No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Back to the Future: Rising to the Semmelweis Challenge in Hand Hygiene
Future Microbiology
Abstract
Hand hygiene is the single most important intervention for reducing healthcare associated infections and preventing the spread of antimicrobial resistance. This sentence begins most publications regarding hand hygiene in the medical literature. But why - as we mark 150 years since the publication of Ignaz Semmelweis' landmark monograph on the subject - do we continue to repeat it? One might be tempted to regard it as a truism. However, while tremendous progress has certainly been made in this field, a significant amount of work is yet to be done in both strengthening the evidence regarding the impact of hand hygiene and maximizing its implementation. Hand hygiene cannot yet be taken for granted. This article summarizes historical perspectives, dynamics of microbial colonization and efficacy of hand cleansing methods and agents, elements and impacts of successful hand hygiene promotion, as well as scale-up and sustainability. We also explore hand hygiene myths and current challenges such as monitoring, behavior change, patient participation and research priorities.
... His family home was close to Buda Castle where he went to school. Semmelweis initially pursued an arts degree at the university in Pest, a separate town from Buda at the time [1,2], and then moved on to medical studies from 1837, first in Pest, then in Vienna, Austria. In 1846, Semmelweis worked as an assistant in obstetrics at the Vienna General Hospital, one of the largest obstetric clinics in Europe. ...
... The disease was widely attributed to miasma, 'an emanation or an atmosphere that hovers in the surroundings and causes sickness to those exposed to it by the pervasiveness of its malignant presence'. The high mortality rate among pregnant women, mostly related to infectious diseases and sepsis, was considered to be associated with local cosmotelluric forces, hygrometric forces, polar currents, or radiation from the constellations [1][2][3]. ...
... However, mortality from childbed fever was much higher in the latter ward. As soon as he started working in this ward, Semmelweis was struck by the difference [2,4]. The clue to the solution of this enigma was provided by the death of Semmelweis' friend and colleague, Jakob Kolletschka, who developed a condition resembling childbed fever following a scalpel laceration while supervising an autopsy. ...
... More intrusive observations involve use of radio frequency identification (RFID) tags that track employee movement and interface with soap or alcohol-based hand rub (ABHR) dispensers to determine HW compliance (Levchenko, Boscart, & Fernie, 2013;Marra et al., 2014;Staats, Dai, Hofmann, & Milkman, 2015). In person observations are a less resource intensive means for monitoring HW that may obstruct freedom, depending on individual perception (Stewardson, Allegranzi, Sax, Kilpatrick, & Pittet, 2011). While this rung in the IL implies no corrective action taken, numerous studies show evidence for the Hawthorne effect inflating HW compliance whenever employees are cognizant of being observed (Hagel et al., 2015;Srigley, Furness, Baker, & Gardam, 2014;Yin et al., 2014). ...
... Proper HW is a simple, yet powerful procedure shown to combat infection transmission, antibiotic resistance (Trampuz & Widmer, 2004), diarrhea (Ejemot-Nwadiaro, Ehiri, Meremikwu, & Critchley, 2012), and reduce the risk of foodborne disease (FDA, 2009). Poor HW compliance, despite millions of dollars spent and numerous interventions, remains a problem (Stewardson et al., 2011). As B.F. Skinner points out, "Human behavior is perhaps the most difficult subject to which the methods of science have ever been applied" (Skinner, 1953), with this truth reflected in the obstacles faced by HW interventionists and food industry leaders in creating lasting behavior change (Erasmus et al., 2010;Gawande, 2004;Soon et al., 2012;Viator et al., 2015). ...
... More intrusive observations involve use of radio frequency identification (RFID) tags that track employee movement and interface with soap or alcohol-based hand rub (ABHR) dispensers to determine HW compliance (Levchenko, Boscart, & Fernie, 2013;Marra et al., 2014;Staats, Dai, Hofmann, & Milkman, 2015). In person observations are a less resource intensive means for monitoring HW that may obstruct freedom, depending on individual perception (Stewardson, Allegranzi, Sax, Kilpatrick, & Pittet, 2011). While this rung in the IL implies no corrective action taken, numerous studies show evidence for the Hawthorne effect inflating HW compliance whenever employees are cognizant of being observed (Hagel et al., 2015;Srigley, Furness, Baker, & Gardam, 2014;Yin et al., 2014). ...
... Proper HW is a simple, yet powerful procedure shown to combat infection transmission, antibiotic resistance (Trampuz & Widmer, 2004), diarrhea (Ejemot-Nwadiaro, Ehiri, Meremikwu, & Critchley, 2012), and reduce the risk of foodborne disease (FDA, 2009). Poor HW compliance, despite millions of dollars spent and numerous interventions, remains a problem (Stewardson et al., 2011). As B.F. Skinner points out, "Human behavior is perhaps the most difficult subject to which the methods of science have ever been applied" (Skinner, 1953), with this truth reflected in the obstacles faced by HW interventionists and food industry leaders in creating lasting behavior change (Erasmus et al., 2010;Gawande, 2004;Soon et al., 2012;Viator et al., 2015). ...
Proper handwashing is a simple, cost effective means for reducing the risk of foodborne disease transmission. Low compliance rates are often observed among food handlers, and a wide range of interventions have attempted to increase compliance, often with little success. Promoting lasting behavior change is difficult, and theoretical models like the Intervention Ladder developed by the Nuffield Council on Bioethics function as useful paradigms to help guide and promote behavior change.
While the Intervention Ladder was developed to address issues like infectious disease, obesity, and drug use, it is applicable to the food industry with regards to promoting food safety practices like handwashing. The aim of this review is to expand on the Intervention Ladder and describe its application in the food industry. We believe the Intervention Ladder can serve as a model to benefit food industry stakeholders through providing strategies to promote handwashing compliance. We have modified the original model to include various levels of employee freedom that might impact which strategy is most appropriate depending on the circumstances. Limitations for each strategy are also considered, and directions for future research are included to help guide and expand the knowledge base of food safety behavior change strategies.
... Furthermore, in long-term care facilities, infection control measures are more difficult to implement than in acute care settings. The very low compliance with hand hygiene rules in most hospitals [47] is a major obstacle to preventing the cross-transmission of resistant and susceptible micro-organisms. Life in hospitals and in the community comprises a succession of small mistakes, which usually have little impact but may increase the risk of cross-transmitting resistant micro-organisms. ...
... Similar positive results were obtained in young infants with C. difficile resistant to S. boulardii and Lactobacillus rhamnosus, as well as to many antibiotics [59]. The effect of transplanting E. coli, instead of the entire normal gut microbiome, has not been widely studied in humans464748, and the data are conflicting. Positive results were obtained in animals, particularly mice [78]. ...
The gut contains very large numbers of bacteria. Changes in the composition of the gut flora, due in particular to antibiotics, can happen silently, leading to the selection of highly resistant bacteria and Candida species. These resistant organisms may remain for months in the gut of the carrier without causing any symptoms or translocate through the gut epithelium, induce healthcare-associated infections, undergo cross-transmission to other individuals, and cause limited outbreaks. Techniques are available to prevent, detect, and treat the carriage of resistant organisms in the gut. However, evidence on these techniques is scant, the only exception being selective digestive decontamination (SDD), which has been extensively studied in neutropenic and ICU patients. After the destruction of resistant colonizing bacteria, which has been successfully obtained in several studies, the gut could be re-colonized with normal faecal flora or probiotics. Studies are warranted to evaluate this concept.
... A number of studies have attempted to identify the reasons for poor hand hygiene adherence rates and several additional studies have attempted to pinpoint barriers to universal performance of hand hygiene. Among other obstacles, healthcare personnel may underestimate the consequences of inadequate hand hygiene [6] or may misunderstand the purpose of hand hygiene [7]. In any event, healthcare workers routinely miss opportunities to prevent healthcare-associated infections by failing to perform hand hygiene at critical times. ...
... Healthcare-associated infections do not carry fingerprints or time stamps to identify the offending healers who failed the patient. Absent that, as Didier Pittet [7] has written, ''Hand hygiene performance remains the only measure to judge the degree of system safety-and the only possibility for those concerned to know how they are performing.'' Facilities and entrepreneurs have turned to creative strategies for monitoring and improving compliance [8][9][10]. ...
... on the subject? One might be tempted to regard it as a truism (22). ...
... The evidence base is relatively weak. 32 The workforce's poor hand hygiene adherence is noteworthy (40% in one systematic review 33 ) and this is unlikely to be much better in times of staff shortage and rising case complexity. How to address those individuals with consistently poor adherence is unresolved. ...
In this overview, we articulate research needs and opportunities in the field of infection prevention that have been identified from insights gained during operative infection prevention work, our own research in healthcare epidemiology, and from reviewing the literature. The 10 areas of research need are: 1) transmissions and interruptions, 2) personal protective equipment and other safety issues in occupational health, 3) climate change and other crises, 4) device, diagnostic, and antimicrobial stewardship, 5) implementation and de-implementation, 6) health care outside the acute care hospital, 7) low- and middle-income countries, 8) networking with the “neighbors”, 9) novel research methodologies, and 10) the future state of surveillance. An introduction and chapters 1–5 are presented in part I of the article, and chapters 6–10 and the discussion in part II. There are many barriers to advancing the field, such as finding and motivating the future IP workforce including professionals interested in conducting research, a constant confrontation with challenges and crises, the difficulty of performing studies in a complex environment, the relative lack of adequate incentives and funding streams, and how to disseminate and validate the often very local quality improvement projects. Addressing research gaps now (i.e., in the postpandemic phase) will make healthcare systems more resilient when facing future crises.
... Hand hygiene and hand rubbing are unequivocally the first line of defense in patient safety and even social safety in a pandemic. Since the ground-breaking discovery of Ignaz Semmelweis, hand hygiene protocols have been created, reassessed, reviewed, and rewritten [1]. In 2009 the World Health Organisation (WHO) initiated the "SAVE LIVES: Clean Your Hands" program, marking hand hygiene as the cornerstone of infection transmission prevention. ...
Background
Current hand hygiene guidelines do not provide recommendations on a specific volume for the clinical hand rubbing procedure. According to recent studies volume should be adjusted in order to achieve complete coverage. However, hand size is a parameter that highly influences the hand coverage quality when using alcohol-based handrubs (ABHR). The purpose of this study was to establish a quantitative correlation between applied ABHR volume and achieved hand coverage.
Method
ABHR based hand hygiene events were evaluated utilizing a digital health device, the Semmelweis hand hygiene system with respect to coverage achieved on the skin surface. Medical students and surgical residents (N = 356) were randomly selected and given predetermined ABHR volumes. Additionally, hand sizes were calculated using specialized software developed for this purpose. Drying time, ABHR volume awareness, as well spillage awareness were documented for each hand hygiene event.
Results
Hand coverage achieved during a hand hygiene event strongly depends on the applied ABHR volume. At a 1 ml dose, the uncovered hand area was approximately 7.10%, at 2 ml it decreased to 1.68%, and at 3 ml it further decreased to 1.02%. The achieved coverage is strongly correlated to hand size, nevertheless, a 3 ml applied volume proved sufficient for most hand hygiene events (84%). When applying a lower amount of ABHR (1.5 ml), even people with smaller hands failed to cover their entire hand surface. Furthermore, a 3 ml volume requires more than the guideline prescribed 20–30 s to dry. In addition, results suggest that drying time is not only affected by hand size, but perhaps other factors may be involved as well (e.g., skin temperature and degree of hydration). ABHR volumes of 3.5 ml or more were inefficient, as the disinfectant spilled while the additional rubbing time did not improve hand coverage.
