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Xiao S, Li C, Zhao F, Lin R, Zhang N, Li Y. A coupled hand and surface hygiene criterion on heterogeneous surface touch networks. JOURNAL OF HAZARDOUS MATERIALS 2024; 479:135589. [PMID: 39191014 DOI: 10.1016/j.jhazmat.2024.135589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 07/27/2024] [Accepted: 08/19/2024] [Indexed: 08/29/2024]
Abstract
Contaminated hands of people and contaminated surfaces of inanimate objects (fomites) can spread microbes that cause enteric and respiratory infections. Thus, hand hygiene and surface hygiene are probably the most widely adopted public health interventions for controlling such infections. However, conclusions of studies on the effectiveness of these interventions are often inconsistent, likely because such studies have examined these interventions separately and thus not detected their interactions, leading to differing conclusions about their individual impact. In this study, it is proposed that hand and environmental surface hygiene (including disinfection) should be coupled to control contamination spread between surfaces, especially within heterogeneous surface touch networks. In these networks, surfaces and individuals have varying contact frequencies and patterns, reflecting the diverse and non-uniform interactions that typically occur in real-world environments. Accordingly, we propose a new theoretical framework to delineate the relationships between hand hygiene and surface hygiene. In addition, the performance of a model based on this framework that used real-world behavioural data from a graduate student office is reported. Moreover, a coupled hygiene criterion for heterogeneous networks is derived. This criterion stipulates that the product of the pathogen-removal rates for hands and surfaces must exceed a cleaning threshold to ensure the exponential decay of contamination. Failure to meet this threshold results in a non-zero steady prevalence of contamination. Furthermore, the cleaning threshold increases as the numbers of surfaces and hands increase, highlighting the significant impact of network structures on hygiene practices. Thus, extensive cleaning may be necessary in crowded indoor environments with many surfaces and occupants, such as cruise ships, to prevent super-large outbreaks of, for example, noroviral infections. Overall, the findings of this study reveal how improved and integrated hygiene control can prevent fomite transmission.
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Affiliation(s)
- Shenglan Xiao
- Shenzhen Key Laboratory of Pathogenic Microbes and Biosafety, School of Public Health (Shenzhen), Shenzhen Campus of Sun Yat-sen University, Shenzhen 518107, PR China; Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, PR China
| | - Congying Li
- Shenzhen Key Laboratory of Pathogenic Microbes and Biosafety, School of Public Health (Shenzhen), Shenzhen Campus of Sun Yat-sen University, Shenzhen 518107, PR China
| | - Fangli Zhao
- Shenzhen Key Laboratory of Pathogenic Microbes and Biosafety, School of Public Health (Shenzhen), Shenzhen Campus of Sun Yat-sen University, Shenzhen 518107, PR China
| | - Ruizhen Lin
- Shenzhen Key Laboratory of Pathogenic Microbes and Biosafety, School of Public Health (Shenzhen), Shenzhen Campus of Sun Yat-sen University, Shenzhen 518107, PR China
| | - Nan Zhang
- Beijing Key Laboratory of Green Built Environment and Energy Efficient Technology, Beijing University of Technology, Beijing 100124, PR China
| | - Yuguo Li
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong, PR China.
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Boyce JM, Pittet D. Rinse, gel, and foam - is there any evidence for a difference in their effectiveness in preventing infections? Antimicrob Resist Infect Control 2024; 13:49. [PMID: 38730473 PMCID: PMC11084031 DOI: 10.1186/s13756-024-01405-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/01/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Following publication of the 2009 World Health Organizations Guidelines for Hand Hygiene in Health Care, a debate has emerged regarding the relative antimicrobial efficacy of the different formats (rinse, gel, foam) of ABHRs and their ability to contribute to reduction of healthcare-associated infections (HAIs). METHODS Data regarding the in-vivo antimicrobial efficacy of ABHRs and other factors that likely affect their effectiveness in reducing HAIs were reviewed, and a comprehensive review of studies that reported the effectiveness of each of the three ABHR formats to improve hand hygiene compliance and reduce HAIs was conducted. RESULTS The amount of rubbing time it takes for hands to feel dry (dry time) is the major driver of ABHR antimicrobial efficacy. ABHR format is not a major factor, and several studies found that rinse, gel, and foam ABHRs have comparable in-vivo antimicrobial efficacy. Other factors that likely impact the ability of ABHRs to reduce transmission of healthcare-associated pathogens and HAIs include ABHR formulation, the volume applied to hands, aesthetic characteristics, skin tolerance, acceptance by healthcare personnel, and hand hygiene compliance rates. When accompanied by complementary strategies, promoting the use of each of the three ABHR formats has been associated with improvements in hand hygiene compliance rates. A review of 67 studies failed to identify an ABHR format that was significantly more effective in yielding statistically significant reductions in transmission of healthcare-associated pathogens or HAIs. CONCLUSIONS Current evidence is insufficient to definitively determine if one ABHR format is more effective in reducing transmission of healthcare-associated pathogens and HAIs. More rigorous studies such as multicenter randomized controlled trials comparing the different formats are needed to establish if one format is significantly more effective in reducing HAIs.
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Affiliation(s)
| | - Didier Pittet
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Reinoso Schiller N, Bludau A, Mathes T, König A, von Landesberger T, Scheithauer S. Unpacking nudge sensu lato: insights from a scoping review. J Hosp Infect 2024; 143:168-177. [PMID: 37949370 DOI: 10.1016/j.jhin.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Abstract
Nudges may play an important role in improving infection prevention and control (IPC) in hospitals. However, despite the novelty of the framework, their objectives, strategies and implementation approaches are not new. This review aims to provide an overview of the methods typically used by nudge interventions in IPC in hospitals targeting healthcare workers (HCWs). The initial search in PubMed yielded nine hits. Consequently, the search criteria were broadened and a second search was conducted, introducing 'nudge sensu lato' which incorporates insights from sources beyond the traditional nudge framework while maintaining the same objectives, strategies and approaches. During the second search, PubMed, Epistemonikos, Web of Science and PsycInfo were searched in accordance with the PRISMA guidelines. Abstracts were screened, and reviewers from an interdisciplinary team read the full text of selected papers. In total, 5706 unique primary studies were identified. Of these, 67 were included in the review, and only four were listed as nudge sensu stricto, focusing on changing HCWs' hand hygiene. All articles reported positive intervention outcomes. Of the 56 articles focused on improving hand hygiene compliance, 71.4% had positive outcomes. For healthcare equipment disinfection, 50% of studies showed significant results. Guideline adherence interventions had a 66.7% significant outcome rate. The concept of nudge sensu lato was introduced, encompassing interventions that employ strategies, methods and implementation approaches found in the nudge framework. The findings demonstrate that this concept can enhance the scientific development of more impactful nudges. This may help clinicians, researchers and policy makers to develop and implement effective nudging interventions.
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Affiliation(s)
- N Reinoso Schiller
- Department for Infection Control and Infectious Diseases, University Medical Centre Göttingen, Georg-August University Göttingen, Göttingen, Germany.
| | - A Bludau
- Department for Infection Control and Infectious Diseases, University Medical Centre Göttingen, Georg-August University Göttingen, Göttingen, Germany
| | - T Mathes
- Department of Medical Statistics, University Medical Centre Göttingen, Georg-August University Göttingen, Göttingen, Germany
| | - A König
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre Göttingen, Georg-August University Göttingen, Göttingen, Germany
| | - T von Landesberger
- Chair for Visualization and Visual Analytics, University of Cologne, Cologne, Germany
| | - S Scheithauer
- Department for Infection Control and Infectious Diseases, University Medical Centre Göttingen, Georg-August University Göttingen, Göttingen, Germany
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Habihirwe P, Marini H, Wurtz B, Vermeulin T, Lottin M, Gehanno JF, Boulet L, Vergnes H, Edet S, Guet L, Le Roy F, Merle V. Compliance with good practice guidelines for the prevention of vascular access infections: the multi-centre PHYDEL survey in French haemodialysis units. J Hosp Infect 2023; 142:1-8. [PMID: 37734680 DOI: 10.1016/j.jhin.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/01/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND French guidelines for the prevention of vascular access infections in a haemodialysis setting were released in 2005. Compliance with these guidelines is currently unknown. The aim of this study was to assess compliance with the guidelines for vascular access infection prevention in French haemodialysis units, and to describe the difficulties reported. METHODS A cross-sectional survey was conducted between March and December 2019 in 200 haemodialysis units in France, selected at random. Data were collected via questionnaire, completed by telephone interview with an infection control practitioner. A practice was deemed compliant when >85% of units declared that they always complied with the guidelines. RESULTS In total, 103 units (51.5%) agreed to participate. Most practices complied with the guidelines; however, some practices did not reach the 85% compliance threshold for working in pairs when connecting central venous catheter (CVC) lines, performing hand hygiene before disconnecting lines, rinsing antiseptic soap before painting CVC exit site or arteriovenous fistula (AVF) puncture site, allowing antiseptic paint to dry, handling CVC branches with antiseptic impregnated gauze, performing hand hygiene after AVF compression with gloves, wearing protective eyewear when connecting/disconnecting CVC or when puncturing AVF, and wearing a gown when puncturing AVF. The most frequently reported difficulties were understaffing, difficulties with skin preparation because of exit site skin damage, and lack of buttonhole technical expertise. CONCLUSIONS Despite good overall compliance, this survey highlights some shortcomings in compliance with infection prevention guidelines, which could be associated with either higher risk of vascular access infection or increased blood-borne virus transmission.
