‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene

A New Performance Metric to Estimate the Risk of Exposure to Infection in a Health Care Setting: Descriptive Study

Background

Despite several measures to monitor and improve hand hygiene (HH) in health care settings, health care-acquired infections (HAIs) remain prevalent. The measures used to calculate HH performance are not able to fully benefit from the high-resolution data collected using electronic monitoring systems.

Objective

This study proposes a novel parameter for quantifying the HAI exposure risk of individual patients by considering temporal and spatial features of health care workers’ HH adherence.

Methods

Patient exposure risk is calculated as a function of the number of consecutive missed HH opportunities, the number of unique rooms visited by the health care professional, and the time duration that the health care professional spends inside and outside the patient’s room without performing HH. The patient exposure risk is compared to the entrance compliance rate (ECR) defined as the ratio of the number of HH actions performed at a room entrance to the total number of entrances into the room. The compliance rate is conventionally used to measure HH performance. The ECR and the patient exposure risk are analyzed using the data collected from an inpatient nursing unit for 12 weeks.

Results

The analysis of data collected from 59 nurses and more than 25,600 records at a musculoskeletal rehabilitation unit at the Toronto Rehabilitation Institute, KITE, showed that there is no strong linear relation between the ECR and patient exposure risk (r=0.7, P<.001). Since the ECR is calculated based on the number of missed HH actions upon room entrance, this parameter is already included in the patient exposure risk. Therefore, there might be scenarios that these 2 parameters are correlated; however, in several cases, the ECR contrasted with the reported patient exposure risk. Generally, the patients in rooms with a significantly high ECR can be potentially exposed to a considerable risk of infection. By contrast, small ECRs do not necessarily result in a high patient exposure risk. The results clearly explained the important role of the factors incorporated in patient exposure risk for quantifying the risk of infection for the patients.

Conclusions

Patient exposure risk might provide a more reliable estimation of the risk of developing HAIs compared to ECR by considering both the temporal and spatial aspects of HH records.

Six Moments of Infection Prevention in Injection Drug Use: An Educational Toolkit for Clinicians

BACKGROUND

Injection drug use-associated bacterial and viral infections are increasing. Expanding access to harm reduction services, such as safe injection education, are effective prevention strategies. However, these strategies have had limited uptake. New tools are needed to improve provider capacity to facilitate dissemination of these evidence-based interventions.

METHODS

The "Six Moments of Infection Prevention in Injection Drug Use" provider educational tool was developed using a global, rather than pathogen-specific, infection prevention framework, highlighting the prevention of invasive bacterial and fungal infections in additional to viral pathogens. The tool's effectiveness was tested using a short, paired pre/post survey that assessed provider knowledge and attitudes about harm reduction.

RESULTS

Seventy-five respondents completed the paired surveys. At baseline, 17 respondents (22.6%) indicated that they had received no prior training in harm reduction and 28 (37.3%) reported discomfort counseling people who inject drugs (PWID). Sixty respondents (80.0%) reported they had never referred a patient to a syringe service program (SSP); of those, 73.3% cited lack of knowledge regarding locations of SSPs and 40.0% reported not knowing where to access information regarding SSPs. After the training, 66 (88.0%) reported that they felt more comfortable educating PWID (P < .0001), 65 respondents (86.6%) reported they planned to use the Six Moments model in their own practice, and 100% said they would consider referring patients to an SSP in the future.

CONCLUSIONS

The Six Moments model emphasizes the importance of a global approach to infection prevention and harm reduction. This educational intervention can be used as part of a bundle of implementation strategies to reduce morbidity and mortality in PWID.

Optimising recruitment to a late-phase tuberculosis clinical trial: a qualitative study exploring patient and practitioner experiences in Uzbekistan

BACKGROUND

Addressing the global burden of multidrug-resistant tuberculosis (MDR-TB) requires identification of shorter, less toxic treatment regimens. Médecins Sans Frontières (MSF) is currently conducting a phase II/III randomised controlled clinical trial, to find more effective, shorter and tolerable treatments for people with MDR-TB. Recruitment to the trial in Uzbekistan has been slower than expected; we aimed to study patient and health worker experiences of the trial, examining potential factors perceived to impede and facilitate trial recruitment, as well as general perceptions of clinical research in this context.

METHODS

We conducted a qualitative study using maximum variation, purposive sampling of participants. We carried out in-depth interviews (IDIs) and focus group discussions (FGDs) guided by semi-structured topic guides. In December 2019 and January 2020, 26 interviews were conducted with patients, Ministry of Health (MoH) and MSF staff and trial health workers, to explore challenges and barriers to patient recruitment as well as perceptions of the trial and research in general. Preliminary findings from the interviews informed three subsequent focus group discussions held with patients, nurses and counsellors. Focus groups adopted a person-centred design, brainstorming potential solutions to problems and barriers. Interviews and FGDs were audio recorded, translated and transcribed verbatim. Thematic analysis, drawing on constant comparison, was used to analyse the data.

RESULTS

Health system contexts may compete with new approaches especially when legislative health regulations or policy around treatment is ingrained in staff beliefs, perceptions and practice, which can undermine clinical trial recruitment. Trust plays a significant role in how patients engage with the trial. Decision-making processes are dynamic and associated with relationship to diagnosis, assimilation of information, previous knowledge or experience and influence of peers and close relations.

CONCLUSIONS

This qualitative analysis highlights ways in which insights developed together with patients and healthcare workers might inform approaches towards improved recruitment into trials, with the overall objective of delivering evidence for better treatments.

Hand hygiene among nurses in pediatric blood and marrow transplantation setting: a best practice implementation project

OBJECTIVES

The aim of this project was to promote evidence-based best practice regarding hand hygiene among nurses in a pediatric blood and marrow transplantation (BMT) setting.

INTRODUCTION

Healthcare-associated infections (HAI) represent important complications of healthcare with potentially major impact on patient outcomes. Most HAI are transmitted through the hands of healthcare professionals (HCP) and therefore hand hygiene is the simplest, most effective and proven method for preventing HAI. However, the overall compliance rate of HCP with hand hygiene remains at a very low level. In this case, it is necessary to implement strategies to improve the compliance with hand hygiene of the HCP with the purpose of reducing HAI rates, mortality and costs, all the more so as it is known that patients with BMT have an increased risk of HAI.

METHODS

This best practice implementation project was based on the JBI methodological approach and included three phases of activity: a baseline audit, implementation of strategies and a follow-up audit. The project was conducted in the pediatric BMT setting of a large university hospital located in Bucharest, Romania, and the sample included 10 nurses and five relatives of pediatric patients from this ward.

RESULTS

As a result of the implementation of strategies, improvements were observed across seven audit criteria, given that for two audit criteria out of a total of nine audit criteria compliance was maximum (100%) since the baseline phase. Moreover, the post implementation audit showed a complete compliance (100%) for six audit criteria. However, for the other three audit criteria the compliance in follow-up audit was high: 92, 85 and 80%, respectively.

CONCLUSION

The strategies applied within this evidence implementation project were appropriate, so the project was a success. However, permanent actions are required to sustain changes in practice and improvements made.

