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Hand hygiene-related clinical trials reported since 2010: A systematic review
Abstract
Considerable emphasis is currently placed on reducing healthcare-associated infection through improving hand hygiene compliance among healthcare professionals. There is also increasing discussion in the lay media of perceived poor hand hygiene compliance among healthcare staff. Our aim was to report the outcomes of a systematic search for peer-reviewed, published studies – especially clinical trials – that focused on hand hygiene compliance among healthcare professionals. Literature published between December 2009, after publication of the World Health Organization (WHO) hand hygiene guidelines, and February 2014, which was indexed in PubMed and CINAHL on the topic of hand hygiene compliance, was searched. Following examination of relevance and methodology of the 57 publications initially retrieved, 16 clinical trials were finally included in the review. The majority of studies were conducted in the USA and Europe. The intensive care unit emerged as the predominant focus of studies followed by facilities for care of the elderly. The category of healthcare worker most often the focus of the research was the nurse, followed by the healthcare assistant and the doctor. The unit of analysis reported for hand hygiene compliance was ‘hand hygiene opportunity’; four studies adopted the ‘my five moments for hand hygiene’ framework, as set out in the WHO guidelines, whereas other papers focused on unique multimodal strategies of varying design. We concluded that adopting a multimodal approach to hand hygiene improvement intervention strategies, whether guided by the WHO framework or by another tested multimodal framework, results in moderate improvements in hand hygiene compliance.
Supplementary resource (1)
... In the studies by Makhni et al. and Wong et al., peaks of 100% were achieved during the pandemic, although these results were not sustained over time across all wards [7,9]. For comparison, a systematic review of HH-related clinical trials published in 2016 estimated a mean baseline compliance rate of 34.1% [15], and a nationwide study of German hospitals reported a median consumption of 35.9 mL/PD in 2015 [16]. The mean alcohol-based handrub usage among all hospitals in 2021 was 41.63 mL/PD, with an important increase compared to years 2017-2019. ...
... This strategy has been evaluated in other settings, as data on product usage are relatively simple to obtain and no additional staff or other resources are required [25]. Further, this metric is not subject to the Hawthorne effect [15,20]. ...
... Observation sessions provide a platform for HH education, and the My 5 Moments for HH approach provides an evidence-based conceptual framework for interventions [11]. Further, alcohol-based handrub usage estimates can be inaccurate, due to the removal or redistribution of product, or to its use by patients and visitors [15,17]. Finally, direct observation not only allows to measure HH adherence, but it also has an enhancing effect on compliance rates [23,24]. ...
Hand hygiene (HH) is among the most effective measures for reducing the transmission of healthcare-associated infections and SARS-CoV-2. We aimed to assess HH practices among healthcare workers (HCWs) of three hub hospitals in Northern Italy during the COVID-19 pandemic, by assessing HH compliance measured by direct observation and alcohol-based handrub usage. An observational study was conducted over a period of three months, between February and April 2021. HH compliance audits were conducted using the WHO My 5 Moments for HH approach. Multivariable logistic regression was used to evaluate independent predictors of HH compliance: ward type, HCW category and HH indication. Spearman correlation was used to investigate the relationship between HH compliance and alcohol-based handrub consumption. In total, 2880 HH opportunities were observed, with an overall compliance of 68%. Significant differences were found in compliance rates across ward types, HCW categories and HH indications. The mean alcohol-based handrub usage among included wards was 41.63 mL/PD. No correlation was identified between compliance rates and alcohol-based handrub consumption (ρ 0.023, p 0.943). This study provided a snapshot of HH practices in a pandemic context, which could be useful as a reference for future studies.
... In the context of the COVID-19 pandemic, the importance of HCW HH compliance has been brought into focus. This systematic review builds on our previous systematic review of this topic published in this journal [1], which focused on the period 2010-2015, and is designed to inform healthcare leaders and practitioners regarding effectiveness and character of HH promotion strategies internationally within the past six years, using evidence from published clinical trials with sound methodological design. ...
... Healthcare-associated infections (HCAIs) are defined as infections that arise following use of a healthcare service, and are associated with increased patient morbidity and mortality [1] [2]. In fact, HCAIs have been estimated to affect 7% of patients in developed countries and over 25% of patients in developing countries [3]. ...
... Along with these interventions, the WHO developed the "My five moments for HH" which encouraged HCWs to perform HH before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings [5]. In subsequent years, the USA, Canada, the UK and Ireland, amongst many other countries, have revised and updated national guidelines for HH based on these campaigns [1]. ...
Background
There is general consensus that hand hygiene is the most effective way to prevent healthcare associated infections. However, low rates of compliance amongst healthcare workers have been reported globally. The COVID-19 pandemic has further emphasized the need for global improvement in healthcare worker hand hygiene compliance.
Aim
This comprehensive systematic review provides an up-to-date compilation of clinical trials, reported between 2014 and 2020, assessing hand hygiene interventions in order to inform healthcare leaders and practitioners regarding approaches for reduction of healthcare-associated infections using hand hygiene.
Methods
We searched CINAHL, Cochrane, EMbase, Medline, Pubmed, and Web of Science databases for clinical trials published between March 2014 and December 2020 on the topic of hand hygiene compliance among healthcare professionals. From these searches, a total of 332 papers were identified of which 57 studies met criteria.
Findings
Forty-five of the 57 studies (79%) included were conducted in Asia, Europe and the USA. A large majority of these clinical trials were conducted in acute care facilities, including hospital wards and intensive care facilities. Nurses were the largest group of healthcare workers studied followed by physicians, represented in 44 (77%) and 41 (72%) studies, respectively. Thirty-six studies (63%) adopted the World Health Organisation multimodal framework or a variation of it, and many of these recorded hand hygiene opportunities at each of the five moments, although recording of hand hygiene technique was not common.
Conclusion
Both single intervention and multimodal hand hygiene strategies can achieve modestto moderate improvements in hand hygiene compliance among healthcare workers.
... Compliance with 'before moments' (i.e., Moment 1 and 2) typically seems to be lower than compliance with 'after moments' (i.e., Moment 3,4, and 5, see Figure 1). This pattern is evident in both large-scale data obtained via institutionalised in-house compliance observations within the German ASH framework [3,4] as well as research data (see [5][6][7] for systematic reviews and [8] for a 96-hours observation in three intensive care units, see also [9] for a comparison of routine in-house data and research data). Considering HHC rates for each moment separately provides not only detailed information for performance feedback but also enables a differentiated analyse of potential predictors, which might differ between the '5 moments'. ...
... The difference between 'before' and 'after moments' was less pronounced for more empathic HCWs or wards and larger for less empathic HCWs or wards, with lower 'before-moment' HCC (compared to 'after-moment' HHC). Previous findings consistently revealed that HHC with 'before moments' was lower than compliance with 'after moments' [5][6][7]. Our study is no exception to this pattern, but provides a theoretically sound explanation based on HCWs inter-personal orientation. ...
Background
Hand hygiene at critical time-points (as established by the WHO model ‘Five moments for hand hygiene’) remains the leading measure for minimising the risk of healthcare-associated infections. While many interventions have been tested to improve hand hygiene compliance (HHC) of healthcare workers (HCWs), little is known about the relation between HHC and HCW empathy. Aim: The aim of this study was to investigate the relation between moment-specific HHC rates and HCWs’ empathy, at both individual and ward levels. Methods: HHC data was collected via observation and self-report, staffs’ empathy levels were measured using an established questionnaire. The survey was conducted on 38 wards of three tertiary-care hospitals in Germany. Observation data was obtained via in-house observations which were conducted up to eight months before or after the survey. Findings: Evidence for the expected correlation between HCW empathy and moment-specific HHC was found for both observed HHC (Moment 1: r = .483, p = .031; Moment 2: r = 588, p = .006) and self-reported HHC (Moment 1: r = .093, p = .092; Moment 2: r = .145, p = .008). In analyses of variance the critical interaction effect between empathy (i.e., lower vs. higher empathy) and designated time-point of hand hygiene (i.e., before vs. after reference task) was also significant. Conclusion: HCWs’ empathy should be considered as an important factor in explaining differences between moment-specific HHC rates. In consequence, empathy comes into focus not only as a crucial factor for high-quality patient care, but as an important contributor to improving HHC, too.
... Although Hand Hygiene (HH) is the single most effective measure to prevent Healthcare-associated Infections (HAIs), making handwashing a habit among healthcare workers remains a huge challenge. [1][2][3] We investigated if a Sound Alert tool can improve HH compliance. ...
Background and Objectives: To investigate whether or not it is possible to use a Sound Alert as a tool to improve Hand Hygiene (HH) compliance. Material and methods: This is a pilot study from an Internal Medicine Unit with 16 beds at a Private Hospital in Belo Horizonte, Minas Gerais, Brazil. The Sound Alert is composed by a bell MP3 wireless with micro SD 128MB as its memory card. Handwash compliance was indirectly measured by two indicators: a) monthly volume of alcohol preparation for hands used (mL) for each patient-day; b) monthly volume of soap preparation for hands used (mL) for each patientday. Results: In the pilot study period, the monthly volume of alcohol preparation for hands increased to 26 mL per patient-day (r2 = 0.99; p
... 11 A systematic review of hand hygiene studies in both developed and developing countries reporting an overall baseline concordance of 34.1% before interventions, from 8 studies. 12 In our recent review of the literature, we found 9 studies reporting hand hygiene compliance rate in Sub Saharan Africa (SSA). 13 These studies including a total of 3,221 observed hand hygiene opportunities and 994 participants demonstrated a mean compliance rate of just 21.1% (range 9.2%-54%). ...
Background:
Health care associated infections (HCAIs) are a global challenge and hand hygiene is the primary measure to reduce these. In developing countries, patients are between 2 and 20 times more likely to acquire an HCAI compared with developed countries. Estimates of hand hygiene in Sub-Saharan Africa suggests 21% concordance. There are few studies investigating barriers and facilitators and those published tend to be surveys. This study aimed to understand barriers and facilitators to hand hygiene in a hospital in Nigeria.
Methods:
A theoretically underpinned in-depth qualitative interview study with thematic analysis of nurses and doctors working in surgical wards.
Results:
There were individual and institutional factors constituting barriers or facilitators: (1) knowledge, skills, and education, (2) perceived risks of infection to self and others, (3) memory, (4) the influence of others and (5) skin irritation. Institutional factors were (1) environment and resources and (2) workload and staffing levels.
Conclusions:
Our study presents barriers and facilitators not previously reported and offers nuances and detail to those already reported in the literature. Although the primary recommendation is adequate resources, however small local changes such as gentle soap, simple skills and reminder posters and mentorship or support could address many of the barriers listed.
... It encompasses five components: system change, involvement and availability of alcoholic preparation at assistance points and access to running water; staff education; evaluation of HH practices and feedback of indicators of staff compliance; reminders in the workplace; and promotion of an institutional safety climate, with the express support of managers and leaders. (8) The priority for patient safety regarding HH in the hospital environment is essential (9,10) especially in Intensive Care Units. The Neonatal Intensive Care Unit (NICU), as it is a place of care for severe newborns or at risk of death, and therefore, high demand for care, requires professional attention regarding the act of HH. ...
... 48,49 This reinforces the need to employ multiple strategies within a workplace to maximise behaviour change and acceptance. [50][51][52] Engaging Nurse Champions to drive the change, with strong executive leadership and support, will help drive the initiative and improve infection control practice. 1,23 This HH pilot trial highlighted that the core business of providing veterinary care supersedes other activities, such as continuing education. ...
ABSTRACT Hand hygiene is one of the most important infection prevention and control
strategies to reduce pathogen transfer in healthcare settings. While there are dedicated
evidence-based hand hygiene interventions and protocols to support human healthcare
providers, there are no comparable resources to support veterinary care. A pilot trial for the implementation of a hand hygiene education and compliance program was conducted in six heterogenous small animal veterinary practices. Hand hygiene compliance was evaluated using a standardised and validated program, based on the World Health Organization’s 5 Moments for Hand Hygiene program. Veterinary Nurse Champions undertook dedicated hand hygiene training and were supported by the first author throughout the pilot trial. Hand hygiene compliance was low (14%) pre-trial, improved to 46% after the six-week trial period and remained at 35% six months after conclusion of the trial. Compliance for all five Moments improved compared to the pre-trial period in the immediate post-trial period. Of the five Moments, there was a statistically significant increase in compliance with Moments 3 (after a procedure/body fluid risk), 4 (after touching a patient) and 5 (after touching a patient’s surroundings) in the immediate post-trial period, however, by 6 months post-trial, only Moment 5 showed a significant improvement. Barriers to improvement included poor availability of hand hygiene products, lack of time due to clinical workload requirements, lack of awareness, and an
ingrained workplace culture.
... For Sur Hospital, ABHR had significant reduction on CRAb incidence when its use exceeded certain thresholds. The value of ABHR on reducing healthcare-acquired infections has been demonstrated in several studies [32][33][34]. ...