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Affiliation(s)
- P Habihirwe
- Department of Infection Control, CHU Rouen, Rouen, France
| | - H Marini
- Department of Infection Control, CHU Rouen, Rouen, France; Research Group Dynamiques et Evènements des Soins et des Parcours, CHU Rouen, Rouen, France
| | - B Wurtz
- Department of Infection Control, CHU Rouen, Rouen, France; Research Group Dynamiques et Evènements des Soins et des Parcours, CHU Rouen, Rouen, France; REIN Registry, Agence de Biomédecine, Paris, France
| | - T Vermeulin
- Research Group Dynamiques et Evènements des Soins et des Parcours, CHU Rouen, Rouen, France; Comprehensive Cancer Centre Henri Becquerel, UNICANCER, Rouen, France
| | - M Lottin
- Department of Infection Control, CHU Rouen, Rouen, France; Research Group Dynamiques et Evènements des Soins et des Parcours, CHU Rouen, Rouen, France
| | - J F Gehanno
- Department of Occupational Health, CHU Rouen, Rouen, France
| | - L Boulet
- Department of Infection Control, CHU Rouen, Rouen, France; Research Group Dynamiques et Evènements des Soins et des Parcours, CHU Rouen, Rouen, France
| | | | - S Edet
- REIN Registry, Agence de Biomédecine, Paris, France; Department of Nephrology and Haemodialysis, CHU Rouen, Rouen, France; ANIDER Rouen Normandie, Rouen, France
| | - L Guet
- CPIAS Normandie, Rouen, France
| | - F Le Roy
- Department of Nephrology and Haemodialysis, CHU Rouen, Rouen, France
| | - V Merle
- Department of Infection Control, CHU Rouen, Rouen, France; Research Group Dynamiques et Evènements des Soins et des Parcours, CHU Rouen, Rouen, France; REIN Registry, Agence de Biomédecine, Paris, France.
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Carling PC, Parry MF, Olmstead R. Environmental approaches to controlling Clostridioides difficile infection in healthcare settings. Antimicrob Resist Infect Control 2023; 12:94. [PMID: 37679758 PMCID: PMC10483842 DOI: 10.1186/s13756-023-01295-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 08/25/2023] [Indexed: 09/09/2023] Open
Abstract
As today's most prevalent and costly healthcare-associated infection, hospital-onset Clostridioides difficile infection (HO-CDI) represents a major threat to patient safety world-wide. This review will discuss how new insights into the epidemiology of CDI have quantified the prevalence of C. difficile (CD) spore contamination of the patient-zone as well as the role of asymptomatically colonized patients who unavoidable contaminate their near and distant environments with resilient spores. Clarification of the epidemiology of CD in parallel with the development of a new generation of sporicidal agents which can be used on a daily basis without damaging surfaces, equipment, or the environment, led to the research discussed in this review. These advances underscore the potential for significantly mitigating HO-CDI when combined with ongoing programs for optimizing the thoroughness of cleaning as well as disinfection. The consequence of this paradigm-shift in environmental hygiene practice, particularly when combined with advances in hand hygiene practice, has the potential for significantly improving patient safety in hospitals globally by mitigating the acquisition of CD spores and, quite plausibly, other environmentally transmitted healthcare-associated pathogens.
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Haghpanah F, Lin G, Klein E. Deconstructing the effects of stochasticity on transmission of hospital-acquired infections in ICUs. ROYAL SOCIETY OPEN SCIENCE 2023; 10:230277. [PMID: 37711144 PMCID: PMC10498044 DOI: 10.1098/rsos.230277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 08/17/2023] [Indexed: 09/16/2023]
Abstract
The inherent stochasticity in transmission of hospital-acquired infections (HAIs) has complicated our understanding of transmission pathways. It is particularly difficult to detect the impact of changes in the environment on acquisition rate due to stochasticity. In this study, we investigated the impact of uncertainty (epistemic and aleatory) on nosocomial transmission of HAIs by evaluating the effects of stochasticity on the detectability of seasonality of admission prevalence. For doing so, we developed an agent-based model of an ICU and simulated the acquisition of HAIs considering the uncertainties in the behaviour of the healthcare workers (HCWs) and transmission of pathogens between patients, HCWs, and the environment. Our results show that stochasticity in HAI transmission weakens our ability to detect the effects of a change, such as seasonality patterns, on acquisition rate, particularly when transmission is a low-probability event. In addition, our findings demonstrate that data compilation can address this issue, while the amount of required data depends on the size of the said change and the degree of uncertainty. Our methodology can be used as a framework to assess the impact of interventions and provide decision-makers with insight about the minimum required size and target of interventions in a healthcare facility.
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Affiliation(s)
| | - Gary Lin
- One Health Trust, Washington, DC, USA
| | - Eili Klein
- One Health Trust, Washington, DC, USA
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Dexter F, Brown JR, Wall RT, Loftus RW. The efficacy of multifaceted versus single anesthesia work area infection control measures and the importance of surgical site infection follow-up duration. J Clin Anesth 2023; 85:111043. [PMID: 36566648 PMCID: PMC9892236 DOI: 10.1016/j.jclinane.2022.111043] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/28/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Earlier a randomized trial showed efficacy of a multifaceted intervention approach for reducing surgical site infection: hand hygiene, vascular care, environmental cleaning, patient decolonization (nasal povidone iodine, chlorhexidine wipes), with feedback on pathogen transmission. The follow-up prospective observational study showed effectiveness when applied to all operating rooms of an inpatient surgical suite. In practice, many organizations will at baseline not be using conditions equivalent to the control groups but instead functionally have had ongoing a single intervention for infection control (e.g., encouraging better hand hygiene). Organizations also differ in how well and long they survey every surgical patient for postoperative surgical site infection. Thus, estimation of the expected net cost savings from implementing multifaceted intervention depends on the relative efficacy of multifaceted approach versus single intervention approaches and on the incidence of surgical site infection, the latter depending itself on the monitoring period for infection development. METHODS The retrospective cohort analysis included 4865 patients from two single intervention and two multifaceted studies, each of the four studies with matched control groups. We used Poisson regression with robust variance to estimate the relative risk reduction in surgical site infections for the multifaceted approach versus single interventions and, with 30-day follow-up versus ≥60-day follow-up for infection. RESULTS The multifaceted approach was associated with an estimated 68% reduction in postoperative surgical site infections relative to single interventions (risk ratio 0.32, 97.5% confidence interval 0.15-0.70, P = 0.001). There were approximately 2.61-fold more surgical site infections detected with follow-up for at least 60 days of medical records relative to 30 days of records reviewed (97.5% CI 1.62 to 4.21, P < 0.001). CONCLUSIONS An evidence-based, multifaceted approach to anesthesia work area infection control can generate substantial reductions in surgical site infections. A follow-up period of at least 60-days is indicated for infection detection.
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Affiliation(s)
- Franklin Dexter
- University of Iowa, 200 Hawkins Drive, Iowa City, IA 52240, United States.
| | - Jeremiah R Brown
- Dartmouth-Hitchcock Medical Center, WTRB 6, Lebanon, NH 03756, United States.
| | - Russell T Wall
- MedStar Georgetown University Hospital, 3800 Reservoir Road, NW, CCC Building, Lower Level, Washington, DC 20007, United States.
| | - Randy W Loftus
- University of Iowa, 200 Hawkins Drive, Iowa City, IA 52240, United States.
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Wu S, Wang RS, Huang YN, Wan TTH, Tung TH, Wang BL. Effect of Hand Hygiene Intervention in Community Kindergartens: A Quasi-Experimental Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14639. [PMID: 36429356 PMCID: PMC9691028 DOI: 10.3390/ijerph192214639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 06/16/2023]
Abstract
This study aimed to evaluate the effect of hand hygiene interventions on the overall hand hygiene (HH) status of teaching instruction of hand hygiene in kindergartens, given the vulnerability of kindergarten children and their high risk due to infectious diseases and the current COVID-19 epidemic. We investigated the HH status of teachers from two kindergartens in the same community. The participants were recruited from 28 classes in both kindergartens. After completing the baseline survey, the intervention program consisted of three components: lectures on infectious diseases, lectures on HH, and seven-step hand washing techniques conducted in two kindergartens. The intervention program effectively increased teachers' perceived disease susceptibility (p < 0.05), reduced the total bacterial colonization of children's hands (p < 0.001), and improved the HH environment (p < 0.01). We recommend that health authorities or kindergartens adopt this HH intervention program to effectively improve the HH status in kindergartens and allow for preventive responses to the COVID-19 epidemic or other emerging infectious diseases.
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Affiliation(s)
- Shiyang Wu
- Department of Public Health, Macau University of Science Technology, Macau 999078, China
| | - Richard Szewei Wang
- Affiliation Program of Data Analytics and Business Computing, Stern School of Business, New York University, New York, NY 10012, USA
| | - Yu-Ni Huang
- College of Public Health, National Taiwan University, Taipei 100, Taiwan
| | - Thomas T. H. Wan
- School of Global Health Management and Informatics, University of Central Florida, Orlando, FL 32816, USA
| | - Tao-Hsin Tung
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou 317000, China
| | - Bing-Long Wang
- School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
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Szumska E, Czajkowski P, Zablocki M, Rozkiewicz D. The Association between Hand Disinfection Techniques and Their Barriers, as Well as the "Bare below the Elbows" Concept, among Healthcare Professionals-A Study Based on a Polish Population. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191811781. [PMID: 36142054 PMCID: PMC9517209 DOI: 10.3390/ijerph191811781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/05/2022] [Accepted: 09/15/2022] [Indexed: 06/01/2023]
Abstract
Hand hygiene is the most effective way to prevent nosocomial infections. Nevertheless, the hands of healthcare professionals are still the primary route of transmission of pathogens responsible for such infections. The aim of this study was to evaluate hand disinfection techniques and investigate the risk factors that may explain the improper hand disinfection techniques among healthcare workers. We selected 7544 hospital workers directly involved in patient care. We recorded data based on the questionnaires, demographic data, and the preparation of hands for disinfection, including risk factors. Correct hand disinfection was verified by COUCOU BOX, with a UV camera. Proper hand disinfection was demonstrated among 4879 (64.7%) subjects, while 2665 (35.3%) subjects disinfected their hands incorrectly. In most places of work, nurses properly disinfected their hands more often than the physicians, particularly in general departments (62.1% vs. 69.2%; p = 0.0019). We observed that long nails and artificial/polished nails were more often observed in the group of nurses than in the group of physicians (7.3% vs. 4.7%, respectively; p = 0.0006 and 19.3% vs. 10.1%; p = 0.0000), while an inverse relationship was found in relation to watches (24.0% vs. 12.0%; p = 0.0000) and long sleeves (24.4% vs. 8.1%; p = 0.0000). Incorrect and less effective hand hygiene among some groups of hospital workers is still present. Therefore, the continuation of education actions concerned with hand hygiene among healthcare workers is needed.
