The "Elbow-Way" to Proper Handwashing: A Device Improvised for Health Facilities Where there is no Running Water.

I MT Niemogha1,0 AAtoyebi', F. T. Ogunsola , TOdugbemi' ' Departments of Medical Microbiology': and Surgery',

Lagos University Teaching Hospital, Lagos.

ABSTRACT Lack of running pipe-borne water is common to de­

veloping countries and therefore, water used in hospi­ tals and laboratories are collected in buckets or basins from wells or bore holes. This often leads to contamina­ tion of the water from contact with the hands when this is used for routine handwashing.

By impr�vising a plastic intravenous infusion bottle as soap dispen�r, a longitudinal water tank with tap to deliver water, a hose-pipe connected to a plastic bowl on a table and a box containing clean towels, a handwashing set was designed. By applying pressure with the elbow on soap dispenser to obtain liquid soap and turning the tap with the elbow, hands can be properly washed. Use ing the elbow to control all manouvres reduced the chance of water contamination as no contact was made with the hands.

The use of home-made liquid antiseptic soap also made the set useful in preventing contamination, espe­ cially as the shelflife of the prepared soap was shown to be up to four weeks with no significant microbial growth.

More than 70% of health professionals on a trial run were assertive of the usefulness of the handwashing device. Overall result showed that hands were properly washed and contamination was minimal using the impro­ vised device when there is no running tap water.

Key Words: Handwashing, Elbow-way, Water Contami­ nation, Running water.

IN1RODUCTION -

Unless properly disinfected, the hands of doctors, nurses and other medical attendants which get in con­ tact with patients are almost certain to be vehicles of

· transfer of infectious agents. Handwashing is therefore an important infection control practice by hospital staff and its role in the control of infectious agents cannot be overemphasized!".

A century and half years after Dr. Ignaz Semmelweis, an obstetrician, was reported to have noted that deaths from puerperal sepsis resulted from poor compliance with routine handwashing, the problem still remains", Gram-

negative bacteria are responsible for a high proportion of nosocomial infections particularly among the critically ill and the spread is principally via the hands of staff'. Hand washing is thus an important method of prevention of nosocomial infections which affect up to 30% of pa­ tients in Intensive Care Units (ICU)'. Although it has been established that infection rates decline with increas­ ing handwashing frequency, handwashing rates in lCUs are poor amongst professionals, with the exception of medical attendants in whom a trend towards an increased frequency in handwashing was shown after performance feedback'.

Compliance is even more difficult in developing countries where there is often no running water. Ighedosa" described the "Two-Bowl Initiative" as a means of ensur­

ing routine handwashing in developing countries but the procedure appears a little cumbersome for routine use. In communities where running water is a problem, further techniques and methodologies should be formulated to allow for compliance with proper handwashing. This paper describes another simple device for handwashing in health facilities in developing countries so as to sur­ mount the multifarious problems encountered with infec­ tion control due to lack of running water.

MATERIALS A.NP METHODS

Readily available materials are utilized to fabricate a handwash set-up for use when there is no running water.

· Materials: Empty plastic intravenous (IV) normal saline infusion bottles; empty beverage tin (e.g. boumvita or cerelac containers); table (3 feet high, 3 feet long and 2 feet wide), plastic sink (2 Y, feet high} or plastic bowl and a support stand (2 Y, feet high) with a hole drilled at the side of the bowl to hold an outlet pipe; metal box or a carton properly wrapped with foil with an opening at the bottom to pull out hand towels; nails; plaster; plastic bin; s_oap dispenser; 4 yards of polyester cotton and longitu­ dinal tank ( e.g. Geepee tanks} to contain 25 litres of water for at least 40 handwashing sessions.

Design ofhandwash set-up: A Simple hand-wash set-up

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"Elbow-Way" To Proper flandwashing

consists of a dispenser, a longitudinal water tank (which occupies just a linle space), a sink, an aluminium or metal box (to contain hand towels), a water hose and a table. (Figure I).

Figure I_: Photograph of the hundwashing unlt designed using locally available n_1aterials

Two set-ups are possible depending on the institu­ tional requirements. Rather than procure a ready made dispenser, it wih suffice to use an empty plastic bottle of lV fluid as a dispenser. S\mi\arly, rather than procure a

metal water tank, alternative B uses a Geepee plastic con­ tainer to which a tap can be attached (with iron cap with interspaced rods constructed by a welder). In addition, a plastic bowl on a wooden stand can be used rather than purchasing a 2Y, feet tall plastic sink (Alternative A).

Methodoigy of preparing liquid soap Any antiseptic soap (e.g. Dettol", Delta", Asepso"

or Carat", etc) may be used. Using a clean nylon sheet as underlay, break the soap into small pieces. Put the anti­ septic soap (in small pieces) into an empty beverage tin, add 500mls of water, bring to boil and stir until a uniform paste is formed. Pour into ernpty'(Iv) plastic intravenous infusion bottle through a hole (1 cm diameter) bored at the top. Seal hole with melted plastic, ensure that it is

airtight. Seal IV bottle opening at the neck before pour ing in Liquid Soap to avoid initial leakage.

