk of pathogen transmission to the patients by the healthcare staff. The World Health Organization has also emphasized the use of gloves when it comes to contact with body fluids and secretions or when necessary for meeting the precautionary requirements [1, 9]. In addition, studies have shown that hand hygiene role is not well known and an average of hand washings rate is usually less than 50% among nurses, so the majority of

Other study findings show that healthcare personnel express various barriers for poor hand hygiene such as skin irritation, lack of hygiene products, negative view of patients when nurses wear gloves, forgetfulness, ignoring instructions, lack of time, high workload, personnel shortage, and lack of scientific evidence on hand hygiene reducing hospital infections [12–14]. On the other hand, evidence suggests that hand hygiene among the healthcare personnel is influenced by religion and culture [15]; attitude and awareness [16]; and personal and organizational factors [17]. The results of some studies have shown that personal factors such as age, gender, education, and the organizational factors include management style, work environment, and education are important factors among the healthcare personnel [17–19]. A review of the studies shows that the acceptance of hand hygiene among nurses is low [20, 21], and some studies have reported a direct correlation

between hand hygiene rate among the nurses and medical staffs in ICU units and a statistical high rate of hospital infections [22–24]. Considering the importance of hand hygiene in reducing hospital infections, especially in ICUs, the review of previous studies show that the factors affecting the hand hygiene compliance on reduction of infection among hospitalized patients have not been explored among the Iranian ICU nurses; therefore, the present study aimed to investigate the factors affecting the compliance of hand hygiene among ICU nurses in

This cross-sectional descriptive study was conducted in 2015, in Tabriz, Iran by targeting ICU nurses who worked in teaching hospitals. A total of 200 ICU nurses participated in this study by self-reporting a researcher-made 29-item questionnaire. There were two parts in the questionnaire for assessing nurses' demographic characteristics such as age, gender, and marital status. On the second part of the questionnaire, nurses were asked about personal (eight items) and organizational (21 items) factors. The scoring was based on the Likert scale from "very effective = 5" to "without effect = 1". The content validity of the questionnaire was established by several nursing professors from the Tabriz University of Medical Sciences. The reliability of the questionnaire was performed by a test-retest method, and the

Information about the overall goals of the study was provided for all participants, and a written informed consent was signed by each participant. Voluntary

them wear gloves in order to protect themselves [6, 10, 11].

several hospitals in Tabriz, Iran.

correlation coefficient of items was calculated to be 78%.

**2. Materials and methods**

**1. Introduction**

**22**

The demographic results of this study shown in **Table 1** consist of 200 ICU nurses from Tabriz hospitals in Iran. Majority of nurses were female, married, held an undergraduate degree, and their mean age was 33.9 ± 3.4. Most of them were working in various shifts and reported attending hand hygiene workshops.

Participating nurses agreed with the personal factors such as "positive effects of hand hygiene on reducing the incidence of hospital infections, hand injuries due to the use of washing solutions, high workload and lack of time, firm belief about the effect of hand washing, and wearing of gloves instead of hand hygiene" were effective factors in hands hygiene and identified items "mental disturbances, the preference of satisfying the patient's needs for hand hygiene, and the gender of nurses (male or female)" were ineffective or low for hands hygiene compliance (**Table 2**).

The findings of this study showed that majority of nurses had considered organizational factors including ICU employment, simultaneous care of several patients, type of hand washing solution, availability of hand washing solutions, presence and location of sinks in ICU, offering continuing education programs, emergency care for patients, care for isolated patients, and organizational support to be influential in hand washing behavior. Other organizational factors included short-term care such as vital signs control, sufficient amount of paper napkins, impacts of higher skill senior nurses on junior nurses, head nurse continuous


### **Table 1.**

*Demographic characteristics of study participants.*


### **Table 2.**

*The influence of personal factors on hand hygiene compliance.*


**25**

*Investigating the Factors Affecting the Hand Hygiene Compliance from the Viewpoints of Iranian…*

**Training effectiveness level: number (%)**

11 Enough paper hold 43 (21.5) 33 (16.5) 80 (40) 35 (17.5) 9 (4.5) 3.33

(62.5)