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Affiliation(s)
- Emilia Szumska
- Medilab Sp. z o. o., Niedzwiedzia 60, 15-531 Bialystok, Poland
| | - Przemyslaw Czajkowski
- Clinical Research Centre, Medical University of Bialystok, Jana Kilinskiego 1, 15-089 Bialystok, Poland
| | - Michal Zablocki
- Medilab Sp. z o. o., Niedzwiedzia 60, 15-531 Bialystok, Poland
| | - Dorota Rozkiewicz
- Department of Pediatric Infectious Diseases, Medical University of Bialystok, Waszyngtona 17, 15-274 Bialystok, Poland
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Zhang Y, Song Q, Tian Y, Zhao G, Zhou Y. Insights into biomacromolecule-based alcogels: A review on their synthesis, characteristics and applications. Food Hydrocoll 2022. [DOI: 10.1016/j.foodhyd.2022.107574] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Wall RT, Datta S, Dexter F, Ghyasi N, Robinson ADM, Persons D, Boling KA, McCloud CA, Krisanda EK, Gordon BM, Koff MD, Yeager MP, Brown J, Wong CA, Loftus RW. Effectiveness and feasibility of an evidence-based intraoperative infection control program targeting improved basic measures: a post-implementation prospective case-cohort study. J Clin Anesth 2022; 77:110632. [PMID: 34929497 DOI: 10.1016/j.jclinane.2021.110632] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/04/2021] [Accepted: 12/09/2021] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE A randomized controlled study demonstrated that an optimized intraoperative infection control program targeting basic preventive measures can reduce Staphylococcus aureus transmission and surgical site infections. In this study we address potential limitations of operating room heterogeneity of infections and compliance with behavioral interventions following adoption into clinical practice. DESIGN A post-implementation prospective case-cohort study. SETTING Twenty-three operating rooms at a large teaching hospital. PATIENTS A total of 801 surgical patients [425 (53%) women; 350 (44%) ASA > 2, age 54.6 ± 15.9 years] were analyzed for the primary and 804 for the secondary outcomes. INTERVENTIONS A multifaceted, evidence-based intraoperative infection control program involving hand hygiene, vascular care, and environmental cleaning improvements was implemented for 23 operating room environments. Bacterial transmission monitoring was used to provide monthly feedback for intervention optimization. MEASUREMENTS S. aureus transmission (primary) and surgical site infection (secondary). MATERIALS AND METHODS The incidence of S. aureus transmission and surgical site infection before (3.5 months) and after (4.5 months) infection control optimization was assessed. Optimization was defined by a sustained reduction in anesthesia work area bacterial reservoir isolate counts. Poisson regression with robust error variances was used to estimate the incidence risk ratio (IRR) of intraoperative S. aureus transmission and surgical site infection for the independent variable of optimization. MAIN RESULTS Optimization was associated with decreased S. aureus transmission [24% before (85/357) to 9% after (42/444), IRR 0.39, 95% CI 0.28 to 0.56, P < .001] and surgical site infections [8% before (29/360) and 3% after (15/444) (IRR 0.42, 95% CI 0.23 to 0.77, P = .005; adjusted for American Society of Anesthesiologists' physical status, aIRR 0.45, 95% CI 0.25 to 0.82, P = .009]. CONCLUSION An optimized intraoperative infection control program targeting improvements in basic preventive measures is an effective and feasible approach for reducing S. aureus transmission and surgical site infection development.
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Affiliation(s)
- Russell T Wall
- Department of Anesthesia, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Subhradeep Datta
- Medical Student Class of 2022, Georgetown University, Washington, DC, United States
| | - Franklin Dexter
- Department of Anesthesia, University of Iowa, Iowa City, IA, United States
| | - Niloofar Ghyasi
- Medical Student Class of 2022, Georgetown University, Washington, DC, United States
| | - Alysha D M Robinson
- Medical Laboratory Scientist, RDB Bioinformatics, Iowa City, IA, United States
| | - Deanna Persons
- Laboratory Assistant, RDB Bioinformatics, Iowa City, IA, United States
| | - Kate A Boling
- Research Assistant, Georgetown University, Washington, DC, United States
| | | | - Emily K Krisanda
- Medical Student Class of 2022, Georgetown University, Washington, DC, United States
| | - Brandon M Gordon
- Information Technologist, RDB Bioinformatics, Iowa City, IA, United States
| | - Matthew D Koff
- Department of Anesthesia, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
| | - Mark P Yeager
- Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
| | - Jeremiah Brown
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH, United States
| | - Cynthia A Wong
- Department of Anesthesia, University of Iowa, Iowa City, IA, United States
| | - Randy W Loftus
- Department of Anesthesia, University of Iowa, Iowa City, IA, United States.
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Guía clínica de la Sociedad Española de Nefrología para la prevención y tratamiento de la infección peritoneal en diálisis peritoneal. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Mouajou V, Adams K, DeLisle G, Quach C. HAND HYGIENE COMPLIANCE IN THE PREVENTION OF HOSPITAL ACQUIRED INFECTIONS: A SYSTEMATIC REVIEW. J Hosp Infect 2021; 119:33-48. [PMID: 34582962 DOI: 10.1016/j.jhin.2021.09.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Healthcare worker's (HCW) hands are known to be a primary source of transmission of hospital-acquired infections (HAIs). Thus, practicing hand hygiene (HH) and adhering to HH guidelines are both expected to decrease the risk of transmission but there is no consensus on the optimal hand hygiene compliance (HHC) rate that HCWs should aim for. AIM The objective of this study was to systematically review the published literature to determine an optimal threshold of HCW HHC rate associated with the lowest incidence rate of HAIs. METHODS This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. We searched online databases using a comprehensive search criterion for randomized controlled trials and non-randomized controlled studies, investigating the impact of HCW's HHC rate on HAI rates in patients of all ages, within healthcare facilities in high income countries. FINDINGS Of the 8,093 articles citations and abstracts screened, 35 articles were included in the review. Most studies reported overall HAIs per 1000 patient-days and device-associated HAIs per 1000 device-days. Most studies reported HHC rates between 60%-70%. Lower incidence HAI rates seemed to be achieved with HHC rates of approximately 60%. Studies included were not originally designed to assess the impact of HHC on HAI rates but risk of bias was assessed as per our predetermined exposure and outcome criterion. 11 (31%) of studies were deemed at low risk of bias. CONCLUSIONS Although HHC is part of HCW's code of conduct, very high HHC rates were difficult to reach. In observational studies, HHC and HAI followed a negative relationship up to about 60%. Due to flaws in study design, causality could not be inferred; only general trends could be discussed. Given the limitations, there is a need for high-quality evidence to support the implementation of specified targets of HHC rates.
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Affiliation(s)
- V Mouajou
- Department of Microbiology, Infectious Disease and Immunology, University of Montreal, Montreal, QC, Canada
| | - K Adams
- Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada; Research Centre, CHU Sainte-Justine, Montreal, QC, Canada
| | - G DeLisle
- Research Centre, CHU Sainte-Justine, Montreal, QC, Canada
| | - C Quach
- Department of Microbiology, Infectious Disease and Immunology, University of Montreal, Montreal, QC, Canada; Research Centre, CHU Sainte-Justine, Montreal, QC, Canada; Infection Prevention and Control, CHU Sainte-Justine, Montreal, QC, Canada.
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Health Care Environmental Hygiene: New Insights and Centers for Disease Control and Prevention Guidance. Infect Dis Clin North Am 2021; 35:609-629. [PMID: 34362536 DOI: 10.1016/j.idc.2021.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Recent research has significantly clarified the impact of optimizing patient-zone environmental hygiene. New insights into the environmental microbial epidemiology of many hospital-associated pathogens, especially Clostridioides difficile, have clarified and quantified the role of ongoing occult pathogen transmission from the near-patient environment. The recent development of safe, broadly effective surface chemical disinfectants has led to new opportunities to broadly enhance environmental hygiene in all health care settings. The Centers for Disease Control and Prevention has recently developed a detailed guidance to assist all health care settings in implementing optimized programs to mitigate health care-associated pathogen transmission from the near-patient surfaces.
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A Review of Clostridioides difficile Infection and Antibiotic-Associated Diarrhea. Gastroenterol Clin North Am 2021; 50:323-340. [PMID: 34024444 DOI: 10.1016/j.gtc.2021.02.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Antibiotic-associated diarrhea and Clostridioides difficile infection (CDI) occur frequently among adults. The pathophysiology of CDI is related to disruption of normal gut flora and risk factors include hospitalization, use of antibiotic therapy, and older age. Clinical manifestations can range from mild disease to toxic megacolon. Diagnosis is challenging and is based on a combination of clinical symptoms and diagnostic tests. Therapy includes cessation of antibiotics, or use of other agents depending on the severity of illness. Many novel agents for the treatment and prevention of CDI show promise and are under investigation.
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Principi N, Gnocchi M, Gagliardi M, Argentiero A, Neglia C, Esposito S. Prevention of Clostridium difficile Infection and Associated Diarrhea: An Unsolved Problem. Microorganisms 2020; 8:E1640. [PMID: 33114040 PMCID: PMC7690700 DOI: 10.3390/microorganisms8111640] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/18/2020] [Accepted: 10/19/2020] [Indexed: 02/08/2023] Open
Abstract
For many years, it has been known that Clostridium difficile (CD) is the primary cause of health-care-associated infectious diarrhea, afflicting approximately 1% of hospitalized patients. CD may be simply carried or lead to a mild disease, but in a relevant number of patients, it can cause a very severe, potentially fatal, disease. In this narrative review, the present possibilities of CD infection (CDI) prevention will be discussed. Interventions usually recommended for infection control and prevention can be effective in reducing CDI incidence. However, in order to overcome limitations of these measures and reduce the risk of new CDI episodes, novel strategies have been developed. As most of the cases of CDI follow antibiotic use, attempts to rationalize antibiotic prescriptions have been implemented. Moreover, to reconstitute normal gut microbiota composition and suppress CD colonization in patients given antimicrobial drugs, administration of probiotics has been suggested. Finally, active and passive immunization has been studied. Vaccines containing inactivated CD toxins or components of CD spores have been studied. Passive immunization with monoclonal antibodies against CD toxins or the administration of hyperimmune whey derived from colostrum or breast milk from immunized cows has been tried. However, most advanced methods have significant limitations as they cannot prevent colonization and development of primary CDI. Only the availability of vaccines able to face these problems can allow a resolutive approach to the total burden due to this pathogen.