Bacteriological Assessment

A serial dilution of the liquid soap was done and bacteriologically assessed. One millilitre of soap paste· from IV infusion bottle was added into 9 .Omls of sterile water and then one ml. of diluted soap was sequentially transferred into 9.0mls of another sterile water until seri­ ally diluted to the 6• bottle. A loopful of each serially diluted soap paste was cultured on agar prepared from Mackonkey (Oxoid CM7) and blood agar base (Oxoid CM65). Incubation was done at 37°C and read between 18 -24 hours. This was repeated every week for 12 weeks using standard bact�riological procedures ".

Application ofll,e "Elbow-Way" to Handwashing: Two hundred healthcare workers participated in the

hand washing trials making use of the device designed. Three steps were taken using the 'Elbow-Way" for a proper handwash: With the left elbow applying pressure on the improvised soap dispenser (plastic IV infusion bottle), the liquid soap was squeezed on to the right palm, both left and right palms were scrubbed together and then the elbow was used to tum the tap to release water to wash hands. The elbow was again used to close the tap. With the left hand 10' pull towel, both hands were wiped dry.

Measurement of Water for Hand Wash A total of200 hand-washes were carried out by 50

of each category of health care workers recruited. They consisted of medical doctors, nurses, laboratory scien­ tists and other health workers (wardrnaids, laboratory as­ sistants/technicians) at the surgical wards of the Lagos · University Teaching Hospital and the Medical Microbi­ ology and Parasitology laboratories. The. quantity of water used for each hand-wash was measured with l litre

conical flask and the average noted.

Acceptability of the handwashing device: A short questionnaire was drawn on the accept­

ability of the handwashing device and technique and this was applied to those who participated in using the de­ vice as detailed above. The question was to rate the de­ vice as (a) Very Useful (b) CumbersorneIc) Nonchalant. All the 200 participants in the trial hand-washes responded to the que.stionnaire.

.RESULTS

Cost Implication . The cost of installing the device was evaluated and

it showed that one alternative costs less than half of the other, viz:

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"Elbow-H'ay" To Proper Handwashing

.\able I '

Health Workers and "Reactions to Hand Washing Device

Comment on Doctors Nurses Laboratory Other l l c a l i h Hand-washing device Scientists Workers

(SO) (50) (50) (50)

Very Useful 40 (80)%) · 35 (70%) 12 (84%) 45 (90%) Cumbersome · s c 1 6 % ) 10 (20%) 6 (12%) 2 (4%) Nonchalant 2 (4%) 5 (IQ%) 2 (4%) 3 (6%)

Table2

Bacterial Isolates from Prepared Liquid Soap and Indication for Shelf Life of Soap

-

- ' Frequency of Occurrence of Bacterial lso]ates

-

Week of Isolation DI D2 D3 D4 DS D6

-

1st Week 0 0 0 0 0 0 2nd Week 0 0 0 0 0 0

3rd Week 0 0 0 0 0 0 4th Week 0 0 0 0 0 0 5th Week 9 4 0 0 0 0

CONS CONS 6th Week (IO)A ei (12)Aei ( 10) Aei (7) Aci (4) Aci

(10) CONS (18)CON5 (12) CONS ( 1 0 ) CONS (3) CONS 0

7th Week (30) Pseud (20) Pseud (10) Pseud (8) Pseud (5) Pseud (4) Pscud ( 1 5 ) B a e ( 1 8 ) B a e (8) Bae (6) Ilae (0) Bae (2) Bae (IO)Aei (12 )Aei (5) Aei (4) Bae ( I ) Aei

8th Week 40 Pseud 30 Pseud (30) Pseud (20) Pseud (10) Pseud (6) Pseud (20) Bae (20) Bae ( 1 5 ) Bae (IO)Bae (5) Bae 2 (Bae)

DI 10 D6

CONS

Aci P.seud Bae

{)

I/JO - J-/000000 (.serial dilution liquid soapy

Coagula.se negative Staphylococcus Acinetobacler sp. Pseudomonas sp.

Bacillus .sp. number of colonies

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"Etbow-Wav" To Proper llandwashing

Costing For Alternative A:- A total nmount ofNine thou­

sand. three hundred and flfly Naira (N9,350.00) is required. /\ soap dispenser (N200.00). Water tank (5,000.00), Plas­ tic sink (N2.000.00): I lose-pipe (N·l50.00), no, (N600.00). Iron cap (N500.00), I land towel \N500.00), Plastic bin

(NS0.00) and Plastic funnel (NS0.00).

Costing For Alternative 8: A total amount of three thou­ sand five hundred and fifty Nairn (NJ,550.00) is required. Intravenous infusion plastic bottle (free), Plastic funnel (NS0.00), Plastic tank with tap (N 1,500.00), Iron cap (NS00.00), Bowl and stand (NS00.00), Water hose (N450.00), Plastic bin (NS0.00), Carton (free}, hand towel (N500.00).

Alternative 1-3 is cheaper since some of the materials used arc meant to be discarded and therefore not costing any money.