Observational Study of Hand Hygiene Compliance at a Trauma Hospital in Iraqi Kurdistan

Healthcare-associated infections, commonly caused by poor hand hygiene, represent a significant source of disease and economic burden for healthcare systems, especially those in resource-limited settings. The few existing studies on hand hygiene compliance in resource-limited hospital settings suggest that compliance is insufficient. The difference in compliance rates between units in resource-limited trauma hospitals is largely unknown. We aimed to assess hand hygiene compliance rates among healthcare workers at a trauma hospital in Iraqi Kurdistan and compare the levels of compliance between the emergency room (ER), the intensive care unit (ICU), and the acute care ward (ACW). We carried out overt observations in 2018 using the validated World Health Organization ‘five moments for hand hygiene’ observational tool. We observed a total of 622 hand hygiene opportunities performed by 149 healthcare workers. Hand hygiene compliance was defined as handwashing with soap and water or the use of alcohol-based hand rub, in accordance with the ‘five moments for hand hygiene’ concept. Overall, the hand hygiene compliance rate was found to be 6.8% (95% confidence interval 5.0–9.1). Compliance was significantly lower in the ER (1.0%), compared with the ICU (8.1%) (p = 0.0012), and the ACW (11.1%) (p < 0.0001). In all three units, the availability of alcohol-based hand rub and handwashing sinks was insufficient in relation to the number of patient beds. We conclude that the overall level of hand hygiene compliance was low, with the lowest level of compliance in the ER. Our findings call for improved resource allocation and strengthened hand hygiene routines. These relatively simple measures could potentially lower the incidence of healthcare-associated infections and improve the mortality and morbidity of patients in already overburdened healthcare systems.

Internet of Things to Explore Moment 2 of "WHO My Five Moments" for Hand Hygiene

Background: Electronic hand hygiene surveillance systems are developing and considered to be more reliable than direct observation for hand hygiene monitoring. However, none have the capability to assess compliance in complex nursing care.

Materials and Methods: We combined two different technologies, a hand hygiene monitoring system (radiofrequency identification, RFID) and a nursing care recorder at the bedside, and we merge their data to assess hand hygiene performance during nursing. Nursing tasks were classified as standard task procedures or aseptic task procedures corresponding to moment 2 among the five moments for hand hygiene recommended by the WHO. All statistical analyses were performed using R, version 3.6.2. For mixed models, the package “lme4” was used.

Results: From the merged database over the 2-year study period, 30,164 nursing tasks were identified for analysis, 25,633 were classified as standard task procedures, and 4,531 were classified as aseptic task procedures for nursing care. Hand disinfection with an alcohol-based solution was not detected with our system in 42.5% of all the recorded tasks, 37% of all the aseptic task procedures, and 47.1% of all the standard task procedures for nursing (p = 0.0362), indicating that WHO moment 2 was not respected in 37% of mandatory situations.

Conclusion: Using a combination of different technologies, we were able to assess hand hygiene performance in the riskiest circumstances.

Knowledge about COVID-19 and pandemic impact on Madrid dental students (Spain)

Background

COVID-19 has had a major impact on dental activity, with implications on dental education. The aim of this study was to assess the knowledge about it and the pandemic impact on Spanish dental students.

Material and Methods

An observational and cross-sectional study with a 17-items questionnaire was conducted. It was divided into three sections, sociodemographic data, self-perception and knowledge about the COVID-19 protective measures and repercussions on dental students. This survey was carried out in May 2020, and the response rate was 46.16%. The statistical analysis was performed by the Pearson chi-square test and Fisher’s exact test.

Results

A total of 235 students responded to the questionnaire, with an average age of 22.3 years. Attendance at COVID-19 training courses, knowledge about the Personal Protective Equipment (PPE) management and the incubation period had the worst results, compared to the knowledge about hand washing, wearing gloves and masks and symptomatology who got higher percentages. 31.1% of participants reported presenting symptomatology related to SARS-CoV-2, although only 8.2% were diagnosed and 46.6% suffered quarantine. 62.5% were afraid to catch the disease.

Conclusions

The results of this study show that there are deficiencies in the knowledge of important aspects of COVID-19 in dental students, which implies a commitment of the university in its training, as well as the realization of diagnostic controls for the disease.

Key words:Dental students, SARS-CoV-2, COVID-19, survey, knowledge.

[Level of Complete Knowledge on Five Moments of Hand Hygiene among Nurses Working at Integrated Nursing Care Service Wards]

PURPOSE

This study aimed to identify the level of complete knowledge about hand hygiene indications among nurses working at integrated nursing care service wards.

METHODS

A total of 127 nurses in eight integrated nursing care service wards completed structured sheets while observing a video based on six scenarios developed by the research team. Complete knowledge level was calculated as the percentage (%) of participants who responded correctly to all questions among participants. Complete knowledge levels according to the scenarios were calculated and compared according to general characteristics using the chi-squared test or Wilcoxon rank-sum test.

RESULTS

The complete knowledge level for each scenario ranged from 7.9% (scenario 6) to 42.5% (scenarios 4 and 5), and no one had complete knowledge of all scenarios. Only 3.1% of participants demonstrated complete knowledge in more than four scenarios, and 26.0% had complete knowledge of four or more hand hygiene moments. Complete knowledge level per scenario did not differ depending on work experience at hospitals and study wards, or prior hand hygiene training in the last year.

CONCLUSION

As the complete knowledge level regarding hand hygiene moment is very low, it is suggested that regular hand hygiene training should be provided to nurses using video media that reflect real nursing tasks. Thus, they can acquire complete knowledge of when hand hygiene is needed or not during complex nursing work situations.

Colonization resistance against multi-drug-resistant bacteria: a narrative review

Colonization resistance by gut microbiota is a fundamental phenomenon in infection prevention and control. Hospitalized patients may be exposed to multi-drug-resistant bacteria when hand hygiene compliance among healthcare workers is not adequate. An additional layer of defence is provided by the healthy gut microbiota, which helps clear the exogenous bacteria and acts as a safety net when hand hygiene procedures are not followed. This narrative review focuses on the role of the gut microbiota in colonization resistance against multi-drug-resistant bacteria, and its implications for infection control. The review discusses the underlying mechanisms of colonization resistance (direct or indirect), the concept of resilience of the gut microbiota, the link between the antimicrobial spectrum and gut dysbiosis, and possible therapeutic strategies. Antimicrobial stewardship is crucial to maximize the effects of colonization resistance. Avoiding unnecessary antimicrobial therapy, shortening the antimicrobial duration as much as possible, and favouring antibiotics with low anti-anaerobe activity may decrease the acquisition and expansion of multi-drug-resistant bacteria. Even after antimicrobial therapy, the resilience of the gut microbiota often occurs spontaneously. Spontaneous resilience explains the existence of a window of opportunity for colonization of multi-drug-resistant bacteria during or just after antimicrobial therapy. Strategies favouring resilience of the gut microbiota, such as high-fibre diets or precision probiotics, should be evaluated.