Abstract: Solutions are needed to inform antimicrobial stewardship (AMS) regarding balancingthe access to effective antimicrobials with the need to control antimicrobial resistance. Theoreticaland mathematical models suggest a non-linear relationship between antibiotic use and resistance,indicating the existence of thresholds of antibiotic use beyond which resistance would be triggered.It is anticipated that thresholds may vary across populations depending on host, environment, andorganism factors. Further research is needed to evaluate thresholds in antibiotic use for a specificpathogen across different settings. The objective of this study is to identify thresholds of populationantibiotic use associated with the incidence of carbapenem-resistant Acinetobacter baumannii (CRAb)across six hospital sites in Oman. The study was an ecological, multi-centre evaluation that involvedcollecting historical antibiotic use and CRAb incidence over the period from January 2015 to December2019. By using non-linear time-series analysis, we identified different thresholds in the use of third-generation cephalosporins, piperacillin-tazobactam, aminoglycoside, and fluoroquinolones acrossparticipating hospitals. The identification of different thresholds emphasises the need for tailoredanalysis based on modelling data from each hospital. The determined thresholds can be used toset targets for each hospital AMS, providing a balance between access to these antibiotics versuscontrolling CRAb incidence.
... En relación a esto, proponemos el uso de la gamificación (técnica de aprendizaje que traslada la mecánica de los juegos al ámbito educativo-profesional con el fin de conseguir mejores resultados para absorber conocimientos, mejorar alguna habilidad para recompensar acciones concretas…), como una opción innovadora para mejorar el conocimiento sobre la importancia, necesidad y forma correcta de realizar la higiene de manos que puede suponer un nuevo horizonte de posibilidades para abordar el aprendizaje en ciencias de la salud, (Kingston, O'Connell y Dunne, 2016) aumentando la motivación de los jugadores y la retención del aprendizaje (Murad, 2017). Todo esto demuestra que, con las metodologías docentes actuales, no es suficiente para la interiorización del hábito de la higiene de manos y justifica así la necesidad de la continuidad de este proyecto y la necesidad en la implantación de la herramienta de gamificación diseñada para la mejora de los resultados expuestos. ...
The following work presents a research experience, which was torn with a teaching group
from the Social Studies and Civic Education Teaching.It was executed at the National
University of Costa Rica, as an initiative since the aforementioned career accreditation.
This teaching staff worked with the digital knowledge of their discipline, which allowed
them to learn about different proposals for the use of technology and to reflect
theoretically on the meaning of incorporating them in the educational context.This
proposal was developed in a workshop format, where a series of tools were used, with the
objective that the participants develop their own mediation activities in their different
educational contexts, basing on innovative approaches from active learning.
... In spite of its importance, observational studies show that hand hygiene compliance among healthcare workers are mostly below 50% (3). The compliance rates are low and it is considered a universal problem (4,5). Furthermore, medical students have a lack of information problem that may cause non-compliance (6). ...
Aim: We aimed to find out if there is statistically significant difference in self-reported hand hygiene compliance among Year-5 medical students, Year-6 medical students, and residents in Gazi University Faculty of Medicine between right before and after the first confirmed case of COVID-19 in Turkiye. Materials and Methods: Two cross-sectional surveys were carried out to reveal self-reported hand hygiene compliance among participants right before and after the first confirmed case of COVID-19 in Turkiye. Participants were Year-5 and Year-6 medical students and residents in Gazi University Faculty of Medicine. Convenience sampling was used. There were 833 participants in total. The survey form consists of 10 items that were constituted by examining World Health Organization guidelines on hand hygiene. The compliance scores before and after the first confirmed case were compared by performing T-Test. Results: Out of 10 items, there was significant difference in Year-5 medical students’, Year-6 medical students’ and residents’ self-reported hand hygiene compliance scores between before and after the first confirmed case of COVID-19 in 6 items, 10 items, and 8 items, respectively (p
... For Sur Hospital, ABHR had significant reduction on CRAb incidence when its use exceeded certain thresholds. The value of ABHR on reducing healthcare-acquired infections has been demonstrated in several studies [32][33][34]. ...
... For Sur Hospital, ABHR had significant reduction on CRAb incidence when its use exceeded certain thresholds. The value of ABHR on reducing healthcare-acquired infections has been demonstrated in several studies [32][33][34]. ...
Solutions are needed to inform antimicrobial stewardship (AMS) regarding balancing the access to effective antimicrobials with the need to control antimicrobial resistance. Theoretical and mathematical models suggest a non-linear relationship between antibiotic use and resistance, indicating the existence of thresholds of antibiotic use beyond which resistance would be triggered. It is anticipated that thresholds may vary across populations depending on host, environment, and organism factors. Further research is needed to evaluate thresholds in antibiotic use for a specific pathogen across different settings. The objective of this study is to identify thresholds of population antibiotic use associated with the incidence of carbapenem-resistant Acinetobacter baumannii (CRAb) across six hospital sites in Oman. The study was an ecological, multi-centre evaluation that involved collecting historical antibiotic use and CRAb incidence over the period from January 2015 to December 2019. By using non-linear time-series analysis, we identified different thresholds in the use of third- generation cephalosporins, piperacillin-tazobactam, aminoglycoside, and fluoroquinolones across participating hospitals. The identification of different thresholds emphasises the need for tailored analysis based on modelling data from each hospital. The determined thresholds can be used to set targets for each hospital AMS, providing a balance between access to these antibiotics versus controlling CRAb incidence.
... For Sur Hospital, ABHR had significant reduction on CRAb incidence when its use exceeded certain thresholds. The value of ABHR on reducing healthcare-acquired infections has been demonstrated in several studies [32][33][34]. ...
Solutions are needed to inform antimicrobial stewardship (AMS) regarding balancing the access to effective antimicrobials with the need to control antimicrobial resistance. Theoretical and mathematical models suggest a non-linear relationship between antibiotic use and resistance, indicating the existence of thresholds of antibiotic use beyond which resistance would be triggered. It is anticipated that thresholds may vary across populations depending on host, environment, and organism factors. Further research is needed to evaluate thresholds in antibiotic use for a specific pathogen across different settings. The objective of this study is to identify thresholds of population antibiotic use associated with the incidence of carbapenem-resistant Acinetobacter baumannii (CRAb) across six hospital sites in Oman. The study was an ecological, multi-centre evaluation that involved collecting historical antibiotic use and CRAb incidence over the period from January 2015 to December 2019. By using non-linear time-series analysis, we identified different thresholds in the use of third-generation cephalosporins, piperacillin-tazobactam, aminoglycoside, and fluoroquinolones across participating hospitals. The identification of different thresholds emphasises the need for tailored analysis based on modelling data from each hospital. The determined thresholds can be used to set targets for each hospital AMS, providing a balance between access to these antibiotics versus controlling CRAb incidence.
... Specifically, Wetzker et al (2016) provided data from German hospitals indicating that HHC before patient contact is lower (70%) compared to HHC after patient contact (82,5%). These findings are mirrored in a systemic review of published studies by Kingston et al (2016) which also indicates that HHC is lower before patient contact (21%) compared to HHC after patient contact (47%). These findings are noteworthy given that patients are more vulnerable regarding infections, as they can be weakened by their medical condition (immune status, wounds) and/or the treatment they receive. ...
Aim
The “Five moments of hand hygiene” (World Health Organization 2009) can be classified into moments of hand hygiene before and after patient care. Based on research indicating that hand hygiene compliance differs with regard to moments before and after patient care, this research evaluates the effectiveness of an empathy-based intervention in motivating hand hygiene compliance with regard to moments before patient care which protect vulnerable individuals from contamination and infection.
Subjects and method
An online experiment involving 68 healthcare professionals working at a German hospital during the first wave of the COVID-19 pandemic investigates whether instructing healthcare professionals to consider consequences for others (vs for themselves) if they contracted SARS-CoV-2 promotes hand hygiene compliance referring to moments before (vs after) patient care.
Results
In the condition in which healthcare professionals considered consequences for others if they contracted SARS-CoV-2 (other-focus condition), ratings of importance increased ( M = 3.49, SD = 1.30) compared to the condition in which healthcare professionals considered consequences for themselves ( M = 2.68, SD = 1.24), F (1,66) = 6.87, p = .011, part η ² = .09. Participants in the other-focus condition reported more intentions to comply with “before moments” in the future ( M = 3.34, SD = 1.14) compared to participants in the self-focus condition ( M = 2.77, SD = 0.80), F (1,66) = 6.15, p = .016, part η ² = .09.
Conclusion
Results indicate that activating an empathic focus in the context of the current pandemic promotes perceived importance and motivation of healthcare professionals to comply with moments aiming at protecting vulnerable others.
... It refers to the phenomenon that people have specific intentions for how they would like to act, but-often without understanding the reasons themselves-fail to act on these intentions. For example, nurses in hospitals know the importance of handwashing, yet often wash their hands less frequently than advised (3)(4)(5). Another important domain in the healthcare context is the positioning of severely affected immobile patients: Nurses, therapists, or caregivers often do not apply the positioning methods they learned frequently enough, or optimally, to prevent complications and enhance patient wellbeing (6)(7)(8)(9). Determining why this is the case is crucial to derive recommendations on how to improve this situation. ...
Background
After learning new skills, healthcare professionals do not always apply them in practice, despite being motivated. This may be referred to as an intention-behavior gap. One example is the positioning of immobilized and disabled patients in hospitals, nursing homes, or neurorehabilitation clinics. Positioning is crucial to prevent complications such as pressure sores, pneumonia, and deep vein thrombosis. However, it is often not carried out optimally even when professionals have completed education programs. The LiN-method is a positioning procedure involving a special focus on aligning and stabilizing body parts, which has been shown to have advantages over conventional positioning. We assess which factors may facilitate or hinder the use of LiN in clinical practice after participants complete training.
Methods
A longitudinal survey with 101 LiN-course participants was conducted in Germany. Each participant completed a questionnaire directly after the course and 12 weeks later, including a report of the frequency of use in practice. They also completed a questionnaire which surveyed 23 aspects that might facilitate or hinder use of the new skills, covering the workplace, socio-collegial factors, motivation, self-confidence, and mindset.
Results
Most assessed aspects were associated with LiN-use, with the highest correlations found for confidence with the method, perceived ease of application, sufficient time, assessing one's skills as sufficient, remembering the relevant steps, and a work environment open to advanced therapeutic concepts. To reduce data complexity, the questionnaire was subjected to a factor analysis, revealing six factors. A regression analysis showed that four factors predicted use 12 weeks after course completion, in the following order of importance: (1) subjective aspects/confidence, (2) access to materials, (3) work context, and (4) competent support in the workplace.
Conclusion
Numerous aspects are associated with the use of recently acquired clinical or nursing skills, such as LiN. Many of these can be improved by appropriately setting up the workplace. The aspects most associated with use, however, are confidence with the method and self-perceived competence of healthcare professionals. While causality still needs to be demonstrated, this suggests that education programs should support participants in developing confidence and foster a mindset that allows for making mistakes. While causality still needs to be demonstrated, this suggests that education programs should support participants in developing confidence and foster a mindset of continuous learning.
... 17,19,20 In addition, studies have shown that compliance with hand hygiene among healthcare providers improved moderately after hand hygiene interventions. 6,7,21 Analysis of the study variables revealed that adequate level of knowledge with regards to hand hygiene and good perception of the risk of acquiring HCAIs were the predictors of compliance with hand hygiene among the study participants. ...
Background: Despite the well-recognized role of hand hygiene in the prevention of healthcare associated infections, the rate of compliance with hand hygiene among healthcare providers remains poor in Nigeria. Objective: To assess the predictors of compliance with hand hygiene among healthcare providers in south-south Nigeria. Methods: A cross-sectional study design with prospective covert observation of compliance with hand hygiene was employed to assess the hand hygiene compliance among 565 healthcare providers. Data was collected using a self-administered semi-structured questionnaire and an observation checklist. Descriptive and inferential analyses of data collected were carried out using the IBM SPSS version 22 software. Results: The covertly observed and self-reported compliance rates were 18.6% and 16.9% respectively. The rates of compliance with hand hygiene observed for 'after blood and body fluids exposure' (50.7 %) and 'before aseptic procedures' (30.7%) were relatively higher than compliance rates observed for the other moments for hand hygiene. Adequate knowledge of hand hygiene (AOR = 2.70; 95% CI: 1.60-4.58), in-service training on IPC (AOR = 2.31; 95% CI: 1.45-3.67) and good perception of the risk of acquiring HCAIs (AOR = 1.69; 95% CI: 1.04-2.77) were predictors of compliance with hand hygiene. Conclusion: The study brings to the fore the low rates of covertly observed and self-reported compliance with hand hygiene among the study participants. There is need for the management of the selected health facilities to stimulate and motivate healthcare providers to improve their compliance with hand hygiene.
... In healthcare settings, the hands of healthcare workers play a critical role in the spread of HAI, including multidrug resistant infections. Numerous studies have shown that improved hand hygiene among healthcare workers can reduce the spread of these infections [4,9]. Hence, many hospitals in LMICs are implementing hand hygiene programs [4]. ...
