Behavioural considerations for hand hygiene practices: the basic building blocks

Systematic Review of Studies on Compliance with Hand Hygiene Guidelines in Hospital Care

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.

Social Marketing Analysis of 2 Years of Hand Hygiene Promotion

Objective.

To assess published hand hygiene behavioral interventions that employed a social marketing framework and to recommend improvements to future interventions.

Methods.

We performed a systematic literature review by searching the PubMed database and the Cumulative Index to Nursing and Allied Health Literature for published articles about hand hygiene behavioral interventions in healthcare facilities, schools, and community settings. Our analysis included articles that describe multifaceted interventions and evaluated them with predefined social marketing benchmark criteria.

Results.

Of 53 interventions analyzed in this review, 16 (30.2%) employed primary formative audience research, 5 (9.4%) incorporated social or behavioral theories, 27 (50.9%) employed segmentation and targeting of the audience, 44 (83.0%) used components of the “marketing mix,” 3 (5.7%) considered the influence of competing behaviors, 7 (13.2%) cultivated relationships with the target audience, and 15 (28.3%) provided simple behavioral messages. Thirty-five (66.0%) of the interventions demonstrated a significant improvement in performance, but only 21 (39.6%) were considered to have a strong evaluative design. The median duration of the interventions was 8.0 months.

Conclusions.

From a social marketing perspective, the promotion of hand hygiene could be improved in several ways. The effectiveness of social marketing in hand hygiene promotion should be tested in future interventions.

Contact precautions and hand hygiene in veterinary clinics

Hand hygiene, contact precautions, and other basic infection control measures are crucial in veterinary clinics, because these facilities can be community mixing pots of animals and people with a wide range of health and disease-carrier states. Veterinary staff must be knowledgeable and well trained regarding when and how to apply situation-appropriate contact precautions and to properly perform hand hygiene. The limited information on the use of contact precautions and hand hygiene practices among veterinary staff suggests that compliance is low. Improving the infection control culture in clinics and in veterinary medicine is critical to achieving better compliance with these practices.

Hand Hygiene Practices in Medical Students: A Follow-Up Study

Objective. The study was conducted to study the impact of various measures instituted to improve hand hygiene practices of the medical students after having documented poor hand hygiene awareness and compliance in a study conducted in 2012. Methods. A self-designed questionnaire based on World Health Organization's concept of "Five Moments for Hand Hygiene" was used to evaluate the awareness of the indications of hand hygiene. Compliance was observed during Objective Structured Clinical Examination (OSCE) sessions. Fifty-one students participated voluntarily in the study. Results. The awareness and compliance of hand hygiene among the medical students in 2014 had shown statistically significant improvement (P < 0.005) as compared to figures of the study conducted in 2012. Conclusion. Dedicated multifaceted intervention can improve the hand hygiene practices in medical students.

Challenges in conducting research in pediatric long-term care facilities

BACKGROUND

Children residing in long-term care facilities (LTCFs) have complex medical problems and unique care needs, yet research in this setting is rare. As part of an intervention study to improve patient safety (Keep It Clean for Kids [KICK]), we describe the challenges encountered and recommend approaches to build a successful and sustained collaborative relationship between pediatric LTCFs and the research team.

METHODS

We implemented a program with 5 components: leadership commitment, active staff participation by the creation of KICK teams, workflow assessments, staff training in the World Health Organization's "5 Moments for Hand Hygiene," and electronic monitoring and feedback to staff regarding hand hygiene practices.

RESULTS

Major challenges encountered were establishing trust, building research teams, enhancing staff participation, and engaging families and visitors. Approaches to deal with these challenges are discussed.

CONCLUSIONS

Conducting research in pediatric LTCFs requires sustained commitment to dealing with challenges and establishing collaborative relationships with administrative and frontline staff.

Management of the slowly emerging zoonosis, Hendra virus, by private veterinarians in Queensland, Australia: a qualitative study

Background

Veterinary infection control for the management of Hendra virus (HeV), an emerging zoonosis in Australia, remained suboptimal until 2010 despite 71.4% (5/7) of humans infected with HeV being veterinary personnel or assisting a veterinarian, three of whom died before 2009. The aim of this study was to identify the perceived barriers to veterinary infection control and HeV management in private veterinary practice in Queensland, where the majority of HeV outbreaks have occurred in Australia.

Results

Most participants agreed that a number of key factors had contributed to the slow uptake of adequate infection control measures for the management of HeV amongst private veterinarians: a work culture characterised by suboptimal infection control standards and misconceptions about zoonotic risks; a lack of leadership and support from government authorities; the difficulties of managing biosecurity and public health issues from a private workforce perspective; and the slow pattern of emergence of HeV. By 2010, some infection control and HeV management changes had been implemented. Participants interviewed agreed that further improvements remained necessary; but also cautioned that this was a complex process which would require time.

Conclusion

Private veterinarians and government authorities prior to 2009 were unprepared to handle new slowly emerging zoonoses, which may explain their mismanagement of HeV. Slowly emerging zoonoses may be of low public health significance but of high significance for specialised groups such as veterinarians. Private veterinarians, who are expected to fulfil an active biosecurity and public health role in the frontline management of such emerging zoonoses, need government agencies to better recognise their contribution, to consult with the veterinary profession when devising guidelines for the management of zoonoses and to provide them with greater leadership and support. We propose that specific infection control guidelines for the management of slowly emerging zoonoses in private veterinary settings need to be developed.