52 (26) 125

139 (69.5) **Effective Somewhat** 

**effective**

95 (47.5) 69 (34.5) 21 (10.5) 11 (5.5) 4 (2) 4.20

78 (39) 80 (40) 30 (15) 10 (5) 2 (1) 4.11

39 (19.5) 68 (34) 68 (34) 20 (10) 5 (2.5) 3.58

38 (19) 46 (23) 90 (45) 22 (11) 4 (2) 3.46

27 (13.5) 60 (30) 82 (41) 29 (14.5) 2 (1) 3.41

18 (9) 3 (1.5) 2 (1) 4.11

44 (22) 13 (6.5) 4 (2) — 4.59

18 (9) 43 (21.5) 44 (22) 80 (40) 15 (7.5) 2.85

23 (11.5) 29 (14.5) 23 (11.5) 23 (11.5) 102 (51) 2.24

32 (16) 41 (20.5) 67 (33.5) 55 (27.5) 5 (2.5) 3.20

28 (14) 42 (21) 68 (34) 58 (29) 4 (2) 3.16

24 (12) 32 (16) 79 (39.5) 57 (28.5) 8 (4) 3.04

26 (13) 29 (14.5) 79 (39.5) 58 (29) 8 (4) 3.04

**Little effective** **Without effect**

**Mean**

*DOI: http://dx.doi.org/10.5772/intechopen.81561*

**Very effective**

**No Organizational factors**

6 Type of hand

7 Existence of

8 Existence of

10 Conducting continuing education programs (retraining) in the ward or hospital

washing solution used in the hospital

sufficient amount of hand washing solutions

sufficient number of sink in ward

9 Putting sinks at the appropriate place in ward

12 Emergency care for critically ill patients

13 Caring for isolated patients

14 Carrying out shortterm care such as blood pressure control

15 The impact of senior nurses "performance on novice nurses" performance

16 Continuous head nurse supervision for nursing staff

17 Give feedback

18 Continuous

19 Give feedback

manager

about hand hygiene by the head nurse

about hand hygiene by infection control

supervision by infection control manager on nurses' hand hygiene


*Investigating the Factors Affecting the Hand Hygiene Compliance from the Viewpoints of Iranian… DOI: http://dx.doi.org/10.5772/intechopen.81561*

*Surgical Infections - Some Facts*

**factors**

**Very effective**

**No Personal** 

1 The positive effect of hand hygiene compliance on reducing the incidence of nosocomial infections

2 Skin damage due to the use of washing solutions

3 Prefer to meet patient's needs rather than hand hygiene

4 Workload and lack of time

5 Firm belief about effectiveness of hand washing

6 Preoccupation and negligence

7 Sex type of nurses

8 Sufficient

**Table 2.**

wearing gloves instead of hand hygiene compliance

**24**

**No Organizational factors**

1 Being employed in ICU ward

2 Nonholiday work shifts

4 Simultaneous care of a large number of patients

> prompt action in multiple care and procedures for several patients

5 The need for

**Training effectiveness level: number (%)**

3 Holiday work shifts 15 (7.5) 25 (12.5) 30 (15) 63 (31.5) 67 (33.5) 2.29

**Effective Somewhat** 

**effective**

84 (42) 76 (38) 28 (14) 11 (5.5) 1(.5) 4.16

**Training effectiveness level: number (%)**

142 (71) 57 (28.5) 1 (5) — — 4.71

113 (56.5) 68 (34) 14 (7) 5 (2.5) — 4.45

24 (12) 47 (23.5) 71 (35.5) 49 (24.5) 9 (4.5) 3.14

33 (16.5) 114 (57) 34 (17) 13 (6.5) 6 (3) 3.78

109 (54.5) 78 (39) 11 (5.5) 2 (1) — 4.47

12 (6) 27 (13.5) 61 (30.5) 91 (45.5) 9 (4.5) 2.71

14 (7) 52 (26) 40 (20) 49 (24.5) 45 (22.5) 2.71

33 (16.5) 107 (53.5) 33 (16.5) 16 (8) 11 (5.5) 3.68

**Little effective** **Without effect**

**Mean**

**effective**

**Effective Somewhat** 

19 (9.5) 24 (12) 28 (14) 61 (30.5) 68 (34) 2.33

26 (13) 56 (28) 62 (31) 50 (25) 6 (3) 3.23

19 (9.5) 8 (4) 59 (29.5) 101 (50.5) 13 (6.5) 3.73

**Little effective** **Without effect**

**Mean**

**Very effective**

*The influence of personal factors on hand hygiene compliance.*


### **Table 3.**

*Effective organizational factors on hand hygiene compliance.*

supervision on hand hygiene practice, getting feedback from infection control staffs, keeping organization's officials accountable in cases of "ineffective or low hand hygiene performance" (**Table 3**).