Healthcare-associated infections (HAIs) result in millions of avoidable deaths or prolonged lengths of stay in hospitals and cause huge economic loss to health systems and communities. Primarily, HAIs spread through the hands of healthcare workers, so improving hand hygiene can reduce their spread. We evaluated hand hygiene practices and promotion across 13 public health hospitals (six secondary and seven tertiary hospitals) in the Western Area of Sierra Leone in a cross-sectional study using the WHO hand hygiene self-Assessment framework in May 2021. The mean score for all hospitals was 273 ± 46, indicating an intermediate level of hand hygiene. Nine hospitals achieved an intermediate level and four a basic level. More secondary hospitals 5 (83%) were at the intermediate level, compared to tertiary hospitals 4 (57%). Tertiary hospitals were poorly rated in the reminders in workplace and institutional safety climate domains but excelled in training and education. Lack of budgets to support hand hygiene implementation is a priority gap underlying this poor performance. These gaps hinder hand hygiene practice and promotion, contributing to the continued spread of HAIs. Enhancing the distribution of hand hygiene resources and encouraging an embedded culture of hand hygiene practice in hospitals will reduce HAIs.
... These campaigns are mainly based on improving hand hygiene practices in health care settings through the implementation of the WHO multimodal hand hygiene strategy [6]. Over the last two decades, an increasing body of evidence has accumulated to suggest that improved hand hygiene can reduce healthcare-associated infections [3,7]. ...
Hand hygiene actions are essential to reduce healthcare-associated infections and the development of antimicrobial resistance. In this cross-sectional study at two tertiary hospitals, Freetown, Sierra Leone, we observed hand hygiene compliance (defined as using handwash with soap and water or alcohol-based hand rub (ABHR) amongst healthcare workers between June and August 2021. Using the WHO Hand Hygiene tool, observations were made in relation to the type of opportunity, different wards and types of healthcare worker. Overall, 10,461 opportunities for hand hygiene were observed, of which 5086 (49%) resulted in hand hygiene actions. ABHR was used more often than handwash (26% versus 23%, p < 0.001). Overall, compliance was significantly better: after being with a patient/doing a procedure than before (78% after body fluid exposure risk compared with 24% before touching a patient—p < 0.001); in Paediatric (61%) compared with Medical wards (46%)—p < 0.001; and amongst nurses (52%) compared with doctors (44%)—p < 0.001. Similar patterns of compliance were observed within each hospital. In summary, hand hygiene compliance was sub-optimal, especially before being with a patient or before clean/aseptic procedures. Improvement is needed through locally adapted training, hand hygiene reminders in wards and outpatient departments, uninterrupted provision of ABHR and innovative ways to change behaviour.
... For instance, our recent review of studies from SSA countries that reported on compliance found an overall compliance rate of 21.1% (Ataiyero et al., 2019). A large systematic review of studies from developed countries also reported less than 40% hand hygiene compliance rate (Erasmus et al., 2010) while a more recent systematic review which included 16 studies from both developed and developing countries also estimated an overall mean baseline compliance of 34.1% before interventions (Kingston et al., 2016). Despite the infrastructural deficit and their poor positioning in SSA countries, compared to developed countries where hand hygiene facilities are abundant, hand hygiene compliance rates of HCWs in both developed and developing countries are comparable. ...
Background
Patients sometimes contract healthcare associated infections (HCAI) which are unrelated to their primary reasons for hospital admission. Surgical site infections are the most investigated and most recurrent type of HCAI in developing countries, affecting up to one-third of surgical patients.
Objective
This study aimed to assess and offer context to the hand hygiene resources available in a Nigerian teaching hospital through ward infrastructure survey, and to determine the hand hygiene compliance rate among surgical healthcare workers (HCWs) in a Nigerian teaching hospital through hand hygiene observations.
Methods
Ward infrastructure survey was conducted in the two adult surgical wards of the hospital using the World Health Organisation (WHO) hand hygiene ward infrastructure survey form. Hand hygiene observations were monitored over seven days in the surgical wards using a modified WHO hand hygiene observation form.
Results
Hand hygiene resources were insufficient, below the WHO recommended minimum standards. Seven hundred hand hygiene opportunities were captured. Using SPSS version 24.0, we conducted a descriptive analysis of audit results, and results were presented according to professional group, seniority and hand hygiene opportunities of the participants. Overall hand hygiene compliance was 29.1% and compliance was less than 40% across the three professional groups of doctors, nurses and healthcare assistants.
Conclusion
Hand hygiene compliance rates of the surgical HCWs are comparable to those in other Sub-Saharan African countries as well as in developed countries.
... Appropriate hand hygiene during patient care is an important action for preventing and controlling infections (2). However, international compliance of hand hygiene among health care providers around the world is unacceptably low (5,6). HCAIs lead to high mortality and cost in almost all countries especially in developing countries such as our country, Iran (7). ...
Background:
Proper hand hygiene is the most important action in preventing healthcare-associated infections (HCAIs). In this study, the knowledge and perception of hand hygiene assessed among nurses as the most exposed personnel to patients.
Methods:
In this analytical cross-sectional study, the nurses working in different wards of a collegiate tertiary hospital in Tehran were investigated by standardized WHO questionnaires.
Results:
Of the 101 participating nurses 89 (88.1%) were females. 81 (80.2%) had received formal related training. The 69 respondents estimated the mean prevalence of HCAI to be 38.91% and 98 (97.1%) considered hand hygiene an effective prevention in this regard. 78 (77.3%) perceived hand hygiene as the center priority; 82, 83 and 79 of participants would think that good hand hygiene matters for their superiors, colleagues and patients, respectively. The practice of hand hygiene was stated to be difficult by 48 (47.5%) respondents. There was no significant difference in self-reporting of hand hygiene practice among nurses in age (P=0.68), the degree of education (P=0.574), work experience (P=0.64), nor their wards (P=0.131). There was a significant reverse relationship with the supposed difficulty level of doing hand hygiene (P=0.049). The mean score of the nurses' knowledge was 66.53 (±9.41) based on the answers to the questions of the knowledge questionnaire.
Conclusion:
Knowledge and perception of hand hygiene, as this study showed, might not to be satisfactory; therefore, planning to improve these indicators and regular monitoring using standard tools is necessary for all healthcare centers.
... It should be noted that the total number of school children may fluctuate slightly during the school year.3 Without sanitary facilities for children with disabilities.4 Percentage of toilets seats in relation to the total number of school children.5 Consisting of one sanitary facility for girls, one sanitary facility for boys and three sanitary facilities used by both genders. ...
Hand hygiene is a cornerstone of infection prevention. However, few data are available for school children on their knowledge of infectious diseases and their prevention. The aim of the study was to develop and apply a standardized questionnaire for children when visiting primary schools to survey their knowledge about infectious diseases, pathogen transmission and prevention measures. Enrolling thirteen German primary schools, 493 questionnaires for grade three primary school children were included for further analyses, comprising 257 (52.1%) girls and 236 (47.9%) boys with an age range of 8–11 years. Out of 489 children, 91.2% participants indicated that they knew about human-to-human transmissible diseases. Of these, 445 children responded in detail, most frequently mentioning respiratory and gastrointestinal diseases, followed by childhood diseases. Addressing putative hygiene awareness-influencing factors, it was worrisome that more than 40.0% of the children avoided visiting the sanitary facilities at school. Most of the children (82.9%) noted that they did not like to use the sanitary facilities at school because of their uncleanliness and the poor hygienic behavior of their classmates. In conclusion, basic infection awareness exists already in primary school age children. Ideas about the origin and prevention of infections are retrievable, however, this knowledge is not always accurate and adequately contextualized. Since the condition of sanitary facilities has a strong influence on usage behavior, the child’s perspective should be given more consideration in the design and maintenance of sanitary facilities.
... When we reviewed the literature, we found that there were many kinds of interventions to improve HHC. 46 However, it is precisely that the observation and monitoring of HHC itself cannot achieve relative consistency and is affected by whether the monitors are professionally trained, the personal observation bias of the monitors. [47][48][49] The state of the World's HAND HYGIENE documented that there is also growing interesting in electronic monitoring, focused on the point of care, as reliable systems are developed. ...
Background
Hand hygiene (HH) is a cost-effective measure to reduce healthcare-associated infections. The overall characteristics and changes of hand hygiene compliance (HHC) among healthcare providers during the COVID-19 pandemic provided evidence for targeted HH intervention measures.
Aim
To systematically review the literature and conduct a meta-analysis of studies investigating the rate of HHC and the characteristics of HH during the COVID-19 pandemic.
Methods
The PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang Data, VIP and CBM databases were searched. All the original articles with valid HHC data among healthcare providers during the COVID-19 pandemic (from January 1, 2020 to October 1, 2021) were included. Meta-analysis was performed using a DerSimonian and Laird model to yield a point estimate and a 95% CI for the HHC rate. The heterogeneity of the studies was evaluated using the Cochrane Q test and I² statistics and a random-effects model was used to contrast between different occupations, the WHO five-moments of HH and different observation methods. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were followed.
Findings
Seven studies with 2377 healthcare providers reporting HHC were identified. The estimated overall HHC was 74%, which was higher than that reported in previous studies (5%-89%). Fever clinic has become a new key place for HHC observation. Nurses had the highest HHC (80%; 95% CI:74%–87%) while auxiliary workers (70%; 95%CI:62%–77%) had the lowest. For the WHO five-moments, the healthcare providers had the highest HHC after contact with the body fluids of the patients (91%; 95% CI:88%–94%), while before contact with patients healthcare providers had the lowest HHC (68%; 95% CI:62%–74%) which was consistent with before the pandemic. There existed great HHC differences among different monitoring methods (automatic monitoring system:53%; 95% CI:44%–63% vs openly and secretly observation: 91%; 95% CI: 90%–91%).
Conclusions
During the COVID-19 pandemic, the compliance of healthcare providers’ HH showed a great improvement. The fever clinics have become the focused departments for HH monitoring. The HHC of auxiliary workers and the HH opportunity for “before contact with patients” should be strengthened. In the future, it will be necessary to develop standardized HH monitoring tools for practical work.
... La higiene de manos (HM), es decir, cualquier medida adoptada para la limpieza de las manos mediante fricción con un preparado de base alcohólica (PBA) o lavado con agua y jabón disminuye la transmisión cruzada de microorganismos a través de las manos de los profesionales sanitarios (1,2,3) y ayuda a controlar las resistencias a los antibióticos (4) . Se considera, además, la medida más eficaz, económica y sencilla en la prevención de las infecciones relacionadas con la asistencia sanitaria (IRAS) (5) . ...
Objetivo. El objetivo de este trabajo es evaluar la implementación de la aplicación de una estrategia multimodal para impulsar la promoción de la Higiene de Manos (HM).
Métodos. Se utilizó la «Guía de aplicación de la estrategia multimodal de la Organización Mundial de la Salud para la mejora de la higiene de manos». La estrategia se planteó como un estudio de intervención para promover la HM en el Complejo Hospitalario Universitario Insular Materno Infantil en el período 2012-2020.
Resultados. El cumplimiento global de las indicaciones de HM al final del periodo de estudio fue del 59,2%. El consumo de productos de base alcohólica aumentó con respecto a los años anteriores (p
... There are various microbes that colonize the hand skin. These include the Resident flora which cannot be merely eliminated through simple hand washing and the Transient microbes which are highly associated with most hospital infections and can be eliminated via hand washing (Kingston, O'Connell, & Dunne, 2016) Poor hand washing amongst health workers in the developing nations are due to inadequate access to and poor use of WASH services or facilities in the health facility (UNICEF & UNICEF, 2016).During hospitalization, patients are exposed to microbes which are responsible for HCAI causation depending on the agent's virulence, environment and host factors (WHO, 2012).In the year 2009 the World Health Organization launched recommendations on hand hygiene in health care and the First Global Patient Safety Challenge, "Clean Care is Safer Care," program has dedicated its attention promoting uptake of hand hygiene practice in the health system through implementation of viable interventions (Abdella, 2014). ...