Evaluation of the short-term and long-term effect of a short series of hand hygiene campaigns on improving adherence in a tertiary care hospital in India

Hand hygiene compliance at our institution was monitored by direct observation before and after a series of 2 hand hygiene awareness campaigns across an18-month time period to analyze the effect of these campaigns. A total of 5,059 opportunities for hand hygiene were observed. Compliance increased from 28.1% (95% confidence interval [CI], 18.7%-43.2%) to 42.5% (95% CI, 30.7%-54.8%) after the 2 campaigns (P < .0001) but dropped to 36.4% (95% CI, 30.5%-44.5%) after 2 years (P < .001). Three of the 8 intensive care units that showed a significant increase after the campaigns did not maintain the increased compliance at 2 years' follow-up. We conclude that educational programs should be repeatedly conducted to maintain high adherence to hand hygiene standards in health care settings.

Management of hospital infection control in iran: a need for implementation of multidisciplinary approach

Nosocomial, or hospital-acquired, infections are considered the most common complications affecting hospitalized patients. According to results obtained from studies conducted in the Children Medical Center Hospital, a teaching children's hospital and a tertiary care referral unit in Tehran, Iran, improvements in infection control practices in our hospital seem necessary. The aim of this study was to identify risk management and review potential hospital hazards that may pose a threat to the health as well as safety and welfare of patients in an Iranian referral hospital. Barriers to compliance and poor design of facilities, impractical guidelines and policies, lack of a framework for risk management, failure to apply behavioral-change theory, and insufficient obligation and enforcement by infection control personnel highlight the need of management systems in infection control in our hospital. In addition, surveillance and early reporting of infections, evaluation of risk-based interventions, and production of evidence-based guidelines in our country are recommended.

Doctor, do you have a moment? National Hand Hygiene Initiative compliance in Australian hospitals

OBJECTIVES

To examine hand hygiene compliance rates for medical and nursing staff, compliance with hand hygiene before touching a patient (Moment 1 of the Five moments for hand hygiene), and the effect of differential sampling of staff on the average national rate. Also, to establish whether hand hygiene rates impact Staphylococcus aureus bloodstream infections (SABSI).

DESIGN AND SETTING

Analysis of data from three different cross-sectional datasets--Hand Hygiene Australia data for 246,665 hand hygiene opportunities during the first quarter (1 January to 31 March) of 2013 from 82 public hospitals representing eight Australian states and territories, and hand hygiene rates and SABSI rates from the MyHospitals website reported for 1 July 2011 to 30 June 2012.

MAIN OUTCOME MEASURES

Compliance by medical and nursing staff for each hospital size (> 400 beds, 301-400 beds, 201-300 beds, and 101-200 beds); the proportion of hospitals with hand hygiene compliance rates for before touching a patient at or above, or below the national threshold of 70%; the impact of hand hygiene on SABSI.

RESULTS

Medical staff consistently performed below the national threshold for hand hygiene compliance regardless of hospital size. Nurses' compliance was consistently above the threshold, and this inflated the total average national rate. A third of the patient interaction hand hygiene opportunities recorded involved before touching a patient, for which compliance was below the national threshold in 68% of hospitals. Hand hygiene has little impact on the rate of SABSI (incidence rate ratio, 0.97; P < 0.01).

CONCLUSIONS

Posting a national unadjusted average hand hygiene compliance rate on a public website conceals the fact that most hospitals and medical staff are performing below the national hand hygiene compliance threshold. Given the poor compliance after 4 years of auditing to capture non-compliance, we must shift our focus to providing medical staff with immediate feedback and move to improving a single hand hygiene indication at a time, starting with before touching a patient.

Preventing transmission of MRSA: a qualitative study of health care workers' attitudes and suggestions

BACKGROUND

Health care workers' (HCWs) perceptions and attitudes affect implementation of precautions to prevent transmission of drug-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA). Identification of challenges and barriers to recommended practices is a critical component of promoting a safe clinical environment of care.

METHODS

Semistructured interviews addressed how MRSA affects HCWs, prevention of transmission, and challenges and barriers HCWs experience when entering a MRSA isolation room and performing appropriate hand hygiene.

RESULTS

The purposive sample of 26 acute care HCWs (16 registered nurses; 1 physician; 6 allied health professionals; and 3 support staff) self-selected from 276 responding to a questionnaire on MRSA. Analysis identified 18 themes across seven categories. Most participants reported feeling responsible for preventing transmission, and having the knowledge and desire to do so. However, many also reported challenges to following consistent hand hygiene and use of contact precautions. Barriers included patient care demands, equipment and environmental issues such as availability of sinks, time pressures, the practices of other HCWs, and the need for additional signs indicating which patients require contact precautions.

CONCLUSIONS

The HCWs reported a need for improved clarity of isolation protocols throughout patients' hospital journey, additional rooms and staff for isolation patients, improved education and communication (including timely and appropriate signage), and an emphasis on involving all HCWs in reducing contamination.

Patients' hand hygiene at home predicts their hand hygiene practices in the hospital

We examine factors associated with hand hygiene practices of hospital patients. Hygiene in the hospital decreased compared to that at home, and home practices were strongly associated with hospital practices. Understanding and leveraging the intrinsic value some patients associate with hand hygiene may be important for improving overall hospital hygiene and decreasing healthcare-associated infections.

Use of hand-held computers to determine the relative contribution of different cognitive, attitudinal, social, and organizational factors on health care workers' decision to decontaminate hands

BACKGROUND

Observational and survey methods have limitations in measuring hand hygiene behavior. The ability of a personal digital assistant to anonymously gather data at the point of decision making could potentially address these.