Conclusions
Hand sizes differ a lot among HCWs. After objectively measuring participants, the surface of the smallest hand was just over half compared to the largest hand (259 cm ² and 498 cm ² , respectively). While a 3 ml ABHR volume is reasonable for medium-size hands, the need for an optimized volume of handrub for each individual is critical, as it offers several advantages. Not only it can ensure adequate hand hygiene quality, but also prevent unnecessary costs. Bluntly increasing the volume also increases spillage and therefore waste of disinfectant in the case of smaller hands. In addition, adherence could potentially decrease due to the required longer drying time, therefore, adjusting the dosage according to hand size may also increase the overall hand hygiene compliance.
... Hand sanitation is an essential, not optional, method of infection prevention. Since Semmelweis first reported the benefit of hand hygiene in the mid-19th century, 8 hand hygiene has been, and should remain, the cornerstone of all interventions for preventing health care-associated infections. Use of either alcohol-based sanitizing solutions or soap and water has been found to notably reduce respiratory viruses, Staphylococcus aureus, gastrointestinal infection, and other outbreaks in health care settings. ...
... "In the absence of the possibility to directly link individual infectious outcomes to individual hand hygiene failures… hand hygiene performance remains the only measure to judge the degree of system safety…." (Stewardson et al. 2011). Despite the proven effectiveness of hand hygiene in preventing MDRO transmission (Pittet et al. 2000;Johnson et al. 2005), compliance is often poor. ...
In this chapter we review the development of hospital infection prevention and control (IPC) since the nineteenth century and its increasingly important role in reducing the spread of antibiotic resistance (ABR). Excessive rates of hospital-acquired infection (HAI) fell dramatically, towards the end of the nineteenth century, because of improved hygiene and surgical antisepsis, but treatment remained rudimentary until effective antibiotics became widely available in the mid-twentieth century. While antibiotics had profound clinical benefits, their widespread appropriate and inappropriate use in humans and animals inevitably led to the emergence of antibiotic resistance (ABR). Within 50 years, this could no longer be offset by a reliable supply of new drugs, which slowed to a trickle in the 1980s. In hospitals, particularly, high rates of (often unnecessary) antibiotic use and ABR are exacerbated by person-to-person transmission of multi-drug resistant organisms (MDRO), which have, so far, largely resisted the introduction of antimicrobial stewardship (AMS) programs and repeated campaigns to improve infection prevention and control (IPC). Despite clear evidence of efficacy in research settings, both AMS and IPC programs are often ineffective, in practice, because of, inter alia, insufficient resourcing, poor implementation, lack of ongoing evaluation and failure to consult frontline staff. In this chapter we review reasons for the relatively low priority given to preventive programs despite the ethical obligation of healthcare organisations to protect current and future patients from preventable harm. The imminent threat of untreatable infections may provide an impetus for a shared organisational and professional commitment to promoting the cultural and behavioural changes needed to successfully reduce the burdens of ABR and drug-resistant HAIs.
... A prominent indicator of human progress is the massive increase in life expectancy occurring during the last century. Basic scientific research has led to increased hygiene (Stewardson et al., 2011) , food availability through plant biotechnology (Kirakosyan et al., 2009) , disease prevention (Bennett et al., 2015) , and new cancer therapies (Ye, 2016) . ...
Over the past 50 years, songbirds have become a valuable model organism for scientists studying vocal communication from its behavioral, hormonal, neuronal, and genetic perspectives. Many advances in our understanding of vocal learning result from research using the zebra finch, a close-ended vocal learner. We review some of the manipulations used in zebra finch research, such as isolate housing, transient/irreversible impairment of hearing/vocal organs, implantation of small devices for chronic electrophysiology, head fixation for imaging, aversive song conditioning using sound playback, and mounting of miniature backpacks for behavioral monitoring. We highlight the use of these manipulations in scientific research, and estimate their impact on animal welfare, based on the literature and on data from our past and ongoing work. The assessment of harm-benefits tradeoffs is a legal prerequisite for animal research in Switzerland. We conclude that a diverse set of known stressors reliably lead to suppressed singing rate, and that by contraposition, increased singing rate may be a useful indicator of welfare. We hope that our study can contribute to answering some of the most burning questions about zebra finch welfare in research on vocal behaviors.
... The reasons in part could be an underestimation of the consequence of inadequate HH and misunderstanding of the purpose of HH, particularly in new trainee residents posted in ICU on a rotation basis. [7,8] The risk factors of lower HH compliance in doctors (residents and consultants) as compared to nursing staff are working in ICUs, understaffing, overcrowding, highintensity patient care, insufficient time and materials, and lack of institutional priority. [9] We used the health education module for HH throughout the study period along with the institute policy for infection control. ...
Background: Intensive care patients are at risk for healthcare-associated infections (HCAIs), and hand hygiene (HH) compliance in health-care workers (HCWs) is reportedly low. This study aimed to compare closed-circuit television (CCTV) monitoring to direct observation on the HH compliance and its impact on HCAIs. Methods: In a prospective cohort study, HCWs were observed for HH compliance and HCAIs were studied. The study period was August 1, 2014–December 31, 2014 (direct observation period), and March 1, 2015–July 31, 2015 (CCTV monitoring period), with 2 months washout period. A HH education module (running a video daily, reinforcement of HH everyday evening, 2-weekly classes about HH importance, and posters reinforcing the importance of HH on the prominent sites of pediatric intensive care unit) was implemented in both periods. Each day was divided into blocks of 6-h. One hour from each block was randomly selected stratified by day and night shifts. HH compliance was observed according to the World Health Organization, “My Five Moments of HH.” Results: A total of 751 patients (direct observation period n = 369, CCTV monitoring period n = 382) were admitted. The HH compliance rate was higher in the CCTV monitoring period (56.6%, n = 5953 / 10519) as compared to that of the direct observation period (36.1%, n = 2178 / 6028) (relative risk = 1.57, 95% confidence interval: 1.51 - 1.63, P ≤ 0.001). Ventilator-associated pneumonia (4.7 vs. 12 / 1000 ventilation-day) and central line-associated bloodstream infection (1.9 vs. 6.6 / 1000 central line-day) were lower in the CCTV monitoring period. There was no difference in mortality between the study periods (18.3%, n = 70 / 382 vs. 21.1%, n = 78 / 369, relative risk = 0.87, 95% confidence interval: 0.65–1.16, P = 0.333). Conclusion: CCTV monitoring was associated with improved HH compliance, which was associated with lower HCAIs.
... Hand hygiene is the most important measure to prevent healthcare-associated infections, slow down major epidemics and prevent the spread of antimicrobial resistance [1]. In the last 20 years, performing hand hygiene with alcohol-based handrub (ABHR) has become globally accepted [2]. ...
Background:
Hand hygiene can only be efficient if the whole hand surface is treated with sufficient alcohol-based handrub (ABHR); therefore, the volume of handrub applied is a critical factor in patient safety. The proper amount of ABHR should be provided by handrub dispensers. The aim of this study was to investigate the dispensing performance of wall-mounted ABHR dispensers commonly employed in hospital settings.
Method:
In a multicenter study, we tested 46 dispensers (22 in laboratory and 24 in clinical environments), measuring dispensed ABHR volume during continuous use and after a period of non-use. The influence of the pumping mechanism, liquid level, ABHR formats, handrub composition, temperature, and atmospheric pressure was investigated.
Results:
A total of 7 out of the 22 investigated dispensers (32%) lost a significant amount of handrub; greater than 30% of the nominal volume after 8 h of non-use, thus frequently dispensing suboptimal volume, as measured in laboratory settings. Key influencing factors were found to be handrub format (gel or liquid), handrub level in the container and type of dispenser. When gel ABHR was used, after 4 h of non-use of the dispensers, the volume of the dispensed amount of ABHR insignificantly changed (97% of the original amount), while it technically decreased to zero in the case of liquid ABHR (1% of the original amount). The liquid level had a medium effect on the dispensed volume in each investigated case; the magnitude of this effect varied widely depending on the dispensing mechanism. When dispensers were in continuous use, they dispensed a cumulated 3 mL of ABHR from two consecutive pushes, while when they were not in use for 1 h, up to 4 consecutive pushes were necessary to provide a total of 3 mL ABHR. Design and production quality were also identified as important contributing factors with respect to the volume dispensed. Data collected in clinical settings confirmed these findings, for multiple types of dispensers.
Conclusion:
All ABHR dispensers should be regularly audited to control the reference volume distributed, with particular attention paid to regular mechanical pump units filled with liquid handrub.
... Both authors implicated, for first time, the role of human hands contaminated with "cadaverous particles" in the deadly transmission process. Their legacy persists today, with considerable influence on current medicine, in which hand hygiene remains a liturgy in surgical procedures and is also a general measure with a pivotal role in the prevention and control of communicable diseases (4,5). ...
... A discernible distinction was that the first facility was controlled by medical students who performed autopsies while the second was run by midwives who did not. 4 In wake of a colleague acquiring a similar illness from an accidental stab with an autopsy knife, he postulated that the transfer of "cadaveric particles" from the autopsy room to pregnant women in the labor room caused contamination that prompted puerperal fever in the principal facility and subsequently, higher death rate. 5 Acting swiftly on his observations, Semmelweis immediately instituted a hand washing protocol at his clinic which required all medical students to wash their hands with chlorinated lime before conducting any obstetrical examinations or deliveries. ...
Background:
Semmelweis reflex is a human behavioral tendency to stick to preexisting beliefs and to reject fresh ideas that contradict them (despite adequate evidence). We aim to familiarize the readers with the term that not only has a significant historical background but also grave clinical implications.
Methods:
A keyword search for "Semmelweis reflex," "Belief perseverance," "handwashing," and "Idea rejection" was conducted using PubMed Central, MEDLINE, and Google SCHOLAR. Literature published in paper-based journals and books was also searched. All manuscripts pertaining to these keywords were thoroughly analyzed for this review.
Results:
The first section of our paper briefs the story of Ignaz Semmelweis and brushes on the contributions of other intellectual researchers that were rebuffed initially. The discussion further explains the root cause of this dismissal, an inherent bias against uncertainty that may be at the core of our fear for new ideas. Finally, this review explores the means by which we can prevent ourselves from being a victim of rejection.
Conclusions:
The age-old prejudice that is Semmelweis reflex is explored in this review. With careful and thorough study design, scientific rigor, and critical self-analysis of the manuscript, one can avoid being victimized by this reflex. The dual edged nature of this reflex lays unveiled when its importance is highlighted in the prematurely accepted medical failures. Understanding that any new idea goes through the grill of being critically analyzed and perceived encourages the scientist to hold on to the original thought as it may rather be practice changing.
... Poor personal hygiene by food handling employees is one of the five principle risk factors in retail foodservice that contribute to foodborne disease occurrence (FDA, 2010), and poor hygiene was the second highest factor contributing to outbreaks in a 24 year period from the mid 1970's to late 1990's (Michaels et al., 2004). Hand hygiene deserves special attention due to the role of the hands as a causal agent in contributing to illnesses both historically and in the present day (Stewardson, Allegranzi, Sax, Kilpatrick, & Pittet, 2011). Handwashing, through wetting the hands, application of soap, lathering for 20 s, and drying with a single-use paper towel, is a simple, yet effective procedure for removing potential foodborne pathogens from employees' hands (Todd et al., 2010). ...