Compliance with hygiene practices among healthcare workers at an academic hospital emergency department

Introduction

Healthcare-associated infections (HCAIs) are an important contributor to patient morbidity and mortality. Healthcare workers (HCWs) hands are the chief mode of transmission of HCAIs. The emergency centre (EC) is frequently the first point of contact for patients within the health care system. The aim of this study is to determine compliance with hygiene practices among healthcare workers at a tertiary hospital EC.

Methods

Hygiene practices of staff were observed over a six-week period. Data pertaining to compliance rates with hand cleansing and other hygiene practices was collected. Consent was obtained retrospectively to avoid influencing participant behaviour.

Results

From a total of 477 potential hygiene opportunities, compliance with hand hygiene was only 34.4% (n = 164). Hand cleansing with an alcohol-based hand rub was observed in 87 (26.7%) of the 326 (68.3%) opportunities where it was indicated, while handwashing with soap and water was observed in 35 (23.2%) of the 151 opportunities where this was indicated. Compliance to each of the six steps of handwashing ranged between 62.2% and 83.5%, with there being a gradual deterioration in compliance from step one through to step six. Compliance with ‘bare below the elbows’ was observed in 242 (50.7%) opportunities while disposable surgical gloves were worn on 85 (44.7%) of the 190 opportunities where this was indicated.

Conclusion

Compliance with hygiene practices among EC HCWs is suboptimal. Various strategies including ongoing systematic training and regular audits may improve overall hygiene practices among EC staff.

Health Care Environmental Hygiene: New Insights and Centers for Disease Control and Prevention Guidance

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.

Increasing hand-hygiene compliance in clinical settings using a baby-eyes sticker

This double-blind field study tested the effectiveness of a baby-eyes image in promoting healthcare workers’ hand-hygiene compliance in a hospital setting. Adults are inclined to take care of babies and aspire to be their role models; therefore, they should wash their hands thoroughly when being watched by babies. Participants were healthcare workers from the obstetrical and neonatology units of a women’s hospital in Hangzhou. We recorded and coded 3,360 hours and 10,325 hand-hygiene events over a five-week period—from 16 October to 20 November 2018. Three types of stickers, depicting baby eyes, adult eyes, or flowers, were placed above handwashing basins to compare hand-hygiene behavior between the three conditions. Each condition continued for one week, and experimenters interchanged the stickers in each unit to control for the location and sequence effects. Participants in the baby-eyes condition (72.9%) were more likely to use sanitizer than those in the flowers condition (69.4%; χ2 = 9.74, p < .01, φc = 0.034). Moreover, participants in the baby-eyes condition were more likely to use sanitizer than those in the adult-eyes condition (70.8%); however, the difference only trended towards significance ( χ2 = 2.38, p = .066, φc = 0.023). The mean handwashing time between the three conditions was significant (Welch’s F(2, 3488.436) = 3.50, p < .05, η2 = 0.001). Washing time in the baby-eyes condition (17.41 ± 12.02) was significantly longer than in the adult-eyes condition (16.36 ± 11.47; p < .05). The presence of a baby-eyes image promoted hand-hygiene compliance in the hospital environment. This finding can be adopted to change public health behaviors. It also holds theoretical implications that enhance our understanding of how being monitored by children can enhance responsible behaviors.

Hand hygiene in health care: 20 years of ongoing advances and perspectives

Health-care-associated infections are the most prevalent adverse events of hospital care, posing a substantial threat to patient safety and burden on society. Hand hygiene with alcohol-based hand rub is the most effective preventive strategy to reduce health-care-associated infections. Over the past two decades, various interventions have been introduced and studied to improve hand hygiene compliance among health-care workers. The global implementation of the WHO multimodal hand hygiene improvement strategy and constant efforts to replace the use of soap and water with alcohol-based hand rub have led to a faster and more efficient hand cleaning method. These strategies have strongly contributed to the success of behaviour change and a subsequent decrease in health-care-associated infections and cross-transmission of multidrug-resistant organisms worldwide. The WHO multimodal behaviour change strategy requires a series of elements including system change as a prerequisite for behaviour, change, education, monitoring and performance feedback, reminders in the workplace, and an institutional safety climate. Successful adoption of the promotion strategy requires adaptation to available resources and sociocultural contexts. This Review focuses on the major advances and challenges in hand hygiene research and practices in the past 20 years and sets out various ways forward for improving this lifesaving action.

Measuring hygiene competence: the picture-based situational judgement test HygiKo

BACKGROUND

With the onset of the COVID-19 pandemic at the beginning of 2020, the crucial role of hygiene in healthcare settings has once again become very clear. For diagnostic and for didactic purposes, standardized and reliable tests suitable to assess the competencies involved in "working hygienically" are required. However, existing tests usually use self-report questionnaires, which are suboptimal for this purpose. In the present study, we introduce the newly developed, competence-oriented HygiKo test instrument focusing health-care professionals' hygiene competence and report empirical evidence regarding its psychometric properties.

METHODS

HygiKo is a Situational Judgement Test (SJT) to assess hygiene competence. The HygiKo-test consists of twenty pictures (items), each item presents only one unambiguous hygiene lapse. For each item, test respondents are asked (1) whether they recognize a problem in the picture with respect to hygiene guidelines and, (2) if yes, to describe the problem in a short verbal response. Our sample comprised n = 149 health care professionals (79.1 % female; age: M = 26.7 years, SD = 7.3 years) working as clinicians or nurses. The written responses were rated by two independent raters with high agreement (α > 0.80), indicating high reliability of the measurement. We used Item Response Theory (IRT) for further data analysis.

RESULTS

We report IRT analyses that show that the HygiKo-test is suitable to assess hygiene competence and that it allows to distinguish between persons demonstrating different levels of ability for seventeen of the twenty items), especially for the range of low to medium person abilities. Hence, the HygiKo-SJT is suitable to get a reliable and competence-oriented measure for hygiene-competence.

CONCLUSIONS

In its present form, the HygiKo-test can be used to assess the hygiene competence of medical students, medical doctors, nurses and trainee nurses in cross-sectional measurements. In order to broaden the difficulty spectrum of the current test, additional test items with higher difficulty should be developed. The Situational Judgement Test designed to assess hygiene competence can be helpful in testing and teaching the ability of working hygienically. Further research for validity is needed.

Predictors of missed infection control care: A tri-partite international study

AIM

This study aimed to quantify types and frequencies of missed infection control care and to develop a theoretical model for estimating nurses' consensus scores about this form of missed care.

DESIGN

A non-experimental research design using self-audit data was selected to collect information about the types and frequencies of missed infection control care from nurses employed in hospitals located in three different countries. Data collection commenced mid-year 2018.

METHODS

A multivariate approach was used to apply the consensus scores of 1.911 internationally based nurses in the missed opportunities for maintaining infection control.

RESULTS/FINDINGS

Thirteen variables exert direct effects on the nurses' total scores underpinning missed infection control care. These include the methods used to prevent hospital-acquired infections, surveillance and hand hygiene practices. Significant nurses' demographic factors also included their countries of origin, employment status, employer type, job retention intentions, work intensity, length of clinical experience and staff development attendance.

CONCLUSION

In magnitude of importance and having the largest effect on missed infection control care is missed care related to reducing hospital-acquired infections followed closely by surveillance. Missed infection control care can be quantified, and variances in its practices can be accounted by exploring the nurses' differing demographic factors, including the nurses' country of origin.

