In this present investigation, a questionnaire was utilized to collect information from a sample of HCWs in randomly selected emergency care setting of Italian hospitals regarding their knowledge, attitudes, and behaviors about HAIs.
Participants' knowledge concerning the various aspects of HAIs was generally high and consistent with current scientific evidence, since the vast majority were aware about some infections that a HCW can acquire from a patient and the standard precautions. In contrast, there are wide areas where the knowledge was lower, particularly regarding infections that a HCW can transmit to a patient. Based on this consideration, this specific population needs to learn more in order to reduce the rate of HAIs. Continuing medical benefits in the hospital environment require continuing educational input.
In this investigation, the working activity was found to be a significant determinant of the amount of knowledge about standard precautions and hands hygiene after removing gloves as control measures for HAIs, their perceived risk of acquiring a HAI, using gloves and performing hands hygiene measures. Nurses were more likely to have a higher level of knowledge, to have a higher perceived risk, and to use appropriate HAIs' control measures than physicians. It is possible that such differences may be attributed to the more active involvement in preventive activities regarding HAIs. Moreover, provision of information about HAIs influence knowledge and behaviors because HCWs were able to answer correctly and to appropriately use HAIs control measures if they have received information from educational courses and scientific journals. This shows that providing HCWs with appropriate information is enough to ensure understanding, especially in a particular risk group like the sample of this study.
Results from this nationwide survey indicate that most respondents often or always used gloves and performed hands hygiene measures after removing gloves for the prevention of the HAIs. No differences were observed in reported compliance with recommendations according to gender and age of the HCWs. Instead, two independent predictors of compliance were positively associated: fewer patients cared in a day and know that hands hygiene measures after removing gloves is a control measure. The finding that lower knowledge is linked to the underuse of appropriate control measures confirm the need to intensify educational programs. Moreover, the use of protective barriers was considerably lower than those observed in previous surveys. For instance, in a sample of emergency medicine residents in the United States, 96% and 99% used gloves at least 95% of the time for irrigation and incision and for drainage procedures, respectively [11
]. Physicians and nurses in pediatric EDs in Canada self-reported a high rate of handwashing before and after all patients with a mean score, out of 5 possible points, of 4.9 and 4.5, respectively, and for wearing gloves when examining patients of 3.3 and 3.2 [10
]. A national telephone survey among orthopedic surgeons in accident and EDs throughout England found that 99% routinely used gloves in a major trauma scenario, but only 18% and 21% used face mask and eye protection, respectively [12
]. Finally, our values were higher than those in EDs in the United Kingdom and New Zealand, with values of 27% and 58% and of 14% and 12%, respectively, for asepsis in invasive procedures and hands hygiene between patient consultations [9
Another key finding was that the attitudes towards HAIs are encouraging, since a high percentage of respondents reported positive global and specific beliefs. In particular, 94.5% indicated that guidelines should be established and followed. The multivariate analysis indicated that being nurses, knowing that HCWs' hands are vehicle for transmission of nosocomial pathogens, requiring and receiving information about HAIs were significantly independent predictors of a high perceived risk of acquiring a HAI.
There are some potential limitations in the design and measurements of this study that should be considered when interpreting the results. First, it provides as a cross-sectional study, only circumstantial evidence for the casual nature of the relationships that have been observed. No direct relationship between variables and outcomes can be proved but substantial evidence has been demonstrated for the association discussed. A second limitation is the potential reporting bias associated with the self-administered questionnaire. Concern always exists about accuracy in these surveys and it is difficult to determine with certainty whether the responses reflect what HCWs actually do. Specifically, compliance to control measures was based solely upon the subjective views of HCWs with the possibility that they tend to over-report compliance, notwithstanding that all interviews were anonymous. A more effective method of measuring compliance would be the direct observation of actual practice although the effect of being monitored may improve compliance by itself. A final limitation was that the response rate of 55% was disappointingly low, and one reason may be the time constraints faced by busy practitioners. We were not able to gather detailed information on non-respondents and, therefore, we were unable to assess whether there was a subgroup that systematically failed to respond. Although this response rate does not reflect internal validity of the findings, it may decrease the overall generalizability of the results to all HCWs in EDs. However, because HCWs tend to be relatively homogeneous with respect to attitudes and behaviors, the response rate may not have led to significant non-response bias.