### **4. Discussion**

The results of this study showed that several factors from nurses' point of view affected the hand hygiene practices. Based on their importance, these factors were attitude and beliefs about the impact of hand hygiene, the shortage of personnel and excessive workload, forgetfulness, and the belief in the cleansing solution hazards for the skin. In other studies, most nurses did not believe in hand hygiene, and the rate among medical personnel was low [12, 19, 21, 25, 26] pointing to a global concern [27]. Farbakhsh et al. found a low rate of hand hygiene practice among the Iranian nurses [28]. Similarly, Ghorbani et al. [29] showed that compliance of hand hygiene rate and wearing gloves among the nurses in ICU units was low, and most nurses used gloves without hand hygiene [29]. On the other hand, from the nurses' point of view, there were barriers to hand hygiene, which made it less likely for them to use hygiene while working with the patient. The results of Pan et al. research in 2013 revealed that hand washing could have negative effects on the skin, since frequent washing with soap resulted in dry skin, sensitivities, and dermatitis [30]. Therefore, nurses in certain places refrained from hand hygiene. In a study by De Wandel et al. [12], researchers found that disinfectant solutions with drying and irritation to the skin were obstacles to the hand hygiene practice. They reported that general attitude of nurses in ICUs were positive toward hand hygiene and increased work load did not directly affect health of their hands [12].

However, the results of other studies have indicated that a busy and high stressed environment negatively affect hand hygiene practices [31–33]. In a study by McArdle et al. [33], the shortage of personnel and heavy workload made hand hygiene less important because more time and energy were needed to take care of several patients [33]. High level of work pressure and nursing shortage generally affected the quality of nursing care [34–36]. Evidence suggests that knowledge and attitude of healthcare staff and how hand hygiene could reduce infection were directly influenced by the level of hands hygiene promotion [37–39]. In fact, the positive attitude of nurses showed that they were influenced by their knowledge about the scientific evidence of hand hygiene efficacy [16, 40]. Ravaghi et al.

**27**

**5. Conclusions**

infections.

**6. Limitations**

*Investigating the Factors Affecting the Hand Hygiene Compliance from the Viewpoints of Iranian…*

[41] indicated that increased knowledge of personnel can improve their attitude toward hand hygiene. They also found that junior nurses were more accepting hand hygiene compared to senior nurses [41]. Nicol et al. [42] reported that staffs' sense of responsibility, work ethics, and level of experience played an important role on hand hygiene compliance [42]. While Whitby et al. [43] asserted that nurses had unpleasant feelings and discomfort regarding hand hygiene, where they had to be encouraged to protect themselves and ultimately change their attitude toward hand hygiene [43]. In contrast, Hazavehei et al. showed that personnel's level of knowledge and attitude toward hands hygiene was high, but these factors alone seemed

In this study, we found that nurses in ICUs needed to enhance their hand hygiene practices. These results were inconsistent with findings of some researches in the past [14, 45, 46]. It is likely that different participants' attitudes and practices generated different results, and in this study, nurses' gender had no effect on the hand hygiene, while other studies indicated that female nurses practiced more hand hygiene than male nurses [19, 47]. Similar to this study, Nazari and Asgari found that hand hygiene practices were the same between male and female nurses [6]. Our findings, similar to other studies, showed that availability of hand sanitizer's increased the rate of hand hygiene among nurses and healthcare personnel, but heavy workload and overcrowding will reduce the rate [20, 31, 48]. Our findings of effective health education and staff encouragement on promotion of hand hygiene among the nurses were consistent with other study findings [49–52]. Ashraf et al. [31] showed that heavy workload and overcrowding limited hand hygiene, especially when there were insufficient supplies such as paper towels gloves, hand washing solutions, skin irritation due to persistent washing, and absence of washstand sink nearby [31]. Other studies have reported the lack of time and sinks [53], high workload, patient's condition, and lack of hand washing solutions [20], and lack of time as a reason for less hand hygiene practices [48]. In a review by Smiddy et al. [32], researchers showed that high workload and shortage of personnel were barriers to hand hygiene [32]. Other studies indicated that shortage of nursing staff in ICUs had a negative effect on hand hygiene and an increase in mortality rates [33]. In other words, a sufficient number of nursing personnel could effectively reduce