METHODS

Participants were provided with a personal digital assistant to be used for three 2-hour periods and asked to rate influential factors of the Health Belief Model (HBM). Participants were also required to enter what they thought they should do and what they actually did.

RESULTS

A total of 741 hand hygiene opportunities was recorded. All HBM constructs were higher for hand hygiene opportunities where there was compliance versus noncompliance, with a significant difference for patient pressure, my risk, perceived benefits, perceived seriousness, and availability of good facilities. Only 20% of doctors, 28% of nurses, and 66% of physiotherapists always did what they thought they should. There was no correlation between self-reported and actual compliance.

CONCLUSION

The HBM appeared to be a useful theoretical framework. Surprisingly, participants rated their compliance as high despite having recorded instances where they did not do what they thought they should do. This suggests that staff may have a different definition of compliance than strict observation of the guidelines.

Hand hygiene performance and beliefs among public university employees

The workplace is an important location to access community members, and employers have a direct interest in employee well-being. A survey administered to a random sample of employees at a Midwestern US university tested the ability of a model informed by the theory of planned behavior to predict hand hygiene practices and beliefs using structural equation modeling. Questions demonstrated acceptable validity and reliability. Constructs predicted self-reported hand hygiene behaviors, and hand hygiene behaviors reduced the odds of reporting sickness from respiratory tract and gastrointestinal infections. The findings support multi-modal hand hygiene improvement interventions.

Increasing hand washing compliance with a simple visual cue

We tested the efficacy of a simple, visual cue to increase hand washing with soap and water. Automated towel dispensers in 8 public bathrooms were set to present a towel either with or without activation by users. We set the 2 modes to operate alternately for 10 weeks. Wireless sensors were used to record entry into bathrooms. Towel and soap consumption rates were checked weekly. There were 97,351 hand-washing opportunities across all restrooms. Towel use was 22.6% higher (P=.05) and soap use was 13.3% higher (P=.003) when the dispenser presented the towel without user activation than when activation was required. Results showed that a visual cue can increase hand-washing compliance in public facilities.

Adherence to hand hygiene in high-risk units of a tertiary care hospital in India

To improve the compliance to hand hygiene in our health care workers, 3 hand hygiene awareness weeks have been conducted over the past one-and-a-half years in our hospital. This observational audit conducted from October 2011 to March 2012 was planned to assess the impact of the above awareness drives. Although overall compliance increased significantly in 7 intensive care units from 23.1% to 41.2% (P < .0001), several deficiencies were noticed both in technique used as well as during specific opportunities of hand hygiene.

Changes in hand hygiene compliance after a multimodal intervention and seasonality variation

BACKGROUND

Hand hygiene is the most important measure to reduce health care-related infections and colonization with multiresistant micro-organisms. We sought to determine the rate and seasonality of handwashing compliance in a university-affiliated hospital.

METHODS

In January 2006 (baseline period), handwashing observation was first made in an intensive care unit. From March to May 2006, there was an intervention period; and, from June 2006 to August 2009, we followed hand hygiene compliance. Seasonality curves for handwashing compliance were made during follow-up period.

RESULTS

During baseline period, a total of 166 observations was made. During follow-up, 17,664 opportunities for hand hygiene were observed. Compliance improved from 30.0% to a mean of 56.7% after the intervention (P < .001). The highest mean rate of compliance was 77.9% for nurses, compared with 52.6% for technicians (P < .001) and 44.6% for physicians (P < .001). Compliance was lower during summer days (first trimester of the year) and increased after March and April and slowly decreased through the end of the year.

CONCLUSION

One of the reasons for the lower handwashing compliance in the first 3 months of the year is that, in Brazil, this is the summer vacation time; and, because of that, the staff's workload and the number of less well-trained personnel are higher. We emphasize the importance of continuously monitoring hand hygiene to determine the seasonal aspects of compliance.

Improving hand hygiene compliance in the anesthesia working room work area: More than just more hand rubs

BACKGROUND

The anesthesia working area represents an environment with a high density of invasive and, thus, infection-prone procedures. The 2 primary goals of this study were (1) to perform a precise analysis of anesthesia-related hand hygiene (HH) procedures and (2) to optimize HH compliance.

METHODS

We conducted a prospective, triphase before/after study to determine opportunities for and compliance with hand disinfection (World Health Organization definition) in an anesthesia working area. Standard operating procedures were optimized for invasive procedures during 2 predefined intervention periods to improve work flow practices.

RESULTS

Seven hundred fifty anesthesia procedures were evaluated with 12,142 indications for HH. Compliance significantly increased from 10% (465/4,636) to 30% (1,202/4,029) and finally to 55% (1,881/3,477; all P < .001) in phases I, II, and III, respectively. We identified a significant increase in the number of hand rubs performed during 1 anesthesia procedure (2 to 8, respectively; P < .001) in parallel with a significant decrease in number of opportunities needing a hand rub (24 to 14, respectively; P < .0001) because of improved work flow practices. Notably, the greatest improvement was seen before aseptic tasks (8% to 55%, respectively).

CONCLUSION

Our study provides the first detailed data on anesthesia-related and indication-specific HH. Importantly, HH compliance improved significantly without a noticeable increasing workload.

Hand hygiene behavior: translating behavioral research into infection control practice

BACKGROUND

In 2009, the World Health Organization (WHO) recommended "My Five Moments for Hand Hygiene" (5MHH) to optimize hand hygiene (HH). Uptake of these recommendations by healthcare workers (HCWs) remains uncertain.

