Infection Control & Hospital Epidemiology
1001
Fig. 1. Anatomically based assessment scale. (A) Anatomic scale: palmar and dorsal sides. NOTE. 1, wrist; 2, thenar eminence; 3, intermediate zone; 4, hypothenar eminence; 5, interdigital space; for the thumb: P1: proximal phalanx; P2: distal phalanx; for other fingers: P1: proximal phalanx; P2: intermediate phalanx; P3: distal phalanx. (B) Frequency of handwashing for each side: palmar and dorsal sides. NOTE. Frequency of handwashing for each zone from 0 (0%=not cleaned) to 1 (100% cleaned zone); results for 30 participants.
consistency of the scale was analyzed using the Cronbach α coefficient. Interobserver reproducibility was analyzed using intraclass correlation coefficient (ICC), comparison of means, number of incorrect items between 2 independent observers, and linear regression analysis (R2). The paired Student t test was used to compare the mean of the scores obtained by the 2 observers. The F test was used to compare the variance of scores of the 2 observers. A comparison between the palmar and dorsal sides for right and left hands was analyzed using the paired Student t test. The efficacy of hand washing was determined for each zone between zero (not cleaned) to 1 (100% cleaned). An analysis of difference in the washing of each zone was conducted using the analysis of variance (ANOVA) test for all zones and each hand separately. The correlation of scores with professional status was analyzed using a linear regression analysis. A P value of <.05 was considered significant.
Results
The average observation scores were 49.7±10.17 for observer 1 and 49.10±10.23 for observer 2. The Cronbach α coefficient was 0.73 for the palmar side and 0.83 for the dorsal side. No differences were detected in mean score (P=.78) or variance (P=.94) between the observers. Our linear regression analysis resulted in an R2 of 0.91, and the ICC was 0.99 (Figure 2). The comparison between the 2 hands showed some differences. For the palmar sides, the scores were 17.5±2.0 for the right hand and 17.8±2.0 for the left hand (P=.001). For the dorsal sides, the scores were 11.6±3.2 for the right hand and 12.4±3.1 for the left hand (P<.0001). We also detected a difference in washing for different zones of the hands (F=13.2; P<.0001): F values were 5.5 for the palmar side of the right hand, 7.6 for the dorsal side of the right hand, 6.5 for the palmar side of the left hand, and 7.4 for the dorsal side of the left hand (P<.0001 for all of these). Among the washed zones, wrists, finger extremities, and interdigital spaces had the lowest scores (Figure 1b). Scores depended only on the performance, without correlation to professional status (F=0.0005; P=.94).
Fig. 2. Linear regression analysis with equation to analyze interobserver reproducibility between the 2 observers to assess hand hygiene using the anatomically based assessment scale.
Discussion
We designed an anatomically based assessment scale of the quality of handwashing with ABHR. This scale showed good internal consistency, and it was reproducible, with excellent interobserver reproducibility and a strong correlation between observers’ mean scores. The good internal consistency of the anatomical scale may allow adequate assessment of the recommended handwashing procedure. A valid instrument is crucial to the assessment of handwashing because fundamental problems with hand hygiene lead to the spread of nosocomial infections.1 The excellent inter- observer reproducibility of this assessment tool reflects the objec- tivity of the anatomical scale as well as its potential for further use by a single observer. This scale can be used to assess hand hygiene score regardless of the professional status of the participant. Recently, Lehotsky et al4 analyzed the correlation of ultraviolet (UV)-dyed ABHR-treated hand areas and the reduction of micro- biological contamination on the specific parts of the hand. They demonstrated that UV markers can highlight the areas of the hand surface that are adequately disinfected with acceptable accuracy
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