Hand hygiene is a simple act of hand cleansing and the most effective measure of decreasing healthcare-associated infections among the health care workers. The infections not only lengthen the hospitalization period but also increase financial burden to individual, family and a country at large for example in Europe approximately €13-24 billion is spent annually. Hand hygiene compliance has remained unacceptably as low as 40% worldwide with the developing countries reporting a lower percentage. The broad objective of this study was to determine the level of compliance with hand hygiene standards amongst the health care providers in selected public hospitals in Uasin Gishu County. The study used the cross-sectional study design. The lower level health facilities were selected randomly while higher level health facilities were selected purposively. Sample size determination was done using Fisher's (1999) formula and Cochran's correction formula was used due to the population of health workers being below 10,000. A total of 301 sample size was arrived at and additional ten percent of the 301 sample size was included to accommodate for attrition hence having a total sample size of 331 respondents. The Simple random sampling technique was used to identify the 331 health care providers taking into consideration the use of probability proportionate to sample size technique in obtaining the number of health care providers from each health facility. The Data collection instruments included a self-administered questionnaire and observational checklist. Quantitative Data analysis was carried out by utilizing the Statistical Package for Social Sciences (SPSS) software version 20. The findings revealed a compliance rate of 49.8%. Pearson's test of correlation revealed that the main determinants of compliance with hand hygiene standards were professional cadre (r=014; P=0.015), training (r=0.371; P=<0.01) level of education (r= 0.168; P=0.004), availability of clean running water (r=0.271; P=<0.01) and hand washing soap (r=0.168; P=0.003). The study recommends that the policy makers and health stakeholders need to come up with a policy that ensures that the health care workers adhere to hand hygiene standards and ensure adequate provision of hand hygiene facilities so as to enhance compliance with hand hygiene standards.
... Hand hygiene is also one of the main strategies for the prevention of health care related infections. 14 Regarding the correct position of the patient to receive NUT, a study that implemented an initiative for the prevention of pneumonia corroborates our findings by indicating that an essential care in the prevention of pneumonia is the maintenance of the head position between 30º and 45º. Oral hygiene, however, was not something recurrently mentioned in the present study, but it was also mentioned in the aforementioned study. ...
Objetivo: analisar a percepção dos técnicos de enfermagem sobre o cuidado em terapia nutricional enteral, durante um cenário de simulação clínica. Método: estudo qualitativo, com base em um cenário de simulação clínica, realizado com 64 técnicos de enfermagem, em um hospital universitário do Sul do Brasil, em agosto de 2017. As falas foram audiogravadas, transcritas e, posteriormente, submetidas a análise de conteúdo. Resultados: foram evidenciadas quatro categorias sobre o cuidado em terapia nutricional enteral nas etapas de: administração da TNE; manutenção da sonda nasoenteral; registros de enfermagem e orientações ao paciente em uso de TNE. Conclusão: refletir sobre o cuidado prestado, por meio de um cenário de simulação clínica, pode colaborar com melhorias acerca do processo de trabalho da equipe de enfermagem e com o fortalecimento e segurança dos cuidados prestados.
... (1) In the hospital setting the importance of HH is well recognised but poorly implemented as evidenced by a systematic review that demonstrated mean HH compliance rates of 34%, only increasing by 23% following intervention. (2) The reasons for this are multifaceted, ranging from potentially unrealistic compliance goals to the necessity of a behavioural change that is required to produce a sustained improvement. ...
... While there are numerous single studies (e.g. [6], [7,8]) and a number of meta-analyses [9,10] on the issue of hygiene, these mostly focus on interventions for improving hand hygiene. A massive international campaign for the prevention of infection, the "My Five Moments of Hand Hygiene"-program [11], also puts the emphasis on hand hygiene. ...
Background
With the onset of the COVID-19 pandemic at the beginning of 2020, the crucial role of hygiene in healthcare settings has once again become very clear. For diagnostic and for didactic purposes, standardized and reliable tests suitable to assess the competencies involved in “working hygienically” are required. However, existing tests usually use self-report questionnaires, which are suboptimal for this purpose. In the present study, we introduce the newly developed, competence-oriented HygiKo test instrument focusing health-care professionals’ hygiene competence and report empirical evidence regarding its psychometric properties.
Methods
HygiKo is a Situational Judgement Test (SJT) to assess hygiene competence. The HygiKo-test consists of twenty pictures (items), each item presents only one unambiguous hygiene lapse. For each item, test respondents are asked (1) whether they recognize a problem in the picture with respect to hygiene guidelines and, (2) if yes, to describe the problem in a short verbal response. Our sample comprised n = 149 health care professionals (79.1 % female; age: M = 26.7 years, SD = 7.3 years) working as clinicians or nurses. The written responses were rated by two independent raters with high agreement (α > 0.80), indicating high reliability of the measurement. We used Item Response Theory (IRT) for further data analysis.
Results
We report IRT analyses that show that the HygiKo-test is suitable to assess hygiene competence and that it allows to distinguish between persons demonstrating different levels of ability for seventeen of the twenty items), especially for the range of low to medium person abilities. Hence, the HygiKo-SJT is suitable to get a reliable and competence-oriented measure for hygiene-competence.
Conclusions
In its present form, the HygiKo-test can be used to assess the hygiene competence of medical students, medical doctors, nurses and trainee nurses in cross-sectional measurements. In order to broaden the difficulty spectrum of the current test, additional test items with higher difficulty should be developed. The Situational Judgement Test designed to assess hygiene competence can be helpful in testing and teaching the ability of working hygienically. Further research for validity is needed.
... Studies assessing hand hygiene compliance have shown baseline compliance rates of 34% on average, rising to 57% after interventions such as training, performance feedback and compliance monitoring. [5] There are many reasons for poor compliance, but the harsh reality is that the simplest (and cheapest) intervention was not implemented effectively in nearly half of the studies reported. Other recommended interventions include contact precautions, patient isolation or cohorting, environmental cleaning and taking surveillance cultures from patients and environment. ...
... One of the factors might be the relatively short period of time compared to other studies that lasted between 16 weeks and 16 months. 10,20,21,[30][31][32][33] Another factor could be duration or design of education sessions or the use of a single strategy. A Cochrane review evaluating methods to improve hand hygiene concludes that introducing ABHR, accompanied by education is not enough, multiple strategies are needed. ...
Background:
Healthcare associated infections is a global burden and is one of the main causes of maternal and neonatal morbidity and mortality during the time of labour when admitted to the hospital. Healthcare workers' hands are in most cases the vehicle for transmission of microorganisms from patient to patient. Good hand hygiene practices at the bedside are a simple way of reducing healthcare associated infections. The objective was to assess the impact of a criterion-based audit on infection prevention performance and knowledge during vaginal delivery at a hospital in Tanzania. The quantitative findings were discussed with staff to identify barriers and solutions to quality improvement.
Methods:
A mixed-method uncontrolled, before and after intervention study by criterion-based audit was performed at the labour ward at Kilimanjaro Christian Medical Centre. Criteria for best practice were established together with key staff based on national and international guidelines. Sixty clean procedures during vaginal birth were observed and assessed by a structured checklist based on the audit criteria. Baseline findings were discussed with staff and an intervention performed including a short training and preparation of alcohol-based hand rub. Hereafter another 60 clean procedures were observed, and performance compared to the care before the intervention. Furthermore, a knowledge test was performed before and after the intervention.
Results:
Hand washing increased significantly after a procedure from 46.7% to 80% (RR=1.71 95% CI; 1.27 to 2.31), the use of alcohol-based hand rub before a procedure from 1.7% to 33.3% p<.001), and the use of alcohol-based hand rub after procedure from 0% to 30% p<.00l). After the intervention the mean score for the knowledge test increased insignificantly from 59.3% to 65.3%, (mean difference = 6.1%, 95% CI; -4.69 to 16.88).
Conclusion:
The criterion-based audit process identified substandard care for infection prevention at the labour ward. An intervention of discussing baseline findings and a short training session and introducing alcohol-based hand rub resulted in improvements on infection prevention performance.
... Multifaceted approach (e.g. education, training, observation, feedback, easy access to hand hygiene supplies, dedication of financial resources, praises by superior, strong hospital leadership, prioritization to IPC needs, collaborating with a private advertising firm in a marketing campaign and active participation at institutional level) is highly suggested to reduce HAIs by improving compliance among HCWs with IPC measures [93,94]. ...
Background
Knowledge of infection prevention and control (IPC) procedures among healthcare workers (HCWs) is crucial for effective IPC. Compliance with IPC measures has critical implications for HCWs safety, patient protection and the care environment.
Aims
To discuss the body of available literature regarding HCWs' knowledge of IPC and highlight potential factors that may influence compliance to IPC precautions.
Design
A systematic review. A protocol was developed based on the Preferred Reporting Items for Systematic reviews and Meta-Analysis [PRISMA] statement.
Data sources
Electronic databases (PubMed, CINAHL, Embase, Proquest, Wiley online library, Medline, and Nature) were searched from 1 January 2006 to 31 January 2021 in the English language using the following keywords alone or in combination: knowledge, awareness, healthcare workers, infection, compliance, comply, control, prevention, factors . 3417 papers were identified and 30 papers were included in the review.
Results
Overall, the level of HCW knowledge of IPC appears to be adequate, good, and/or high concerning standard precautions, hand hygiene, and care pertaining to urinary catheters. Acceptable levels of knowledge were also detected in regards to IPC measures for specific diseases including TB, MRSA, MERS-CoV, COVID-19 and Ebola. However, gaps were identified in several HCWs' knowledge concerning occupational vaccinations, the modes of transmission of infectious diseases, and the risk of infection from needle stick and sharps injuries. Several factors for noncompliance surrounding IPC guidelines are discussed, as are recommendations for improving adherence to those guidelines.
Conclusion
Embracing a multifaceted approach towards improving IPC-intervention strategies is highly suggested. The goal being to improve compliance among HCWs with IPC measures is necessary.
... Whereas hand hygiene is widely considered the most effective method to prevent healthcare-associated infections, hand hygiene compliance among HCP remains poor. 15 Accordingly, many strategies have been proposed to enhance hand hygiene compliance. 16 We hypothesize that analogous approaches are needed to optimize facemask compliance, particularly given the potential for complacency among HCP and the duration of the COVID-19 pandemic. ...
Objective
Prior studies of universal masking have not measured facemask compliance. We performed a quality improvement study to monitor and improve facemask compliance among healthcare personnel (HCP) during the coronavirus disease 2019 (COVID-19) pandemic.
Design
Mixed-methods study
Setting
Tertiary care center in West Haven, Connecticut
Patients
HCP including physicians, nurses, and ancillary staff
Methods
Facemask compliance was measured through direct observations during a 4-week baseline period after universal masking was mandated. Frontline and management HCP completed semi-structured interviews from which a multimodal intervention was developed. Direct observations were repeated during a 14-week period following implementation of the multimodal intervention. Differences between units were evaluated with chi-squared testing using the Bonferroni correction. Facemask compliance between baseline and intervention periods was compared using time series regression.
Results
Among 1,561 observations during the baseline period, median weekly facemask compliance was 82.2% (range, 80.8%-84.4%). Semi-structured interviews were performed with 16 HCP. Qualitative analysis informed the development of a multimodal intervention consisting of audit and passive feedback, active discussion, and increased communication from leadership. Among 2,651 observations during the intervention period, median weekly facemask compliance was 92.6% (range, 84.6%-97.9%). There was no difference in weekly facemask compliance between COVID-19 and non-COVID-19 units. The multimodal intervention was associated with an increase in facemask compliance (β=0.023, p=0.002)
Conclusions
Facemask compliance remained suboptimal among HCP despite a facility-wide mandate for universal masking. A multimodal intervention consisting of audit and passive feedback, active discussion, and increased communication from leadership was effective in increasing facemask compliance among HCP.
Background:
Anaesthesia induction is a fast-paced, complex activity that involves a high density of hand-to-surface exposures. Hand hygiene (HH) adherence has been reported to be low, which bears the potential for unnoticed pathogen transmission between consecutive patients. Therefore, we aimed to study the fit of the WHO's five moments of HH concept to the anaesthesia induction workflow.
Methods:
We analysed video recordings of 59 anaesthesia inductions according to the WHO HH observation method considering each hand-to-surface exposure of every involved anaesthesia provider. Binary logistic regression was used to determine risk factors for non-adherence, i.e., professional category, gender, task role, gloves, holding of objects, team size and HH moment. Additionally, we re-coded half of the videos for self-touching behaviour for quantitative and qualitative analysis.
Results:
Overall, 2240 HH opportunities were met by 105 HH actions (4.7%). The drug administrator role (OR=2.2), the senior physician status (OR=2.1), donning (OR=2.6) and doffing (OR=3.6) of gloves were associated with higher HH adherence. Notably, 47.2% of all HH opportunities were caused by self-touching behaviour. Provider clothes, face, and patient skin were the most frequently touched surfaces.
Conclusions:
The high density of hand-to-surface exposures, a high cognitive load, prolonged glove use, carried mobile objects, self-touching, and personal behaviour patterns were potential causes for non-adherence. A purpose-designed HH concept based on these results, involving the introduction of designated objects and provider clothes to the patient zone, could mitigate HH adherence and microbiologic safety.
Objective:
The purpose of this study is to determine whether use of the video camera surveillance system for hand hygiene (HH) monitoring, video-based education and feedback can improve the HH compliance in a neonatal intensive care unit (NICU).
Methods:
This is an interventional before-after trial conducted in a level-III NICU between July 2019-June 2020. The HH compliance was measured using the randomly selected video-camera footages in the baseline, intervention, and maintenance periods. After the baseline, an intervention consisting of feedback, and education with video scenarios was implemented. The primary outcome was the HH compliance change. The compliance rates were tested as an interrupted time series (ITS) with a segmented regression model adjusted for autocorrelation for each study periods.