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Affiliation(s)
| | - Margherita Gnocchi
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, 43126 Parma, Italy; (M.G.); (M.G.); (A.A.); (C.N.)
| | - Martina Gagliardi
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, 43126 Parma, Italy; (M.G.); (M.G.); (A.A.); (C.N.)
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, 43126 Parma, Italy; (M.G.); (M.G.); (A.A.); (C.N.)
| | - Cosimo Neglia
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, 43126 Parma, Italy; (M.G.); (M.G.); (A.A.); (C.N.)
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, University of Parma, 43126 Parma, Italy; (M.G.); (M.G.); (A.A.); (C.N.)
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Sharma A, Fernandez PG, Rowlands JP, Koff MD, Loftus RW. Perioperative Infection Transmission: the Role of the Anesthesia Provider in Infection Control and Healthcare-Associated Infections. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:233-241. [PMID: 32837343 PMCID: PMC7366489 DOI: 10.1007/s40140-020-00403-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
PURPOSE OF REVIEW This review aims to highlight key factors in the perioperative environment that contribute to transmission of infectious pathogens, leading to healthcare-associated infection. This knowledge will provide anesthesia providers the tools to optimize preventive measures, with the goal of improved patient and provider safety. RECENT FINDINGS Over the past decade, much has been learned about the epidemiology of perioperative pathogen transmission. Patients, providers, and the environment serve as reservoirs of origin that contribute to infection development. Ongoing surveillance of pathogen transmission among these reservoirs is essential to ensure effective perioperative infection prevention. SUMMARY Recent work has proven the efficacy of a strategic approach for perioperative optimization of hand hygiene, environmental cleaning, patient decolonization, and intravascular catheter design and handling improvement protocols. This work, proven to generate substantial reductions in surgical site infections, can also be applied to aide prevention of SARS-CoV-2 spread in the COVID-19 era.
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Affiliation(s)
- Archit Sharma
- Department of Anesthesia, University of Iowa, 200 Hawkins Drive, 6512 JCP, Iowa City, IA 52242 USA
| | - Patrick G. Fernandez
- Department of Anesthesia, University of Colorado School of Medicine, Children’s Hospital Colorado, 13123 E. 16th Ave, Aurora, CO 80045 USA
| | - John P. Rowlands
- Delaware Orthopaedic Specialists, Pain Management, 3401 Brandywine Parkway, Wilmington, DE 19803 USA
| | - Matthew D. Koff
- Department of Anesthesia and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, 1 Medical Center Drive, Lebanon, NH 03756 USA
| | - Randy W. Loftus
- Department of Anesthesia, University of Iowa, 200 Hawkins Drive, 6512 JCP, Iowa City, IA 52242 USA
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Schmidt E, Dexter F, Herrmann J, Godding JD, Hadder B, Loftus RW. Assessment of anesthesia machine redesign on cleaning of the anesthesia machine using surface disinfection wipes. Am J Infect Control 2020; 48:675-681. [PMID: 31733809 DOI: 10.1016/j.ajic.2019.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 09/19/2019] [Accepted: 09/20/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The use of surface disinfection wipes after induction of anesthesia improves anesthesia machine cleaning. We assessed whether anesthesia machine surface redesign improves disinfection wipe cleaning by anesthesia residents. METHODS Sixteen anesthesia residents were assigned to 2 cases in series. The first case was randomly assigned to regional knee or hip surgery, a brief or detailed checklist, and the Perseus A500 (redesigned) or GE Aespire 7900 (conventional) machine. The second case was assigned to the opposite for each condition. Setup checklists included cleaning instructions. Eight machine sites representing redesign were contaminated with fluorescent gel prior to setup and reassessed after setup to assess cleaning efficacy. Cleaning was compared by fluorescence quantification of before and after setup images. Our primary hypothesis was that, overall, more sites would be cleaned on the Perseus machine. Our secondary hypothesis was that redesign would affect some sites. RESULTS Overall, the number of sites cleaned did not differ between machines (median 0.74 more sites out of 8 for the Perseus A500; 25th and 75th percentiles, -0.34 and 1.04; P = .093). However, greater cleaning was observed for the work surface and manual bag arm/hose of the Perseus machine (0.58 more sites out of 2; 25th and 75th percentiles, 0.35 and 1.05; P = .0004). CONCLUSIONS The number of sites cleaned overall did not differ between the conventional and redesigned Perseus A500 machines. However, the redesigned work surface and smooth manual bag arm features improved resident cleaning with surface disinfection wipes.
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Cotoia A, Spadaro S, Gambetti G, Koulenti D, Cinnella G. Pathogenesis-Targeted Preventive Strategies for Multidrug Resistant Ventilator-Associated Pneumonia: A Narrative Review. Microorganisms 2020; 8:microorganisms8060821. [PMID: 32486132 PMCID: PMC7356213 DOI: 10.3390/microorganisms8060821] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 05/20/2020] [Accepted: 05/28/2020] [Indexed: 11/18/2022] Open
Abstract
Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in the intensive care unit (ICU), accounting for relevant morbidity and mortality among critically ill patients, especially when caused by multidrug resistant (MDR) organisms. The rising problem of MDR etiologies, which has led to a reduction in treatment options, have increased clinician’s attention to the employment of effective prevention strategies. In this narrative review we summarized the evidence resulting from 27 original articles that were identified through a systematic database search of the last 15 years, focusing on several pathogenesis-targeted strategies which could help preventing MDR-VAP. Oral hygiene with Chlorhexidine (CHX), CHX body washing, selective oral decontamination (SOD) and/or digestive decontamination (SDD), multiple decontamination regimens, probiotics, subglottic secretions drainage (SSD), special cuff material and shape, silver-coated endotracheal tubes (ETTs), universal use of gloves and contact isolation, alcohol-based hand gel, vaporized hydrogen peroxide, and bundles of care have been addressed. The most convincing evidence came from interventions directly addressed against the key factors of MDR-VAP pathogenesis, especially when they are jointly implemented into bundles. Further research, however, is warranted to identify the most effective combination.
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Affiliation(s)
- Antonella Cotoia
- Department of Anesthesia and Intensive Care, University of Foggia, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Viale Pinto 241, 71122 Foggia, Italy; (G.G.); (G.C.)
- Correspondence:
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, Anesthesia and Intensive Care Section, University of Ferrara, Azienda Ospedaliera- Universitaria Sant’Anna, Via Aldo Moro 8, 44124 Ferrara, Italy;
| | - Guido Gambetti
- Department of Anesthesia and Intensive Care, University of Foggia, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Viale Pinto 241, 71122 Foggia, Italy; (G.G.); (G.C.)
| | - Despoina Koulenti
- 2nd Critical Care Department, Attikon University Hospital, 12462 Athens, Greece;
- UQCCR, Faculty of Medicine, The University of Queensland, Brisbane QLD 4029, Australia
| | - Gilda Cinnella
- Department of Anesthesia and Intensive Care, University of Foggia, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Viale Pinto 241, 71122 Foggia, Italy; (G.G.); (G.C.)
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20
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Martos-Cabrera MB, Mota-Romero E, Martos-García R, Gómez-Urquiza JL, Suleiman-Martos N, Albendín-García L, Cañadas-De la Fuente GA. Hand Hygiene Teaching Strategies among Nursing Staff: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16173039. [PMID: 31443355 PMCID: PMC6747325 DOI: 10.3390/ijerph16173039] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/17/2019] [Accepted: 08/18/2019] [Indexed: 12/23/2022]
Abstract
Background: Patient safety is a priority of any healthcare system, and one of the most effective measures is hand hygiene. For this, it is important that health staff have correct adherence and perform the technique properly. Otherwise, the incidence of nosocomial infections can increase, with consequent complications. The aim here was to analyze hand hygiene training and the effectiveness of different methods and educational strategies among nurses and whether they maintained correct adherence over time. Methods: A systematic review was conducted in the sources CINAHL (Cumulative Index to Nursing and Allied Health Literature), Dialnet, Lilacs (Latin American and Caribbean Health Sciences Literature), ProQuest (Proquest Health and Medical Complete), Medline, SciELO (Scientific Electronic Library Online), and Scopus. The search equation with Medical Subject Headings (MeSH) descriptors was “Nurs* AND (handwashing OR hand hygiene) AND clinical trial”. The review was performed following the recommendations of the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: n = 17 clinical trials were included, with a total of 5747 nurses and nursing students. Strategies such as reminder sounds, practical simulations, videos, and audiovisual media improved handwashing compliance. Adherence overtime increased by up to 60%. The greatest effectiveness was related to the use of povidone–iodine, which reduced colony formation compared Hand hygiene teaching strategies among nursing staff: a systematic review to soap. Conclusions: The strategies that go beyond teaching techniques such as lectures may be more effective at increasing hand hygiene compliance. Combined approaches to learning/instruction improve user satisfaction by enabling self-management, flexibility, and repetition.
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Affiliation(s)
| | | | - Raúl Martos-García
- Andalusian Health Service, Avenida del Sur N. 11, 18014 Granada, Spain
- Red Cross School of Nursing, University of Sevilla, Avenida la Cruz Roja N. 1, 41009 Sevilla, Spain
| | - José L Gómez-Urquiza
- Faculty of Health Sciences, University of Granada, Avenida de la Ilustración N. 60, 18016 Granada, Spain
| | - Nora Suleiman-Martos
- Faculty of Health Sciences, University of Granada, Calle Cortadura Del Valle S.N., 51001 Ceuta, Spain.
| | - Luis Albendín-García
- Andalusian Health Service, Avenida del Sur N. 11, 18014 Granada, Spain
- Faculty of Health Sciences, University of Granada, Avenida de la Ilustración N. 60, 18016 Granada, Spain
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Abstract
Clostridioides difficile (formerly Clostridium difficile) infection is the most frequently identified health care-associated infection in the United States. C difficile has also emerged as a cause of community-associated diarrhea, resulting in increased incidence of community-associated infection. Clinical illness ranges in severity from mild diarrhea to fulminant colitis and death. Appropriate management of infection requires understanding of the various diagnostic assays and therapeutic options as well as relevant measures to infection prevention. This article provides updated recommendations regarding the prevention, diagnosis, and treatment of incident and recurrent C difficile infection.