This study assessed hospitality students’ perceptions of a video game to determine likelihood of acceptance as one of three components of a habit-focused intervention to promote handwashing practices. The game was designed to be played while simultaneously washing hands and involved pressing a foot pedal that caused a character to jump over pipes to progress through a level. Students were shown a video of the game components and how to play it then given a survey based on a variant of the Technology Acceptance Model. Based on a 7-point Likert scale from “1 = Strongly disagree” to “7 = Strongly agree”, mean values for preference, perceived ease of use, perceived enjoyment, and perceived usefulness were, respectively, 4.73 ± 1.55, 5.26 ± 1.31, 4.98 ± 1.33, and 4.64 ± 1.56. Students (n = 100) expressed a slightly positive response towards video game use as evident by the survey results; one third of respondents had an average preference of “Agree” or higher for using the video game in foodservice. This study suggests the video game in its current state may have limited effectiveness in promoting handwashing practices. Future work should involve improving the game mechanics or implementing alternative reward mechanisms for promoting handwashing habits in foodservice.
... Over the last few decades there has been an increasing body of evidence to show that improved hand hygiene, with a particular focus on the use of ABHR, can reduce HAI rates Kingston et al., 2016); in particular bloodstream and surgical site infections (Stewardson et al., 2011). LMICs are underrepresented in these studies, with a systematic review on hand hygiene compliance finding that only 2 of 16 high-quality studies were performed within a LMIC context (Kingston et al., 2016). ...
Existing data suggests that hospital patients in LMICs are exposed to rates of HAIs at least 2-fold higher than in HICs. Hand hygiene is an evidence-based strategy to reduce both the transmission of pathogens via the hands of HCWs and the subsequent incidence of HAIs. In addition to the universal challenges to the implementation of effective hand hygiene strategies, hospitals in LMICs face a range of unique barriers, including overcrowding and securing a reliable and sustainable supply of ABHR. The WHO Multimodal Hand Hygiene Improvement Strategy and its associated resources represent an evidence-based framework for developing a locally-adapted implementation plan for hand hygiene promotion.
... A prominent indicator of human progress is the massive increase in life expectancy occurring during the last century. Basic scientific research has led to increased hygiene (Stewardson et al., 2011) , food availability through plant biotechnology (Kirakosyan et al., 2009) , disease prevention (Bennett et al., 2015) , and new cancer therapies (Ye, 2016) . ...
Over the past 50 years, songbirds have become a valuable model organism for scientists studying vocal communication from its behavioral, hormonal, neuronal, and genetic perspectives. Many advances in our understanding of vocal learning result from research using the zebra finch, a close-ended vocal learner. We review some of the manipulations used in zebra finch research, such as isolate housing, transient/irreversible impairment of hearing/vocal organs, implantation of small devices for chronic electrophysiology, head fixation for imaging, aversive song conditioning using sound playback, and mounting of miniature backpacks for behavioral monitoring. We highlight the use of these manipulations in scientific research, and estimate their impact on animal welfare, based on the literature and on data from our past and ongoing work. The assessment of harm-benefits tradeoffs is a legal prerequisite for animal research in Switzerland. We conclude that a diverse set of known stressors reliably lead to suppressed singing rate, and that by contraposition, increased singing rate may be a useful indicator of welfare. We hope that our study can contribute to answering some of the most burning questions about zebra finch welfare in research on vocal behaviors.
... Both authors implicated, for first time, the role of human hands contaminated with "cadaverous particles" in the deadly transmission process. Their legacy persists today, with considerable influence on current medicine, in which hand hygiene remains a liturgy in surgical procedures and is also a general measure with a pivotal role in the prevention and control of communicable diseases (4,5). ...
Biology of Hand-to-Hand Bacterial Transmission, Page 1 of 2
Abstract
Numerous studies have demonstrated that adequate hand hygiene among hospital staff is the best measure to prevent hand-to-hand bacterial transmission. The skin microbiome is conditioned by the individual physiological characteristics and anatomical microenvironments. Furthermore, it is important to separate the autochthonous resident microbiota from the transitory microbiota that we can acquire after interactions with contaminated surfaces. Two players participate in the hand-to-hand bacterial transmission process: the bacteria and the person. The particularities of the bacteria have been extensively studied, identifying some genera or species with higher transmission efficiency, particularly those linked to nosocomial infections and outbreaks. However, the human factor remains unstudied, and intrapersonal particularities in bacterial transmission have not been yet explored. Herein we summarize the current knowledge on hand-to-hand bacterial transmission, as well as unpublished results regarding interindividual and interindividual transmission efficiency differences. We designed a simple in vivo test based on four sequential steps of finger-to-finger contact in the same person artificially inoculated with a precise bacterial inoculum. Individuals can be grouped into one of three observed transmission categories: high, medium, and poor finger-to-finger transmitters. Categorization is relevant to predicting the ultimate success of a human transmission chain, particularly for the poor transmitters, who have the ability to cut the transmission chain. Our model allowed us to analyze transmission rate differences among five bacterial species and clones that cause nosocomial infections, from which we detected that Gram-positive microorganisms were more successfully transmitted than Gram-negative. Keywords: Skin; Individual Differences; Bacterial Transmission Efficiency
... GN-infections in turn lead to substantial morbidity, mortality and costs [6]. Interventions aimed at reducing the spread of nosocomial pathogens include contact precautions and isolation of patients, especially when multi-drug resistant (MDR) organisms are involved [7] and hand hygiene [8], which has been considered the most important control measures [9]. Despite evidence that transmission of pathogens by way of health care workers' hands is a major cause of nosocomial infections [10], compliance with policies and procedures for infection control has been uniformly poor [11]. ...
Background
Cross-transmission of nosocomial pathogens occurs frequently in intensive care units (ICU). The aim of this study was to investigate whether the introduction of a single room policy resulted in a decrease in transmission of multidrug-resistant (MDR) bacteria in an ICU. Methods
We performed a retrospective study covering two periods: between January 2002 and April 2009 (old-ICU) and between May 2009 and March 2013 (new-ICU, single-room). These periods were compared with respect to the occurrence of representative MDR Gram-negative bacteria. Routine microbiological screening, was performed on all patients on admission to the ICU and then twice a week. Multi-drug resistance was defined according to a national guideline. The first isolates per patient that met the MDR-criteria, detected during the ICU admission were included in the analysis. To investigate the clonality, isolates were genotyped by DiversiLab (bioMérieux, France) or Amplified Fragment Length Polymorphism (AFLP). To guarantee the comparability of the two periods, the ‘before’ and ‘after’ periods were chosen such that they were approximately identical with respect to the following factors: number of admissions, number of beds, bed occupancy rate, per year and month. ResultsDespite infection prevention efforts, high prevalence of MRD bacteria continue to occur in the original facility. A marked and sustained decrease in the prevalence of MDR-GN bacteria was observed after the migration to the new ICU, while there appear to be no significant changes in the other variables including bed occupancy and numbers of patient admissions. Conclusion
Single room ICU design contributes significantly to the reduction of cross transmission of MRD-bacteria.
... Therefore, extensive purging was the preferred treatment (6). In 1857, Semmelweis married Maria Weidenhoffer (1837-1910) and they had five children (3). In 1858, Semmelweis finally published his own account of his work in an essay entitled, "The Etiology of Childbed Fever". ...
Puerperal fever was common in mid-19(th)-century hospitals and often fatal, with mortality at 10%-35%. Ignaz Philipp Semmelweis was a Hungarian gynecologist who is known as a pioneer of antiseptic procedures. Semmelweis discovered that the incidence of puerperal fever could be drastically cut by the use of hand disinfection in obstetrical clinics. He is also described as the "savior of mothers" and "father of infection control". This paper provides an overview on the process of preventing puerperal fever and the life story of the physician behind this attempt, Ignaz Semmelweis, through philately.
... Few works in Medicine have had the interventional impact of the book "Etiology, Concept and Prophylaxis of Childbed Fever" by Ignaz Philipp Semmelweis, published in 1847. More than 165 years later, hand hygiene remains a general measure that significantly contributes to the prevention and control of communicable diseases; in healthcare settings, improved hand hygiene practices reduce cross-transmission of multidrug-resistant microorganisms, prevent healthcare-associated infections, and save costs (Stewardson et al. 2011;Monnet and Sprenger 2012). Surprisingly, during these 165 years, very little has been done to investigate the biological basis underlying the process of bacterial transmission by hands, and particularly from the side of possible variations among individual hosts. ...
A fingertip-to-fingertip intraindividual transmission experiment was carried out in 30 healthy volunteers, using four MLST-typed Enterococcus faecium clones. Overall results showed an adequate fit goodness to a theoretical exponential model, whereas four volunteers (13%) exhibited a significantly higher finger-to-finger bacterial transmission efficiency. This observation might have deep consequences in nosocomial epidemiology. © 2014 The Authors. MicrobiologyOpen published by John Wiley & Sons Ltd.
... The concept of cleaning hands with an antiseptic agent probably emerged in the early 19th century 5 and the first evidence of its superiority over plain soap and water in reducing transmission of health care-associated infection was provided by Ignaz Semmelweis in 1846 5,6 . Formal written guidelines on hand washing practices in hospitals have been developed by the Centers for Disease Control and Prevention (CDC) and Association for Professionals in Infection Control 7-10 . ...
While communicable diseases are the leading causes of morbidity and mortality in Malawi, the contribution of nosocomial or hospital-acquired infections (HAIs) is unknown but could be substantial. The single most important method of preventing nosocomial infections is hand hygiene. We report a study which was conducted in 2011 to investigate adherence to hand hygiene protocols by clinicians and medical students working at Queen Elizabeth Central Hospital in Blantyre, Malawi.
There were two parts to the study: a single blinded arm in which participants were observed without their knowledge by trained nurses; and a second arm which included self-completion of questionnaire after participant consent was obtained. The 2009 World Health Organization hand hygiene technique and recommendations which were adopted by Queen Elizabeth Central Hospital were used to define an opportunity for hand washing and effectiveness of hand washing. Hand hygiene effectiveness was defined as adherence to at least 6 out of 7 steps (80%) of the hand hygiene technique when using alcohol-based formulation or at least 8 out of 10 steps (80%) of the hand hygiene technique when using water and soap formulation before and after having direct contact with patients or their immediate surroundings.
Clinicians were found to have disinfected their hands more than medical students (p<0.05) but effectiveness was similar and very low between the two groups (p=0.2). No association was also found between having a personal hand sanitizer and hand hygiene practice (p=0.3). Adherence to hand hygiene was found to be 23%. Most of the participants mentioned infection transmission prevention as a reason for disinfecting their hands. Other reasons mentioned included: a routine personal hand hygiene behaviour and discomfort if not washing hands. The top three reasons why they did not disinfect hands were forgetfulness, unavailability of sanitizers and negligence.
Adherence to hand hygiene practice was found to be low, with forgetfulness and negligence being the major contributing factors. A hospital-wide multifaceted program aiming at clinicians and students education, adoption of alcohol based hand rubs as a primary formulation, production of colored poster reminders and encouraging role modeling of junior practitioners by senior practitioners can help improve compliance to hand hygiene.
... light switches, telephone dial buttons and handsets [48]. Meticulous hand hygiene is the best measure to prevent the common cold; frequent hand washing and avoid touching one's nose and eyes515253 . The use of alcohol-based hand sanitizers is also effective [54,55]. ...
Asthma is a major public health problem with a huge social and economic burden affecting 300 million people worldwide. Viral respiratory infections are the major cause of acute asthma exacerbations and may contribute to asthma inception in high risk young children with susceptible genetic background. Acute exacerbations are associated with decreased lung growth or accelerated loss of lung function and, as such, add substantially to both the cost and morbidity associated with asthma.