METHODS

We prospectively observed HCW compliance to 5 MHH. After observations, eligible HCWs who consented to interviews completed surveys on factors associated with HH compliance based on constructs from the transtheoretical model of behavioral change (TTM) and the theory of planned behavior (TPB). Survey results were compared with observed HCW behaviors.

RESULTS

There were 968 observations among 123 HCWs, of whom 110 (89.4%) were female and 63 (51.3%) were nurses. The mean HH compliance for all 5 MHH was 23.2% (95% confidence interval [CI], 18.1%-28.3%) by direct observation versus 82.4% (95% CI, 79.9%-84.9%) by self report. The HCW 5 MHH compliance was associated with critical care unit encounters (P < .05), medicine unit encounters (P - 0.08, P < .001]), immunocompromised patient encounters (P < .05), and HCW prioritized patient advocacy (P < .001). Self-reported TTM stages of action or maintenance (P < .08) and the total TPB behavior score correlated with observed 5 MHH (r = 0.21, P < .02) and with self-reported 5 MHH compliance (r = 0.53, P < .001).

CONCLUSION

Observed HCW compliance to 5 MHH was associated with the type of hospital unit, type of provider-patient encounter, and theory-based behavioral measures of 5 MHH commitment.

Enhancing a safe water intervention with student-created visual aids to promote handwashing behavior in Kenyan primary schools

The Nyando Integrated Child Health Education (NICHE) project was a collaborative effort by the U.S. Centers for Disease Control and local partners to assess the effectiveness of multiple interventions for improving child survival in western Kenya. To increase handwashing in schools, NICHE trained teachers and installed handwashing stations with treated water and soap in 51 primary schools. This cluster-randomized trial evaluated an additional educational strategy (a poster contest themed, "Handwashing with Soap") to improve handwashing behavior in 23 NICHE primary schools. Pupils were engaged in the poster development. Pupil handwashing behavior was observed unobtrusively at baseline and after four months. Intervention schools displayed a significant increase in the number of handwashing stations and proportion of teacher-supervised stations over the study period. No significant between-group differences of intervention in handwashing frequency, soap availability, or visibility of handwashing stations was observed. Despite finding a limited effect beyond the NICHE intervention, the trial appeared to promote sustainability across some measures.

Hand hygiene compliance in transplant and other special patient groups: an observational study

BACKGROUND

This study evaluates hand hygiene behavior of health care workers in a German university hospital stratified for treatment of special patient groups (eg, transplant patients).

METHODS

From 2008 to 2010, comprehensive education and training of all health care workers was implemented to improve hand hygiene compliance. Consumption rates of alcohol-based hand rub and gloves were collected and evaluated.

RESULTS

Of the 5,647 opportunities of hand disinfection evaluated, 1,607 occurred during care for transplant patients. To our knowledge, this is the largest survey of hand hygiene compliance in special patient groups on intensive care units in a university hospital in Germany. Health care workers on surgical intensive care units showed lower hand hygiene compliance compared with health care workers on other types of intensive care units. Compliance toward hand hygiene was significantly higher on hemato-oncologic and pediatric wards. In general, hand disinfection was performed significantly more frequently after an intervention than before (P < .05, 95% confidence interval: 1.24-1.84). Overall, there was no significant difference in hand hygiene compliance when caring for transplant patients or other patients (odds ratio, 1.16; 95% confidence interval: 0.95-1.42). Nurse's and physician's hand hygiene compliance improved because of education.

CONCLUSION

Hand hygiene compliance is not increased in the care for transplant patients (despite their predisposition for nosocomial infections) compared with other patients. Additional studies will be necessary to further investigate these findings.

Zoonotic disease risk perceptions and infection control practices of Australian veterinarians: call for change in work culture

This study was conducted to determine the perceptions of zoonotic disease risk among Australian veterinarians, the infection control practices they use to protect themselves from zoonotic diseases, and the factors influencing their use of these protective practices. A questionnaire was designed and piloted prior to its administration to veterinarians at the annual Australian Veterinary Association Conference in May 2011. The questionnaire comprised 21 closed, semi-closed and open questions. Data from the questionnaire were analyzed using ordinal logistic regression analyses to determine significant factors for veterinarians’ use of personal protective equipment (PPE).

A total of 344 veterinarians completed the questionnaire of which 63.7% were women, 63.2% worked in small/companion animal practice, and 79.9% worked in private veterinary practice. Of the respondents, 44.9% reported contracting a zoonosis during their careers with 19.7% reporting a suspected case and 25.2% reporting a confirmed incidence. Around 40–60% of veterinarians perceived exposure to zoonosis likely or very likely in a variety of situations. With reference to current national industry guidelines, the reported use of PPE was less than “adequate” for most scenarios except for performing postmortems, surgery or dental procedures. No PPE was used by 60–70% of veterinarians for treating respiratory and neurological cases and by 40–50% when treating gastrointestinal and dermatological cases. Workplace conditions need improvement as 34.8% of workplaces did not have isolation units for infected animals, 21.1% did not have separate eating areas for staff, and 57.1% did not have complete PPE kits for use. Veterinarians were more likely to use PPE if they had undertaken postgraduate education, perceived that zoonosis exposure from animals and procedures was likely, consciously considered PPE use for every case they dealt with and believed that liability issues and risks encouraged use of PPE. In contrast, those working in private practices, those who tended to ‘just hope for the best’ when trying to avoid zoonotic diseases, and those who were not aware of industry guidelines were less likely to use PPE.