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Affiliation(s)
- Alice Y Guh
- From the Centers for Disease Control and Prevention, Atlanta, Georgia. (A.Y.G., P.K.K.)
| | - Preeta K Kutty
- From the Centers for Disease Control and Prevention, Atlanta, Georgia. (A.Y.G., P.K.K.)
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Alshehari AA, Park S, Rashid H. Strategies to improve hand hygiene compliance among healthcare workers in adult intensive care units: a mini systematic review. J Hosp Infect 2018; 100:152-158. [PMID: 29559231 DOI: 10.1016/j.jhin.2018.03.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 03/13/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hand hygiene compliance among healthcare workers (HCWs) in intensive care units (ICUs) is disconcertingly low. AIM To identify the effective intervention(s) for increasing HH compliance among HCWs in adult ICUs. METHODS Two major electronic databases, OVID Medline and CINAHL, were searched by using a combination of MeSH terms and text words (e.g. hand hygiene, hand washing, compliance, adher*, improve*, develop* and intensive care unit) for relevant articles. This was supplemented by Google Scholar and hand searching of included bibliographies. Data from identified articles were then abstracted, quality-assessed, and combined into a summary effect. FINDINGS Of 89 titles and abstracts that were identified, 14 articles were finally included. Overall study quality was good. However, variations in design, setting, sample size, and intervention(s) tested precluded a meta-analysis; hence a narrative synthesis was conducted. The interventions included education, observation, provision of supplies, improving access and directive support; tested singly or in combination; resulted in positive outcomes in all but one study. A combination of administrative support, 'supplies', education and training, reminders, surveillance, and performance feedback raised the compliance from a baseline of 51.5% to a record 80.1%; but no set of intervention(s) could improve the compliance to the desired near-100% level. CONCLUSION Available data suggest that multi-modal interventions are effective in raising the compliance to a 'plateau' level but not up to the desired standard. Methodologically appropriate trials of combined interventions could enhance the evidence about interventions to improve hand hygiene compliance among ICU staff.
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Affiliation(s)
| | - S Park
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - H Rashid
- National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases (NCIRS), The Children's Hospital at Westmead, New South Wales, Australia; Marie Bashir Institute for Infectious Diseases and Biosecurity, School of Biological Sciences and Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
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Sickbert-Bennett EE, DiBiase LM, Willis TMS, Wolak ES, Weber DJ, Rutala WA. Reduction of Healthcare-Associated Infections by Exceeding High Compliance with Hand Hygiene Practices. Emerg Infect Dis 2018; 22:1628-30. [PMID: 27532259 PMCID: PMC4994356 DOI: 10.3201/eid2209.151440] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Improving hand hygiene from high to very high compliance has not been documented to decrease healthcare-associated infections. We conducted longitudinal analyses during 2013-2015 in an 853-bed hospital and observed a significantly increased hand hygiene compliance rate (p<0.001) and a significantly decreased healthcare-associated infection rate (p = 0.0066).
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Abstract
Performing proper hand hygiene and surgical hand antisepsis is essential to reducing the rates of health care-associated infections, including surgical site infections. The updated AORN "Guideline for hand hygiene" provides guidance on hand hygiene and surgical hand antisepsis, the wearing of fingernail polish and artificial nails, proper skin care to prevent dermatitis, the wearing of jewelry, hand hygiene product selection, and quality assurance and performance improvement considerations. This article focuses on key points of the guideline to help perioperative personnel make informed decisions about hand hygiene and surgical hand antisepsis. The key points address the necessity of keeping fingernails and skin healthy, not wearing jewelry on the hands or wrists in the perioperative area, properly performing hand hygiene and surgical hand antisepsis, and involving patients and visitors in hand hygiene initiatives. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.
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Kashyap B, Gupta K, Gomber S, Gupta N, Bhardwaj A, Singh NP, Kumar A. Hand hygiene compliance among health care workers in pediatric oncology ward of a tertiary care hospital: A cross sectional observational study. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2017. [DOI: 10.1016/j.injms.2017.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Gould DJ, Moralejo D, Drey N, Chudleigh JH, Taljaard M. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev 2017; 9:CD005186. [PMID: 28862335 PMCID: PMC6483670 DOI: 10.1002/14651858.cd005186.pub4] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure. This is an update of a previously published review. OBJECTIVES To assess the short- and long-term success of strategies to improve compliance to recommendations for hand hygiene, and to determine whether an increase in hand hygiene compliance can reduce rates of health care-associated infection. SEARCH METHODS We conducted electronic searches of the Cochrane Register of Controlled Trials, PubMed, Embase, and CINAHL. We conducted the searches from November 2009 to October 2016. SELECTION CRITERIA We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series analyses (ITS) that evaluated any intervention to improve compliance with hand hygiene using soap and water or alcohol-based hand rub (ABHR), or both. DATA COLLECTION AND ANALYSIS Two review authors independently screened citations for inclusion, extracted data, and assessed risks of bias for each included study. Meta-analysis was not possible, as there was substantial heterogeneity across studies. We assessed the certainty of evidence using the GRADE approach and present the results narratively in a 'Summary of findings' table. MAIN RESULTS This review includes 26 studies: 14 randomised trials, two non-randomised trials and 10 ITS studies. Most studies were conducted in hospitals or long-term care facilities in different countries, and collected data from a variety of healthcare workers. Fourteen studies assessed the success of different combinations of strategies recommended by the World Health Organization (WHO) to improve hand hygiene compliance. Strategies consisted of the following: increasing the availability of ABHR, different types of education for staff, reminders (written and verbal), different types of performance feedback, administrative support, and staff involvement. Six studies assessed different types of performance feedback, two studies evaluated education, three studies evaluated cues such as signs or scent, and one study assessed placement of ABHR. Observed hand hygiene compliance was measured in all but three studies which reported product usage. Eight studies also reported either infection or colonisation rates. All studies had two or more sources of high or unclear risks of bias, most often associated with blinding or independence of the intervention.Multimodal interventions that include some but not all strategies recommended in the WHO guidelines may slightly improve hand hygiene compliance (five studies; 56 centres) and may slightly reduce infection rates (three studies; 34 centres), low certainty of evidence for both outcomes.Multimodal interventions that include all strategies recommended in the WHO guidelines may slightly reduce colonisation rates (one study; 167 centres; low certainty of evidence). It is unclear whether the intervention improves hand hygiene compliance (five studies; 184 centres) or reduces infection (two studies; 16 centres) because the certainty of this evidence is very low.Multimodal interventions that contain all strategies recommended in the WHO guidelines plus additional strategies may slightly improve hand hygiene compliance (six studies; 15 centres; low certainty of evidence). It is unclear whether this intervention reduces infection rates (one study; one centre; very low certainty of evidence).Performance feedback may improve hand hygiene compliance (six studies; 21 centres; low certainty of evidence). This intervention probably slightly reduces infection (one study; one centre) and colonisation rates (one study; one centre) based on moderate certainty of evidence.Education may improve hand hygiene compliance (two studies; two centres), low certainty of evidence.Cues such as signs or scent may slightly improve hand hygiene compliance (three studies; three centres), low certainty of evidence.Placement of ABHR close to point of use probably slightly improves hand hygiene compliance (one study; one centre), moderate certainty of evidence. AUTHORS' CONCLUSIONS With the identified variability in certainty of evidence, interventions, and methods, there remains an urgent need to undertake methodologically robust research to explore the effectiveness of multimodal versus simpler interventions to increase hand hygiene compliance, and to identify which components of multimodal interventions or combinations of strategies are most effective in a particular context.
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Affiliation(s)
- Dinah J Gould
- Cardiff UniversitySchool of Healthcare SciencesEastgate HouseCardiffWalesUK
| | - Donna Moralejo
- Memorial UniversitySchool of NursingH2916, Health Sciences Centre300 Prince Philip DriveSt. John'sNLCanadaA1B 3V6
| | - Nicholas Drey
- City, University of LondonCentre for Health Services ResearchNorthampton SquareLondonUKEC1V 0HB
| | - Jane H Chudleigh
- City, University of LondonSchool of Health SciencesNorthampton SquareLondonUKEC1V 0HB
| | - Monica Taljaard
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramThe Ottawa Hospital ‐ Civic Campus1053 Carling Ave, Box 693OttawaONCanadaK1Y 4E9
- University of OttawaSchool of Epidemiology, Public Health and Preventive MedicineOttawaONCanada
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Halpern NA. Innovative Designs for the Smart ICU. Chest 2017; 145:646-658. [PMID: 27845639 DOI: 10.1378/chest.13-0004] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Accepted: 10/28/2013] [Indexed: 11/01/2022] Open
Abstract
Successfully designing a new ICU requires clarity of vision and purpose and the recognition that the patient room is the core of the ICU experience for patients, staff, and visitors. The ICU can be conceptualized into three components: the patient room, central areas, and universal support services. Each patient room should be designed for single patient use and be similarly configured and equipped. The design of the room should focus upon functionality, ease of use, healing, safety, infection control, communications, and connectivity. All aspects of the room, including its infrastructure; zones for work, care, and visiting; environment, medical devices, and approaches to privacy; logistics; and waste management, are important elements in the design process. Since most medical devices used at the ICU bedside are really sophisticated computers, the ICU needs to be capable of supporting the full scope of medical informatics. The patient rooms, the central ICU areas (central stations, corridors, supply rooms, pharmacy, laboratory, staff lounge, visitor waiting room, on-call suite, conference rooms, and offices), and the universal support services (infection prevention, finishings and flooring, staff communications, signage and wayfinding, security, and fire and safety) work best when fully interwoven. This coordination helps establish efficient and safe patient throughput and care and fosters physical and social cohesiveness within the ICU. A balanced approach to centralized and decentralized monitoring and logistics also offers great flexibility. Synchronization of the universal support services in the ICU with the hospital's existing systems maintains unity of purpose and continuity across the enterprise and avoids unnecessary duplication of efforts.
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Affiliation(s)
- Neil A Halpern
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center; and Weill Cornell Medical College, New York, NY.