Bacteriological assessment

naetcrinl lond nf liquid soap showed no bacterial count by method I until the fourth week when 4 colonies of coagulasc negative Staphylococcus (CONS) were iso­ lated. By S1h and 61h weeks, other organisms had come up.

Dilution 1/ 10 had IO colonies of A cinctobacter spp. and 10 colonies of CONS respectively while dilution I x JO' had 4 colonies of Acinetobacter sp and 3 of CONS. By

the S'h week, the paste had become flaky and the number of colonies had increased (Table 1 ). Bacteriological analy­ sis showed that I 111011th shelf' life was ideal for the pre­

pared liquid soap in dispenser as they showed no growth.

Acccptnhility Mure than 70� 0 of the healthcare workers were posi­

dvc in their assertion that the device is very useful. The lower cadres of health workers (apnrt from doctors and nurses i:c. laboratory assistants, wardmaids) had the high­ est acceptance rate of90o/o. Twenty percent of the nurses fell it was cumbersome while I 0% were non-chalant. (Table 2).

Vol1111,c of Water /\ total volume of 120 litres was used by 200 per­

sonnel. giving an average of600 111ls per session of proper routine hand wash.

DISCUSSION

1 landwashing is known to be an important factor in the prevention of nosocornial infections but compliance is often poor'·'·'·'. Simple hanclwashing with soap and water is known to remove transient bacteria from the hands

but Niemogha et al" still isolated various strains of gram • negative and grain positive bacteria from "scrubbed hands" in their study on surgical hand scrub. The origin or such rn icrobes was I inked to use of water from contain­ ers whcu there was no running pipe-borne water. Diluted disinfectants are also known sources of nosocomial in­

fections 12·". This design is, therefore, aimed at provid­ ing a simple technique for our environment where run­ ning water is a problem.

The requirements are a dispenser, a longitudinal plastic tank for water, a box for hand towels and a plastic bowl for use as sink. There are two types, Alternative A and Alternative B. The cheaper alternative is for small hospitals that cannot afford the expensive items. The technique is to utilize the elbow to control all manouvres. The left elbow is applied on dispenser to put soap on the right palm. Thereafter, the left elbow is placed on tap to turn on water to wash hands. This method can be used in the theatre, on the wards and in the laboratories.

The «elbow-way" docs not give room for Contact of probably contaminated materials with the hands and

therefore contamination is reduced. It is a cheap way to effect proper handwashing as locally available materials can be used. Less than N I 0,000 (Ten thousand naira) will be required for alternative A but institutions that cannot afford this may spend NJ,000 (Three thousand naira) or less to ensure proper handwashing making use of Alter­ native B. A 12-litre tank containing water will be suffi­ cient. for 20 handwashing sessions, but a busy ward will require 25-litrc tank water for about 40 hand washes.

In some developed countries, the use of a handwashing machine has been shown to improve handwashing compliance and actually brought about re­ duct ion in lhc transmission or infection 7•1�. A similar level of compliance can also be achieved using the as­ sembled handwashing device especially as majority of health workers reacted positively. The notable number of nurses that described it as cumbersome can be attrib­ uted to the need for orderly steps to be taken for a proper handwash. This aspect is however a necessity and the use of the device is really feasible for widespread use in developing countries. There have' been various reports on transmission of infection to patients from the hands of hospital personnel u,16• Since in this device, no direct. hand contact is made with contaminated materials during a proper handwashing session, cross infection will cer­

tainly be minimal. The problem of compliance will also be minimal as

more than 70% of health professionals accepted the de­ vice. Unlike the finding of Van de Mortel and Heyman" where compliance was highest amongst wardsmen (90%)

and lowest amongst visiting medical officers (20%), the

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"Elbow-Way" To Proper Hondwashtng

high level of acceptance even amongst medical doctors has further confirmed the feasibility of widespread use of this device in both urban and rural areas of developing countries.

The cost burden of nosocornial infections versus cost-effectiveness- of handwashing techniques has been the subject of debate 17• Cost analysis of this device has

shown that only Ten thousand Naira (N 10,000) is needed to purchase standard materials for a complete handwash set up while smaller health institutions that cannot afford this can use as little as N3,000 to ensure proper handwashing towards an effective infection control sys­ tem.

. It is noteworthy that bacterial growth were obtained from liquid soap from the 6• week and this simply indi­ cates thatthe shelf-life of prepared liquid soap is just one month and thereafter freshly prepared soap is required. The water in the tank can also be made cleaner by the addition of a lump ofalum, whichwill coagulate the sus­ pended organic matter to which microbes may adhere. The flocculent precipitate that results will carry down most suspended materials and in this way most contami­ nants can be readily filtered out and such a simple proce­ dure will be adequate for control of transmission of mi­ crobes via the hands ",

Standard guidelines on infection control, as given by the Joint Commission for Accreditation of Hospitals (JCA!-1), on how to minimize risks of infection to patients

· "·'° can be readily achieved using this device. This handwashing device is advocated for use in hospitals, laboratories and even operating theatres in developing countries, when running water is not available.

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