The results suggest that veterinarians’ perceptions and workplace policies and culture substantially influence their use of PPE. Efforts should be made to encourage veterinarians and their workplaces to use infection control practices to protect themselves and their staff from zoonotic diseases.

Student and infection prevention and control nurses’ hand hygiene decision making in simulated clinical scenarios: a qualitative research study of hand washing, gel and glove use choices

Final year nursing students and infection prevention and control nurses were recorded verbalising their hand hygiene decision-making while working through clinical scenarios on a computer, to understand what factors they were taking into account in choosing a decontamination method (hand washing or alcohol based hand rub/gel) or to wear gloves. Results demonstrated an overuse of gloves, and underuse of gel. Three main themes emerged: ‘Experience or expectation’; this was what they had seen on placement, or it was what ‘we’ do. ‘Just in case,’ was characterised by an awareness that what they would do wasn’t actually necessary but they tended to do it anyway. Thirdly, ‘gel doesn’t feel clean,’ was characterised by a feeling that using gel didn’t make the nurses feel clean after ‘dirty’ tasks, even though gel is actually more effective. There was little evidence that participants were making risk assessments based on the individual patient characteristics given, or the tasks, as they had been taught to do. Choice of hand decontamination agent and whether to use gloves appeared to be based on an habitual characterisation of whether the task was ‘clean’ or ‘dirty,’ with a very low threshold for ‘dirty’ based on an excessive perception of risk to the student.

Hand hygiene perception among health care workers in Hungarian hospitals: prior to a nationwide microbiological survey

Transmission of pathogens via healthcare workers' (HCWs) hands is one of the most frequent means of spreading multi-resistant organisms and occurring healthcare-associated infections (HAIs) in hospitals. The role of contaminated hands in pathogen transmission was recognized by Hungarian physician, Ignác Semmelweis. Hand hygiene prevents cross-infections in hospitals, but numerous epidemiological and microbiology-based studies have documented low compliance of HCWs with this simple procedure. Furthermore, hand hygiene perception of HCWs plays an important role in determining hand hygiene compliance. Our aim was to describe the opinion of HCWs about their perception regarding hand hygiene practice. Our further goal was to strengthen a laboratory basis for bacterial backup control of nosocomial pathogens. A cross-sectional descriptive study was conducted between December 2010 and February 2011 in 13 participating hospitals in Hungary. HCWs know that there is correlation between contaminated hands and HAIs (83%), but neither the frequency (62%) nor the implementation (73%) of their hand hygiene performance are satisfying.We recommend that multimodal interventions - highlighted active microbiological surveillance of HCWs' hands - are the most suitable strategies to reduce the occurrence of HAIs and to determine their impact on cross-transmission of microorganisms and to overcome barriers of HCWs.

Relationship between systems-level factors and hand hygiene adherence

This study was a cross-sectional descriptive survey of acute care hospitals in California to describe staff hand hygiene compliance and related predictors and explore the relationship between hand hygiene adherence and health care-associated infections. Although there was a relatively small sample size, institutions with morning huddles reported a significantly higher proportion of 95% or more hand hygiene compliance. Huddles are an organizational tool to improve teamwork and communication and may offer promise to influence hand hygiene adherence.

Sustained improvements in handwashing indicators more than 5 years after a cluster-randomised, community-based trial of handwashing promotion in Karachi, Pakistan

OBJECTIVE

To evaluate handwashing behaviour 5 years after a handwashing intervention in Karachi, Pakistan.

METHODS

In 2003, we randomised neighbourhoods to control, handwashing promotion, or handwashing promotion and water treatment. Intervention households were given soap +/- water treatment product and weekly handwashing education for 9 months. In 2009, we re-enrolled 461 households from the three study groups: control (160), handwashing (141), and handwashing + water treatment (160) and assessed hygiene-related outcomes, accounting for clustering.

RESULTS

Intervention households were 3.4 times more likely than controls to have soap at their handwashing stations during the study visit [293/301 (97%) vs. 45/159 (28%), P < 0.0001]. While nearly all households reported handwashing after toileting, intervention households more commonly reported handwashing before cooking [relative risk (RR) 1.2 (95% confidence interval (CI) 1.0-1.4)] and before meals [RR 1.7 (95% CI, 1.3-2.1)]. Control households cited a mean of 3.87 occasions for washing hands; handwashing households, 4.74 occasions; and handwashing + water treatment households, 4.78 occasions (P < 0.0001). Households reported purchasing a mean of 0.65 (control), 0.91 (handwashing) and 1.1 (handwashing + water treatment) bars of soap/person/month (P < 0.0001).

CONCLUSIONS

Five years after receiving handwashing promotion, intervention households were more likely to have soap at the household handwashing station, know key times to wash hands and report purchasing more soap than controls, suggesting habituation of improved handwashing practices in this population. Intensive handwashing promotion may be an effective strategy for habituating hygiene behaviours and improving health.

Improving hand hygiene compliance in healthcare settings using behavior change theories: reflections

BACKGROUND

Although hand hygiene is the most effective method for preventing healthcare-associated infections, hand hygiene practice falls short in many healthcare facilities. The compliance rate is mostly linked to system design and easily accessible hand hygiene products. System change, healthcare worker motivation, and complex behavioral considerations seem to play a significant role.

SUMMARY

This article discusses the application of behavioral theories in hand hygiene promotion in a theoretical manner. The program relies on the transtheoretical model (TTM) of health behavior change, John Keller's (ARCS) Model of Motivational Design, and the theory of planned behavior (TPB). Thus, the program links attitudes and behavior to hand hygiene promotion.