While the importance of preventing viral infection is well established, preventive strategies have not been well explored. Good personal hygiene, hand-washing and avoidance of cigarette smoke are likely to reduce respiratory viral infections. Eating a healthy balanced diet, active probiotic supplements and bacterial-derived products, such as OM-85, may reduce recurrent infections in susceptible children. There are no practical anti-viral therapies currently available that are suitable for widespread use.
Hand hygiene is the best measure to prevent the common cold. A healthy balanced diet, active probiotic supplements and immunostimulant OM-85 may reduce recurrent infections in asthmatic children.
Social pediatrics as a subdiscipline of pediatrics focuses on the comprehensive protection and interdisciplinary care of children and adolescents with developmental disorders, chronic diseases, disabilities or special healthcare needs, with the best possible support for participation and well-being, taking family and the social environment into account.
However, elements of social pediatrics can be found in other child health disciplines as they also require consideration of the social context of a sick child or adolescent for holistic treatment (biopsychosocial model).
If this view is extended to a group of people or an entire population with the aim of preventing diseases, identifying health risks at an early stage or preventing the progression of disease based on epidemiological data by means of prevention or interventional measures in the health, social, educational or youth welfare sector, this is referred to as public health. Child public health and social pediatrics are thus two sides of the same coin.
Institutionalized child public health is administratively and organizationally mapped and implemented in child and adolescent health services of the Public Health Service. Exemplarily, the individual, operational, social compensatory and epidemiological components of these activities are presented in this overview using the example of school entrance examinations.
Finally, the need for a prevention strategy is outlined as an urgent policy goal in the field of child public health to counteract impending future crises as early as possible (war and migration, climate change or chronic non-infectious diseases).
El presente trabajo aborda la evaluación de la gestión de la calidad de la atención que reciben los neonatos con complicaciones afiliados al Seguro Médico Siglo XXI (SMSXXI). En particular se enfoca en dos padecimientos rastreadores financiados por el SMSXXI: asfixia perinatal e hipoxia intrauterina, y dos padecimientos financiados por el Fondo de Protección contra Gastos Catastróficos (FPGC): sepsis neonatal y prematuridad. El estudio es ampliamente justificable pues estos padecimientos representan las principales complicaciones al nacimiento, un elevado riesgo de mortalidad, un alto gasto para su atención y el trabajo de personal de salud altamente especializado.
Background: To begin our research into the effects of human decision-making bias in cyber security, we explored an extensive list of decision-making biases, focusing on those with rigorous scientific research and robust empirical findings. From this literature review, a list was created of 87 biases along with definitions, study examples, and references for major and related works. These were presented to the cyber security professionals who related cyber examples. These examples are being compiled into a document that will be submitted for peer-review. While the list presented here is not exhaustive, we believe the survey of relevant biases detailed in the spreadsheet can provide utility to the community.
Análisis de los procesos de gestión de la calidad y resultados de evaluación de indicadores de calidad de la atención en 28 hospitales, en relación con dos padecimientos rastreadores del Seguro Médico Siglo XXI (SMSXXI): asfixia perinatal e hipoxia intrauterina (CIE 10 P21 y P20); y dos del Fondo de Protección contra Gastos Catastróficos (FPGC): sepsis neonatal (CIE 10 P36) y prematuridad (CIE 10 P07). El documento concluye con la presentación de una serie de recomendaciones y
propuestas de mejora derivadas de la evaluación.
The aim of this review is to show the historical aspects of hands washing for healthy life and explains how can reduce the transmission of community-acquired infectious agents by healthcare workers and patients. This review article is prepared based on available database. The key words used were hands washing, risk assessment, hands hygiene, bacterial flora, contamination, infection, nosocomial, tap water, sanitizer, bacterial resistance, hands bacterial flora, washing methods, antiseptics, healthcare workers, healthcare personnel, from PubMed, ScienceDirect, Embase, Scopus, Web of Sciences, and Google Scholar. Data were descriptively analyzed. The insistence on hand washing has a history of 1400 years. The research results indicate that the bacteria released from the female washed hands in wet and dry condition was lower than from the male's hands with a significance level (3 CFU vs. 8 CFU; confidence interval 95%, P ≤ 0.001). The valuable results of the study indicated that released amount of bacterial flora from wet hands is more than 10 times in compared to dry hands. In addition, established monitoring systems for washing hands before and after patient's manipulation as well as after toilet were dominant indices to prevent the transfer of infectious agents to the patients. Increasing awareness and belief of the healthcare workers have shown an important role by about 30% reduction in the transfection. Hand washing could reduce the episodes of transmission of infectious agents in both community and healthcare settings. However, hand washing is an important key factor to prevent transmission of infectious agents to patients. There is no standard method for measuring compliance. Thus, permanent monitoring of hand washing to reduce the transmission of infections is crucial. Finally, the personnel must believe that hand washing is an inevitable approach to infection control.
Background
The British Columbia Provincial Hand Hygiene Working Group was formed in September 2010 and tasked with the development and implementation of a provincial hand hygiene (HH) program for health care.
Methods
As part of an evaluation of the provincial HH program, qualitative key informant interviews of program developers, senior administrators, and field workers were performed from December 2011 to March 2012 (phase 1) and again in April to June 2013 (phase 2).
Results
The following 5 broad themes were identified: (1) the provincial HH program became a platform for cooperation; (2) standardization (of HH audits and program components) strengthened and provided credibility to the provincial HH program; (3) quality results and good communication enabled a learning process that resulted in positive change management; (4) with ownership came pride and program success; and (5) management support and infrastructure is needed to sustain a positive culture change.
Conclusion
Positive behavior change for HH can be achieved on a provincial scale through a program that is standardized, has mandated components, is well communicated, owned by the frontline workers, and receives sustained support from senior management.
Healthcare-acquired infections are a major source of morbidity and mortality in people living in residential aged care facilities. Compliance with hand hygiene by healthcare workers can reduce the risk of infection to residents, yet compliance rates are generally low. Infection-control advocates within the aged care sector are looking to conduct programs to improve rates among their staff. This review was conducted to identify a reproducible intervention to improve staff hand hygiene compliance within an Australian residential aged care facility.
Method: Medline, Embase, and CINAHL databases were searched for combinations of 'hand hygiene', 'hand washing', 'residential aged care facility', 'aged care', 'nursing home' and 'long-term care facility' from 2000 to current. Articles were excluded if the information was not clearly stated as pertaining to a residential aged care facility or if the data investigated staff knowledge or perceptions of hand hygiene.
Results: Most of the five articles included in the review reported an improvement in compliance rates. Studies were multimodal, had an education or training component, and included the promotion of alcohol-based hand rubs. Several used aspects of the World Health Organization's hand hygiene initiatives. Compliance audit tools across the studies were not consistent; thus, results may not be comparable.
Conclusion: There are few published studies which report interventions that improve hand hygiene compliance among healthcare workers within residential aged care facilities. Successful studies included the promotion of alcohol-based hand rubs. More research is needed to improve hand hygiene compliance in the aged care sector.
Aim:
The aim of this paper is to provide a review of the hand hygiene literature and to give an example of the use of this literature to create a multimodal sustainable hand hygiene program.
Background:
The literature describes six key ingredients to consider when designing a hand hygiene program. These ingredients include leadership engagement, environmental assessment, education, a tight feedback loop, communication and routine revitalization. Programs tend to be more successful when several of these ingredients are utilized.
Program implementation:
The multimodal program created and implemented at one academic medical center is described. This program is an example of using the six key ingredients found in the literature with an interesting marketing and revitalization strategy.
Conclusion:
The literature offers strategies that have led to successful programs in the past. The multimodal use of these strategies was demonstrated in the creation of a successful hand hygiene program at one academic medical center.
Background and study aims:
Although hand hygiene is the most important measure in preventing infection transmission in healthcare settings, adherence to recommendations among healthcare workers is low. We implemented and assessed the impact of a World Health Organization-recommended educational intervention to improve hand hygiene adherence at the endoscopy unit of a Brazilian tertiary hospital.
Patients and methods:
Hand hygiene adherence and techniques used by healthcare workers of the endoscopy unit in the course of their duties were observed unobtrusively by four nurses from the infection control unit. Data were collected at every opportunity for hand hygiene. Evaluations were carried out before and 1 and 10 months after an educational intervention. The intervention consisted of task-orientated training sessions, with live demonstrations of the multitude of opportunities for hand hygiene and the appropriate techniques. In addition to assessing hand hygiene practices, we also evaluated staff knowledge through standardized questionnaires administered before and after the education intervention. Adherence was defined as hand hygiene/disinfection at an opportunity for hand hygiene.
Results:
Adherence improved from 21.4 % before the intervention to 63.3 % 1 month and 73.5 % 10 months after the educational intervention. Correct answers to the questionnaire were 82.1 % on pre-intervention test and 85.7 % on post-intervention test.
Conclusion:
Hand hygiene rates were low before the education intervention and improved significantly after it. Against expectations, adherence to hand hygiene practices had increased further at 10 months after the intervention, reinforcing the intervention's positive impact.
Qualitative research produces large amounts of textual data in the form of transcripts and observational fieldnotes. The systematic and rigorous preparation and analysis of these data is time consuming and labour intensive. Data analysis often takes place alongside data collection to allow questions to be refined and new avenues of inquiry to develop. Textual data are typically explored inductively using content analysis to generate categories and explanations; software packages can help with analysis but should not be viewed as short cuts to rigorous and systematic analysis. High quality analysis of qualitative data depends on the skill, vision, and integrity of the researcher; it should not be left to the novice.
Different approaches to implementation of hygiene compliance monitoring are presented. The architecture and operation of an embedded distributed system for hygiene compliance monitoring are described. The performance of the system does not depend on the number of monitored areas, number of caregivers being monitored, and no network infrastructure is required. Note to Practitioners-The embedded system for hand hygiene monitoring system was designed to be used in healthcare institutions. The main function of the system is to monitor hand hygiene compliance according to the rules (based on the Ministry of Health and Long-Term Care guidelines) implemented as a part of the system software. The main components of the system are wearable electronic monitors, disinfectant dispensers, and monitored zones installed in the areas essential for hand hygiene compliance.
This is the second in a four-part series of articles detailing the epistemology of patient safety research. This article concentrates on issues of study design. It first considers the range of designs that may be used in the evaluation of patient safety interventions, highlighting the circumstances in which each is appropriate. The paper then provides details about an innovative study design, the stepped wedge, which may be particularly appropriate in the context of patient safety interventions, since these are expected to do more good than harm. The unit of allocation in patient safety research is also considered, since many interventions need to be delivered at cluster or service level. The paper also discusses the need to ensure the masking of patients, caregivers, observers and analysts wherever possible to minimise information biases and the Hawthorne effect. The difficulties associated with masking in patient safety research are described and suggestions given on how these can be ameliorated. The paper finally considers the role of study design in increasing confidence in the generalisability of study results over time and place. The extent to which findings can be generalised over time and place should be considered as part of an evaluation, for example by undertaking qualitative or quantitative measures of fidelity, attitudes or subgroup effects.
To conduct an independent evaluation of the first phase of the Health Foundation's Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals.
Mixed method evaluation involving five substudies, before and after design.
NHS hospitals in the United Kingdom.
Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals.
The SPI1 was a compound (multi-component) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change.
Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P < 0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration--monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items)--there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for "difference in difference" 2.1, 99% confidence interval 1.0 to 4.3; P = 0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P = 0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from 17% (63) to 13% (49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P = 0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals.
The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening.
To investigate the effectiveness of a multifaceted hand hygiene program involving the use of pocket-sized containers of antiseptic gel in long-term care facilities (LTCFs) with elderly residents.