the hospital infection rates [54] in support of the results of in this study.

Based on the results of present study, there are numerous personal and organizational factors affecting the compliance of hand hygiene among the ICU nurses. Working in ICU, personal beliefs, knowledge, and attitude toward the effects of hand hygiene on reducing infections; availability hand hygiene supplies; continuous health education training; and a supportive organizational management are all part of an effective hand hygiene practice. Therefore, these results could help hospital administrators to effectively implement policies to increase the rate of hand hygiene practices among the healthcare providers and hospital staffs to reduce preventable

The ICU nurses from Tabriz hospitals in Iran took part in this study, and researchers acknowledge the study limitation regarding generalizability of the results. Therefore, it is recommended that similar research to be conducted among a

*DOI: http://dx.doi.org/10.5772/intechopen.81561*

insufficient to reach their goals [44].

*Investigating the Factors Affecting the Hand Hygiene Compliance from the Viewpoints of Iranian… DOI: http://dx.doi.org/10.5772/intechopen.81561*

[41] indicated that increased knowledge of personnel can improve their attitude toward hand hygiene. They also found that junior nurses were more accepting hand hygiene compared to senior nurses [41]. Nicol et al. [42] reported that staffs' sense of responsibility, work ethics, and level of experience played an important role on hand hygiene compliance [42]. While Whitby et al. [43] asserted that nurses had unpleasant feelings and discomfort regarding hand hygiene, where they had to be encouraged to protect themselves and ultimately change their attitude toward hand hygiene [43]. In contrast, Hazavehei et al. showed that personnel's level of knowledge and attitude toward hands hygiene was high, but these factors alone seemed insufficient to reach their goals [44].

In this study, we found that nurses in ICUs needed to enhance their hand hygiene practices. These results were inconsistent with findings of some researches in the past [14, 45, 46]. It is likely that different participants' attitudes and practices generated different results, and in this study, nurses' gender had no effect on the hand hygiene, while other studies indicated that female nurses practiced more hand hygiene than male nurses [19, 47]. Similar to this study, Nazari and Asgari found that hand hygiene practices were the same between male and female nurses [6].

Our findings, similar to other studies, showed that availability of hand sanitizer's increased the rate of hand hygiene among nurses and healthcare personnel, but heavy workload and overcrowding will reduce the rate [20, 31, 48]. Our findings of effective health education and staff encouragement on promotion of hand hygiene among the nurses were consistent with other study findings [49–52]. Ashraf et al. [31] showed that heavy workload and overcrowding limited hand hygiene, especially when there were insufficient supplies such as paper towels gloves, hand washing solutions, skin irritation due to persistent washing, and absence of washstand sink nearby [31]. Other studies have reported the lack of time and sinks [53], high workload, patient's condition, and lack of hand washing solutions [20], and lack of time as a reason for less hand hygiene practices [48]. In a review by Smiddy et al. [32], researchers showed that high workload and shortage of personnel were barriers to hand hygiene [32]. Other studies indicated that shortage of nursing staff in ICUs had a negative effect on hand hygiene and an increase in mortality rates [33]. In other words, a sufficient number of nursing personnel could effectively reduce the hospital infection rates [54] in support of the results of in this study.

### **5. Conclusions**

*Surgical Infections - Some Facts*

**No Organizational factors**

20 Application of punitive methods by the organization's authorities

21 Applying

encouragement methods by the organization's authorities

hand hygiene performance" (**Table 3**).