CONCLUSIONS

The TTM of health behavior change helps to tailor interventions to predict and motivate individual movement across the pathway to change. A program could be based on this theory with multiple intercalations with John Keller's ARCS and the TPB. Such a program could be strengthened by linking attitudes and behavior to promote hand hygiene. The program could utilize different strategies such as organization cultural change that may increase the attention as well as fostering the movement in the ARCS stages. In addition, modeling TPB by creating peer pressure, ability to overcome obstacles, and increasing knowledge of the role of hand hygiene may lead to the desired outcome. The understanding and application of behavior change theories may result in an effective program to improve awareness and raise intention and thus may increase the potential for success of hand hygiene promotion programs.

"The 3/3 strategy": a successful multifaceted hospital wide hand hygiene intervention based on WHO and continuous quality improvement methodology

Background

Only multifaceted hospital wide interventions have been successful in achieving sustained improvements in hand hygiene (HH) compliance.

Methodology/Principal Findings

Pre-post intervention study of HH performance at baseline (October 2007– December 2009) and during intervention, which included two phases. Phase 1 (2010) included multimodal WHO approach. Phase 2 (2011) added Continuous Quality Improvement (CQI) tools and was based on: a) Increase of alcohol hand rub (AHR) solution placement (from 0.57 dispensers/bed to 1.56); b) Increase in frequency of audits (three days every three weeks: “3/3 strategy”); c) Implementation of a standardized register form of HH corrective actions; d) Statistical Process Control (SPC) as time series analysis methodology through appropriate control charts. During the intervention period we performed 819 scheduled direct observation audits which provided data from 11,714 HH opportunities. The most remarkable findings were: a) significant improvements in HH compliance with respect to baseline (25% mean increase); b) sustained high level (82%) of HH compliance during intervention; c) significant increase in AHRs consumption over time; c) significant decrease in the rate of healthcare-acquired MRSA; d) small but significant improvements in HH compliance when comparing phase 2 to phase 1 [79.5% (95% CI: 78.2–80.7) vs 84.6% (95% CI:83.8–85.4), p<0.05]; e) successful use of control charts to identify significant negative and positive deviations (special causes) related to the HH compliance process over time (“positive”: 90.1% as highest HH compliance coinciding with the “World hygiene day”; and “negative”:73.7% as lowest HH compliance coinciding with a statutory lay-off proceeding).

Conclusions/Significance

CQI tools may be a key addition to WHO strategy to maintain a good HH performance over time. In addition, SPC has shown to be a powerful methodology to detect special causes in HH performance (positive and negative) and to help establishing adequate feedback to healthcare workers.

An observational study of hand hygiene compliance in paediatric wards

AIMS AND OBJECTIVES

To measure healthcare workers', children's and visitors' hand hygiene compliance in a paediatric oncology ward and a paediatric respiratory ward in an English hospital.

BACKGROUND

Children are especially vulnerable to healthcare-associated infections, yet few studies have reported on hand hygiene compliance in paediatric clinical areas.

DESIGN

This was an observational study.

METHOD

We measured hand hygiene compliance over an eight-hour period in two hospital wards using the 'five moments of hand hygiene' observation tool. We monitored a total of 407 hand hygiene opportunities.

RESULTS

Overall opportunities for compliance were 74% for healthcare workers (n = 315) and children and visitors 23% (n = 92). Compliance was 84% for allied health professionals, 81% for doctors, 75% for nurses and 73% for ancillary and other staff. Hand hygiene compliance varied depending on which of the five moments of hygiene healthcare workers were undertaking (p < 0·001), with compliance before child contact 90% (140/155); after child contact 78% (89/114); after body fluid exposure 75% (3/4); and after surroundings contact 36% (15/42). For healthcare workers and visitors, there was no evidence of an association between time of day and their hand hygiene compliance, and for visitors to the oncology ward, hand hygiene compliance was higher (p < 0·05).

CONCLUSION

Owing to the nature of the clinical environments, we are unable to draw conclusions about children's hand hygiene compliance; however, visitors' compliance was low. Among healthcare workers, levels of compliance were higher compared with previous reported estimates.

RELEVANCE TO CLINICAL PRACTICE

Visitors had the lowest level of compliance yet owing to the nature of the clinical environments, nearly a quarter of care is delivered by them rather than healthcare workers, and so, this offers opportunities for specific future interventions aimed at families and carers.

Factors influencing compliance to hygiene routines in community care - the viewpoint of medically responsible nurses in Sweden

AIMS AND OBJECTIVES

The aim of the study was to describe factors influencing compliance to hygiene routines in community care in Swedish municipalities from the perspective of medically responsible nurses (MRN).

METHOD

A web-based questionnaire was sent to all MRNs in Swedish municipalities, N = 268. Beside demographical background data, the questionnaire contained two core open-ended questions generating free text data. Data were analysed with descriptive statistics and qualitative content analysis.

RESULT

Four categories of factors were found: resources, management, staff and external factors. All four categories contained subcategories.

CONCLUSION

To some extent, the challenges to uphold adequate compliance to hygiene routines seem different in community care than in hospitals. Resources regarding equipment and supplies seem as an uncertain asset and uneven distributed among municipalities. Home likeness was seen as a major obstacle for upholding adequate hygiene routines. To uphold sufficient hygiene routines in a person's home or in a home-like environment might be one of the major challenges for community health care in the future. The MRN's narratives suggest that Registered Nurses have a key role in upholding sufficient hygiene in community care. This report might contribute in providing them with more knowledge to take on this urgent task.