IMPACT

Variations in missed infection control care can be accounted for across three countries. While ward hygiene is underestimated by staff as a mechanism to minimize nosocomial infections, infection control surveillance remains the key to reducing hospital-acquired infections. The study's outcomes invite the use of an ongoing, whole-of-organization approach to infection control with scrutiny being needed for improved staff adherence particularly with hand hygiene.

Assessing the application of human-centered design to translational research

Introduction:

Human-centered design (HCD) training offers the potential to improve both team processes and products. However, the use of HCD to improve the quality of team science is a relatively recent application, and its benefits and challenges have not been rigorously evaluated. We conducted a qualitative study with health sciences researchers trained in HCD methods. We aimed to determine how researchers applied HCD methods and perceived the benefits and barriers to using HCD on research teams.

Methods:

We conducted 1-hour, semi-structured interviews with trainees from three training cohorts. Interviews focused on perceptions of the training, subsequent uses of HCD, barriers and facilitators, and perceptions of the utility of HCD to science teams. Data analysis was conducted using Braun and Clarke’s process for thematic analysis.

Results:

We interviewed nine faculty and nine staff trained in HCD methods and identified four themes encompassing HCD use, benefits, challenges, and tensions between HCD approaches and academic culture.

Conclusions:

Trainees found HCD relevant to research teams for stakeholder engagement, research design, project planning, meeting facilitation, and team management. They also described benefits of HCD in five distinct areas: creativity, egalitarianism, structure, efficiency, and visibility. Our data suggest that HCD has the potential to help researchers work more inclusively and collaboratively on interdisciplinary teams and generate more innovative and impactful science. The application of HCD methods is not without challenges; however, we believe these challenges can be overcome with institutional investment.

User knowledge factors that hinder the design of new home healthcare devices: investigating thirty-eight devices and their manufacturers

Background

The demand for home healthcare devices arises; however, many home healthcare devices on the market are not designed to reflect the needs and features of the end-users. This study explored the user knowledge factors that hindered the design of new home healthcare devices and the interrelationships between the factors.

Methods

The abovementioned factors were identified from analysing the project documents of thirty-eight carefully selected home healthcare devices produced by five manufacturers; followed by interviewing the thirty stakeholders playing key roles in developing the devices.

Results

The design of the home healthcare devices was influenced by (1) the user insights utilised in formulating project strategies; (2) the sources of user information; (3) the execution of user research; and (4) the formulation of the manufacturers’ principal innovation processes.

Conclusions

The users’ characteristics and needs were not sufficiently reflected in developing new home healthcare devices. One root cause was that the end-users were not perceived by the manufacturers as a key success factor in most cases, given that most of the devices were initiated following the public sector’s requests. Actual or potential applications of this study include the facilitation of the appropriate application of human factors methods in developing new home healthcare devices and the improvement of the user performance of the end-devices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01464-3.

Hand Hygiene during the Early Neonatal Period: A Mixed-Methods Observational Study in Healthcare Facilities and Households in Rural Cambodia

BACKGROUND

Globally, infections are the third leading cause of neonatal mortality. Predominant risk factors for facility-born newborns are poor hygiene practices that span both facilities and home environments. Current improvement interventions focus on only one environment and target limited caregivers, primarily birth attendants and mothers. To inform the design of a hand hygiene behavioural change intervention in rural Cambodia, a formative mixed-methods observational study was conducted to investigate the context-specific behaviours and determinants of handwashing among healthcare workers, and maternal and non-maternal caregivers along the early newborn care continuum.

METHODS

Direct observations of hygiene practices of all individuals providing care to 46 newborns across eight facilities and the associated communities were completed and hand hygiene compliance was assessed. Semi-structured interactive interviews were subsequently conducted with 35 midwives and household members to explore the corresponding cognitive, emotional and environmental factors influencing the observed key hand hygiene behaviours.

RESULTS

Hand hygiene opportunities during newborn care were frequent in both settings (n = 1319) and predominantly performed by mothers, fathers and non-parental caregivers. Compliance with hand hygiene protocol across all caregivers, including midwives, was inadequate (0%). Practices were influenced by the lack of accessible physical infrastructure, time, increased workload, low infection risk perception, nurture-related motives, norms and inadequate knowledge.

CONCLUSIONS

Our findings indicate that an effective intervention in this context should be multi-modal to address the different key behaviour determinants and target a wide range of caregivers.

Hand hygiene compliance in companion animal clinics and practices in Switzerland: An observational study

Background: Hand hygiene (HH) is one of the most important measures to prevent healthcare‐associated infections. Data on HH compliance in companion animal veterinary institutions in Europe are sparse.

Methods: This observational study assessed HH according to WHO standards in three large and two medium‐sized clinics and two primary care practices in Switzerland. Associations with HH indication, professional group, clinical area and institution were determined using a generalized linear mixed effects model.

Results: Based on 2056 observations, overall HH compliance [95% confidence interval] was 32% [30%‐34%]. HH compliance was highest in the consultation area (41% [38%‐45%]) and after contact to body fluids (45% [40%‐50%]), and lowest in the pre‐OR area (20% [15%‐24%]) and before clean/aseptic procedures (12% [9%‐15%]). Veterinarians showed a higher HH compliance (37% [34%‐40%]) than veterinary nurses (25% [22%‐28%]). HH compliance was lower before clean/aseptic procedures compared to all other indications (all p < 0.015 except ‘before touching a patient’ in medium‐sized clinics/practices, p = 0.095) and higher in the consultation area compared to all other areas in large clinics (all p < 0.04).

Conclusion: Effective HH training should urgently be promoted for all veterinary personnel with special emphasis on the importance of HH before clean/aseptic procedures.

Present and Future Perspectives on Therapeutic Options for Carbapenemase-Producing Enterobacterales Infections

Carbapenem-resistant Enterobacterales (CRE) are included in the list of the most threatening antibiotic resistance microorganisms, being responsible for often insurmountable therapeutic issues, especially in hospitalized patients and immunocompromised individuals and patients in intensive care units. The enzymatic resistance to carbapenems is encoded by different β-lactamases belonging to A, B or D Ambler class. Besides compromising the activity of last-resort antibiotics, CRE have spread from the clinical to the environmental sectors, in all geographic regions. The purpose of this review is to present present and future perspectives on CRE-associated infections treatment.

Central Line Care and Management: Adopting Evidence-Based Nursing Interventions

Central line-associated bloodstream infections occur not only in the intensive care unit but also the non-intensive care units of the hospital. The purpose of this article is to review current evidence to guide perianesthesia nurses in the care of a patient with a central vascular access device (CVAD). The CVAD bundle focuses on five key elements: hand hygiene, maximal sterile barrier, chlorhexidine antiseptic, catheter site selection, and daily evaluation of the need for the device. Once the CVAD is placed, evidence-based care and maintenance are the responsibility of the nurse. Ensuring proper maintenance and care of a CVAD falls within nursing practice and interventions can significantly reduce the patient's risk of central line-associated bloodstream infection. The single most crucial step a nurse can take to help prevent central line-associated bloodstream infections is performing proper hand hygiene. Other interventions focus on dressing management, bathing practices, access of intravenous infusion sets, blood draws, and management of port line occlusions. Familiarity and adoption of best practice interventions in the maintenance and care of patients with CVADs will help the perianesthesia nurse protect patients and prevent harm.