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Kuwaiti AA, Subbarayalu AV. Reducing Hospital-acquired Infection Rate using the Six Sigma DMAIC Approach. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2017; 5:260-266. [PMID: 30787799 PMCID: PMC6298305 DOI: 10.4103/sjmms.sjmms_98_16] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Hospital-acquired infection (HAI) is one of the most common complications occurring in a hospital setting. Although previous studies have demonstrated the application of data-driven Six Sigma DMAIC (Define, Measure, Analyze, Improve and Control) methodology in various health-care settings, no such studies have been conducted on HAI in the Saudi Arabian context. Objective: The purpose of this research was to study the effect of the Six Sigma DMAIC approach in reducing the HAI rate at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. Methods: Historical data on HAI reported at inpatient units of the hospital between January and December 2013 were collected, and the overall HAI rate for the year 2013 was determined. The Six Sigma DMAIC approach was then prospectively implemented between January and December 2014, and its effect in reducing the HAI rate was evaluated through five phases. The incidence of HAI in 2013 was used as the problem and a 30% reduction from 4.18 by the end of 2014 was set as the project goal. Potential causes contributing to HAI were identified by root cause analysis, following which appropriate improvement strategies were implemented and then the pre- and postintervention HAI rates were compared. Results: The overall HAI rate was observed as 4.18. After implementing improvement strategies, the HAI rate significantly reduced from 3.92 during the preintervention phase (first quarter of 2014) to 2.73 during the postintervention phase (third quarter of 2014) (P < 0.05). A control plan was also executed to sustain this improvement. Conclusion: The results show that the Six Sigma “DMAIC” approach is effective in reducing the HAI rate.
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Affiliation(s)
- Ahmed Al Kuwaiti
- Deanship of Quality and Academic Accreditation, Imam Abdulrahman Bin Faisal University, Dammam 34212, Kingdom of Saudi Arabia
| | - Arun Vijay Subbarayalu
- Deanship of Quality and Academic Accreditation, Imam Abdulrahman Bin Faisal University, Dammam 34212, Kingdom of Saudi Arabia
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Affiliation(s)
- Philip C Carling
- Department of Infectious Diseases, Carney Hospital, 2100 Dorchester Avenue, Boston, MA 02124, USA.
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Hardy JM, Owen TJ, Martinez SA, Jones LP, Davis MA. The effect of nail characteristics on surface bacterial counts of surgical personnel before and after scrubbing. Vet Surg 2017; 46:952-961. [DOI: 10.1111/vsu.12685] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 01/25/2017] [Accepted: 02/14/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Jade M. Hardy
- Department of Veterinary Clinical Sciences; College of Veterinary Medicine, Washington State University; Pullman Washington
| | - Tina J. Owen
- Department of Veterinary Clinical Sciences; College of Veterinary Medicine, Washington State University; Pullman Washington
| | - Steven A. Martinez
- Department of Veterinary Clinical Sciences; College of Veterinary Medicine, Washington State University; Pullman Washington
| | - Lisa P. Jones
- Department of Veterinary Clinical Sciences; College of Veterinary Medicine, Washington State University; Pullman Washington
| | - Margaret A. Davis
- Department of Veterinary Clinical Sciences; College of Veterinary Medicine, Washington State University; Pullman Washington
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Electronic monitoring in combination with direct observation as a means to significantly improve hand hygiene compliance. Am J Infect Control 2017; 45:528-535. [PMID: 28456322 DOI: 10.1016/j.ajic.2016.11.029] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/26/2016] [Accepted: 11/27/2016] [Indexed: 01/16/2023]
Abstract
Monitoring hand hygiene compliance among health care personnel (HCP) is an essential element of hand hygiene promotion programs. Observation by trained auditors is considered the gold standard method for establishing hand hygiene compliance rates. Advantages of observational surveys include the unique ability to establish compliance with all of the World Health Organization "My 5 Moments for Hand Hygiene" initiative Moments and to provide just-in-time coaching. Disadvantages include the resources required for observational surveys, insufficient sample sizes, and nonstandardized methods of conducting observations. Electronic and camera-based systems can monitor hand hygiene performance on all work shifts without a Hawthorne effect and provide significantly more data regarding hand hygiene performance. Disadvantages include the cost of installation, variable accuracy in estimating compliance rates, issues related to acceptance by HCP, insufficient data regarding their cost-effectiveness and influence on health care-related infection rates, and the ability of most systems to monitor only surrogates for Moments 1, 4, and 5. Increasing evidence suggests that monitoring only Moments 1, 4, and 5 provides reasonable estimates of compliance with all 5 Moments. With continued improvement of electronic monitoring systems, combining electronic monitoring with observational methods may provide the best information as part of a multimodal strategy to improve and sustain hand hygiene compliance rates among HCP.
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Cooper CC, Jump RLP, Chopra T. Prevention of Infection Due to Clostridium difficile. Infect Dis Clin North Am 2016; 30:999-1012. [PMID: 27660089 DOI: 10.1016/j.idc.2016.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Clostridium difficile is one of the foremost nosocomial pathogens. Preventing infection is particularly challenging. Effective prevention efforts typically require a multifaceted bundled approach. A variety of infection control procedures may be advantageous, including strict hand decontamination with soap and water, contact precautions, and using chlorine-containing decontamination agents. Additionally, risk factor reduction can help reduce the burden of disease. The risk factor modification is principally accomplished though antibiotic stewardship programs. Unfortunately, most of the current evidence for prevention is in acute care settings. This review focuses on preventative approaches to reduce the incidence of Clostridium difficile infection in healthcare settings.
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Affiliation(s)
- Christopher C Cooper
- Division of Infectious Diseases, Wayne State University, 3990 John R. Street, 5 Hudson, Detroit, MI 48201, USA
| | - Robin L P Jump
- Infectious Disease Section, Medical Division, Geriatric Research Education and Clinical Center (GRECC), Louis Stokes Cleveland Veterans Affairs Medical Center, 10701 East Boulevard, Cleveland, OH 44106, USA; Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Teena Chopra
- Division of Infectious Diseases, Wayne State University, 3990 John R. Street, 5 Hudson, Detroit, MI 48201, USA.
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Lai NM, Lai NA, O'Riordan E, Chaiyakunapruk N, Taylor JE, Tan K. Skin antisepsis for reducing central venous catheter-related infections. Cochrane Database Syst Rev 2016; 7:CD010140. [PMID: 27410189 PMCID: PMC6457952 DOI: 10.1002/14651858.cd010140.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The central venous catheter (CVC) is a device used for many functions, including monitoring haemodynamic indicators and administering intravenous medications, fluids, blood products and parenteral nutrition. However, as a foreign object, it is susceptible to colonisation by micro-organisms, which may lead to catheter-related blood stream infection (BSI) and in turn, increased mortality, morbidities and health care costs. OBJECTIVES To assess the effects of skin antisepsis as part of CVC care for reducing catheter-related BSIs, catheter colonisation, and patient mortality and morbidities. SEARCH METHODS In May 2016 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations and Epub Ahead of Print); Ovid EMBASE and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA We included randomised controlled trials (RCTs) that assessed any type of skin antiseptic agent used either alone or in combination, compared with one or more other skin antiseptic agent(s), placebo or no skin antisepsis in patients with a CVC in place. DATA COLLECTION AND ANALYSIS Two authors independently assessed the studies for their eligibility, extracted data and assessed risk of bias. We expressed our results in terms of risk ratio (RR), absolute risk reduction (ARR) and number need to treat for an additional beneficial outcome (NNTB) for dichotomous data, and mean difference (MD) for continuous data, with 95% confidence intervals (CIs). MAIN RESULTS Thirteen studies were eligible for inclusion, but only 12 studies contributed data, with a total of 3446 CVCs assessed. The total number of participants enrolled was unclear as some studies did not provide such information. The participants were mainly adults admitted to intensive care units, haematology oncology units or general wards. Most studies assessed skin antisepsis prior to insertion and regularly thereafter during the in-dwelling period of the CVC, ranging from every 24 h to every 72 h. The methodological quality of the included studies was mixed due to wide variation in their risk of bias. Most trials did not adequately blind the participants or personnel, and four of the 12 studies had a high risk of bias for incomplete outcome data.Three studies compared different antisepsis regimens with no antisepsis. There was no clear evidence of a difference in all outcomes examined, including catheter-related BSI, septicaemia, catheter colonisation and number of patients who required systemic antibiotics for any of the three comparisons involving three different antisepsis regimens (aqueous povidone-iodine, aqueous chlorhexidine and alcohol compared with no skin antisepsis). However, there were great uncertainties in all estimates due to underpowered analyses and the overall very low quality of evidence presented.There were multiple head-to-head comparisons between different skin antiseptic agents, with different combinations of active substance and base solutions. The most frequent comparison was chlorhexidine solution versus povidone-iodine solution (any base). There was very low quality evidence (downgraded for risk of bias and imprecision) that chlorhexidine may reduce catheter-related BSI compared with povidone-iodine (RR of 0.64, 95% CI 0.41 to 0.99; ARR 2.30%, 95% CI 0.06 to 3.70%). This evidence came from four studies involving 1436 catheters. None of the individual subgroup comparisons of aqueous chlorhexidine versus aqueous povidone-iodine, alcoholic chlorhexidine versus aqueous povidone-iodine and alcoholic chlorhexidine versus alcoholic povidone-iodine showed clear differences for catheter-related BSI or mortality (and were generally underpowered). Mortality was only reported in a single study.There was very low quality evidence that skin antisepsis with chlorhexidine may also reduce catheter colonisation relative to povidone-iodine (RR of 0.68, 95% CI 0.56 to 0.84; ARR 8%, 95% CI 3% to 12%; ; five studies, 1533 catheters, downgraded for risk of bias, indirectness and inconsistency).Evaluations of other skin antiseptic agents were generally in single, small studies, many of which did not report the primary outcome of catheter-related BSI. Trials also poorly reported other outcomes, such as skin infections and adverse events. AUTHORS' CONCLUSIONS It is not clear whether cleaning the skin around CVC insertion sites with antiseptic reduces catheter related blood stream infection compared with no skin cleansing. Skin cleansing with chlorhexidine solution may reduce rates of CRBSI and catheter colonisation compared with cleaning with povidone iodine. These results are based on very low quality evidence, which means the true effects may be very different. Moreover these results may be influenced by the nature of the antiseptic solution (i.e. aqueous or alcohol-based). Further RCTs are needed to assess the effectiveness and safety of different skin antisepsis regimens in CVC care; these should measure and report critical clinical outcomes such as sepsis, catheter-related BSI and mortality.