Results:
We identified a total of 8335 HH indications. There was an increase in the total compliance rate of 9.0% (95% CI(-2%-20%)) at the time of intervention with increase in rate after intervention of 0.26% (95% CI(-0.31%-0.84%)) per day. The hand hygiene compliance before-patient contact significantly increase 19.8% (95% CI(4.8%-34.8%). Incorrect gloves use improved insignificantly with the intervention -3.4% (95% CI(-13.4%-6.7%)).
Conclusion:
In this study HH monitoring using video-camera footage combined with an intervention includes feedback, and education improved HH compliance. However, these improvements were not sustained in the long term. Frequent feedback and education may be required to sustain high compliance.
Background
Direct observation of hand hygiene compliance is the “gold standard” despite limitations and potential for bias. Previous literature highlights poorer hand hygiene compliance amongst physicians than nurses and suggests that covert monitoring may give better compliance estimates than overt monitoring.
Aim
This review aimed to explore differences in compliance between physicians and nurses further, and to analyse if compliance estimates differed when observations were covert rather than overt.
Methods
A systematic search of databases PubMed, EMBASE, CENTRAL and CINAHL was performed. Experimental or observational studies in hospital settings in high-income countries published in English from 2010 onwards were included if estimates for both physicians and nurses using direct observation were reported. The search yielded 4814 studies, of which 105 were included.
Findings
The weighted pooled compliance rate for nurses was 52% (95% CI 47% to 57%) and for doctors was 45% (95% CI 40% to 49%). Heterogeneity was considerable (I²=99%). The majority of studies were at moderate or high risk of bias. Random-effects meta-analysis of low risk of bias studies suggests higher compliance for nurses than physicians for both overt (difference of 7%, 95% CI for the difference 0.8% to 13.5%, p=0.027) and covert (difference of 7%, 95% CI 3% to 11%, p=0.0002) observation. Considerable heterogeneity was found in all analyses.
Conclusion
Wide variability in compliance estimates and differences in the methodological quality of hand hygiene studies were identified. Further research with meta-regression should explore sources of heterogeneity and improve the conduct and reporting of hand hygiene studies.
Hand hygiene (HH) compliance among health-care workers has not satisfactorily improved despite multiple educative approaches. Between October 2019 and February 2020, we performed a self-evaluation test and a direct observation for the compliance of the 5 Moments for Hand Hygiene program advocated by the World Health Organization at two Japanese hospitals. Average percentages of self-evaluated HH compliance were as follows: (i) 76.9% for “Before touching a patient,” (ii) 85.8% for “Before clean/aseptic procedures,” (iii) 95.9% for “After body fluid exposure/risk,” (iv) 84.0% for “After touching a patient,” and (v) 69.2% for “After touching patient surroundings.” On the other hand, actual HH compliance was 11.7% for “Before touching a patient” and 18.0% for “After touching a patient or patient surroundings.” The present study demonstrated a big gap between self-evaluation and actual HH compliance among nurses working at hospitals, indicating the need of further providing the education in infection prevention.
Objective:
The aim of the study was to report the results of a multimodal strategy for improvement of hand hygiene (HH) compliance in a third-level hospital in Mexico.
Methods:
This is an epidemiological study in a public, acute care, academic, tertiary referral center from 2009 to 2019. Healthcare worker (HCW) compliance with HH was assessed after implementation of the World Health Organization multimodal strategy that included permanent and widespread access to alcohol-based hand rubs; educational activities for staff, students, patients, and relatives; reminders in healthcare areas; patient empowerment; water quality surveillance; frequent evaluation of compliance; and feedback. The primary outcome was HH compliance rate (measured by direct observation). The association of HH with healthcare-associated infections was the secondary outcome.
Results:
A total of 60,685 HH opportunities were evaluated. The HH compliance rate increased significantly from 39.83% (95% confidence interval [CI] = 38.83%-40.84%) to 64.81% (95% CI = 64.08%-65.54%), mostly due to HH compliance in World Health Organization moments 3 to 5 (r = 0.86, P = 0.001). A statistically significant inverse association was found between HH compliance rates and surgical site infection rates (incidence rate ratio = 0.9977, 95% CI = 0.9957-0.9997, P = 0.029).
Conclusions:
A multimodal strategy in a Latin American setting showed an increase in HH compliance over 10 years of follow-up that should nonetheless be improved. An association between HH compliance and surgical site infection rates was noticed, but this did not occur with other healthcare-associated infections; this underscores the need for a comprehensive bundled approach in their prevention.
Introduction: Health care-associated infections (HCAIs) poses a real and serious threat to both the patients and health care workers. A significant number of patients acquired health care associated infections worldwide, and this has devastating effect on both the patient and the health system. It is estimated that more than 1.4 million people worldwide are suffering from infections acquired in hospitals. Even though infection prevention plays a key role in preventing and reducing the rate of healthcare associated infection, little is known about current staffing and structure of infection prevention and control programs. Objective: To assess Infection prevention practice and associated factors among healthcare providers in Bishoftu Referral Hospital south east Ethiopia from Dec 4, 2019 to Dec 20, 2019 G.C. Methodology: Institution based cross-sectional study was conducted to assess practice towards infection prevention and associated factors in Bishoftu Referral Hospital. The data was collected using structured self-administered questionnaire and supported by an observational check list. Infection prevention practice was calculated using 22 items and median was used a cutoff point to generate a binary practice outcome. The data was entered into EPI info 7 and then exported to SPSS version 20 for data management and analysis. Bivariate and Multivariable logistic regression analysis was carried to assess significance of determinants. Results: One hundred fifty eight (158) health care professionals were included in the study. This study showed that 60.4% of Health Care Providers had safe infection prevention Practice (95% CI (51.9%, 68.2%). Among the determinant factors, working in emergency ward [AOR=4.327, 95% CI (0.412, 45.464)], knowing the presence of infection prevention committee [AOR=7.629, 95% CI (1.580, 36.831)] and being a midwife [AOR=16.39, 95% CI (1.074, 250.171)] were significantly associated with safe infection prevention practice. Conclusion and Recommendation: The findings of this study show that around 40% of healthcare professional didn't adhere to safe infection prevention. Working wards, infection prevention committee and profession were factors significantly associated with infection prevention practice. The hospital should give emphasis for all working wards to increase adherence to infection prevention practice.
Background
Scientific evidence suggest that hand hygiene as one of the most effective measures to control infection. To promote good hand hygiene practices, the WHO introduced May 5 as World Hand Hygiene Day (WHHD), and international stakeholders established Global Handwashing Day (GHD) on October 15. However, its contributions to raising public awareness of hand hygiene is unclear.
Methods
This study evaluates the impact of the WHHD and GHD on the public awareness of hand hygiene in Japan, the United Kingdom, the United States, and worldwide from 2016 to 2020, using the relative search volume (RSV) of “Hand hygiene” in Google Trends as a surrogate. To identify a statistically significant timepoint of a trend change, we performed Joinpoint regression analysis.
Results
Upticks of the RSVs as well as joinpoints were noted worldwide around the WHHD and GHD from 2016 to 2019, but no joinpoints were identified around the WHHD and GHD in 2020. No such changes were observed in Japan, the United Kingdom, and the United States during these periods.
Conclusions
While the WHHD was originally established to raise awareness of hand hygiene in healthcare facilities, our result suggests that the WHHD and GHD may not have effectively disseminated the importance of hand hygiene to the general public at a country level. Additional policy measures to advocate hand hygiene to the public are necessary to communicate its benefits.
Resumen
Introducción
Un conocimiento adecuado sobre la higiene de manos (HM) por parte de los profesionales sanitarios es el primer paso para la adherencia a cualquier programa de disminución de infección relacionada con la asistencia sanitaria. El objetivo del estudio fue identificar el nivel de conocimientos y percepciones sobre higiene de manos de los profesionales en un hospital de tercer nivel en Gran Canaria.
Material y método
Estudio transversal y analítico a través de un cuestionario auto administrado a un colectivo de 170 sanitarios. Se calculó la asociación entre las características de los profesionales y el conocimiento y percepción sobre la HM mediante una regresión logística.
Resultados
La mayoría recibió formación en HM 120 (70,6%) y prefería utilizar productos de base alcohólica 105 (62%). Consideraron las manos como principal vía de transmisión cruzada de microorganismos 133 (78,2%). Creían que la fuente más frecuente de gérmenes causantes de infecciones relacionadas con la asistencia sanitaria (IRAS) eran las superficies hospitalarias 116 (68,2%). Respecto a las barreras para no realizar HM, la más mencionada fue el daño que produce en las manos 72 (42,1%). La medida considerada más efectiva para aumentar el cumplimiento de HM fue la presencia de instrucciones claras y visibles en todas las áreas de trabajo 133 (78%).
Conclusión
A pesar de tener formación previa sobre HM, los conocimientos de los profesionales son deficientes. La formación previa seguido del tiempo trabajado son los determinantes más importantes de los conocimientos y percepciones sobre HM.
Background:
Healthcare worker's (HCW) hands are known to be a primary source of transmission of hospital-acquired infections (HAIs). Thus, practicing hand hygiene (HH) and adhering to HH guidelines are both expected to decrease the risk of transmission but there is no consensus on the optimal hand hygiene compliance (HHC) rate that HCWs should aim for.
Aim:
The objective of this study was to systematically review the published literature to determine an optimal threshold of HCW HHC rate associated with the lowest incidence rate of HAIs.
Methods:
This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. We searched online databases using a comprehensive search criterion for randomized controlled trials and non-randomized controlled studies, investigating the impact of HCW's HHC rate on HAI rates in patients of all ages, within healthcare facilities in high income countries.
Findings:
Of the 8,093 articles citations and abstracts screened, 35 articles were included in the review. Most studies reported overall HAIs per 1000 patient-days and device-associated HAIs per 1000 device-days. Most studies reported HHC rates between 60%-70%. Lower incidence HAI rates seemed to be achieved with HHC rates of approximately 60%. Studies included were not originally designed to assess the impact of HHC on HAI rates but risk of bias was assessed as per our predetermined exposure and outcome criterion. 11 (31%) of studies were deemed at low risk of bias.
Conclusions:
Although HHC is part of HCW's code of conduct, very high HHC rates were difficult to reach. In observational studies, HHC and HAI followed a negative relationship up to about 60%. Due to flaws in study design, causality could not be inferred; only general trends could be discussed. Given the limitations, there is a need for high-quality evidence to support the implementation of specified targets of HHC rates.
Structured Summary
Background
In the current era, the importance of proper hand hygiene to reduce the transmission of infectious diseases has become difficult to debate. Yet, compliance rates remain low and are affected by many factors amongst which user acceptability of hand hygiene products.
Aim
The present study aimed at investigating drivers of preference towards different hand hygiene formulations.
Methods
Three different formulations (liquid, foam and gel) of the same brand were randomly and blindly evaluated by 54 participants based on the WHO Protocol for Evaluation of Tolerability and Acceptability of Alcohol-based Handrubs.
Results
The majority (76%) of respondents indicated that the product formulation impacts their level of compliance with hand hygiene protocols. The preferred formulation was liquid, with 50% of participants ranking it as first choice. General product satisfaction, the products texture, the drying speed and the ease of application, were the statistically significant drivers for participants to rank a formulation as their first choice versus not ranking it as their first choice.
Conclusions
When designing alcohol formulations and implementing hand hygiene protocols, understanding drivers of preference for formulations may enhance product user acceptability and therefore compliance with hand hygiene.
Hand hygiene by health care personnel is an important measure for preventing health care-associated infections, but adherence rates and technique remain suboptimal. Alcohol-based hand rubs are the preferred method of hand hygiene in most clinical scenarios, are more effective and better tolerated than handwashing, and their use has facilitated improved adherence rates. Obtaining accurate estimates of hand hygiene adherence rates using direct observations of personnel is challenging. Combining automated hand hygiene monitoring systems with direct observations is a promising strategy, and is likely to yield the best estimates of adherence. Greater attention to hand hygiene technique is needed.
Global challenges such as the COVID-19 pandemic or the impending climate change require each and every one of us to perform long-term self-restrictive behaviours, implying personal costs, for the sake of vulnerable others and future generations. We argue that empathy – conceptualised as other-oriented moral emotional process – can impact how we think, feel and act towards others in times of such disruptive global developments. Our research highlights how and under which circumstances empathy fosters solidarity with others in need. We review our findings which corroborate empathy’s potential in directly changing health-relevant behaviour (such as hand hygiene behaviour or adherence to COVID-19 pre-emptive measures) and as well as pro-environmental actions, which serve to protect others’ well-being through self-discipline and self-restriction. Furthermore, we also review and discuss research which indicates potential boundary conditions of empathy-induced prosocial responses to the plight of vulnerable individuals.
Background: Infection control is important in in-hospital nurseries. There is a concern that healthcare workers who are parents may become carriers and transmit infectious diseases to infants and patients.