Hand Areas Which Are Commonly Missed during Hand Disinfection by Nursing Students Who Completed a Basic Educational Course in Hand Hygiene

BACKGROUND

Teaching nursing students how to correctly perform hand hygiene procedures may guarantee a reduction in transmitting pathogens through direct contact and, thus, it may lead to a decrease in the number of hospital infections. The aim of the study, which was conducted in low fidelity simulation conditions, was to assess the performance and the efficiency of a hand-rubbing disinfection technique among nursing students on the last day of their course.

MATERIALS AND METHODS

The study was conducted in a group of 190 nursing students studying at the Jagiellonian University and it focused on the performed hand-rubbing disinfection procedure. The accuracy of the task performance was assessed by measuring the percentage of the amount of Fluo-Rub (B. Braun) fluorescent alcohol-based gel remaining on students' hands after disinfection. The gel was rubbed into particular hand parts including four surfaces (left palm, right palm, left back and right back) divided into thirteen areas (I-XIII) and each surface was examined separately. The results were then dichotomized based on the cut-off point of 10% and two categories: "clean" and "dirty" were established. Additionally, the range of negligence in the disinfection procedure was assessed by counting the total number of the areas classified as "dirty". The comparison of continuous and categorical variables was conducted by means of Friedman's and Cochrane's tests, respectively.

RESULTS

It was found out that the palm surfaces that were commonly missed during hand disinfection included the whole thumb (I and VI), the fingertip of the little finger (V) and the midpalm (XIII), whereas in the case of back surfaces (on both right and left hand) the most commonly missed areas were the fingertips and the whole thumb I-VI. Only 30 students (13%) had all 52 areas of both hands completely clean, whereas more than one third-66 students (33%)-failed to disinfect properly more than 10 areas out of all assessed ones on the surfaces of both hands.

CONCLUSIONS

In the examined group of nursing students, a significant lack of compliance with hand disinfection procedures was observed and it was related mainly to thumbs and back parts of both hands. Therefore, it is essential to conduct systematic training sessions and assessment of hand hygiene procedures for nursing students at the end of every educational stage as it can lead to their developing these skills properly.

Pharmacotherapeutics of SARS-CoV-2 Infections

The COVID-19 pandemic has affected more than 38 million people world-wide by person to person transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Therapeutic and preventative strategies for SARS-CoV-2 remains a significant challenge. Within the past several months, effective treatment options have emerged and now include repurposed antivirals, corticosteroids and virus-specific antibodies. The latter has included convalescence plasma and monoclonal antibodies. Complete viral eradication will be achieved through an effective, safe and preventative vaccine. To now provide a comprehensive summary for each of the pharmacotherapeutics and preventative strategies being offered or soon to be developed for SARS-CoV-2.

A two-component intervention to improve hand hygiene practices and promote alcohol-based hand rub use among people who inject drugs: a mixed-methods evaluation

Background

Inconsistent hand hygiene puts people who inject drugs (PWID) at high risk of infectious diseases, in particular skin and soft tissue infections. In healthcare settings, handwashing with alcohol-based hand rubs (ABRH) is recommended before aseptic procedures including intravenous injections. We aimed to evaluate the acceptability, safety and preliminary efficacy of an intervention combining ABHR provision and educational training for PWID.

Methods

A mixed-methods design was used including a pre-post quantitative study and a qualitative study. Participants were active PWID recruited in 4 harm reduction programmes of France and followed up for 6 weeks. After baseline assessment, participants received a face-to-face educational intervention. ABHR was then provided throughout the study period. Quantitative data were collected through questionnaires at baseline, and weeks 2 (W2) and 6 (W6) post-intervention. Qualitative data were collected through focus groups with participants who completed the 6-week study.

Results

Among the 59 participants included, 48 (81%) and 43 (73%) attended W2 and W6 visits, respectively. ABHR acceptability was high and adoption rates were 50% (W2) and 61% (W6). Only a minority of participants reported adverse skin reactions (ranging from 2 to 6%). Preliminary efficacy of the intervention was shown through increased hand hygiene frequency (multivariable linear mixed model: coef. W2 = 0.58, p = 0.002; coef. W6 = 0.61, p = 0.002) and fewer self-reported injecting-related infections (multivariable logistic mixed model: AOR W6 = 0.23, p = 0.021). Two focus groups were conducted with 10 participants and showed that young PWID and those living in unstable housing benefited most from the intervention.

Conclusions

ABHR for hand hygiene prior to injection are acceptable to and safe for PWID, particularly those living in unstable housing. The intervention’s educational component was crucial to ensure adoption of safe practices. We also provide preliminary evidence of the intervention’s efficacy through increased hand hygiene frequency and a reduced risk of infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-05895-1.

Bundle approach used to achieve zero central line-associated bloodstream infections in an adult coronary intensive care unit

Background

Central venous catheterisation is commonly used in critical patients in intensive care units (ICU). It may cause complications and attribute to increase mortality and morbidity. At coronary ICU (CICU) of cardiac hospital, central line-associated bloodstream infection (CLABSI) rate was 2.82/1000 central line days in 2015 and 3.11/1000 central line days in 2016. Working in collaboration with Institute for Healthcare Improvement (IHI), we implemented evidence-based practices in the form of bundles in with the aim of eliminating CLABSI in CICU.

Methods

In collaboration with IHI, we worked on this initiative as multidisciplinary team and tested several changes. CLABSI prevention bundles were tested and implemented, single kit for line insertion, simulation-based training for line insertions, standardised and real-time bundle monitoring by direct observations are key interventions tested. We used model for improvement and changes were tested using small Plan-Do-Study-Act cycles. Surveillance methods and CLABSI definition used according to National Healthcare Safety Network.

Results

The CLABSI rate per 1000 patient-days dropped from 3.1 per 1000 device-days to 0.4 per 1000 device-days. We achieved 757 days free of CLABSI in the unit till December 2018 when a single case happened. After that we achieved 602 free days till July 2020 and still counting.

Conclusions

Implementation of evidence-based CLABSI prevention bundle and process monitoring by direct observation led to significant and subsequently sustained improvement in reducing CLABSI rate in adult CICU.

Are Severe Mastitis Cases in Dairy Cows Associated with Bacteremia?