In this clustered randomized controlled trial, Hong Kong LTCFs for elderly persons were recruited via snowball sampling. Staff hand hygiene adherence was directly observed, and residents' infections necessitating hospitalization were recorded. After a 3-month preintervention period, LTCFs were randomized to receive pocket-sized containers of alcohol-based gel, reminder materials, and education for all HCWs (treatment group) or to receive basic life support education and workshops for all healthcare workers (HCWs) (control group). A 2-week intervention period (April 1-15, 2007) was followed by 7 months of postintervention observations.
In the 3 treatment LTCFs, adherence to hand rubbing increased from 5 (1.5%) of 333 to 233 (15.9%) of 1,465 hand hygiene opportunities (P = .001)and total hand hygiene adherence increased from 86 (25.8%) of 333 to 488 (33.3%) of 1,465 opportunities (P = .01)after intervention; the 3 control LTCFs showed no significant change. In the treatment group, the incidence of serious infections decreased from 31 cases in 21,862 resident-days (1.42 cases per 1,000 resident-days) to 33 cases in 50,441 resident-days (0.65 cases per 1,000 resident-days) (P = .002), whereas in the control group, it increased from 16 cases in 32,726 resident-days (0.49 cases per 1,000 resident-days) to 85 cases in 81,177 resident-days (1.05 cases per 1,000 resident-days) (P = .004]). In the treatment group, the incidence of pneumonia decreased from 0.91 to 0.28 cases per 1,000 resident-days (P = .001) and the death rate due to infection decreased from 0.37 to 0.10 deaths per 1,000 resident-days (P = .01); the control group revealed no significant change.
A hand hygiene program involving the use of pocket-sized containers of antiseptic gel and education could effectively increase adherence to hand rubbing and reduce the incidence of serious infections in LTCFs with elderly residents.
Adherence to hand hygiene among healthcare workers (HCWs) is widely believed to be a key factor in reducing the spread of healthcare-associated infection. The objective of this study was to evaluate the impact of a multifaceted intervention to increase rates of adherence to hand hygiene among HCWs and to assess the effect on the incidence of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) colonization.
Cluster-randomized controlled trial.
Thirty hospital units in 3 tertiary care hospitals in Hamilton, Ontario, Canada.
After a 3-month baseline period of data collection, 15 units were randomly assigned to the intervention arm (with performance feedback, small-group teaching seminars, and posters) and 15 units to usual practice. Hand hygiene was observed during randomly selected 15-minute periods on each unit, and the incidence of MRSA colonization was measured using weekly surveillance specimens from June 2007 through May 2008.
We found that 3,812 (48.2%) of 7,901 opportunities for hand hygiene in the intervention group resulted in adherence, compared with 3,205 (42.6%) of 7,526 opportunities in the control group (P < .001; independent t test). There was no reduction in the incidence of hospital-acquired MRSA colonization in the intervention group.
Among HCWs in Ontario tertiary care hospitals, the rate of adherence to hand hygiene had a statistically significant increase of 6% with a multifaceted intervention, but the incidence of MRSA colonization was not reduced.
Few attempts to increase healthcare workers' hand hygiene compliance have included an in-depth analysis of the social and behavioural context in which hand hygiene is not undertaken. We used a mixed method approach to explore hand hygiene barriers in rural Indonesian healthcare facilities to develop a resource-appropriate adoption of international guidelines. Two hospitals and eight clinics (private and public) in a rural Indonesian district were studied for three months each. Hand hygiene compliance was covertly observed for two shifts each in three adult wards at two hospitals. Qualitative data were collected from direct observation, focus group discussions and semistructured in-depth and informal interviews within healthcare facilities and the community. Major barriers to compliance included longstanding water scarcity, tolerance of dirtiness by the community and the healthcare organisational culture. Hand hygiene compliance was poor (20%; 57/281; 95% CI: 16-25%) and was more likely to be undertaken after patient contact (34% after-patient contact vs 5% before-patient contact, P<0.001) and 'inherent' opportunities associated with contacts perceived to be dirty (49% 'inherent' vs 11% 'elective' opportunities associated with clean contacts, P<0.001). Clinicians frequently touched patients without hand hygiene, and some clinicians avoided touching patients altogether. The provision of clean soap and water and in-service training will not overcome strong social and behavioural barriers unless interventions focus on long term community education and managerial commitment to the provision of supportive working conditions.
After renovation of the adult intensive care unit (ICU) with installation of ten single rooms, an enhanced infection control program was conducted to control the spread of methicillin-resistant Staphylococcus aureus (MRSA) in our hospital.
Since the ICU renovation, all patients colonized or infected with MRSA were nursed in single rooms with contact precautions. The incidence of MRSA infection in the ICU was monitored during 3 different phases: the baseline period (phase 1); after ICU renovation (phase 2) and after implementation of a hand hygiene campaign with alcohol-based hand rub (phase 3). Patients infected with extended spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella species were chosen as controls because they were managed in open cubicles with standard precautions.
Without a major change in bed occupancy rate, nursing workforce, or the protocol of environmental cleansing throughout the study period, a stepwise reduction in ICU onset nonbacteraemic MRSA infection was observed: from 3.54 (phase 1) to 2.26 (phase 2, p = 0.042) and 1.02 (phase 3, p = 0.006) per 1000-patient-days. ICU onset bacteraemic MRSA infection was significantly reduced from 1.94 (phase 1) to 0.9 (phase 2, p = 0.005) and 0.28 (phase 3, p = 0.021) per 1000-patient-days. Infection due to ESBL-producing organisms did not show a corresponding reduction. The usage density of broad-spectrum antibiotics and fluoroquinolones increased from phase 1 to 3. However a significant trend improvement of ICU onset MRSA infection by segmented regression analysis can only be demonstrated when comparison was made before and after the severe acute respiratory syndrome (SARS) epidemic. This suggests that the deaths of fellow healthcare workers from an occupational acquired infection had an overwhelming effect on their compliance with infection control measures.
Provision of single room isolation facilities and promotion of hand hygiene practice are important. However compliance with infection control measures relies largely on a personal commitment, which may increase when personal safety is threatened.
The economical impact of absenteeism and reduced productivity due to acute infectious respiratory and gastrointestinal disease is normally not in the focus of surveillance systems and may therefore be underestimated. However, large community studies in Europe and USA have shown that communicable diseases have a great impact on morbidity and lead to millions of lost days at work, school and university each year. Hand disinfection is acknowledged as key element for infection control, but its effect in open, work place settings is unclear.
Our study involved a prospective, controlled, intervention-control group design to assess the epidemiological and economical impact of alcohol-based hand disinfectants use at work place. Volunteers in public administrations in the municipality of the city of Greifswald were randomized in two groups. Participants in the intervention group were provided with alcoholic hand disinfection, the control group was unchanged. Respiratory and gastrointestinal symptoms and days of work were recorded based on a monthly questionnaire over one year. On the whole, 1230 person months were evaluated.
Hand disinfection reduced the number of episodes of illness for the majority of the registered symptoms. This effect became statistically significant for common cold (OR = 0.35 [0.17 - 0.71], p = 0.003), fever (OR = 0.38 [0.14-0.99], p = 0.035) and coughing (OR = 0.45 [0.22 - 0.91], p = 0.02). Participants in the intervention group reported less days ill for most symptoms assessed, e.g. colds (2.07 vs. 2.78%, p = 0.008), fever (0.25 vs. 0.31%, p = 0.037) and cough (1.85 vs. 2.00%, p = 0.024). For diarrhoea, the odds ratio for being absent became statistically significant too (0.11 (CI 0.01 - 0.93).
Hand disinfection can easily be introduced and maintained outside clinical settings as part of the daily hand hygiene. Therefore it appears as an interesting, cost-efficient method within the scope of company health support programmes.
ISRCTN96340690.
Healthcare-associated infection (HAI) is costly and causes substantial morbidity. We sought to understand why some hospitals were engaged in HAI prevention activities while others were not. Because preliminary data indicated that hospital leadership played an important role, we sought better to understand which behaviors are exhibited by leaders who are successful at implementing HAI prevention practices in US hospitals.
We report phases 2 and 3 of a 3-phase study. In phase 2, 14 purposefully sampled US hospitals were selected from among the 72% of 700 invited hospitals whose lead infection preventionist had completed a quantitative survey on HAI prevention during phase 1. Qualitative data were collected during 38 semistructured phone interviews with key personnel at the 14 hospitals. During phase 3, we conducted 48 interviews during 6 in-person site visits to identify recurrent and unifying themes that characterize behaviors of successful leaders.
We found that successful leaders (1) cultivated a culture of clinical excellence and effectively communicated it to staff; (2) focused on overcoming barriers and dealt directly with resistant staff or process issues that impeded prevention of HAI; (3) inspired their employees; and (4) thought strategically while acting locally, which involved politicking before crucial committee votes, leveraging personal prestige to move initiatives forward, and forming partnerships across disciplines. Hospital epidemiologists and infection preventionists often played more important leadership roles in their hospital's patient safety activities than did senior executives.
Leadership plays an important role in infection prevention activities. The behaviors of successful leaders could be adopted by others who seek to prevent HAI.
Patient empowerment is a new concept in health care that has now been extended to the domain of patient safety. Within the framework of the development of the new World Health Organization (WHO) Guidelines on Hand Hygiene in Health Care, the authors conducted a review of the literature from 1997 to 2008 to identify the evidence supporting programs aimed at encouraging patients to take an active role in their care. Patient empowerment is an integral part of the WHO hand hygiene multimodal strategy. Hand hygiene promotion strategies that have demonstrated evidence of successfully empowering patients include one or all of the following components: educational tools, motivation and reminder tools, and role modeling. What is important is that programs and models to empower patients must be developed with an inbuilt evaluation component that includes both qualitative and quantitative measures to determine not only what works but under what conditions and within which organizational context.
To compare 3 measures of hand hygiene adherence-direct observation, product usage, and electronic counting devices-in an intensive care unit.
A 12-week observational study.
A 40-bed medical-surgical intensive care unit at a private tertiary care hospital. METHODS. Over a 12-week period, we assessed hand hygiene adherence by 3 different methods: direct observation of practice, collection of data from electronic counters for dispensers of alcohol-based hand rub, and measurement of the amount of product used (alcohol-based hand rub and chlorhexidine).
There were 2,249 opportunities for hand hygiene observed, and the overall rate of hand hygiene adherence was 62.3% (representing 1,402 cleansing episodes). A total of 76,389 dispensing episodes were recorded by the electronic devices. The mean number of dispensing episodes per patient-day was 53.8. There was 64.1 mL of alcohol-based hand rub used per patient-day (representing 65.5% of total product used) and 33.8 mL of chlorhexidine used per patient-day (representing 34.5%). There was no significant correlation between observed hand hygiene adherence and total product used per patient-day (r=0.18; P=.59).
Direct observation cannot be considered the gold standard for assessing hand hygiene, because there was no relationship between the observed adherence and the number of dispensing episodes or the volume of product used. Other means to monitor hand hygiene adherence, such as electronic devices and measurement of product usage, should be considered.
More than 5000 ambulatory surgical centers (ASCs) in the United States participate in the Medicare program. Little is known about infection control practices in ASCs. The Centers for Medicare & Medicaid Services (CMS) piloted an infection control audit tool in a sample of ASC inspections to assess facility adherence to recommended practices.
To describe infection control practices in a sample of ASCs.