Study objective: The purpose of this study was to evaluate the effectiveness of a hygienic intervention to prevent infectious diseases from spreading among infants and nursery teachers at an in-hospital nursery.
Methodology: A hygienic intervention consisting of education on hand hygiene, cough etiquette, and environmental cleaning was implemented for infants and nursery teachers at the in-hospital nursery. Hand hygiene adherence of infants and nursery teachers, before and after the intervention, were compared using the χ² test. The relative risk of contracting an infectious disease and the percentage of infection-related absence among infants, before and after the intervention, were also assessed.
Results: Consent was obtained for 29 infants (100% consent rate) and from 22 nursery teachers (92% consent rate). The hand hygiene adherence of the infants significantly improved from 78.2%, before the intervention, to 97.4%, after the intervention (p<0.001). Hand hygiene adherence of the nursery teachers also significantly improved from 37.6%, before the intervention, to 78.2%, after the intervention (p<0.001). On the other hand, the incidence of infectious diseases among the infants was 11.47/1,000 person-days, before the intervention, and 11.31/1,000 person-days, after the intervention, and the relative risk with its 95% confidence interval was 0.99 (0.53-1.83). The percentage of absenteeism due to infection was 2.17% before, and 2.75% after the intervention, and the relative risk with its 95% confidence interval was 1.26 (0.24-6.68).
Conclusions: The hygienic interventions implemented in this study did not change the incidence of infectious diseases and absenteeism among the infants, but improved hand hygiene adherence among infants and nursery teachers in an in-hospital nursery.
Background
Hand hygiene is paramount in preventing the spread of healthcare-associated infections especially during disease epidemics. Compliance rates with hand hygiene policies remain below 50% internationally and may be lower in the outpatient care setting. This study assessed the impact of the patient empowerment model on hand hygiene compliance among healthcare providers.
Methods
From October 2016 to May 2017, patients from a large ambulatory oncology centre were prospectively enrolled. Patients were instructed to observe healthcare providers for hand hygiene compliance and to remind healthcare providers where it was not observed during at least three consecutive encounters. Healthcare provider reactions to this intervention were rated by patients. Patients’ hand hygiene knowledge and beliefs were objectively elicited pre and post-study.
Results
Thirty patients with a median age of 52 years (range 5–91) completed the study for a total of 190 healthcare provider encounters. When initial hand hygiene was not observed, patients offered a reminder in 71 (37.4%) encounters, did not offer a reminder in 73 (38.4%) encounters and forgot to offer a reminder in 24 (14.2%) encounters. Patients perceived positive or neutral reactions in 76.8% of encounters and negative or surprised reactions in 23.2% of encounters. Healthcare provider compliance improved from 11.6% to 48.9% with intervention. Patient hand hygiene knowledge improved by 16% following the study.
Conclusions
Patient-empowered hand hygiene may be a useful adjunct for improving hand hygiene compliance among healthcare providers and improving patient hand hygiene knowledge, although it may confer an emotional burden on patients.
An effective sanitation plan, as part of the entire wellness plan for all animals in a shelter, is essential to guard against such disasters and must be tailored to each shelter's situation. All sanitation protocols must emphasize the importance of reducing the spread of pathogens and ensuring the safety of all staff while also minimizing stress and harm to the animals during the process. Consideration of animal housing design and use is an essential component of an effective sanitation plan. Cleaning and disinfecting agents chosen for usage in a shelter must be effective, safe to use around animals and humans, and practical given each organization's financial resources, ability to provide and monitor staff training and performance, and facility design. Chemical disinfection is the most researched and used form of disinfection in shelters. Cleaning environmental surfaces is only part of the sanitation plan.
Introducción:
La adherencia a la higiene de manos (HM) por parte del personal de salud es de 38% a nivel mundial. Con la estrategia multimodal de la OMS se incluyeron los preparados de base alcohólica como un componente para la mejora de la HM. La campaña “los 5 momentos de la HM” incentiva a utilizar este producto que, entre otros beneficios, su aplicación ocupa menor tiempo en comparación con el lavado de manos.
Objetivo:
Conocer cuáles son los factores facilitadores o las barreras que favorecen o dificultan el uso de preparados de base alcohólica por el personal de salud para aumentar la adherencia a la HM según la estrategia multimodal de la OMS.
Métodos:
Fueron utilizadas dos bases de datos PubMed y CINHAL (años 2009 - 2019). Los artículos fueron seleccionados según criterios de inclusión - exclusión.
Resultados:
De 30 artículos se seleccionaron 12, los que tenían como tema central la adherencia a la HM, personal de salud y preparados de base alcohólica. Se organizaron en facilitadores y barreras: infraestructura, presentación del producto y capacitación del personal.
Discusión:
Los facilitadores y barreras que más impacto reportan en aumentar la adherencia a la HM son la infraestructura, acceso, disponibilidad en el punto de atención, presentación del producto y capacitación al personal de salud sobre los productos de base alcohólica para la desinfección de las manos, con el fin de disminuir las IAAS y brindar una atención segura.
In low- and middle-income countries (LMICs), hand sanitizer may be a convenient alternative to soap and water to increase hand hygiene practices. We explored perceptions, acceptability, and use of hand sanitizer in rural Bangladesh. We enrolled 120 households from three rural villages. Promoters distributed free alcohol-based hand sanitizer, installed handwashing stations (bucket with tap, stand, basin, and bottle for soapy water), and conducted household visits and community meetings. During Phase 1, promoters recommended handwashing with soap or soapy water, or hand sanitizer after defecation, after cleaning a child's anus/feces, and before food preparation. In Phase 2, they recommended separate key times for hand sanitizer: before touching a child ≤ 6 months and after returning home. Three to 4 months after each intervention phase, we conducted a survey, in-depth interviews, and group discussions with child caregivers and male household members. After Phase 1, 82/89 (92%) households reported handwashing with soap after defecation versus 38 (43%) reported hand sanitizer use. Participants thought soap and water removed dirt from their hands, whereas hand sanitizer killed germs. In Phase 2, 76/87 (87%) reported using hand sanitizer after returning home and 71/87 (82%) before touching a child ≤ 6 months. Qualitative study participants reported that Phase 2-recommended times for hand sanitizer use were acceptable, but handwashing with soap was preferred over hand sanitizer when there was uncertainty over choosing between the two. Hand sanitizer use was liked by household members and has potential for use in LMICs, including during the coronavirus pandemic.
Background
Most bloodstream infections related to vascular catheters can be avoided if evidence-based practices are applied during insertion and maintenance. In practice, adherence by healthcare workers (HCW) is unsatisfactory and is the main current challenge. The objective of this study is to investigate associations between adherence to infection control practices and performance in psychological tests. Methods: We conducted a prospective observational study in 4 intensive care units involving health care workers. Physicians were observed for adherence to hand hygiene (HH). Nurses were observed during central venous catheter (CVC) dressing and handling. HCW were then evaluated psychologically.
Results
There were 7,572 observations of 248 HCW. Adherence to different steps of CVC manipulation ranged widely: from 13% for HH before procedure to 95% regarding the use of gloves. Adherence to HH ranged from 14% before to 99% after dressing. For physicians, HH ranged from 10% before touching patients to 98% after touching body fluids, and adherence was associated with age, self-esteem, and aggression. For nurses, adherence was positively associated with deference, and negatively associated with nurturance.
Conclusions
Psychosocial variables affect the quality of care that HCW provide. The next step would be to define what type of psychological interventions could be effective.
This is the second edition of an edited book on Researching Health.
Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
A standardised methodology for a combined point prevalence survey (PPS) on healthcare-associated infections (HAIs) and antimicrobial use in European acute care hospitals developed by the European Centre for Disease Prevention and Control was piloted across Europe. Variables were collected at national, hospital and patient level in 66 hospitals from 23 countries. A patient-based and a unit-based protocol were available. Feasibility was assessed via national and hospital questionnaires. Of 19,888 surveyed patients, 7.1% had an HAI and 34.6% were receiving at least one antimicrobial agent. Prevalence results were highest in intensive care units, with 28.1% patients with HAI, and 61.4% patients with antimicrobial use. Pneumonia and other lower respiratory tract infections (2.0% of patients; 95% confidence interval (CI): 1.8–2.2%) represented the most common type (25.7%) of HAI. Surgical prophylaxis was the indication for 17.3% of used antimicrobials and exceeded one day in 60.7% of cases. Risk factors in the patient-based protocol were provided for 98% or more of the included patients and all were independently associated with both presence of HAI and receiving an antimicrobial agent. The patient-based protocol required more work than the unit-based protocol, but allowed collecting detailed data and analysis of risk factors for HAI and antimicro-bial use.
Objective To conduct a qualitative process evaluation within a cluster-randomised trial of an educational resource intervention to promote hand washing in primary schools and thus reduce absenteeism by reducing the transmission of respiratory and gastrointestinal infections.
Design Focus groups with pupils including drawings of hand washing facilities, semi-structured interviews with teachers, direct observation of intervention delivery and hand washing facilities.
Setting State primary schools within six local authority areas in the South West of England (n=178) were randomised to receive the “Hands up for Max!” intervention in October 2009 (intervention schools) or in Autumn 2010 after all trial follow-up data are collected (control schools). Four intervention and four control schools were selected for the process evaluation from the 24 schools participating in a substudy to collect enhanced absenteeism data.
Participants Pupils in years 2 to 6 (n=95), and key stage 1 (n=8) and key stage 2 (n=8) teachers.
Main Outcome Measures The process evaluation examined how the “Hands up for Max!” educational resource was delivered in intervention schools and explored responses to the intervention among pupils and staff. Ideas, attitudes, knowledge and behaviours relating to hand hygiene and hand washing facilities were explored, and hand washing facilities were observed in both intervention and control schools.
Results The “Hands up for Max!” resource was well received by the intervention schools, although some teachers made useful suggestions for improvements. Schools differed in the way they delivered the intervention and the number of elements of the resource package they used. Pupils in intervention schools recalled learning about the importance of hand washing in reducing the spread of infections and were able to describe, in detail, how to wash their hands properly. In the focus groups, pupils provided insight into reasons why they may not wash their hands, and what might help people wash their hands properly. Use of drawings in the focus groups facilitated discussion about what pupils liked and did not like about the facilities where they washed their hands. Results of the process evaluation were also used to inform development of questionnaires to obtain quantitative data from pupils and staff in all 178 schools participating in the trial.
Conclusion Information from the process evaluation will be useful in understanding any observed differences in quantitative outcomes related to absenteeism and knowledge, attitudes and behaviours related to hand washing, between intervention and control schools.
Although hand hygiene (HH) is key to reducing health care-associated infections, it is well documented that health care worker (HCW) adherence to appropriate HH protocols is relatively low.
This was a collaborative quality improvement project with multiple interventions conducted in a 570-bed academic hospital in Columbia, MO between April 2006 and September 2012. A multimodal action plan to improve HH adherence among all HCWs was developed, addressing 4 key areas: staff education, staff accountability, hand sanitizer product selection and accessibility, and organizational culture. HH adherence and central line-associated bloodstream infection (CLABSI) rates were monitored as outcome measures.
The overall HH adherence rate increased from 58% in April 2006 to 98% in September 2012. The adherence rates increased among all hospital units and among all HCW categories; in September 2012, HH adherence was 96% for physicians, 99% for nursing staff, and 99% for food services staff. CLABSI rates decreased over the same period, from 4.08 per 1000 device-days to 0.42 per 1000 device-days.
This multifactorial quality improvement project resulted in an institution-wide increase in HH adherence and a significant decrease in CLABSIs.
Copyright © 2014 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
Importance
Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria.Objective
To assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care.Design, Setting, and Participants
Cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from January 4, 2012, to October 4, 2012.Interventions
In the intervention ICUs, all health care workers were required to wear gloves and gowns for all patient contact and when entering any patient room.Main Outcomes and Measures
The primary outcome was acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU. Secondary outcomes included individual VRE acquisition, MRSA acquisition, frequency of health care worker visits, hand hygiene compliance, health care–associated infections, and adverse events.Results
From the 26 180 patients included, 92 241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95% CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95% CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95% CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95% CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, −1.71 acquisitions per 1000 person-days, 95% CI, −6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference, 0.89 acquisitions per 1000 person-days; 95% CI, −4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, −2.98 acquisitions per 1000 person-days; 95% CI, −5.58 to −0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, −0.96; 95% CI, −1.71 to −0.21, P = .02), increased room-exit hand hygiene compliance (78.3% vs 62.9%, difference, 15.4%; 95% CI, 8.99% to 21.8%; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, −15.7; 95% CI, −40.7 to 9.2, P = .24).Conclusions and Relevance
The use of gloves and gowns for all patient contact compared with usual care among patients in medical and surgical ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE. Although there was a lower risk of MRSA acquisition alone and no difference in adverse events, these secondary outcomes require replication before reaching definitive conclusions.Trial Registration
clinicaltrials.gov Identifier: NCT0131821
Objective. To assess the feasibility and effectiveness of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach in 19 limited-resource countries and to analyze predictors of poor hand hygiene compliance.