The objective of this study was to investigate the occurrence of bacteremia in dairy cows with severe mastitis. Milk samples were collected from affected udder quarters, and corresponding blood samples were collected from dairy cows with severe mastitis at the time of diagnosis before any therapeutic measures were undertaken. The cultural detection of pathogens in blood classified a bacteremia. Further diagnostic tests were performed to provide evidence of bacteremia. This was realized by PCR with regard to S. aureus, E. coli and S. uberis and the Limulus test. Detection of culturable pathogens in the blood of cows with severe clinical mastitis was rare and occurred in only one of 70 (1.4%) cases. Overall, bacterial growth was detected in 53 of 70 (75.7%) milk samples. S. uberis (22/70), E. coli (12/70) and S. aureus (4/70) were the most frequently isolated pathogens from milk of cows with severe mastitis. PCR was performed in 38 of 70 (54.3%) blood samples. PCR was positive in eight of 38 cases. S. uberis was found most frequently in six blood samples (8.6%). E. coli was found on PCR in one blood sample (1.4%). S. aureus was identified in one blood sample (1.4%). When Coliforms were detected in the quarter milk sample, a Limulus test was performed in the corresponding blood sample. In three of 15 cases, the Limulus test was positive (4.3% of samples). Further studies are needed to investigate the occurrence of bacteremia in cows with severe mastitis in a higher population size.

Physicians' compliance for hand hygiene in medical outpatient clinics: automated hand-hygiene monitoring with touch sensor and wireless internet

BACKGROUND

Outpatient clinics are reservoirs for significant pathogens. Hand hygiene with alcohol-based hand rubs are measures currently in use to prevent horizontal transmission of infections. The extent of compliance with hand hygiene regulations is unclear and difficult to monitor.

METHODS

We built an automated monitoring system with a pressure sensor attached to the alcohol-based hand rubs containers. Wireless fidelity (WIFI)-assisted data collection took place over 9 weeks. Interventions included posters, email reminders and newsletters. Hand hygiene compliance before and after these interventions was evaluated.

RESULTS

Overall compliance with hand hygiene regulations was 6.48%; half of the physicians participating in our study performed hand hygiene at only 3.08% of patient visits. Twenty-four (17.9%) physicians performed hand hygiene with high compliance (≥10%), while 11.2% performed no hand hygiene at all. Physicians in academic positions and those with ≥20 years of experience performed hand hygiene less frequently than did other physicians. Compliance with hand hygiene regulations improved from 6.08% to 6.73% (P < .001) after intervention.

DISCUSSION

Compliance with hand hygiene among physicians in our outpatient clinics was very low and needs to improve.

CONCLUSIONS

Interventions improved the compliance somewhat, although additional interventions including education, training and feedback were suggested.

Perceptions of Nigerian healthcare workers towards hand hygiene: a qualitative study

Introduction

hand hygiene (HH) is an effective measure to reduce healthcare-associated infections and the growing burden of antimicrobial resistance. There is a need to understand the perceptions of healthcare workers towards its practice and the use of alcohol-based hand rubs (ABHR) to make recommendations to promote HH. Our study aimed to explore the perceptions of Nigerian healthcare workers towards HH and the use and availability of ABHR to suggest potential interventions to improve its practice as qualitative evidence in this field is limited in Nigeria.

Methods

a qualitative study design was utilized to understand the perceptions of healthcare workers towards HH and the use of ABHR at Adeoyo Maternity Hospital, Ibadan, Nigeria. Purposive sampling was used to recruit nineteen healthcare workers who were interviewed. Thematic content analysis was used to analyze the data generated.

Results

five themes emerged including discrepancies in what constitutes HH practice as participants, motivation for HH practice, a good knowledge of timing as regards practice, barriers to good practice and evidence of poor practice.

Conclusion

while many healthcare workers know about HH and self-reported compliance towards it seems to be high, knowledge gaps, lack of resources, absence of regulations and poor working conditions were impediments to the successful implementation of HH practices. We recommend that hospitals institute well-articulated HH regulations, continuous education and training of healthcare workers. Hospitals should also ensure adequate provision of resources for hand hygiene and institute a continuous monitoring and feedback program to evaluate compliance with regulations.

The impact of a multimodel approach to designing a new orthopedic department

OBJECTIVE

To determine whether a multifaceted approach effectively influenced antibiotic use in an orthopedics department.

DESIGN

Retrospective cohort study comparing the readmission rate and antibiotic use before and after an intervention.

SETTING

A 1,000-bed, tertiary-care, university hospital.

PATIENTS

Adult patients admitted to the orthopedics department between January 2015 and December 2018.

METHODS

During the preintervention period (2015-2016), 1 general orthopedic department was in operation. In the postintervention period (2017-2018), 2 separate departments were created: one designated for elective "clean" surgeries and another that included a "complicated wound" unit. A multifaceted strategy including infection prevention measures and introducing antibiotic stewardship practices was implemented. Admission rates, hand hygiene practice compliance, surgical site infections, and antibiotic treatment before versus after the intervention were analyzed.

RESULTS

The number of admissions and hospitalization days in the 2 periods did not change. Seven-day readmissions per annual quarter decreased significantly from the preintervention period (median, 7 days; interquartile range [IQR], 6-9) to the postintervention period (median, 4 days; IQR, 2-7; P = .038). Hand hygiene compliance increased and surgical site infections decreased in the postintervention period. Although total antibiotic use was not reduced, there was a significant change in the breakdown of the different antibiotic classes used before and after the intervention: increased use of narrow-spectrum β-lactams (P < .001) and decreased use of β-lactamase inhibitors (P < .001), third-generation cephalosporins (P = .044), and clindamycin (P < .001).

CONCLUSIONS

Restructuring the orthopedics department facilitated better infection prevention measures accompanied by antibiotic stewardship implementation, resulting in a decreased use of broad-spectrum antibiotics and a significant reduction in readmission rates.

Does size matter? The impact of a small but targeted cleaning training intervention within a paediatric ward

Background

Cleaning is a critical tool for infection prevention and control, and is a key intervention for preventing healthcare associated infections (HCAIs) and controlling intermediate transmission routes between patient and environment. This study sought to identify potential areas of weakness in clinical surface cleaning, and assess the effectiveness of a staff group specific training intervention.

Observations

One-hundred hours of audit observations in a paediatric cardiac intensive care unit (CICU) assessed surface cleaning technique of healthcare staff within bedspaces. Cleaning was assessed with a 5-component bundle, with each cleaning opportunity scored out of five.

Training Intervention

Fifty hours of audit observations before and after a training intervention tested the efficacy of a staff group specific education intervention. The intervention was developed and implemented for 69% of nurses and 100% of cleaners.

Results

One hundred and eighteen cleaning opportunities were observed before training, and scored an average of 2.4. One hundred and twenty-one cleaning opportunities were observed after training and scored an average 3.0. On average, before training, each cleaning opportunity by nurses and cleaners fulfilled 2.4 and 2.5, respectively, of the 5 bundle components. Following training, this improved to 3.3 and 2.9 respectively. There was a statistically significant improvement in bundle scores for nurses (P=.004) and cleaners (P=.0003).

Conclusions

Surface wipe methods were inconsistent between all staff groups. The education based intervention resulted in a small improvement in most of the cleaning components. This study has identified how a small but targeted cleaning training intervention can have a significant (P= <.0001) impact on cleaning bundle compliance for both nurses and cleaners.

Hygiene along the continuum of care in the early post-natal period: an observational study in Nigeria

BACKGROUND

Newborns delivered in healthcare facilities in low- and middle-income countries are at an increased risk of healthcare associated infections. Facility-based studies have focused primarily on healthcare worker behaviour during labour & delivery with limited attention to hygiene practices in post-natal care areas and largely ignore the wide variety of actors involved in maternal and neonatal care.