Low compliance to handwashing program and high nosocomial infection in a brazilian hospital

Background. It is a fact that hand hygiene prevents nosocomial infection, but compliance with recommended instructions is commonly poor. The purpose of this study was to implement a hand hygiene program for increase compliance with hand hygiene and its relationship with nosocomial infection (NI) and MRSA infection/colonization rates. Methods. Compliance to hand hygiene was evaluated in a hospital by direct observation and measured of health care-associated infections, including methicillin resistant Staphylococcus aureus, before and after an educational intervention, using visual poster, colorful stamps, and feedback of the results. Results. Overall compliance did not increase during intervention, only handwashing before and after patient contact has improved from 40% to 76% (P = 0.01) for HCWs, but NI and MRSA rates remained high and stable. Conclusion. In a combination of high prevalence of NI and low compliance to hand hygiene, the programme of measure does not motivate the HCW hand hygiene. Future interventions should employ incremental evaluation to develop effective hand hygiene initiatives.

Bundling hand hygiene interventions and measurement to decrease health care-associated infections

Proper performance of hand hygiene at key moments during patient care is the most important means of preventing health care-associated infections (HAIs). With increasing awareness of the cost and societal impact caused by HAIs has come the realization that hand hygiene improvement initiatives are crucial to reducing the burden of HAIs. Multimodal strategies have emerged as the best approach to improving hand hygiene compliance. These strategies use a variety of intervention components intended to address obstacles to complying with good hand hygiene practices, and to reinforce behavioral change. Although research has substantiated the effectiveness of the multimodal design, challenges remain in promoting widespread adoption and implementation of a coordinated approach. This article reviews elements of a multimodal approach to improve hand hygiene and advocates the use of a "bundled" strategy. Eight key components of this bundle are proposed as a cohesive program to enable the deployment of synergistic, coordinated efforts to promote good hand hygiene practice. A consistent, bundled methodology implemented at multiple study centers would standardize processes and allow comparison of outcomes, validation of the methodology, and benchmarking. Most important, a bundled approach can lead to sustained infection reduction.

A multifaceted pilot program to promote hand hygiene at a suburban fire department

BACKGROUND

Firefighters (FFs) and Emergency Medical Services (EMS) personnel provide care in uncontrolled settings, where the risk of hand contamination is great and opportunities for handwashing are few. Knowledge, attitudes, and beliefs about hand hygiene in this group have not been well reported.

METHODS

Written surveys were administered to FFs and EMS personnel to assess their practices, attitudes, and beliefs before and after installation of alcohol hand gel dispensers, hanging of reminder posters, and completion of PowerPoint training.

RESULTS

A majority of the participants (n = 131; 58.5%) indicated they had not received any training on hand hygiene from the fire department before the intervention. Responses to Likert scale questions about attitudes, practices, and beliefs regarding handwashing did not reveal any statistically significant differences between preintervention and postintervention surveys; however, responses to direct questions about the impact of the intervention were more promising.

CONCLUSIONS

Implementation and evaluation of an intervention to target groups of EMS personnel and FFs can guide future efforts to improve hand hygiene practices in this distinctive group.

Hand hygiene improvement in the community: a systems approach

Hand hygiene compliance, which is influenced in part by human behaviour, is central to infection prevention in all care settings. This article focuses specifically on the importance of a multimodal strategy for continued hand hygiene improvement, and its relevance to community nursing. Additionally, the article addresses the challenges and opportunities of infection prevention and control in a community context, and highlights current national and international guidelines that offer a framework and set of principles for implementation and sustainability with a specific focus on the multimodal strategy associated with the WHO Guidelines on Hand Hygiene in Health Care (2009). The authors conclude with some considerations for community nurses when addressing translation of these principles into their everyday working context.

Back to the future: rising to the Semmelweis challenge in hand hygiene

Hand hygiene is the single most important intervention for reducing healthcare associated infections and preventing the spread of antimicrobial resistance. This sentence begins most publications regarding hand hygiene in the medical literature. But why - as we mark 150 years since the publication of Ignaz Semmelweis' landmark monograph on the subject - do we continue to repeat it? One might be tempted to regard it as a truism. However, while tremendous progress has certainly been made in this field, a significant amount of work is yet to be done in both strengthening the evidence regarding the impact of hand hygiene and maximizing its implementation. Hand hygiene cannot yet be taken for granted. This article summarizes historical perspectives, dynamics of microbial colonization and efficacy of hand cleansing methods and agents, elements and impacts of successful hand hygiene promotion, as well as scale-up and sustainability. We also explore hand hygiene myths and current challenges such as monitoring, behavior change, patient participation and research priorities.

It's not all about me: motivating hand hygiene among health care professionals by focusing on patients

Diseases often spread in hospitals because health care professionals fail to wash their hands. Research suggests that to increase health and safety behaviors, it is important to highlight the personal consequences for the actor. However, because people (and health care professionals in particular) tend to be overconfident about personal immunity, the most effective messages about hand hygiene may be those that highlight its consequences for other people. In two field experiments in a hospital, we compared the effectiveness of signs about hand hygiene that emphasized personal safety ("Hand hygiene prevents you from catching diseases") or patient safety ("Hand hygiene prevents patients from catching diseases"). We assessed hand hygiene by measuring the amount of soap and hand-sanitizing gel used from dispensers (Experiment 1) and conducting covert, independent observations of health care professionals' hand-hygiene behaviors (Experiment 2). Results showed that changing a single word in messages motivated meaningful changes in behavior: The hand hygiene of health care professionals increased significantly when they were reminded of the implications for patients but not when they were reminded of the implications for themselves.