Design. An observational, prospective, cohort, interventional, before-and-after study from April 1999 through December 2011. The study was divided into 2 periods: a 3-month baseline period and a 7-year follow-up period.
Setting. Ninety-nine intensive care unit (ICU) members of the INICC in Argentina, Brazil, China, Colombia, Costa Rica, Cuba, El Salvador, Greece, India, Lebanon, Lithuania, Macedonia, Mexico, Pakistan, Panama, Peru, Philippines, Poland, and Turkey.
Participants. Healthcare workers at 99 ICU members of the INICC.
Methods. A multidimensional hand hygiene approach was used, including (1) administrative support, (2) supplies availability, (3) education and training, (4) reminders in the workplace, (5) process surveillance, and (6) performance feedback. Observations were made for hand hygiene compliance in each ICU, during randomly selected 30-minute periods.
Results. A total of 149,727 opportunities for hand hygiene were observed. Overall hand hygiene compliance increased from 48.3% to 71.4% (). Univariate analysis indicated that several variables were significantly associated with poor hand hygiene compliance, including males versus females (63% vs 70%; ), physicians versus nurses (62% vs 72%; ), and adult versus neonatal ICUs (67% vs 81%; ), among others.
Conclusions. Adherence to hand hygiene increased by 48% with the INICC approach. Specific programs directed to improve hand hygiene for variables found to be predictors of poor hand hygiene compliance should be implemented.
Introduction:
Nosocomial infections have long been neglected in Sub-Saharan Africa, and hand hygiene (HH) is usually neglected in hospital settings. This study aimed to provide baseline data on HH compliance among health workers and HH resources in a large West African teaching hospital.
Methodology:
A cross-sectional, unobtrusive observational study assessed personal and care-related HH compliance among doctors and nurses and HH resources in 15 service provision centres of the Korle-Bu Teaching Hospital (KBTH), Ghana, in 2011. Data was collected with an infection prevention checklist and health worker HH compliance form, based on World Health Organization guidelines.
Results:
Care-related HH compliance of doctors and nurses was low and basic HH resources were deficient in all 15 service centres. Care-related HH compliance among doctors ranged from 9.2% to 57% and 9.6% to 54% among nurses. HH compliance was higher when risk was perceived to be higher (i.e., in the emergency and wound dressing/treatment rooms and labour wards). The neonatal intensive care unit (NICU) showed the highest level of compliance among health workers. Facilities for HH, particularly alcohol hand rub and liquid soap dispensers were shown to be deficient.
Conclusions:
Care-related HH compliance among doctors and nurses in this large West African hospital is low; however, the NICU, which had implemented HH interventions, had better HH compliance. HH intervention programs should be designed and promoted in all service centres. Also, the introduction of alcohol-based hand rubs as an accessible and effective HH alternative in Korle-Bu Teaching Hospital is recommended.
There is only limited understanding of why hand hygiene improvement strategies are successful or fail. It is therefore important to look inside the ‘black box’ of such strategies, to ascertain which components of a strategy work well or less well. This study examined which components of two hand hygiene improvement strategies were associated with increased nurses’ hand hygiene compliance.
A process evaluation of a cluster randomised controlled trial was conducted in which part of the nursing wards of three hospitals in the Netherlands received a state-of-the-art strategy, including education, reminders, feedback, and optimising materials and facilities; another part received a team and leaders-directed strategy that included all elements of the state-of-the-art strategy, supplemented with activities aimed at the social and enhancing leadership. This process evaluation used four sets of measures: effects on nurses’ hand hygiene compliance, adherence to the improvement strategies, contextual factors, and nurses’ experiences with strategy components. Analyses of variance and multiple regression analyses were used to explore changes in nurses’ hand hygiene compliance and thereby better understand trial effects.
Both strategies were performed with good adherence to protocol. Two contextual factors were associated with changes in hand hygiene compliance: a hospital effect in long term (p < 0.05), and high hand hygiene baseline scores were associated with smaller effects (p < 0.01). In short term, changes in nurses’ hand hygiene compliance were positively correlated with experienced feedback about their hand hygiene performance (p < 0.05). In the long run, several items of the components ‘social influence’ (i.e., addressing each other on undesirable hand hygiene behaviour p < 0.01), and ‘leadership’ (i.e., ward manager holds team members accountable for hand hygiene performance p < 0.01) correlated positively with changes in nurses’ hand hygiene compliance.
This study illustrates the use of a process evaluation to uncover mechanisms underlying change in hand hygiene improvement strategies. Our study results demonstrate the added value of specific aspects of social influence and leadership in hand hygiene improvement strategies, thus offering an interpretation of the trial effects.
Trial registration
The study is registered in ClinicalTrials.gov, dossier number: NCT00548015.
Consensus for methicillin-resistant Staphylococcus aureus (MRSA) control has still not been reached. We hypothesised that use of rapid MRSA detection followed by contact precautions and single room isolation would reduce MRSA acquisition.
This study was a pre-planned prospective interrupted time series comparing rapid PCR detection and use of long sleeved gowns and gloves (contact precautions) plus single room isolation or cohorting of MRSA colonised patients with a control group. The study took place in a medical-surgical intensive care unit of a tertiary adult hospital between May 21(st) 2007 and September 21(st) 2009. The primary outcome was the rate of MRSA acquisition. A segmented regression analysis was performed to determine the trend in MRSA acquisition rates before and after the intervention.
The rate of MRSA acquisition was 18.5 per 1000 at risk patient days in the control phase and 7.9 per 1000 at-risk patient days in the intervention phase, with an adjusted hazard ratio 0.39 (95% CI 0.24 to 0.62). Segmented regression analysis showed a decline in MRSA acquisition of 7% per month in the intervention phase, (95%CI 1.9% to 12.8% reduction) which was a significant change in slope compared with the control phase. Secondary analysis found prior exposure to anaerobically active antibiotics and colonization pressure were associated with increased acquisition risk.
Contact precautions with single room isolation or cohorting were associated with a 60% reduction in MRSA acquisition. While this study was a quasi-experimental design, many measures were taken to strengthen the study, such as accounting for differences in colonisation pressure, hand hygiene compliance and individual risk factors across the groups, and confining the study to one centre to reduce variation in transmission. Use of two research nurses may limit its generalisability to units in which this level of support is available.
Objective:
To assess the feasibility and effectiveness of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach in 19 limited-resource countries and to analyze predictors of poor hand hygiene compliance.
Design:
An observational, prospective, cohort, interventional, before-and-after study from April 1999 through December 2011. The study was divided into 2 periods: a 3-month baseline period and a 7-year follow-up period.
Setting:
Ninety-nine intensive care unit (ICU) members of the INICC in Argentina, Brazil, China, Colombia, Costa Rica, Cuba, El Salvador, Greece, India, Lebanon, Lithuania, Macedonia, Mexico, Pakistan, Panama, Peru, Philippines, Poland, and Turkey.
Participants:
Healthcare workers at 99 ICU members of the INICC.
Methods:
A multidimensional hand hygiene approach was used, including (1) administrative support, (2) supplies availability, (3) education and training, (4) reminders in the workplace, (5) process surveillance, and (6) performance feedback. Observations were made for hand hygiene compliance in each ICU, during randomly selected 30-minute periods.
Results:
A total of 149,727 opportunities for hand hygiene were observed. Overall hand hygiene compliance increased from 48.3% to 71.4% ([Formula: see text]). Univariate analysis indicated that several variables were significantly associated with poor hand hygiene compliance, including males versus females (63% vs 70%; [Formula: see text]), physicians versus nurses (62% vs 72%; [Formula: see text]), and adult versus neonatal ICUs (67% vs 81%; [Formula: see text]), among others.
Conclusions:
Adherence to hand hygiene increased by 48% with the INICC approach. Specific programs directed to improve hand hygiene for variables found to be predictors of poor hand hygiene compliance should be implemented.
Achieving a sustained improvement in hand-hygiene compliance is the WHO's first global patient safety challenge. There is no RCT evidence showing how to do this. Systematic reviews suggest feedback is most effective and call for long term well designed RCTs, applying behavioural theory to intervention design to optimise effectiveness.Three year stepped wedge cluster RCT of a feedback intervention testing hypothesis that the intervention was more effective than routine practice in 16 English/Welsh Hospitals (16 Intensive Therapy Units [ITU]; 44 Acute Care of the Elderly [ACE] wards) routinely implementing a national cleanyourhands campaign). Intervention-based on Goal & Control theories. Repeating 4 week cycle (20 mins/week) of observation, feedback and personalised action planning, recorded on forms. Computer-generated stepwise entry of all hospitals to intervention. Hospitals aware only of own allocation.direct blinded hand hygiene compliance (%).All 16 trusts (60 wards) randomised, 33 wards implemented intervention (11 ITU, 22 ACE). Mixed effects regression analysis (all wards) accounting for confounders, temporal trends, ward type and fidelity to intervention (forms/month used). INTENTION TO TREAT ANALYSIS: Estimated odds ratio (OR) for hand hygiene compliance rose post randomisation (1.44; 95% CI 1.18, 1.76;p
Background
Many strategies have been designed and evaluated to address the problem of low hand hygiene (HH) compliance. Which of these strategies are most effective and how they work is still unclear. Here we describe frequently used improvement strategies and related determinants of behaviour change that prompt good HH behaviour to provide a better overview of the choice and content of such strategies.
Methods
Systematic searches of experimental and quasi-experimental research on HH improvement strategies were conducted in Medline, Embase, CINAHL, and Cochrane databases from January 2000 to November 2009. First, we extracted the study characteristics using the EPOC Data Collection Checklist, including study objectives, setting, study design, target population, outcome measures, description of the intervention, analysis, and results. Second, we used the Taxonomy of Behavioural Change Techniques to identify targeted determinants.
Results
We reviewed 41 studies. The most frequently addressed determinants were knowledge, awareness, action control, and facilitation of behaviour. Fewer studies addressed social influence, attitude, self-efficacy, and intention. Thirteen studies used a controlled design to measure the effects of HH improvement strategies on HH behaviour. The effectiveness of the strategies varied substantially, but most controlled studies showed positive results. The median effect size of these strategies increased from 17.6 (relative difference) addressing one determinant to 49.5 for the studies that addressed five determinants.
Conclusions
By focussing on determinants of behaviour change, we found hidden and valuable components in HH improvement strategies. Addressing only determinants such as knowledge, awareness, action control, and facilitation is not enough to change HH behaviour. Addressing combinations of different determinants showed better results. This indicates that we should be more creative in the application of alternative improvement activities addressing determinants such as social influence, attitude, self-efficacy, or intention.
Health reform worldwide is required due to the largely aging population, increase in chronic diseases, and rising costs. To meet these needs, nurses are being encouraged to practice to the full extent of their skills and take significant leadership roles in health policy, planning, and provision. This can involve entrepreneurial or intrapreneurial roles. Although nurses form the largest group of health professionals, they are frequently restricted in their scope of practice. Nurses can help to improve health services in a cost effective way, but to do so, they must be seen as equal partners in health service provision. This article provides a global perspective on evolving nursing roles for innovation in health care. A historical overview of entrepreneurship and intrapreneurship is offered. Included also is discussion of a social entrepreneurship approach for nursing, settings for nurse entre/intrapreneurship, and implications for research and practice.
To assess the impact of a hygiene-encouragement program on reducing infection rates (primary end point) by 5%.
A cluster randomized study was carried out over a 5-month period.
Fifty nursing homes (NHs) with 4345 beds in France were randomly assigned by stratified-block randomization to either a multicomponent intervention (25 NHs) or an assessment only (25 NHs).
The multicomponent intervention was targeted to caregivers and consisted of implementing a bundle of infection prevention consensual measures. Interactive educational meetings using a slideshow were organized at the intervention NHs. The NHs were also provided with color posters emphasizing hand hygiene and a kit that included hygienic products such as alcoholic-based hand sanitizers. Knowledge surveys were performed periodically and served as reminders.
The primary end point was the total infection rate (urinary, respiratory, and gastrointestinal infections) in those infection cases classified either as definite or probable. Analyses corresponded to the underlying design and were performed according to the intention-to-treat principle. This study was registered (#NCT01069497).
Forty-seven NHs (4515 residents) were included and followed. The incidence rate of the first episode of infection was 2.11 per 1000 resident-days in the interventional group and 2.15 per 1000 resident-days in the control group; however, the difference between the groups did not reach statistical significance in either the unadjusted (Hazard Ratio [HR] = 1.00 [95% confidence interval (CI) 0.89-1.13]; P = .93]) or the adjusted (HR = 0.99 [95% CI 0.87-1.12]; P = .86]) analysis.
Disentangling the impact of this type of intervention involving behavioral change in routine practice in caregivers from the prevailing environmental and contextual determinants is often complicated and confusing to interpret the results.
To evaluate the effectiveness of a multimodal intervention in primary care health professionals for improved compliance with hand hygiene practice, based on the World Health Organization's 5 Moments for Health Hygiene.