METHODS

This exploratory mixed-methods study took place in six healthcare facilities in Nigeria where 31 structured observations were completed during post-natal care, discharge, and the first 6 hours after return to the home. Frequency of hand hygiene opportunities and hand hygiene actions were assessed for types of patient care (maternal and newborn care) and the role individuals played in caregiving (healthcare workers, cleaners, non-maternal caregivers). Qualitative interviews with mothers were completed approximately 1 week after facility discharge.

RESULTS

Maternal and newborn care were performed by a range of actors including healthcare workers, mothers, cleaners and non-maternal caregivers. Of 291 hand hygiene opportunities observed at health facilities, and 459 observed in home environments, adequate hand hygiene actions were observed during only 1% of all hand hygiene opportunities. Adequate hand hygiene prior to cord contact was observed in only 6% (1/17) of cord contact related hand hygiene opportunities at healthcare facilities and 7% (2/29) in households. Discharge advice was infrequent and not standardised and could not be remembered by the mother after a week. Mothers reported discomfort around telling non-maternal caregivers to practice adequate hand hygiene for their newborn.

CONCLUSIONS

In this setting, hand hygiene practices during post-natal care and the first 6 hours in the home environment were consistently inadequate. Effective strategies are needed to promote safe hand hygiene practices within the post-natal care ward and home in low resource, high-burden settings. Such strategies need to target not just mothers and healthcare workers but also other caregivers.

Variability in the Duration and Thoroughness of Hand Hygiene

We observed 354 hand hygiene instances across 41 healthcare workers doffing personal protective equipment at 4 hospital-based biocontainment units. We measured the duration and thoroughness of each hand hygiene instance. Both parameters varied substantially, with systematic differences between hospitals and differences between healthcare workers accounting for much of the variance.

Continued wearing of gloves: a risk behaviour in patient care

Background

The wearing of gloves is included in the standard principles for preventing healthcare associated infections. A continued wearing of gloves may, however, result in the transmission of organisms instead of preventing infections. Few studies have explored how common it is for surfaces to be touched by potentially contaminated gloves.

Methods

Secondary analysis of field notes from 48 hours of unstructured observations of healthcare personnel's actions during patient care. The new focus was on to what extent healthcare personnel wore gloves that should have been removed or changed, what surfaces were touched by contaminated gloves and what patient-related activities were involved.

Results

A continued wearing of gloves occurred in about half of the observed episodes of patient care. On average, 3.3 surfaces were touched by contaminated gloves. The surfaces most frequently touched were ‘unused single-use items’, ‘equipment controls/switches/regulators/flush buttons’ and ‘bed linen’. This occurred mostly while helping patients with ‘personal hygiene’, when performing ‘test taking’ or during procedures involving the operation of medical or other ‘equipment’.

Conclusion

The continued wearing of gloves during patient-related activities carries the risk of organism transmission, as the gloves touch many surfaces. The most critical moments seem to be when the use of gloves is considered essential. A better understanding of the motivators of improper glove-use behaviour is needed to develop interventions that rectify the improper use of gloves.

Silica nanoparticles with encapsulated DNA (SPED) - a novel surrogate tracer for microbial transmission in healthcare

Background

The increase in antimicrobial resistance is of worldwide concern. Surrogate tracers attempt to simulate microbial transmission by avoiding the infectious risks associated with live organisms. We evaluated silica nanoparticles with encapsulated DNA (SPED) as a new promising surrogate tracer in healthcare.

Methods

SPED and Escherichia coli were used to implement three experiments in simulation rooms and a microbiology laboratory in 2017–2018. Experiment 1 investigated the transmission behaviour of SPED in a predefined simulated patient-care scenario. SPED marked with 3 different DNA sequences (SPED1-SPED3) were introduced at 3 different points of the consecutive 13 touch sites of a patient-care scenario that was repeated 3 times, resulting in a total of 288 values. Experiment 2 evaluated SPED behaviour following hand cleaning with water and soap and alcohol-based handrub. Experiment 3 compared transfer dynamics of SPED versus E. coli in a laboratory using a gloved finger touching two consecutive sites on a laminate surface after a first purposefully contaminated site.

Results

Experiment 1: SPED adhesiveness on bare skin after a hand-to-surface exposure was high, leading to a dissemination of SPED1–3 on all consecutive surface materials with a trend of decreasing recovery rates, also reflecting touching patterns in concordance with contaminated fingers versus palms. Experiment 2: Hand washing with soap and water resulted in a SPED reduction of 96%, whereas hand disinfection led to dispersal of SPED from the palm to the back of the hand. Experiment 3: SPED and E. coli concentration decreased in parallel with each transmission step – with SPED showing a trend for less reduction and variability.

Conclusions

SPED represent a convenient and safe instrument to simulate pathogen spread by contact transmission simultaneously from an infinite number of sites. They can be further developed as a central asset for successful infection prevention in healthcare.

Intervention planning for Antibiotic Review Kit (ARK): a digital and behavioural intervention to safely review and reduce antibiotic prescriptions in acute and general medicine

Background

Hospital antimicrobial stewardship strategies, such as ‘Start Smart, Then Focus’ in the UK, balance the need for prompt, effective antibiotic treatment with the need to limit antibiotic overuse using ‘review and revise’. However, only a minority of review decisions are to stop antibiotics. Research suggests that this is due to both behavioural and organizational factors.

Objectives

To develop and optimize the Antibiotic Review Kit (ARK) intervention. ARK is a complex digital, organizational and behavioural intervention that supports implementation of ‘review and revise’ to help healthcare professionals safely stop unnecessary antibiotics.

Methods

A theory-, evidence- and person-based approach was used to develop and optimize ARK and its implementation. This was done through iterative stakeholder consultation and in-depth qualitative research with doctors, nurses and pharmacists in UK hospitals. Barriers to and facilitators of the intervention and its implementation, and ways to address them, were identified and then used to inform the intervention’s development.

Results

A key barrier to stopping antibiotics was reportedly a lack of information about the original prescriber’s rationale for and their degree of certainty about the need for antibiotics. An integral component of ARK was the development and optimization of a Decision Aid and its implementation to increase transparency around initial prescribing decisions.

Conclusions

The key output of this research is a digital and behavioural intervention targeting important barriers to stopping antibiotics at review (see http://bsac-vle.com/ark-the-antibiotic-review-kit/ and http://antibioticreviewkit.org.uk/). ARK will be evaluated in a feasibility study and, if successful, a stepped-wedge cluster-randomized controlled trial at acute hospitals across the NHS.

Illuminating the dark spaces of healthcare with ambient intelligence

Advances in machine learning and contactless sensors have given rise to ambient intelligence-physical spaces that are sensitive and responsive to the presence of humans. Here we review how this technology could improve our understanding of the metaphorically dark, unobserved spaces of healthcare. In hospital spaces, early applications could soon enable more efficient clinical workflows and improved patient safety in intensive care units and operating rooms. In daily living spaces, ambient intelligence could prolong the independence of older individuals and improve the management of individuals with a chronic disease by understanding everyday behaviour. Similar to other technologies, transformation into clinical applications at scale must overcome challenges such as rigorous clinical validation, appropriate data privacy and model transparency. Thoughtful use of this technology would enable us to understand the complex interplay between the physical environment and health-critical human behaviours.

