Meengs M R, Giles B K, Chisholm C D, Cordell W H, Nelson D R
Emergency Medicine and Trauma Center, Methodist Hospital of Indiana, Indianapolis.
Ann Emerg Med. 1994 Jun;23(6):1307-12. doi: 10.1016/s0196-0644(94)70357-4.
Previous studies, conducted mainly in ICUs, have shown low compliance with hand-washing recommendations, with failure rates approaching 60%. Hand washing in the emergency department has not been studied. We examined the frequency and duration of hand washing in one ED and the effects of three variables: level of training, type of patient contact (clean, dirty, or gloved), and years of staff clinical experience.
Observational.
ED of an 1,100-bed tertiary referral, central city, private teaching hospital.
Emergency nurses, faculty, and resident physicians. Participants were informed that their activities were being monitored but were unaware of the exact nature of the study.
An observer recorded the number of patient contacts and activities for each participant during three-hour observation periods. Activities were categorized as either clean or dirty according to a scale devised by Fulkerson. The use of gloves was noted and hand-washing technique and duration were recorded. A hand-washing break in technique was defined as failure to wash hands after a patient contact and before proceeding to another patient or activity.
Eleven faculty, 11 resident physicians, and 13 emergency nurses were observed. Of 409 total contacts, 272 were clean, 46 were dirty, and 91 were gloved. Hand washing occurred after 32.3% of total contacts (SD, 2.31%). Nurses washed after 58.2% of 146 contacts (SD, 4.1%), residents after 18.6% of 129 contacts (SD, 3.4%), and faculty after 17.2% of 134 contacts (SD, 3.3%). Nurses had a significantly higher hand washing frequency than either faculty (P < .0001) or resident physicians (P < .0001). Hand washes occurred after 28.4% of 272 clean contacts (SD, 2.34%), which was significantly less (P < .0001) than 50.0% of 46 dirty contacts (SD, 7.4%) and 64.8% of 91 gloved contacts (SD, 5.0%). The number of years of clinical experience was not significantly related to hand-washing frequency (P = .82). Soap and water were used in 126 of the hand washes, and an alcohol preparation was used in the remaining six. The average duration of soap-and-water hand washes was 9.5 seconds.
Compliance with hand washing recommendations was low in this ED. Nurses washed their hands significantly more often than either staff physicians or resident physicians, but the average hand-washing duration was less than recommended for all groups. Poor compliance in the ED may be due to the large number of patient contacts, simultaneous management of multiple patients, high illness acuity, and severe time constraints. Strategies for improving compliance with this fundamental method of infection control need to be explored because simple educational interventions have been unsuccessful in other health care settings.
以往主要在重症监护病房进行的研究表明，洗手建议的依从性较低，失败率接近60%。急诊科的洗手情况尚未得到研究。我们调查了一家急诊科的洗手频率和时长，以及三个变量的影响：培训水平、患者接触类型（清洁、污染或戴手套）和工作人员的临床工作年限。
观察性研究。
一家拥有1100张床位的市中心私立教学医院的三级转诊急诊科。
急诊护士、教员和住院医师。参与者被告知他们的活动正在被监测，但不清楚研究的确切性质。
一名观察者在三小时的观察期内记录了每位参与者的患者接触次数和活动。根据富尔克森设计的量表，活动被分类为清洁或污染。记录手套的使用情况以及洗手技术和时长。洗手技术中断被定义为在接触一名患者后且在接触另一名患者或进行另一项活动之前未洗手。
观察了11名教员、11名住院医师和13名急诊护士。在总共409次接触中，272次为清洁接触，46次为污染接触，91次为戴手套接触。洗手发生在总接触次数的32.3%（标准差，2.31%）之后。护士在146次接触中的58.2%（标准差，4.1%）后洗手，住院医师在129次接触中的18.6%（标准差，3.4%）后洗手，教员在134次接触中的17.2%（标准差，3.3%）后洗手。护士的洗手频率显著高于教员（P < .0001）或住院医师（P < .0001）。洗手发生在272次清洁接触中的28.4%（标准差，2.34%）之后，这显著低于46次污染接触中的50.0%（标准差，7.4%）和91次戴手套接触中的64.8%（标准差，5.0%）（P < .0001）。临床工作年限与洗手频率无显著相关性（P = .82）。126次洗手使用了肥皂和水，其余6次使用了酒精制剂。用肥皂和水洗手的平均时长为9.5秒。
该急诊科对洗手建议的依从性较低。护士洗手的频率显著高于工作人员医生或住院医师，但所有组的平均洗手时长均低于推荐时长。急诊科依从性差可能是由于患者接触次数多、同时管理多名患者、疾病严重程度高以及时间紧迫。由于简单的教育干预在其他医疗环境中未取得成功，因此需要探索提高对这种基本感染控制方法依从性的策略。