Cluster randomized trial, parallel 2-group study (intervention and control).
Primary healthcare centers in Madrid, Spain.
Eleven healthcare centers with 198 healthcare workers (general practitioners, nurses, pediatricians, auxiliary nurses, midwives, odontostomatologists, and dental hygienists). Methods. The multimodal hand hygiene improvement strategy consisted of training of healthcare workers by teaching sessions, implementation of hydroalcoholic solutions, and installation of reminder posters. The hand hygiene compliance level was evaluated by observation during regular care activities in the office visit setting, at the baseline moment, and 6 months after the intervention, all by a single external observer.
The overall baseline compliance level was 8.1% (95% confidence interval [CI], 6.2-10.1), and the healthcare workers of the intervention group increased their hand hygiene compliance level by 21.6% (95% CI, 13.83-28.48) compared with the control group.
This study has demonstrated that hand hygiene compliance in primary healthcare workers can be improved with a multimodal hand hygiene improvement strategy.
The impact of antimicrobial scrubs on healthcare worker (HCW) bacterial burden is unknown. Objective. To determine the effectiveness of antimicrobial scrubs on hand and apparel bacterial burden.
Prospective, crossover trial.
Thirty HCWs randomized to study versus control scrubs in an intensive care unit.
Weekly microbiology samples were obtained from scrub abdominal area, cargo pocket, and hands. Mean log colony-forming unit (CFU) counts were calculated. Compliance with hand hygiene practices was measured. Apparel and hand mean log CFU counts were compared.
Adherence measures were 78% (910/1,173) for hand hygiene and 82% (223/273) for scrubs. Culture compliance was 67% (306/460). No differences were observed in bacterial hand burden or in HCWs with unique positive scrub cultures. No difference in vancomycin-resistant enterococci (VRE) and gram-negative rod (GNR) burden was observed. A difference in mean log methicillin-resistant Staphylococcus aureus (MRSA) CFU count was found between study and control scrubs for leg cargo pocket (mean log CFUs, 11.84 control scrub vs 6.71 study scrub; [Formula: see text]), abdominal area (mean log CFUs, 11.35 control scrub vs 7.54 study scrub; [Formula: see text]), leg cargo pocket at the beginning of shift (mean log CFUs, 11.96 control scrub vs 4.87 study scrub; [Formula: see text]), and abdominal area pocket at the end of shift (mean log CFUs, 12.14 control scrubs vs 8.22 study scrub; [Formula: see text]).
Study scrubs were associated with a 4-7 mean log reduction in MRSA burden but not VRE or GNRs. A prospective trial is needed to measure the impact of antimicrobial impregnated apparel on MRSA transmission rates.
Limited vaccine availability and the potential for resistance to antiviral medications have led to calls for establishing the efficacy of non-pharmaceutical measures for mitigating pandemic influenza. Our objective was to examine if the use of face masks and hand hygiene reduced rates of influenza-like illness (ILI) and laboratory-confirmed influenza in the natural setting. A cluster-randomized intervention trial was designed involving 1,178 young adults living in 37 residence houses in 5 university residence halls during the 2007–2008 influenza season. Participants were assigned to face mask and hand hygiene, face mask only, or control group during the study. Discrete-time survival models using generalized estimating equations to estimate intervention effects on ILI and confirmed influenza A/B infection over a 6-week study period were examined. A significant reduction in the rate of ILI was observed in weeks 3 through 6 of the study, with a maximum reduction of 75% during the final study week (rate ratio [RR] = 0.25, [95% CI, 0.07 to 0.87]). Both intervention groups compared to the control showed cumulative reductions in rates of influenza over the study period, although results did not reach statistical significance. Generalizability limited to similar settings and age groups. Face masks and hand hygiene combined may reduce the rate of ILI and confirmed influenza in community settings. These non-pharmaceutical measures should be recommended in crowded settings at the start of an influenza pandemic.
Trail Registration
Clinicaltrials.gov NCT00490633
Previous controlled studies on the effect of non-pharmaceutical interventions (NPI) - namely the use of facemasks and intensified hand hygiene - in preventing household transmission of influenza have not produced definitive results. We aimed to investigate efficacy, acceptability, and tolerability of NPI in households with influenza index patients.
We conducted a cluster randomized controlled trial during the pandemic season 2009/10 and the ensuing influenza season 2010/11. We included households with an influenza positive index case in the absence of further respiratory illness within the preceding 14 days. Study arms were wearing a facemask and practicing intensified hand hygiene (MH group), wearing facemasks only (M group) and none of the two (control group). Main outcome measure was laboratory confirmed influenza infection in a household contact. We used daily questionnaires to examine adherence and tolerability of the interventions.
We recruited 84 households (30 control, 26 M and 28 MH households) with 82, 69 and 67 household contacts, respectively. In 2009/10 all 41 index cases had a influenza A (H1N1) pdm09 infection, in 2010/11 24 had an A (H1N1) pdm09 and 20 had a B infection. The total secondary attack rate was 16% (35/218). In intention-to-treat analysis there was no statistically significant effect of the M and MH interventions on secondary infections. When analysing only households where intervention was implemented within 36 h after symptom onset of the index case, secondary infection in the pooled M and MH groups was significantly lower compared to the control group (adjusted odds ratio 0.16, 95% CI, 0.03-0.92). In a per-protocol analysis odds ratios were significantly reduced among participants of the M group (adjusted odds ratio, 0.30, 95% CI, 0.10-0.94). With the exception of MH index cases in 2010/11 adherence was good for adults and children, contacts and index cases.
Results suggest that household transmission of influenza can be reduced by the use of NPI, such as facemasks and intensified hand hygiene, when implemented early and used diligently. Concerns about acceptability and tolerability of the interventions should not be a reason against their recommendation.
The study was registered with ClinicalTrials.gov (Identifier NCT00833885).
Hand-washing is regarded as a potentially important behavior for preventing transmission of respiratory infection, particularly during a pandemic.
The objective of our study was to evaluate whether a Web-based intervention can encourage more frequent hand-washing in the home, and to examine potential mediators and moderators of outcomes, as a necessary first step before testing effects of the intervention on infection rates in the PRIMIT trial (PRimary care trial of a website based Infection control intervention to Modify Influenza-like illness and respiratory infection Transmission).
In a parallel-group pragmatic exploratory trial design, 517 nonblinded adults recruited through primary care were automatically randomly assigned to a fully automated intervention comprising 4 sessions of tailored motivational messages and self-regulation support (n = 324) or to a no-intervention control group (n = 179; ratio 2:1). Hand-washing frequency and theory of planned behavior cognitions relating to hand-washing were assessed by online questionnaires at baseline (in only half of the control participants, to permit evaluation of effects of baseline assessment on effect sizes), at 4 weeks (postintervention; all participants), and at 12 weeks.
Hand-washing rates in the intervention group were higher at 4 weeks than in the control group (mean 4.40, n = 285 and mean 4.04, n = 157, respectively; P < .001, Cohen d = 0.42) and remained higher at 12 weeks (mean 4.45, n = 282 and mean 4.12, n = 154, respectively; P < .001, Cohen d = 0.34). Hand-washing intentions and positive attitudes toward hand-washing increased more from baseline to 4 weeks in the intervention group than in the control group. Mediation analyses revealed positive indirect effects of the intervention on change in hand-washing via intentions (coefficient = .15, 95% confidence interval [CI], .08-.26) and attitudes (coefficient = 0.16, 95% CI, .09-.26). Moderator analyses confirmed that the intervention was similarly effective for men and women, those of higher and lower socioeconomic status, and those with higher and lower levels of perceived risk.
This study provides promising evidence that Web-based interventions could potentially provide an effective method of promoting hand hygiene in the home. Data were collected during the 2010 influenza pandemic, when participants in both groups had already been exposed to extensive publicity about the need for hand hygiene, suggesting that our intervention could add to existing public health campaigns. However, further research is required to determine the effects of the intervention on actual infection rates. TRIAL: International Standard Randomized Controlled Trial Number (ISRCTN): 75058295; http://www.controlled-trials.com/ISRCTN75058295 (Archived by WebCite at http://www.webcitation.org/62KSbkNmm).
Wearing of gloves reduces transmission of organisms by healthcare workers' hands but is not a substitute for hand hygiene. Results of previous studies have varied as to whether hand hygiene is worse when gloves are worn. Most studies have been small and used nonstandardized assessments of glove use and hand hygiene. We sought to observe whether gloves were worn when appropriate and whether hand hygiene compliance differed when gloves were worn.
Observational study.
Healthcare workers in 56 medical or care of the elderly wards and intensive care units in 15 hospitals across England and Wales.
We observed hand hygiene and glove usage (7,578 moments for hand hygiene) during 249 one-hour sessions. Observers also recorded whether gloves were or were not worn for individual contacts.
Gloves were used in 1,983 (26.2%) of the 7,578 moments for hand hygiene and in 551 (16.7%) of 3,292 low-risk contacts; gloves were not used in 141 (21.1%) of 669 high-risk contacts. The rate of hand hygiene compliance with glove use was 41.4% (415 of 1,002 moments), and the rate without glove use was 50.0% (1,344 of 2,686 moments). After adjusting for ward, healthcare worker type, contact risk level, and whether the hand hygiene opportunity occurred before or after a patient contact, glove use was strongly associated with lower levels of hand hygiene (adjusted odds ratio, 0.65 [95% confidence interval, 0.54-0.79]; P < .0001).
The rate of glove usage is lower than previously reported. Gloves are often worn when not indicated and vice versa. The rate of compliance with hand hygiene was significantly lower when gloves were worn. Hand hygiene campaigns should consider placing greater emphasis on the World Health Organization indications for gloving and associated hand hygiene.
National Research Register N0256159318.
Public health authorities have recognized lack of hand hygiene in hospitals as one of the important causes of preventable mortality and morbidity at population level. The implementation strategy ACCOMPLISH (Actively Creating COMPLIance Saving Health) targets both individual and environmental determinants of hand hygiene. This study aims to evaluate the cost-effectiveness of a multicomponent implementation strategy aimed at the reduction of healthcare associated infections in Dutch hospital care, by promotion of hand hygiene.
The ACCOMPLISH package will be evaluated in a two-arm cluster randomised trial in 16 hospitals in the Netherlands, in one intensive care unit and one surgical ward per hospital.
A multicomponent package, including e-learning, team training, introduction of electronic alcohol based hand rub dispensers and performance feedback.
The primary outcome measure will be the observed hand hygiene compliance rate, measured at baseline and after 6, 12 and 18 months; as a secondary outcome measure the prevalence of healthcare associated infections will be measured at the same time points. Process indicators of the intervention will be collected pre and post intervention. An ex-post economic evaluation of the ACCOMPLISH package from a healthcare perspective will be performed.
Multilevel analysis, using mixed linear modelling techniques will be conducted to assess the effect of the intervention strategy on the overall compliance rate among healthcare workers and on prevalence of healthcare associated infections. Questionnaires on process indicators will be analysed with multivariable linear regression, and will include both behavioural determinants and determinants of innovation. Cost-effectiveness will be assessed by calculating the incremental cost-effectiveness ratio, defined here as the costs for the intervention divided by the difference in prevalence of healthcare associated infections between the intervention and control group.
This study is the first RCT to investigate the effects of a hand hygiene intervention programme on the number of healthcare associated infections, and the first to investigate the cost-effectiveness of such an intervention. In addition, if the ACCOMPLISH package proves successful in improving hand hygiene compliance and lowering the prevalence of healthcare associated infections, the package could be disseminated at (inter)national level.
NTR2448.
Hand hygiene prescriptions are the most important measure in the prevention of hospital-acquired infections. Yet, compliance rates are generally below 50% of all opportunities for hand hygiene. This study aims at evaluating the short- and long-term effects of two different strategies for promoting hand hygiene in hospital nurses.
This study is a cluster randomised controlled trial with inpatient wards as the unit of randomisation. Guidelines for hand hygiene will be implemented in this study. Two strategies will be used to improve the adherence to guidelines for hand hygiene. The state-of-the-art strategy is derived from the literature and includes education, reminders, feedback, and targeting adequate products and facilities. The extended strategy also contains activities aimed at influencing social influence in groups and enhancing leadership. The unique contribution of the extended strategy is built upon relevant behavioural science theories. The extended strategy includes all elements of the state-of-the-art strategy supplemented with gaining active commitment and initiative of ward management, modelling by informal leaders at the ward, and setting norms and targets within the team. Data will be collected at four points in time, with six-month intervals. An average of 3,000 opportunities for hand hygiene in approximately 900 nurses will be observed at each time point.
Performing and evaluating an implementation strategy that also targets the social context of teams may considerably add to the general body of knowledge in this field. Results from our study will allow us to draw conclusions on the effects of different strategies for the implementation of hand hygiene guidelines, and based on these results we will be able to define a preferred implementation strategy for hospital based nursing.
The study is registered as a Clinical Trial in ClinicalTrials.gov, dossier number: NCT00548015.