Nuclear Medicine Clinical Practice in the United States During the COVID-19 Era and Beyond

Traditionally, practice in nuclear medicine has involved strong emphasis on radiation safety principles. Nuclear medicine technologists (NMTs) focus on practices that keep patients, the public, and the technologist safe from potentially harmful effects of unnecessary radiation exposure using concepts of time, distance, and shielding as well as ALARA (As low as reasonably achievable) principles. The current COVID-19 pandemic has brought to light the need to apply focus on infection prevention in practice and update knowledge and procedures on such measures. In this article, the authors outline the need for NMTs to develop practices and values focused on infection prevention measures.

A simulation approach to measure critical safety behaviors when evaluating training methods for respirator education in healthcare workers

•

N95 respirators are a common tool in healthcare for airborne isolation and pandemic response.

•

Simulation can be used to train healthcare workers.

•

Reflective practice may be a training intervention to improve N95 respirator use compared to video alone.

Background

The N95 respirator is the most common safety tool used in hospitals to protect health care workers (HCW) from inhaling airborne particles. Focusing on HCW behavior related to respirator use is an effective route to improve HCW safety and respiratory health.

Methods

Participants were asked to perform the donning and doffing of an N95 respirator to camera. Then they were randomized to a video alone or a reflective practice intervention. After the intervention they repeated the donning and doffing to camera. A critical safety behavior scoring tool (CSBST) was developed to compare the performance of the participants over time at pretest, post-test and 1 month later for follow-up.

Results

The reflective practice intervention group was found to have significantly higher scores on the CSBST at post-test and follow-up than the video alone group. In the reflective practice intervention group, the participants perceived they were better at performing the N95 donning and doffing than the experts scored them.

Conclusions

The CSBST is a tool to measure the performance of HCWs on a specific targeted safety behaviors. The addition of a reflective practice intervention may result in a measurable and sustained improvement in the safety behaviors demonstrated when using the N95 respirator.

A multimodal intervention to improve hand hygiene compliance in peripheral wards of a tertiary care university centre: a cluster randomised controlled trial

Background

Interventions to improve hand hygiene (HH) compliance are a key element in the practice infection prevention and control. It was our objective to assess the effect of a multimodal intervention on HH compliance at a tertiary care university hospital. As a secondary objective, we investigated the effect of the intervention on the occurrence of device-associated bloodstream infections.

Methods

We performed a single centre cluster randomised controlled trial at a university hospital in Germany. Twenty peripheral wards were invited to participate and randomly assigned to either the intervention (n = 10) or control group (n = 10). Quarterly, specifically trained student employees conducted direct compliance observations in all twenty wards. The intervention entailed dissemination of teaching materials on aseptic procedures, equipment with flexibly mountable alcoholic hand rub dispensers, and quarterly feedback on HH compliance.

Results

In total, 21,424 HH opportunities were observed. Overall, compliance did not change significantly in either group (intervention group: 59% vs. 61% (1482 HH actions for 2494 HH opportunities vs. 5033 HH actions for 8215 HH opportunities), odds ratio (OR) 1.08 (95% confidence interval (CI95) 0.88, 1.33)); control group: 59% vs. 60% (1457 HH actions for 2484 HH opportunities vs. 4948 HH actions for 8231 HH opportunities), OR 1.06 (CI95 0.84, 1.35)). Compliance prior to aseptic procedures improved significantly in the intervention group from 44% (168 HH actions for 380 HH opportunities) to 53% (764 HH actions for 1452 HH opportunities) (OR 1.40 (CI95 1.04, 1.89), p = 0.03), while no significant increase was noted in the control group. In the intervention group, significantly fewer device-associated bloodstream infections per 1000 patient-days occurred than in the control group (84 vs. 123, incidence rate ratio 0.61 (CI95 0.46, 0.81), p < 0.01).

Conclusions

The lack of a significant overall improvement of HH compliance demonstrated that comprehensive implementation of HH interventions in multiple wards simultaneously is difficult. However, through targeted intervention measures, we were able to significantly increase HH compliance before aseptic procedures.

Handwashing in averting infectious diseases: Relevance to COVID-19

After officially declared as a pandemic by the World Health Organization (WHO), drastic measures to restrict human movements to contain the COVID-19 infection are employed by most of the countries. Maintaining high personal hygiene by frequent handwashing and be vigilant of clinical signs are widely recommended to reduce the disease burden. The national and international health agencies, including the Centers for Disease Control and Prevention (CDC) and the WHO, have provided guidelines for prevention and treatment suggestions. Here, in this brief article, based on available clinical information, the author discusses why handwashing could be protective of COVID-19 infections. Although a detailed and in-depth discussion of various preventive and protective measures is beyond the scope of this article, this review will focus on the utility of frequent handwashing in minimizing the risk of spreading COVID-19 infection.

Multifaceted interventions for healthcare-associated infections and rational use of antibiotics in a low-to-middle-income country: Can they be sustained?

BACKGROUND

Transmission of infection between patients by health workers, and the irrational use of antibiotics are preventable causes for healthcare-associated infections (HAI) and multi-resistant organisms. A previous study implementing a hand hygiene campaign and antibiotic stewardship program significantly reduced these infections. Sustaining such interventions can be challenging.

AIMS

To evaluate whether there was a sustained effect of a multifaceted infection control and antibiotic stewardship program on HAI and antibiotic use 5 years after it began.

METHODS

A prospective evaluation study was conducted over 26 months (from February 2016 to April 2018) in a teaching hospital in Indonesia, 5 years after the implementation of an antibiotic stewardship and infection control program, which was successful when initially evaluated. All children admitted to the pediatric ICU and pediatric wards were observed daily. Assessment of HAI was made based on the criteria from the Centers for Disease Control and Prevention. Assessment of rational antibiotic use was based on the WHO Pocket Book of Hospital Care for Children. Multivariable logistic regression analysis was used to quantify the relationship between the HAI and the multifaceted intervention.

RESULTS

We observed an increase in HAIs, from 8.6% (123/1419 patients) in the initial post-intervention period in 2011-2013 to 16.9% (314/1855) in the evaluation study (relative risk (RR) (95% CI) 1.95 (1.60 to 2.37)). After adjusting for potential confounders, we found that an increase in HAI in the evaluation period with adjusted OR 1.94 (95% CI 1.53 to 2.45). Inappropriate antibiotic use also increased, from 20.6% (182 of 882 patients who were prescribed antibiotics) to 48.6% (545/1855) (RR 2.35 (2.04 to 2.71)). Hand hygiene compliance also declined from 62.9% (1125/1789) observed moments requiring hand hygiene to 51% (1526/2993) (RR 3.33 (2.99 to 3.70)).

CONCLUSIONS

Healthcare-associated infections and irrational use of antibiotics remain significant even after the implementation of a multifaceted infection control intervention and antibiotic stewardship program. There is a need for continuous input, ongoing surveillance and long-term monitoring of these interventions to sustain compliance and effectiveness and address problems as they emerge.