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Affiliation(s)
- Nai Ming Lai
- Taylor's UniversitySchool of MedicineSubang JayaMalaysia
- Monash University MalaysiaSchool of PharmacySelangorMalaysia
| | - Nai An Lai
- Queen Elizabeth II Jubilee HospitalIntensive Care UnitCnr Troughton and Kessels RoadsCoopers PlainsQueenslandAustralia4108
| | - Elizabeth O'Riordan
- The University of Sydney and The Children's Hospital at WestmeadFaculty of Nursing and MidwiferySydneyNew South WalesAustralia2006
| | - Nathorn Chaiyakunapruk
- Monash University MalaysiaSchool of PharmacySelangorMalaysia
- Faculty of Pharmaceutical SciencesCenter of Pharmaceutical Outcomes Research, Department of Pharmacy PracticeNaresuan UniversityPhitsanulokThailand65000
- The University of QueenslandSchool of Population HealthBrisbaneQueenslandAustralia
| | - Jacqueline E Taylor
- Monash Medical Centre/Monash UniversityMonash Newborn246 Clayton RoadClaytonVictoriaAustralia3168
| | - Kenneth Tan
- Monash UniversityDepartment of Paediatrics246 Clayton RoadClaytonMelbourneVictoriaAustraliaVIC 3168
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Frequency of Hand Decontamination of Intraoperative Providers and Reduction of Postoperative Healthcare-Associated Infections: A Randomized Clinical Trial of a Novel Hand Hygiene System. Infect Control Hosp Epidemiol 2016; 37:888-895. [PMID: 27267310 DOI: 10.1017/ice.2016.106] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Healthcare provider hands are an important source of intraoperative bacterial transmission events associated with postoperative infection development. OBJECTIVE To explore the efficacy of a novel hand hygiene improvement system leveraging provider proximity and individual and group performance feedback in reducing 30-day postoperative healthcare-associated infections via increased provider hourly hand decontamination events. DESIGN Randomized, prospective study. SETTING Dartmouth-Hitchcock Medical Center in New Hampshire and UMass Memorial Medical Center in Massachusetts. PATIENTS Patients undergoing surgery. METHODS Operating room environments were randomly assigned to usual intraoperative hand hygiene or to a personalized, body-worn hand hygiene system. Anesthesia and circulating nurse provider hourly hand decontamination events were continuously monitored and reported. All patients were followed prospectively for the development of 30-day postoperative healthcare-associated infections. RESULTS A total of 3,256 operating room environments and patients (1,620 control and 1,636 treatment) were enrolled. The mean (SD) provider hand decontamination event rate achieved was 4.3 (2.9) events per hour, an approximate 8-fold increase in hand decontamination events above that of conventional wall-mounted devices (0.57 events/hour); P<.001. Use of the hand hygiene system was not associated with a reduction in healthcare-associated infections (odds ratio, 1.07 [95% CI, 0.82-1.40], P=.626). CONCLUSIONS The hand hygiene system evaluated in this study increased the frequency of hand decontamination events without reducing 30-day postoperative healthcare-associated infections. Future work is indicated to optimize the efficacy of this hand hygiene improvement strategy. Infect Control Hosp Epidemiol 2016;37:888-895.
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Neo JRJ, Sagha-Zadeh R, Vielemeyer O, Franklin E. Evidence-based practices to increase hand hygiene compliance in health care facilities: An integrated review. Am J Infect Control 2016; 44:691-704. [PMID: 27240800 DOI: 10.1016/j.ajic.2015.11.034] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 11/28/2015] [Accepted: 11/30/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hand hygiene (HH) in health care facilities is a key component to reduce pathogen transmission and nosocomial infections. However, most HH interventions (HHI) have not been sustainable. AIMS This review aims to provide a comprehensive summary of recently published evidence-based HHI designed to improve HH compliance (HHC) that will enable health care providers to make informed choices when allocating limited resources to improve HHC and patient safety. METHODS The Medline electronic database (using PubMed) was used to identify relevant studies. English language articles that included hand hygiene interventions and related terms combined with health care environments or related terms were included. RESULTS Seventy-three studies that met the inclusion criteria were summarized. Interventions were categorized as improving awareness with education, facility design, and planning, unit-level protocols and procedures, hospital-wide programs, and multimodal interventions. Past successful HHIs may not be as effective when applied to other health care environments. HH education should be interactive and engaging. Electronic monitoring and reminders should be implemented in phases to ensure cost-effectiveness. To create hospitalwide programs that engage end users, policy makers should draw expertise from interdisciplinary fields. Before implementing the various components of multimodal interventions, health care practitioners should identify and examine HH difficulties unique to their organizations. CONCLUSIONS Future research should seek to achieve the following: replicate successful HHI in other health care environments, develop reliable HHC monitoring tools, understand caregiver-patient-family interactions, examine ways (eg, hospital leadership, financial support, and strategies from public health and infection prevention initiatives) to sustain HHC, and use simulated lab environments to refine study designs.
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Affiliation(s)
- Jun Rong Jeffrey Neo
- Department of Design and Environmental Analysis, Cornell University, Ithaca, NY.
| | - Rana Sagha-Zadeh
- Department of Design and Environmental Analysis, Cornell University, Ithaca, NY
| | - Ole Vielemeyer
- Division of Infectious Disease, Weill Cornell Medical College, New York, NY
| | - Ella Franklin
- National Center for Human Factors in Healthcare, MedStar Health, Washington, DC
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Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene. Infect Control Hosp Epidemiol 2016; 35 Suppl 2:S155-78. [DOI: 10.1017/s0899823x00193900] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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An Economic Analysis of Strategies to Control Clostridium Difficile Transmission and Infection Using an Agent-Based Simulation Model. PLoS One 2016; 11:e0152248. [PMID: 27031464 PMCID: PMC4816545 DOI: 10.1371/journal.pone.0152248] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 03/11/2016] [Indexed: 12/18/2022] Open
Abstract
Background A number of strategies exist to reduce Clostridium difficile (C. difficile) transmission. We conducted an economic evaluation of “bundling” these strategies together. Methods We constructed an agent-based computer simulation of nosocomial C. difficile transmission and infection in a hospital setting. This model included the following components: interactions between patients and health care workers; room contamination via C. difficile shedding; C. difficile hand carriage and removal via hand hygiene; patient acquisition of C. difficile via contact with contaminated rooms or health care workers; and patient antimicrobial use. Six interventions were introduced alone and "bundled" together: (a) aggressive C. difficile testing; (b) empiric isolation and treatment of symptomatic patients; (c) improved adherence to hand hygiene and (d) contact precautions; (e) improved use of soap and water for hand hygiene; and (f) improved environmental cleaning. Our analysis compared these interventions using values representing 3 different scenarios: (1) base-case (BASE) values that reflect typical hospital practice, (2) intervention (INT) values that represent implementation of hospital-wide efforts to reduce C. diff transmission, and (3) optimal (OPT) values representing the highest expected results from strong adherence to the interventions. Cost parameters for each intervention were obtained from published literature. We performed our analyses assuming low, normal, and high C. difficile importation prevalence and transmissibility of C. difficile. Results INT levels of the “bundled” intervention were cost-effective at a willingness-to-pay threshold of $100,000/quality-adjusted life-year in all importation prevalence and transmissibility scenarios. OPT levels of intervention were cost-effective for normal and high importation prevalence and transmissibility scenarios. When analyzed separately, hand hygiene compliance, environmental decontamination, and empiric isolation and treatment were the interventions that had the greatest impact on both cost and effectiveness. Conclusions A combination of available interventions to prevent CDI is likely to be cost-effective but the cost-effectiveness varies for different levels of intensity of the interventions depending on epidemiological conditions such as C. difficile importation prevalence and transmissibility.
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Khanafer N, Voirin N, Barbut F, Kuijper E, Vanhems P. Hospital management of Clostridium difficile infection: a review of the literature. J Hosp Infect 2015; 90:91-101. [DOI: 10.1016/j.jhin.2015.02.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 02/17/2015] [Indexed: 12/11/2022]
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Ellingson K, Haas JP, Aiello AE, Kusek L, Maragakis LL, Olmsted RN, Perencevich E, Polgreen PM, Schweizer ML, Trexler P, VanAmringe M, Yokoe DS. Strategies to prevent healthcare-associated infections through hand hygiene. Infect Control Hosp Epidemiol 2015; 35:937-60. [PMID: 25026608 DOI: 10.1086/677145] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Fox C, Wavra T, Drake DA, Mulligan D, Bennett YP, Nelson C, Kirkwood P, Jones L, Bader MK. Use of a patient hand hygiene protocol to reduce hospital-acquired infections and improve nurses' hand washing. Am J Crit Care 2015; 24:216-24. [PMID: 25934718 DOI: 10.4037/ajcc2015898] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Critically ill patients are at marked risk of hospital-acquired infections, which increase patients' morbidity and mortality. Registered nurses are the main health care providers of physical care, including hygiene to reduce and prevent hospital-acquired infections, for hospitalized critically ill patients. OBJECTIVE To investigate a new patient hand hygiene protocol designed to reduce hospital-acquired infection rates and improve nurses' hand-washing compliance in an intensive care unit. METHODS A preexperimental study design was used to compare 12-month rates of 2 common hospital-acquired infections, central catheter-associated bloodstream infection and catheter-associated urinary tract infection, and nurses' hand-washing compliance measured before and during use of the protocol. RESULTS Reductions in 12-month infection rates were reported for both types of infections, but neither reduction was statistically significant. Mean 12-month nurse hand-washing compliance also improved, but not significantly. CONCLUSIONS A hand hygiene protocol for patients in the intensive care unit was associated with reductions in hospital-acquired infections and improvements in nurses' hand-washing compliance. Prevention of such infections requires continuous quality improvement efforts to monitor lasting effectiveness as well as investigation of strategies to eliminate these infections.