All State Survey Agencies were invited to participate. Seven states volunteered; 3 were selected based on geographic dispersion, number of ASCs each state committed to inspect, and relative cost per inspection. A stratified random sample of ASCs was selected from each state. Sample size was based on the number of inspections each state estimated it could complete between June and October 2008. Sixty-eight ASCs were assessed; 32 in Maryland, 16 in North Carolina, and 20 in Oklahoma. Surveyors from CMS, trained in use of the audit tool, assessed compliance with specific infection control practices. Assessments focused on 5 areas of infection control: hand hygiene, injection safety and medication handling, equipment reprocessing, environmental cleaning, and handling of blood glucose monitoring equipment.
Proportion of facilities with lapses in each infection control category.
Overall, 46 of 68 ASCs (67.6%; 95% confidence interval [CI], 55.9%-77.9%) had at least 1 lapse in infection control; 12 of 68 ASCs (17.6%; 95% CI, 9.9%-28.1%) had lapses identified in 3 or more of the 5 infection control categories. Common lapses included using single-dose medication vials for more than 1 patient (18/64; 28.1%; 95% CI, 18.2%-40.0%), failing to adhere to recommended practices regarding reprocessing of equipment (19/67; 28.4%; 95% CI, 18.6%-40.0%), and lapses in handling of blood glucose monitoring equipment (25/54; 46.3%; 95% CI, 33.4%-59.6%).
Among a sample of US ASCs in 3 states, lapses in infection control were common.
Hand hygiene is the most effective way to stop the spread of microorganisms and to prevent healthcare-associated infections (HAI). The World Health Organization launched the First Global Patient Safety Challenge - Clean Care is Safer Care - in 2005 with the goal to prevent HAI globally. This year, on 5 May, the WHO s initiative SAVE LIVES: Clean Your Hands, which focuses on increasing awareness of and improving compliance with hand hygiene practices, celebrated its second global day. In this article, four Member States of the European Union describe strategies that were implemented as part of their national hand hygiene campaigns and were found to be noteworthy. The strategies were: governmental support, the use of indicators for hand hygiene benchmarking, developing national surveillance systems for auditing alcohol-based hand rub consumption, ensuring seamless coordination of processes between health regions in countries with regionalised healthcare systems, implementing the WHO's My Five Moments for Hand Hygiene, and auditing of hand hygiene compliance.
To evaluate the feasibility of using an electronic hand hygiene surveillance and feedback monitoring device.
A 2-phase pilot study included initial direct observation of hand hygiene practices as part of routine hospital quality assurance (phase I) and subsequent monitoring using an electronic hand hygiene surveillance device (phase II).
A 700-bed tertiary care teaching hospital.
Phase I included a convenience sample of healthcare workers. Phase II included 7 medical interns and 7 registered nurses recruited through email and at work-related meetings.
During phase I, healthcare workers were directly observed at patient room entry and exit during the period April through November 2008. During phase II, hand hygiene data were gathered through indirect observation using the electronic device during a 4-week period in August 2009. Twenty patient rooms were fitted with electronic trigger devices that signaled a reader unit worn by participants when they entered the room, and 70 dispensers for liquid soap or hand sanitizer were fitted with triggers that signaled the reader unit when the dispenser was used. The accuracy of the devices was checked by the principal investigator, who manually recorded his room entries and exits and dispenser use while wearing a reader unit.
During phase I, hand hygiene occurred before room entry for 95 (25.1%) and after room exit for 149 (39.4%) of 378 directly observed patient room visits, for a cumulative composite compliance rate of 32.3%. Among the 378 room visits, 347 (91.8%) involved contact with the patient and/or environment. During phase II, electronic monitoring revealed a cumulative composite compliance rate of 25.5%. The electronic device captured 61 (98%) of 62 manually recorded room entries and 133 (95%) of 140 manually recorded dispensing events.
The electronic hand hygiene surveillance device seems to be a practical method for routinely monitoring hand hygiene compliance in healthcare workers.
Foams containing 62% ethanol are used for hand decontamination in many countries. A long drying time may reduce the compliance of healthcare workers in applying the recommended amount of foam. Therefore, we have investigated the correlation between the applied amount and drying time, and the bactericidal efficacy of ethanol foams.
In a first part of tests, four foams (Alcare plus, Avagard Foam, Bode test foam, Purell Instant Hand Sanitizer) containing 62% ethanol, which is commonly used in U.S. hospitals, were applied to 14 volunteers in a total of seven variations, to measure drying times. In a second part of tests, the efficacy of the established amount of foam for a 30 s application time of two foams (Alcare plus, Purell Instant Hand Sanitizer) and water was compared to the EN 1500 standard of 2 x 3 mL applications of 2-propanol 60% (v/v), on hands artificially contaminated with Escherichia coli. Each application used a cross-over design against the reference alcohol with 15 volunteers.
The mean weight of the applied foam varied between 1.78 and 3.09 g, and the mean duration to dryness was between 37 s and 103 s. The correlation between the amount of foam applied and time until hands felt dry was highly significant (p < 0.001; Pearson's correlation coefficient: 0.724; 95% confidence interval: 0.52-0.93). By linear correlation, 1.6 g gave an intercept of a 30 s application time. Application of 1.6 g of Purell Instant Hand Sanitizer (mean log10-reduction: 3.05 +/- 0.45) and Alcare plus (3.58 +/- 0.71) was significantly less effective than the reference disinfection (4.83 +/- 0.89 and 4.60 +/- 0.59, respectively; p < 0.001). Application of 1.6 g of water gave a mean log10-reduction of 2.39 +/- 0.57.
When using 62% ethanol foams, the time required for dryness often exceeds the recommended 30 s. Therefore, only a small volume is likely to be applied in clinical practice. Small amounts, however, failed to meet the efficacy requirements of EN 1500 and were only somewhat more effective than water.
Handwashing practices are often based on tradition and belief. To develop sound rationale for handwashing practices, the physiologic and bacteriologic effects of handwashing must be examined. The purposes of this article are to review the three major microenvironments of the skin with their bacterial flora, to discuss physiologic and bacteriologic characteristics of the skin with particular reference to handwashing, and to describe current handwashing recommendations and practices.
Previous studies 1 of the transmission of staphylococci to newborn infants suggested that organisms on the hands of personnel carriers are more important than organisms expelled into the air from the respiratory tracts of such carriers. In addition, these studies provided evidence which indicates that the air is not a major route of spread of organisms between infants.
The fact that organisms nonetheless do spread readily from one infant to another suggests that the hands of personnel may play a role in the transport of staphylococci between infants. The present studies were
designed to test the effectiveness of handwashing by nursery personnel in preventing the spread of organisms between infants and thus to provide indirect evidence regarding the importance of this mode of spread. In addition, an attempt was made to test the role of the airborne route in the transmission of staphylococci among newborns. In order to provide results
Sir.— The topical use of isopropyl alcohol for fever control in children was once on accepted pediatric practice. Since the late 1950s, this practice has been discouraged following reports of neurotoxic effects that include stupor, narcosis, coma, and even death.1,2 Unfortunately, sponging with rubbing alcohol remains a fairly common method for fever control in children in some communities. We describe a patient with coma secondary to sponging with isopropyl and discuss the clinical clues for the diagnosis.
Patient Report.—Fever to 40°C developed in a previously healthy 18-month-old girl while she was being treated with amoxicillin for otitis media. In an attempt to lower her temperature, her mother repeatedly wrapped towels absorbed with rubbing alcohol around the child's waist for periods of up to four hours. The child became progressively lethargic and ultimately unresponsive to verbal and tactile stimulation. At the time she arrived at our intensive care unit, she was unconscious and unresponsive to pain, with midline fixed miotic pupils
BACKGROUND: Transmission of microorganisms from the hands of health care workers is the main source of cross-infection in hospitals and can be prevented by handwashing. OBJECTIVE: To identify predictors of noncompliance with handwashing during routine patient care. DESIGN: Observational study. SETTING: Teaching hospital in Geneva, Switzerland. PARTICIPANTS: Nurses (66%), physicians (10%), nursing assistants (13%), and other health care workers (11%). MEASUREMENTS: Compliance with handwashing. RESULTS: In 2834 observed opportunities for handwashing, average compliance was 48%. In multivariate analysis, noncompliance was higher among physicians (odds ratio [OR], 2.8 [95% CI, 1.9 to 4.1]), nursing assistants (OR, 1.3 [CI, 1.0 to 1.6]), and other health care workers (OR, 2.1 [CI, 1.4 to 3.2]) than among nurses and was lowest on weekends (OR, 0.6 [CI, 0.4 to 0.8]). Noncompliance was higher in intensive care than in internal medicine units (OR, 2.0 [CI, 1.3 to 3.1]), during procedures that carry a high risk for contamination (OR, 1.8 [CI, 1.4 to 2.4]), and when intensity of patient care was high (compared with 60 opportunities: OR, 2.1 [CI, 1.3 to 3.5]). CONCLUSIONS: Compliance with handwashing was moderate. Variation across hospital ward and type of health care worker suggests that targeted educational programs may be useful. Even though observational data cannot prove causality, the association between noncompliance and intensity of care suggests that understaffing may decrease quality of patient care.
This review describes Semmelweis' achievement 150 years ago. User acceptability of hand disinfectants has been improved, but Semmelweis' observation that handwashing, in contrast to hygienic hand disinfection, is not always sufficiently effective, is not yet generally acknowledged, and the compliance of medical personnel to the rules of hand hygiene still remains an educational problem to be solved. Curr Opin Infect Dis 11:457-460. 1998 Lippincott-Raven Publishers
A 30-month-old child who became comatose following sponging with rubbing alcohol was successfully managed with gastric lavage, 10% dextrose in normal saline, and Isolyte in 10% dextrose. All aliphatic alcohols are central nervous system depressants. Reported serum levels have been between 125–200 mg/100 cc and include both fatalities and self-limited comas. In a discussion of the pathophysiology, it is pointed out that high concentrations of isopropyl alcohol and ethanol can result in cardiac arrest or severe hypotension. Liver damage is common. Treatment includes intensive care with intravenous fluids, temperature control, respiratory assistance, transfusion, gastric lavage, and dialysis.
Multidrug-resistant organisms (MDROs) such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) und extended-spectrum β-lactamase (ESBL-) producing bacteria are an ever-expanding challenge regarding infection control and prevention strategies also in ambulatory healthcare settings. The most important transmission mode for MDROs is direct or indirect contact involving the hands of healthcare workers. Strict adherence to standard precautions (and especially adherence to alcoholic handrub use) is essential in prevention of cross-transmission. Additional measures contribute to the control of MDROs: These include flagging of patients’ records, establishing standards of care for patients with MDROs, continuing education of staff, disclosure of information to other involved healthcare providers and guideline-based antibiotic treatment and prophylaxis. Optimised cooperation of ambulatory healthcare providers and hospitals regarding management and control of MDROs (networking) is a promising future option.
Modern medicine still has to contend with the major problem of infections resulting from patient care. Despite considerable evidence that appropriate hand hygiene is the leading measure to reduce cross-infection, compliance with recommendations remains notoriously low among healthcare workers. In high-demand situations, such as in most critical-care units, or at times of overcrowding or understaffing, promoting hand cleansing with an alcohol-based handrub solution seems to be the most practical means of improving compliance. It requires less time, acts faster, irritates hands less often, and is superior to traditional handwashing or medicated hand antiseptic agents. Furthermore, it was used in the only programme that reported a sustained improvement in hand-hygiene compliance associated with decreased infection rates. Although easy access to fast-acting hand-hygiene agents is the main tool of any campaign to obtain sustained improvement with hand-hygiene practices, a multidisciplinary approach is necessary to produce behavioural change.