*Effective organizational factors on hand hygiene compliance.*

work load did not directly affect health of their hands [12].

However, the results of other studies have indicated that a busy and high stressed environment negatively affect hand hygiene practices [31–33]. In a study by McArdle et al. [33], the shortage of personnel and heavy workload made hand hygiene less important because more time and energy were needed to take care of several patients [33]. High level of work pressure and nursing shortage generally affected the quality of nursing care [34–36]. Evidence suggests that knowledge and attitude of healthcare staff and how hand hygiene could reduce infection were directly influenced by the level of hands hygiene promotion [37–39]. In fact, the positive attitude of nurses showed that they were influenced by their knowledge about the scientific evidence of hand hygiene efficacy [16, 40]. Ravaghi et al.

**4. Discussion**

**Table 3.**

supervision on hand hygiene practice, getting feedback from infection control staffs, keeping organization's officials accountable in cases of "ineffective or low

**Training effectiveness level: number (%)**

**Effective Somewhat** 

**effective**

7 (3.5) 22 (11) 65 (32.5) 69 (34.5) 37 (18.5) 2.47

45 (22.5) 92 (46) 25 (12.5) 19 (9.5) 19 (9.5) 3.63

**Little effective** **Without effect**

**Mean**

**Very effective**

The results of this study showed that several factors from nurses' point of view affected the hand hygiene practices. Based on their importance, these factors were attitude and beliefs about the impact of hand hygiene, the shortage of personnel and excessive workload, forgetfulness, and the belief in the cleansing solution hazards for the skin. In other studies, most nurses did not believe in hand hygiene, and the rate among medical personnel was low [12, 19, 21, 25, 26] pointing to a global concern [27]. Farbakhsh et al. found a low rate of hand hygiene practice among the Iranian nurses [28]. Similarly, Ghorbani et al. [29] showed that compliance of hand hygiene rate and wearing gloves among the nurses in ICU units was low, and most nurses used gloves without hand hygiene [29]. On the other hand, from the nurses' point of view, there were barriers to hand hygiene, which made it less likely for them to use hygiene while working with the patient. The results of Pan et al. research in 2013 revealed that hand washing could have negative effects on the skin, since frequent washing with soap resulted in dry skin, sensitivities, and dermatitis [30]. Therefore, nurses in certain places refrained from hand hygiene. In a study by De Wandel et al. [12], researchers found that disinfectant solutions with drying and irritation to the skin were obstacles to the hand hygiene practice. They reported that general attitude of nurses in ICUs were positive toward hand hygiene and increased

**26**

Based on the results of present study, there are numerous personal and organizational factors affecting the compliance of hand hygiene among the ICU nurses. Working in ICU, personal beliefs, knowledge, and attitude toward the effects of hand hygiene on reducing infections; availability hand hygiene supplies; continuous health education training; and a supportive organizational management are all part of an effective hand hygiene practice. Therefore, these results could help hospital administrators to effectively implement policies to increase the rate of hand hygiene practices among the healthcare providers and hospital staffs to reduce preventable infections.

### **6. Limitations**

The ICU nurses from Tabriz hospitals in Iran took part in this study, and researchers acknowledge the study limitation regarding generalizability of the results. Therefore, it is recommended that similar research to be conducted among a larger number of the ICU nurses in different cities to obtain an overall understanding of factors contributing to a low rate of hand hygiene.

### **Acknowledgements**

Researchers are indebted to the officials at educational centers of hospitals in Tabriz for providing a research friendly environment. Our gratitude is also extended for the financial and spiritual support at the Nursing and Midwifery Faculty of Qazvin. We appreciate the participation of all ICU nurses in this research.

### **Author details**

Esmail Khodadadi PhD in Nursing Education, Iranian Social Security Organization, Iran

\*Address all correspondence to: esmailkhodadadi11@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**29**

*Investigating the Factors Affecting the Hand Hygiene Compliance from the Viewpoints of Iranian…*

Hand hygiene compliance and associated factors among health care providers in Gondar University Hospital, Gondar, North West Ethiopia.

BMC Public Health. 2014;**14**:96

2014;**86**:110-116

1992;**327**:120-122

[9] Loveday H, Lynam S, Singleton J, Wilson J. Clinical glove use: Healthcare workers' actions and perceptions. Journal of Hospital Infection.