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Affiliation(s)
- Cherie Fox
- Cherie Fox is nurse manager of the cardiac intensive care unit, Teresa Wavra is a clinical nurse specialist, Diane Ash Drake is a nurse research scientist, Debbie Mulligan is an infection prevention manager, Yvonne Pacheco Bennett is a staff nurse, Carla Nelson is a infection control practitioner, Peggy Kirkwood is a cardiovascular nurse practitioner, Louise Jones is a staff nurse, and Mary Kay Bader is a neurological/critical care clinical nurse specialist at Mission Hospital, Mission Viejo, California
| | - Teresa Wavra
- Cherie Fox is nurse manager of the cardiac intensive care unit, Teresa Wavra is a clinical nurse specialist, Diane Ash Drake is a nurse research scientist, Debbie Mulligan is an infection prevention manager, Yvonne Pacheco Bennett is a staff nurse, Carla Nelson is a infection control practitioner, Peggy Kirkwood is a cardiovascular nurse practitioner, Louise Jones is a staff nurse, and Mary Kay Bader is a neurological/critical care clinical nurse specialist at Mission Hospital, Mission Viejo, California
| | - Diane Ash Drake
- Cherie Fox is nurse manager of the cardiac intensive care unit, Teresa Wavra is a clinical nurse specialist, Diane Ash Drake is a nurse research scientist, Debbie Mulligan is an infection prevention manager, Yvonne Pacheco Bennett is a staff nurse, Carla Nelson is a infection control practitioner, Peggy Kirkwood is a cardiovascular nurse practitioner, Louise Jones is a staff nurse, and Mary Kay Bader is a neurological/critical care clinical nurse specialist at Mission Hospital, Mission Viejo, California
| | - Debbie Mulligan
- Cherie Fox is nurse manager of the cardiac intensive care unit, Teresa Wavra is a clinical nurse specialist, Diane Ash Drake is a nurse research scientist, Debbie Mulligan is an infection prevention manager, Yvonne Pacheco Bennett is a staff nurse, Carla Nelson is a infection control practitioner, Peggy Kirkwood is a cardiovascular nurse practitioner, Louise Jones is a staff nurse, and Mary Kay Bader is a neurological/critical care clinical nurse specialist at Mission Hospital, Mission Viejo, California
| | - Yvonne Pacheco Bennett
- Cherie Fox is nurse manager of the cardiac intensive care unit, Teresa Wavra is a clinical nurse specialist, Diane Ash Drake is a nurse research scientist, Debbie Mulligan is an infection prevention manager, Yvonne Pacheco Bennett is a staff nurse, Carla Nelson is a infection control practitioner, Peggy Kirkwood is a cardiovascular nurse practitioner, Louise Jones is a staff nurse, and Mary Kay Bader is a neurological/critical care clinical nurse specialist at Mission Hospital, Mission Viejo, California
| | - Carla Nelson
- Cherie Fox is nurse manager of the cardiac intensive care unit, Teresa Wavra is a clinical nurse specialist, Diane Ash Drake is a nurse research scientist, Debbie Mulligan is an infection prevention manager, Yvonne Pacheco Bennett is a staff nurse, Carla Nelson is a infection control practitioner, Peggy Kirkwood is a cardiovascular nurse practitioner, Louise Jones is a staff nurse, and Mary Kay Bader is a neurological/critical care clinical nurse specialist at Mission Hospital, Mission Viejo, California
| | - Peggy Kirkwood
- Cherie Fox is nurse manager of the cardiac intensive care unit, Teresa Wavra is a clinical nurse specialist, Diane Ash Drake is a nurse research scientist, Debbie Mulligan is an infection prevention manager, Yvonne Pacheco Bennett is a staff nurse, Carla Nelson is a infection control practitioner, Peggy Kirkwood is a cardiovascular nurse practitioner, Louise Jones is a staff nurse, and Mary Kay Bader is a neurological/critical care clinical nurse specialist at Mission Hospital, Mission Viejo, California
| | - Louise Jones
- Cherie Fox is nurse manager of the cardiac intensive care unit, Teresa Wavra is a clinical nurse specialist, Diane Ash Drake is a nurse research scientist, Debbie Mulligan is an infection prevention manager, Yvonne Pacheco Bennett is a staff nurse, Carla Nelson is a infection control practitioner, Peggy Kirkwood is a cardiovascular nurse practitioner, Louise Jones is a staff nurse, and Mary Kay Bader is a neurological/critical care clinical nurse specialist at Mission Hospital, Mission Viejo, California
| | - Mary Kay Bader
- Cherie Fox is nurse manager of the cardiac intensive care unit, Teresa Wavra is a clinical nurse specialist, Diane Ash Drake is a nurse research scientist, Debbie Mulligan is an infection prevention manager, Yvonne Pacheco Bennett is a staff nurse, Carla Nelson is a infection control practitioner, Peggy Kirkwood is a cardiovascular nurse practitioner, Louise Jones is a staff nurse, and Mary Kay Bader is a neurological/critical care clinical nurse specialist at Mission Hospital, Mission Viejo, California
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Loftus RW, Koff MD, Birnbach DJ. The Dynamics and Implications of Bacterial Transmission Events Arising from the Anesthesia Work Area. Anesth Analg 2015; 120:853-60. [DOI: 10.1213/ane.0000000000000505] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2015; 35 Suppl 2:S48-65. [PMID: 25376069 DOI: 10.1017/s0899823x00193857] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their Clostridium difficile infection (CDI) prevention efforts. This document updates “Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Ellingson K, Haas JP, Aiello AE, Kusek L, Maragakis LL, Olmsted RN, Perencevich E, Polgreen PM, Schweizer ML, Trexler P, VanAmringe M, Yokoe DS. Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene. Infect Control Hosp Epidemiol 2015. [DOI: 10.1086/651677] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Dubberke ER, Carling P, Carrico R, Donskey CJ, Loo VG, McDonald LC, Maragakis LL, Sandora TJ, Weber DJ, Yokoe DS, Gerding DN. Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 Update. Infect Control Hosp Epidemiol 2015; 35:628-45. [PMID: 24799639 DOI: 10.1086/676023] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Erik R Dubberke
- Washington University School of Medicine, St. Louis, Missouri
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Marra AR, Guastelli LR, de Araújo CMP, dos Santos JLS, Lamblet LCR, Silva M, de Lima G, Cal RGR, Paes ÂT, Neto MC, Barbosa L, Edmond MB, dos Santos OFP. Positive Deviance A New Strategy for Improving Hand Hygiene Compliance. Infect Control Hosp Epidemiol 2015; 31:12-20. [DOI: 10.1086/649224] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.To evaluate the effectiveness of a positive deviance strategy for the improvement of hand hygiene compliance in 2 adult step-down units.Design.A 9-month, controlled trial comparing the effect of positive deviance on compliance with hand hygiene.Setting.Two 20-bed step-down units at a tertiary care private hospital.Methods.The first phase of our study was a 3-month baseline period (from April to June 2008) in which hand hygiene episodes were counted by use of electronic handwashing counters. From July to September 2008 (ie, the second phase), a positive deviance strategy was implemented in the east unit; the west unit was the control unit. During the period from October to December 2008 (ie, the third phase), positive deviance was applied in both units.Results.During the first phase, there was no statistically significant difference between the 2 step-down units in the number of episodes of hand hygiene per 1,000 patient-days or in the incidence density of healthcare-associated infections (HAIs) per 1,000 patient-days. During the second phase, there were 62,000 hand hygiene episodes per 1,000 patient-days in the east unit and 33,570 hand hygiene episodes per 1,000 patient-days in the west unit (P < .01). The incidence density of HAIs per 1,000 patient-days was 6.5 in the east unit and 12.7 in the west unit (P = .04). During the third phase, there was no statistically significant difference in hand hygiene episodes per 1,000 patient-days (P = .16) or in incidence density of HAIs per 1,000 patient-days.Conclusion.A positive deviance strategy yielded a significant improvement in hand hygiene, which was associated with a decrease in the overall incidence of HAIs.
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Rupp ME, Kalil AC. Positive Deviance and Hand Hygiene: More Questions than Answers. Infect Control Hosp Epidemiol 2015; 31:978-9; author reply 979-80. [DOI: 10.1086/656204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Ellingson K, McDonald C. Commentary: Reexamining Methods and Messaging for Hand Hygiene in the Era of Increasing Clostridium difficile Colonization and Infection. Infect Control Hosp Epidemiol 2015; 31:571-3. [DOI: 10.1086/652773] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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McGuckin M, Waterman R. “Cannot Detect a Change” Is Not the Same as “There Is Not a Change”. Infect Control Hosp Epidemiol 2015; 29:576-7; author reply 580-2. [DOI: 10.1086/587807] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, van Beeck EF. Systematic Review of Studies on Compliance with Hand Hygiene Guidelines in Hospital Care. Infect Control Hosp Epidemiol 2015; 31:283-94. [DOI: 10.1086/650451] [Citation(s) in RCA: 657] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objectives.To assess the prevalence and correlates of compliance and noncompliance with hand hygiene guidelines in hospital care.Design.A systematic review of studies published before January 1, 2009, on observed or self-reported compliance rates.Methods.Articles on empirical studies written in English and conducted on general patient populations in industrialized countries were included. The results were grouped by type of healthcare worker before and after patient contact. Correlates contributing to compliance were grouped and listed.Results.We included 96 empirical studies, the majority (n= 65) in intensive care units. In general, the study methods were not very robust and often ill reported. We found an overall median compliance rate of 40%. Unadjusted compliance rates were lower in intensive care units (30%–40%) than in other settings (50%–60%), lower among physicians (32%) than among nurses (48%), and before (21%) rather than after (47%) patient contact. The majority of the time, the situations that were associated with a lower compliance rate were those with a high activity level and/or those in which a physician was involved. The majority of the time, the situations that were associated with a higher compliance rate were those having to do with dirty tasks, the introduction of alcohol-based hand rub or gel, performance feedback, and accessibility of materials. A minority of studies (n= 12) have investigated the behavioral determinants of hand hygiene, of which only 7 report the use of a theoretical framework with inconclusive results.Conclusions.Noncompliance with hand hygiene guidelines is a universal problem, which calls for standardized measures for research and monitoring. Theoretical models from the behavioral sciences should be used internationally and should be adapted to better explain the complexities of hand hygiene.
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