Hand hygiene in pediatric and neonatal intensive care unit patients: daily opportunities and indication- and profession-specific analyses of compliance

BACKGROUND

Hand hygiene is considered to be the single most effective tool to prevent health care-associated infections. Daily hand hygiene opportunities and compliance for pediatric/neonatal intensive care units (ICU) are currently unknown.

METHODS

This was a prospective observational study in pediatric and neonatal ICU patients with analyses of hand hygiene behavior in relation to profession, indication, and shift and correlation with disinfectant usage.

RESULTS

Hand hygiene opportunities were significantly higher for pediatric (321/24 hours) than neonatal (194/24 hours; P = .024) patients. Observed compliance rates were 53% (pediatric) and 61% (neonatal) and found to be significantly higher in nurses (57%; 66%) than in physicians (29%, 52%, respectively; P < .001; P = .017, respectively). For neonates, compliance rates were significantly higher before patient contact and aseptic tasks (78%) than after patient, patient body fluid, or patients' surrounding contact (57%; P < .001). Calculating disinfectant usage revealed a 3-fold lower compliance rate of 17%.

CONCLUSION

This study provides the first data on opportunities for and compliance with hand hygiene in pediatric/neonatal patients encompassing the whole day and night activities and including a comparison of observed and calculated compliance rates. Observation revealed high compliance especially in nurses and in situations of greatest impact. The data provide a detailed characterization of hand hygiene performance in the neonatal/pediatric ICU setting.

"The dirty hand in the latex glove": a study of hand hygiene compliance when gloves are worn

BACKGROUND AND OBJECTIVE

Wearing of gloves reduces transmission of organisms by healthcare workers' hands but is not a substitute for hand hygiene. Results of previous studies have varied as to whether hand hygiene is worse when gloves are worn. Most studies have been small and used nonstandardized assessments of glove use and hand hygiene. We sought to observe whether gloves were worn when appropriate and whether hand hygiene compliance differed when gloves were worn.

DESIGN

Observational study.

PARTICIPANTS AND SETTING

Healthcare workers in 56 medical or care of the elderly wards and intensive care units in 15 hospitals across England and Wales.

METHODS

We observed hand hygiene and glove usage (7,578 moments for hand hygiene) during 249 one-hour sessions. Observers also recorded whether gloves were or were not worn for individual contacts.

RESULTS

Gloves were used in 1,983 (26.2%) of the 7,578 moments for hand hygiene and in 551 (16.7%) of 3,292 low-risk contacts; gloves were not used in 141 (21.1%) of 669 high-risk contacts. The rate of hand hygiene compliance with glove use was 41.4% (415 of 1,002 moments), and the rate without glove use was 50.0% (1,344 of 2,686 moments). After adjusting for ward, healthcare worker type, contact risk level, and whether the hand hygiene opportunity occurred before or after a patient contact, glove use was strongly associated with lower levels of hand hygiene (adjusted odds ratio, 0.65 [95% confidence interval, 0.54-0.79]; P < .0001).

CONCLUSION

The rate of glove usage is lower than previously reported. Gloves are often worn when not indicated and vice versa. The rate of compliance with hand hygiene was significantly lower when gloves were worn. Hand hygiene campaigns should consider placing greater emphasis on the World Health Organization indications for gloving and associated hand hygiene.

TRIAL REGISTRATION

National Research Register N0256159318.

Quality-improvement initiative sustains improvement in pediatric health care worker hand hygiene

OBJECTIVE

To use quality-improvement (QI) methods to develop and test a multimodal intervention to improve hand-hygiene compliance among health care workers (HCWs) to >90%.

METHODS

We used a quasi-experimental staggered intervention that was conducted on 2 similar general pediatric units within a 475-bed tertiary children's hospital. Compliance was defined as acceptable hand hygiene both before and after contact with the patient or the patient's care environment. Measurement of HCW hand-hygiene compliance was performed by covert observations made during routine patient care. Twelve months of preintervention data were collected. QI methods were used to test and implement interventions sequentially in each unit. Interventions addressed leadership support, improving HCW knowledge, hand-hygiene supply availability, and HCW behavior.

RESULTS

Interventions began on unit A on November 10, 2008. Similar interventions were later tested on unit B starting March 23, 2009. By April 1, 2009, compliance increased on unit A (from 65% to 91%) and unit B (from 74% to 92%). Improvement on each unit occurred only after the interventions were introduced. Identifying HCWs who failed to perform hand hygiene and offering alcohol-based hand rub to them before patient contact resulted in the greatest improvement. Improvements were sustained on both units for 18 months.

CONCLUSIONS

Use of QI methods to implement a multimodal intervention resulted in sustained improvement in hand-hygiene compliance. Real-time individual performance feedback or other high-reliability human-factor interventions seem to be necessary to reach and sustain high levels of hand-hygiene compliance.

Hand hygiene practices and adherence determinants in surgical wards across Europe and Israel: a multicenter observational study

We examined hand hygiene practices in surgical wards in 9 countries in Europe and Israel through direct practice observation. There was marked interhospital variation in hand hygiene compliance (range, 14%-76%), as well as glove and alcohol-based handrub use. After multivariable analysis, surgical subspecialty, professional category, type of care activity, and workload were independently associated with compliance. Hand hygiene practices are influenced by numerous factors, and a tailored approach may be required to improve practices.