Human factors engineering is a discipline that studies the capabilities and limitations of humans and the design of devices and systems for improved performance. The principles of human factors engineering can be applied to infection prevention and control to study the interaction between the healthcare worker and the system that he or she is working with, including the use of devices, the built environment, and the demands and complexities of patient care. Some key challenges in infection prevention, such as delayed feedback to healthcare workers, high cognitive workload, and poor ergonomic design, are explained, as is how human factors engineering can be used for improvement and increased compliance with practices to prevent hospital-acquired infections.
The CDC guideline for hand hygiene describes chlorhexidine gluconate as an agent with "substantial residual activity". But not all studies support this claim. In both suspension tests (e.g. EN 13727) and tests under practical conditions (e.g. EN 1500) it is crucial to neutralize any residual activity in the sampling fluid in order to make sure that the agent does not continue to damage surviving cells after exposure. The neutralization step must also be validated. If this is not done the efficacy may be significantly overestimated, and the healthcare professional may rely on data which do not represent the true efficacy of an agent. A review of eight studies which are cited to support "substantial residual activity" show that none of them were performed with validated neutralization. Seven of them do not demonstrate any residual activity for chlorhexidine gluconate. Only in one study some residual activity is described but the validity of the study design does not allow make this claim as no neutralizing agents were used at all. The benefits of using an active agent must outweigh any risks in order to justify its use. If no real benefits are left for chlorhexidine gluconate in hand hygiene, all the risks count even more such as skin irritation, allergic reactions including anaphylactic shock, and acquired bacterial resistance. Unless there is new and valid evidence to clearly support a benefit of using chlorhexidine gluconate in hand hygiene, healthcare workers should prefer formulations without this agent.
Prevalence of hospital-acquired meticillin-resistant Staphylococcus aureus (MRSA) infection or colonisation has been associated with antimicrobial consumption. The impact of antibiotic treatment on nasal colonisation is unknown. We conducted a three-month prospective study of 116 patients with extranasal MRSA infection or colonisation, whose nasal MRSA bacterial loads were determined during and after various antibiotic courses over a period of three weeks. Environmental swabs were also taken from the near patient environment. Concomitant nasal MRSA carriage was observed in 76.7% of extranasal MRSA-colonised or -infected patients. The median nasal MRSA bacterial load increased significantly from 2.78 (range 0-6.15) to 5.30 (range 2.90-8.41) log(10) cfu per swab (cfu/swab) (P<0.001) over 21 days during beta-lactam therapy. It also increased from 0 (range 0-4.00) to 4.30 (range 0-7.46) log(10)cfu/swab (P=0.039) over 14 days during fluoroquinolone therapy. Median bacterial loads were significantly higher for beta-lactam- and fluoroquinolone-treated patients on day 7 [4.78, range 0-7.30], day 14 [4.30, range 0-7.60] and day 21 [5.30, range 2.90-8.41] than controls not receiving antibiotics (P<0.05). These loads then decreased by 2-5log(10)cfu/swab 2 weeks after discontinuation of antibiotics. The environment of patients receiving beta-lactam agents (relative risk: 3.55; 95% confidence interval: 1.30-9.62; P=0.018) or fluoroquinolones (4.32; 1.52-12.31; P=0.008) demonstrated more MRSA contamination than the environment around control patients (0.79; 0.67-0.93; P=0.002). Patients on beta-lactam or fluoroquinolone therapy have increased incidence of MRSA colonisation and higher nasal bacterial loads, and appear to spread their MRSA into the near patient environment.
To evaluate hand hygiene compliance in 2 adult step-down units (SDUs).
A 6-month (from March to September 2007), controlled trial comparing 2 SDUs, one with a feedback intervention program (ie, the intervention unit) and one without (ie, the control unit).
Two 20-bed SDUs at a tertiary care private hospital.
Hand hygiene episodes were measured by electronic recording devices and periodic observational surveys. In the intervention unit, feedback was provided by the SDU nurse manager, who explained twice a week to the healthcare workers the goals and targets for the process measures.
A total of 117,579 hand hygiene episodes were recorded in the intervention unit, and a total of 110,718 were recorded in the control unit (P = .63). There was no significant difference in the amount of chlorhexidine used in the intervention and control units (34.0 vs 26.7 L per 1,000 patient-days; P = .36) or the amount of alcohol gel used (72.5 vs 70.7 L per 1,000 patient-days; P = .93). However, in both units, healthcare workers used alcohol gel more frequently than chlorhexidine (143.2 vs 60.7 L per 1,000 patient-days; P < .001). Nosocomial infection rates in the intervention and control units, respectively, were as follows: for bloodstream infection, 3.5 and 0.79 infections per 1,000 catheter-days (P = .18); for urinary tract infection, 15.8 and 15.7 infections per 1,000 catheter-days (P = .99); and for tracheostomy-associated pneumonia, 10.7 and 5.1 infections per 1,000 device-days (P = .13). There were no cases of infection with vancomycin-resistant enterococci and only a single case of infection with methicillin-resistant Staphylococcus aureus (in the control unit).
The feedback intervention regarding hand hygiene had no significant effect on the rate of compliance. Other measures must be used to increase and sustain the rate of hand hygiene compliance.
The inhalation of ethyl or isopropylalcohol vapor during sponge bathing may result in alcohol intoxication and coma. Ingestion of these alcohols may cause hypoglycemia in children or adults.
The present case is the first reported in which alcohol-induced hypoglycemia developed following inhalation of alcohol.
A six month-old male infant became comatose following sponge bathing with ethyl alcohol. He was found to have acute alcohol intoxication (blood alcohol 220 mg per 100 ml) and severe hypoglycemia (blood glucose 22 mg per 100 ml). The administration of 50% glucose in water intravenously resulted in prompt recovery.
Alcohol sponging to lower elevated temperature is rarely necessary. Cooling with tepid water is effective and considerably less hazardous; the addition of alcohol is not necessary.
Benchmarking of surveillance data for health-care-associated infection (HCAI) has been used for more than three decades to inform prevention strategies and improve patients' safety. In recent years, public reporting of HCAI indicators has been mandated in several countries because of an increasing demand for transparency, although many methodological issues surrounding benchmarking remain unresolved and are highly debated. In this Review, we describe developments in benchmarking and public reporting of HCAI indicators in England, France, Germany, and the USA. Although benchmarking networks in these countries are derived from a common model and use similar methods, approaches to public reporting have been more diverse. The USA and England have predominantly focused on reporting of infection rates, whereas France has put emphasis on process and structure indicators. In Germany, HCAI indicators of individual institutions are treated confidentially and are not disseminated publicly. Although evidence for a direct effect of public reporting of indicators alone on incidence of HCAIs is weak at present, it has been associated with substantial organisational change. An opportunity now exists to learn from the different strategies that have been adopted.
Reduced biocide susceptibility in staphylococci is associated with quaternary ammonium compound (qac) gene-encoding efflux proteins. This study compared the prevalence of antiseptic-resistance genes (qacA/B, smr) in staphylococci colonising nurses and non-healthcare workers. Staphylococcus aureus and coagulase-negative staphylococci (CoNS) isolated from 249 nurses were compared for qacA/B and smr positivity with carriage isolates from non-healthcare workers. Associations between qac genes and antibiotic resistance were investigated and minimum inhibitory concentrations (MICs)/minimum bactericidal concentrations (MBCs) to benzalkonium chloride and chlorhexidine determined. Both genes had higher prevalence in CoNS from nurses (OR: 8.4; 95% CI: 5.4-13.2) and qacA/B was more common in nurses'S. aureus isolates than those of the general population (OR: 5.5; 95% CI: 2.7-11.2). Meticillin-resistant S. aureus (MRSA) carriage was low (3.2% nurses; 0.5% general population). The risk of harbouring qacA/B and smr was associated with presence of mecA (OR: 2.9; 95% CI: 1.8-4.8) and contact with MRSA-infected patients (OR: 2.0; 95% CI: 1.0-3.9) in S. aureus and CoNS. S. aureus with qac genes displayed significantly more antibiotic resistance and all gene-positive isolates had higher MICs and MBCs to antiseptics. Increased prevalence of antiseptic-resistance genes in staphylococci from nurses indicates that the hospital environment could exert selective pressure for carriage of these strains. The increased proportion of qac genes in meticillin-resistant strains suggests co-selection of these genes, as does the increased carriage of gene-positive strains by those in contact with MRSA-positive patients. Reduced antiseptic susceptibility may allow persistence of organisms in the presence of low level residues and contribute to survival of MRSA.
The World Health Organization (WHO) First Global Patient Safety Challenge conducted a baseline survey of coordinated large-scale activities in improving hand hygiene in healthcare in 2007. The survey was repeated in early 2009 to assess current status and generate information on factors contributing to success. Coordinated activities were identified through WHO regional offices and experts in the field. An online survey using a structured questionnaire was conducted during March-April 2009. Personnel involved in all 38 campaigns/programmes in 2009 completed the survey. Of these, 29 were active national/subnational-level initiatives and 22 (75.8%) were initiated after the Challenge launch in October 2005. Main targets were general, district, and university hospitals with increasing coverage of long-term care facilities and primary care. The scope varied from awareness-raising to formal scaled-up activities with ongoing evaluation. Most initiatives (20/29) obtained funding from multiple sources with governments among the main funders; governments also initiated 25/29 (86.2%) programmes. The facilitator role played by the Challenge in initiating and supporting activities with tools and recommendations was clearly identified. The perceived significance of specific barriers varied considerably across initiatives. Those related to commitment (priority and support) and resource availability were important across all regions. Hand hygiene is being promoted in healthcare in many nations/subnations with clear objectives, strategies, and governmental support through policies and resource allocation. While this is important for sustainability, further action is required to initiate coordinated activities across the world, including countries with limited resources.
Infection prevention and control experts have expended valuable health service time developing and implementing tools to audit health workers' hand hygiene compliance by direct observation. Although described as the 'gold standard' approach to hand hygiene audit, this method is labour intensive and may be inaccurate unless performed by trained personnel who are regularly monitored to ensure quality control. New technological devices have been developed to generate 'real time' data, but the cost of installing them and using them during routine patient care has not been evaluated. Moreover, they do not provide as much information about the hand hygiene episode or the context in which hand hygiene has been performed as direct observation. Uptake of hand hygiene products offers an inexpensive alternative to direct observation. Although product uptake would not provide detailed information about the hand hygiene episode or local barriers to compliance, it could be used as a continuous monitoring tool. Regular inspection of the data by infection prevention and control teams and clinical staff would indicate when and where direct investigation of practice by direct observation and questioning of staff should be targeted by highly trained personnel to identify local problems and improve practice.
Healthcare-associated infections (HAIs) affect at least 300,000 patients annually in the UK and represent a significant, yet largely preventable, burden to healthcare systems. Hand hygiene by healthcare workers (HCWs) is the leading prevention measure, but compliance with good practice is generally low. The UK National Patient Safety Agency surveyed the public, inpatients, and HCWs, particularly frontline clinical staff and infection control nurses, in five acute care hospitals to determine whether they agreed that a greater level of involvement and engagement with patients would contribute to increased compliance with hand hygiene and reduce HAIs. Fifty-seven percent (302/530) of the public were unlikely to question doctors on the cleanliness of their hands as they assumed that they had already cleaned them. Forty-three percent (90/210) of inpatients considered that HCWs should know to clean their hands and trusted them to do so, and 20% (42/210) would not want HCWs to think that they were questioning their professional ability to do their job correctly. Most HCWs surveyed (178/254, 71%) said that HAI could be reduced to a greater or lesser degree if patients asked HCWs if they had cleaned their hands before touching them. Inviting patients to remind HCWs about hand hygiene through the provision of individual alcohol-based hand-rub containers and actively supporting an 'It's OK to ask' attitude were perceived as the most useful interventions by both patients and HCWs. However, further work is required to refute the myth among HCWs that patient involvement undermines the doctor- or HCW-patient relationship.