[10] Goldmann D, Larson E. Handwashing and nosocomial infections. New England Journal of Medicine.

[11] Jarvis W. Handwashing—the Semmelweis lesson forgotten? The Lancet. 1994;**344**:1311-1312

[12] De Wandel D, Maes L, Labeau S, Vereecken C, Blot S. Behavioral

of Critical Care. 2010;**19**:230-239

[13] Larson E, Kretzer E. Compliance with handwashing and barrier precautions. Journal of Hospital Infection. 1995;**30**:88-106

[14] Pittet D. Improving adherence to hand hygiene practice: A

Infectious Diseases. 2001;**7**:234

[15] Allegranzi B, Memish ZA,

2009;**37**:28-34

multidisciplinary approach. Emerging

Donaldson L, Pittet D, Safety WHOGP. on Religious CTF, Religion and culture: Potential undercurrents influencing hand hygiene promotion in health care. American Journal of Infection Control.

[16] Elaziz KA, Bakr IM. Assessment of knowledge, attitude and practice of hand washing among health care workers in Ain Shams University hospitals in Cairo. Journal of Preventive Medicine and Hygiene. 2009;**50**:19-25

determinants of hand hygiene compliance in intensive care units. American Journal

*DOI: http://dx.doi.org/10.5772/intechopen.81561*

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[2] Squires JE, Suh KN, Linklater S, Bruce N, Gartke K, Graham ID, et al. Improving physician hand hygiene compliance using behavioural theories: A study protocol. Implementation

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**Acknowledgements**

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**28**

**Author details**

Esmail Khodadadi

provided the original work is properly cited.

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

PhD in Nursing Education, Iranian Social Security Organization, Iran

\*Address all correspondence to: esmailkhodadadi11@gmail.com

larger number of the ICU nurses in different cities to obtain an overall understand-

Researchers are indebted to the officials at educational centers of hospitals in Tabriz for providing a research friendly environment. Our gratitude is also extended for the financial and spiritual support at the Nursing and Midwifery Faculty of Qazvin. We appreciate the participation of all ICU nurses in this

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[7] Rock C, Harris AD, Reich NG, Johnson JK, Thom KA. Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of health care worker time?—A randomized controlled trial. American Journal of Infection Control. 2013;**41**:994-996

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[10] Goldmann D, Larson E. Handwashing and nosocomial infections. New England Journal of Medicine. 1992;**327**:120-122

[11] Jarvis W. Handwashing—the Semmelweis lesson forgotten? The Lancet. 1994;**344**:1311-1312

[12] De Wandel D, Maes L, Labeau S, Vereecken C, Blot S. Behavioral determinants of hand hygiene compliance in intensive care units. American Journal of Critical Care. 2010;**19**:230-239

[13] Larson E, Kretzer E. Compliance with handwashing and barrier precautions. Journal of Hospital Infection. 1995;**30**:88-106

[14] Pittet D. Improving adherence to hand hygiene practice: A multidisciplinary approach. Emerging Infectious Diseases. 2001;**7**:234

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*Surgical Infections - Some Facts*

Medicine. 2000;**26**:14-22

[19] van de Mortel T, Bourke R,

[17] Larson EL, Early E, Cloonan P, Sugrue S, Parides M. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behavioral

[25] Albughbish M, Neisi A, Borvayeh H. Hand Hygiene Compliance among ICU Health Workers in Golestan Hospital in 2013. Jundishapur Scientific Medical Journal. 2016;**15**:355-362

[26] Shimokura G, Weber DJ, Miller WC, Wurtzel H, Alter MJ. Factors associated with personal protection equipment use and hand hygiene among hemodialysis staff. American Journal of Infection

[27] Erasmus V, Kuperus M, Richardus JH, Vos M, Oenema A, Van Beeck E. Improving hand hygiene behaviour of nurses using action planning: A pilot study in the intensive care unit and surgical ward. Journal of Hospital

Control. 2006;**34**:100-107

Infection. 2010;**76**:161-164

2013;**18**:9-13

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Section 3

Infections in Dentistry

Section 3