Background: Although hand hygiene (HH) remains the most important intervention to reduce healthcare associated infections, compliance by healthcare workers (HCWs) remains suboptimal and no interventions have been found to produce sustained, high levels of compliance.
Objective: To assess the efficacy of alcohol sensor technology on improving HH compliance.
Methods: Hand hygiene compliance was determined by a trained nurse-observer over a 4-week period (100 hours total observation time) in a 35-bed inpatient ward at an 820-bed, urban, academic medical center. Three weeks later, 18 nurses on the same unit were assigned to wear alcohol sensor badges (BioVigil LLC, Santa Rosa, CA) for a two-week period. The badges are activated at the doorway and alert the HCW with light and sound upon entry and exit. If alcohol is detected within 8 seconds of room entry a positive recording is made and the badge light turns green. If alcohol is not detected, a negative reading is recorded and the badge light turns red. The compliance data for each badge is instantaneously transmitted via wireless telemetry to a centralized database; however for the purpose of the study no feedback on performance was given to nurses. HH compliance was compared between the two time periods.
Results: In the pre-intervention control phase (1,070 visual observations), HH compliance among nurses was 73%. In the intervention phase (6,318 electronic observations by continuous monitoring), HH compliance was 92% (p<0.0001), and individual compliance ranged from 72% to 100% with a median compliance of 93%. 44% of nurses had compliance rates ≥95%. Compliance on room entry was 90% and on room exit 94%. There was <2% difference in compliance rates between work shifts (7am-3pm, 3-11pm, 11pm-7am). Using the alcohol sensor badges, we determined that there are 10.5 HH opportunities per nurse-hour.
Conclusions: Our study demonstrated easy adoption of an alcohol sensing badge in the clinical setting, with a rapid and significant improvement in HH compliance to very high levels. Nearly half of nurses achieved ≥95% compliance. Moreover, if this technology were coupled with performance feedback by supervisors and patients were instructed to observe the color of the badge light before contact with the HCW, it seems likely that HH compliance could be driven to essentially perfect performance levels. Lastly, we demonstrated that the number of HH opportunities for nurses when formally measured is vast.
Patient safety is a healthcare priority worldwide, with most hospitals engaging in activities to improve care quality, safety and outcomes. Despite these efforts, we have limited understanding of why quality improvement efforts are successful in some hospitals and not others. Using data collected as part of a multi-center study, we closely examined quality improvement efforts and the implementation of recommended practices to prevent central line-associated bloodstream infections (CLABSI) in U.S. hospitals. We compare and contrast the experiences among hospitals to better understand 'how' and 'why' certain hospitals were more successful with practice implementation when taking into consideration specific aspects of the organizational context. This study reveals that among a number of hospitals that focused on implementing practices to prevent CLABSI, the experience and outcomes varied considerably despite using similar implementation strategies. Moreover, our findings provide important insights about how and why different quality improvement strategies might perform across organizations with differing contextual characteristics.
Background:
Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure.
Objectives:
To update the review done in 2007, to assess the short and longer-term success of strategies to improve hand hygiene compliance and to determine whether a sustained increase in hand hygiene compliance can reduce rates of health care-associated infection.
Search strategy:
We conducted electronic searches of: the Cochrane Central Register of Controlled Trials; the Cochrane Effective Practice and Organisation of Care Group specialised register of trials; MEDLINE; PubMed; EMBASE; CINAHL; and the BNI. Originally searched to July 2006, for the update databases were searched from August 2006 until November 2009.
Selection criteria:
Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series analyses meeting explicit entry and quality criteria used by the Cochrane Effective Practice and Organisation of Care Group were eligible for inclusion. Studies reporting indicators of hand hygiene compliance and proxy indicators such as product use were considered. Self-reported data were not considered a valid measure of compliance. Studies to promote hand hygiene compliance as part of a care bundle approach were included, providing data relating specifically to hand hygiene were presented separately. Studies were excluded if hand hygiene was assessed in simulations, non-clinical settings or the operating theatre setting.
Data collection and analysis:
Two reviewers independently extracted data and assessed data quality.
Main results:
Four studies met the criteria for the review: two from the original review and two from the update. Two studies evaluated simple education initiatives, one using a randomized clinical trial design and the other a controlled before and after design. Both measured hand hygiene compliance by direct observation. The other two studies were both interrupted times series studies. One study presented three separate interventions within the same paper: simple substitutions of product and two multifaceted campaigns, one of which included involving practitioners in making decisions about choice of hand hygiene products and the components of the hand hygiene program. The other study also presented two separate multifaceted campaigns, one of which involved application of social marketing theory. In these two studies follow-up data collection continued beyond twelve months, and a proxy measure of hand hygiene compliance (product use) was recorded. Microbiological data were recorded in one study. Hand hygiene compliance increased for one of the studies where it was measured by direct observation, but the results from the other study were not conclusive. Product use increased in the two studies in which it was reported, with inconsistent results reported for one initiative. MRSA incidence decreased in the one study reporting microbiological data.
Authors' conclusions:
The quality of intervention studies intended to increase hand hygiene compliance remains disappointing. Although multifaceted campaigns with social marketing or staff involvement appear to have an effect, there is insufficient evidence to draw a firm conclusion. There remains an urgent need to undertake methodologically robust research to explore the effectiveness of soundly designed and implemented interventions to increase hand hygiene compliance.
Public reporting of hospital performance has been proposed as a means of improving quality of care while ensuring both transparency and accountability.1 Organizations feel pressure to perform well, deriving from their desire to protect market share and defend reputations. This pressure, if effectively harnessed, can lead to an increase in quality improvement activities and better patient outcomes, although the evidence supporting the latter claim is mixed.1
We performed a prospective multicenter study to assess the dryness and irritation of the hands in health care facilities, and to evaluate whether that disinfection with an alcohol-based hand rub (ABHR) is better tolerated than classic handwashing with mild soap and water. Our study was conducted in 9 sites in the summer and winter. A team of investigators evaluated dryness and irritation. This study takes into account most of the individual and environmental risk factors (age, sex, use of a protective agent, constitutional factors, personal factors, external factors, institution, function, and number of consecutive working days). The results from the 1932 assessments collected show that traditional handwashing is a risk factor for dryness and irritation, whereas the use of ABHR causes no skin deterioration and might have a protective effect, particularly in intensive use. These results provide a strong argument to counter the rear-guard resistance to the use of ABHRs.
The role of patients and their relatives as unidentified transient meticillin-resistant Staphylococcus aureus (MRSA) carriers and sources of dissemination in healthcare institutions has not been systematically addressed. Patients' and their relatives' hands may represent a substantial and 'unaccounted for' mode of transmission. This study aimed to verify this hypothesis in our 250-bed community hospital. The trial consisted of a systematic waterless washing and gel rinse disinfection of all patients' and visiting relatives' hands for a period of one year, along with retrospective comparison of the nosocomial infection rates. Under the supervision of infection control personnel, a team of four full-time and four part-time attendants was trained to meet all patients and visiting relatives and encourage them to clean their hands with an alcohol gel rinse twice a day on every weekday. Rates of MRSA infections per thousand admissions, cost-benefit analysis and staff hand hygiene compliance were audited throughout. From the comparative year, the rate of MRSA nosocomial infections per thousand admissions decreased by 51%. Assuming that the incidence of MRSA was maintained from comparative to study year, the intervention may have prevented 51 cases of MRSA infection and resulted in substantial savings. While focusing extensively on staff behaviour to prevent MRSA transmission, we may have overlooked hand hygiene practices by patients and their relatives as a potential mode of transmission. Systematic hand hygiene of patients and relatives appears to be an inexpensive and highly effective preventive measure against MRSA nosocomial transmission.
Alcohol-based hand rubs (ABHRs) are an effective means of decreasing the transmission of bacterial pathogens. Alcohol is not effective against Clostridium difficile spores. We examined the retention of C. difficile spores on the hands of volunteers after ABHR use and the subsequent transfer of these spores through physical contact.
Nontoxigenic C. difficile spores were spread on the bare palms of 10 volunteers. Use of 3 ABHRs and chlorhexidine soap-and-water washing were compared with plain water rubbing alone for removal of C. difficile spores. Palmar cultures were performed before and after hand decontamination by means of a plate stamping method. Transferability of C. difficile after application of ABHR was tested by having each volunteer shake hands with an uninoculated volunteer.
Plain water rubbing reduced palmar culture counts by a mean (+/- standard deviation [SD]) of 1.57 +/- 0.11 log10 colony-forming units (CFU) per cm2, and this value was set as the zero point for the other products. Compared with water washing, chlorhexidine soap washing reduced spore counts by a mean (+/- SD) of 0.89 +/- 0.34 log10 CFU per cm2; among the ABHRs, Isagel accounted for a reduction of 0.11 +/- 0.20 log10 CFU per cm2 (P = .005), Endure for a reduction of 0.37 +/- 0.42 log10 CFU per cm2 (P = .010), and Purell for a reduction of 0.14 +/- 0.33 log10 CFU per cm2 (P = .005). There were no statistically significant differences between the reductions achieved by the ABHRs; only Endure had a reduction statistically different from that for water control rubbing (P = .040). After ABHR use, handshaking transferred a mean of 30% of the residual C. difficile spores to the hands of recipients.
Hand washing with soap and water is significantly more effective at removing C. difficile spores from the hands of volunteers than are ABHRs. Residual spores are readily transferred by a handshake after use of ABHR.
Nosocomial bloodstream infections are a major cause of morbidity and mortality in neonatal intensive care units. Appropriate hand hygiene is singled out as the most important measure in preventing these infections. However, hand hygiene compliance among healthcare professionals remains low despite the well-known effect on infection reduction.
We studied the effectiveness of a hand hygiene education program on the incidence of nosocomial bloodstream infections.
Observational study with two pretests and two posttest measurements and interrupted time series analysis.
A 27 bed level IIID neonatal intensive care unit in a teaching hospital in the Netherlands.
Healthcare professionals who had physical contact with very low birth weight (VLBW) infants.
The study was conducted during a period of 4 years. Medical and nursing staff followed a problem-based education program on hand hygiene. Hand hygiene practices before and after the education program were compared by guided observations. The incidence of nosocomial infections in VLBW infants was compared. In addition, numbers of nosocomial bloodstream infections per day-at-risk in very low birth weight infants were analyzed by a segmented loglinear regression analysis.
During 1201 observations hand hygiene compliance before patient contact increased from 65% to 88% (p<0.001). Median (interquartile range) drying time increased from 4s (4-10) to 10s (7-14) (p<0.001). The proportion of very low birth weight infants with one or more bloodstream infections and the infection rate per 1000 patient days (relative risk reduction) before and after the education program on hand hygiene intervention decreased from 44.5% to 36.1% (18.9%, p=0.03) and from 17.3% to 13.5% (22.0%, p=0.03), respectively. At the baseline the nosocomial bloodstream infections per day-at-risk decreased by +0.07% (95% CI -1.41 to +1.60) per month and decreased with -1.25% (95% CI -4.67 to +2.44) after the intervention (p=0.51). The level of instant change was -14.8% (p=0.48).
The results are consistent with relevant improvement of hand hygiene practices among healthcare professionals due to an education program. Improved hand hygiene resulted in a reduction in nosocomial bloodstream infections.