Interventions to improve hand hygiene compliance in patient care

Capability, Opportunity, Motivation, and Hand Hygiene Behavior in Healthcare Workers: A Structural Equation Modeling

Background

Hand hygiene among healthcare workers is the leading measure to reduce healthcare-associated infections. However, hand hygiene behavior is complex and not readily understood. This study aimed to identify the determinants and the underlying mechanism of hand hygiene behavior based on the capability, opportunity, motivation-behavior model.

Methods

A self-constructed questionnaire survey was conducted among healthcare workers in Chongqing, China. Capability, opportunity, and motivation were designed as independent variables, and hand hygiene behavior was measured as a dependent variable. Internal consistency reliability analysis and confirmatory factor analysis were applied to examine the reliability and validity of the questionnaire. Structural equation modeling was performed to explore the relationships among capability, opportunity, motivation, and hand hygiene behavior.

Results

Four hundred and ninety-nine physicians and nurses were investigated. The Cronbach's α coefficients were above 0.764. Confirmatory factor analysis was confirmed with good data fitness. The structural equation modeling had a good fit (root mean square error of approximation=0.070, comparative fit index=0.960, Tucker-Lewis index=0.956). Both opportunity (β=0.265, p<0.05) and motivation (β=0.333, p<0.05) directly affected hand hygiene behavior. Both capability (β=0.194, p<0.001) and opportunity (β=0.719, p<0.001) were indirectly linked to hand hygiene behavior through motivation.

Conclusion

To improve hand hygiene behavior, more efforts need to be focused on resource provision and motivation enhancement in the future compared to training.

Enablement of nursing home residents in infection prevention during general practitioner visits: A qualitative study

INTRODUCTION

Hand hygiene measures are essential to protect nursing home residents against nosocomial infections. Evidence on the prevention of nosocomial infections for nursing home residents by general practitioners during their medical visits in nursing homes or how they enable nursing home residents to perform hand hygiene measures is lacking. This study aimed to explore hand hygiene behaviors of general practitioners in nursing homes, their attitudes toward infection prevention measures, and the enablement of nursing home residents in performing hand hygiene measures.

MATERIALS AND METHODS

Semi-structured interviews were conducted with general practitioners and nursing home residents in Germany. Interviews were audio-recorded and transcribed. Data were analyzed using thematic content analysis.

RESULTS

Overall, 12 general practitioners and 12 nursing home residents participated in the study. The general practitioners expressed the fact that the possibilities for practicing hand hygiene differ in individual nursing homes. For nursing home residents, the availability of hand rub solutions was limited. Instructions for residents on hand disinfection from general practitioners was not described. Due to the lack of enablement, the residents' knowledge on how to correctly perform hand hygiene was low, although some of the nursing home residents have experience with multidrug-resistant organisms. The nursing home residents varied in their needs for active participation and enablement during the general practitioners visit.

CONCLUSION

Nursing home residents require continuous enablement by their general practitioners to maintain adequate hand hygiene. Therefore, general practitioners should consider the different needs of nursing home residents to ensure adequate individual hand hygiene and safety for the residents. Existing guidelines for infection prevention and control do not adequately cover the nursing home care setting for the enablement of residents to enquire about hand hygiene.

Examining the Importance of Hand Hygiene Policy and Patient Safety Culture on Improving Healthcare Workers' Adherence to Hand Hygiene Practice in Critical Care Settings in the Sultanate of Oman: A Scoping Review

Several studies suggest that adherence to hand hygiene (HH) policy would be enhanced by improving the culture of safety in an organization. This could be achieved through continuous awareness programs about the dramatic effect of HH practice according to the HH policy on improving patient safety and quality care. Understanding the importance and purposes of HH policy by healthcare workers would allow them to prioritize HH policy in their planning. Therefore, healthcare leaders should be responsible and accountable for strengthening their healthcare system by improving infrastructure, providing adequate support and resources, providing comprehensive monitoring and evaluation of patient safety initiatives, monitoring adherence to the regional Gulf Cooperation Council (GCC) and local Oman HH policy and using World Health Organization (WHO) guidelines for patient safety and HH as a basis for providing safer care. This should involve HH policy as a basic and mandatory program during an internship or in new staff orientation programs, spending enough resources on conducting more research studies and benchmarking findings with other international countries or any other organization such as WHO or Centres for Disease Control (CDC). The development of an HH policy at three different levels, macro, meso, and micro, is discussed in this article. In this sense, patient safety and quality care are the most important issues when adopting any policy.

Infection Prevention Performance among Hospital Staff during Vaginal Birth: Results from a Criterion-Based Audit at a Zonal Referral Hospital in Tanzania

BACKGROUND

Healthcare associated infections is a global burden and is one of the main causes of maternal and neonatal morbidity and mortality during the time of labour when admitted to the hospital. Healthcare workers' hands are in most cases the vehicle for transmission of microorganisms from patient to patient. Good hand hygiene practices at the bedside are a simple way of reducing healthcare associated infections. The objective was to assess the impact of a criterion-based audit on infection prevention performance and knowledge during vaginal delivery at a hospital in Tanzania. The quantitative findings were discussed with staff to identify barriers and solutions to quality improvement.

METHODS

A mixed-method uncontrolled, before and after intervention study by criterion-based audit was performed at the labour ward at Kilimanjaro Christian Medical Centre. Criteria for best practice were established together with key staff based on national and international guidelines. Sixty clean procedures during vaginal birth were observed and assessed by a structured checklist based on the audit criteria. Baseline findings were discussed with staff and an intervention performed including a short training and preparation of alcohol-based hand rub. Hereafter another 60 clean procedures were observed, and performance compared to the care before the intervention. Furthermore, a knowledge test was performed before and after the intervention.

RESULTS

Hand washing increased significantly after a procedure from 46.7% to 80% (RR=1.71 95% CI; 1.27 to 2.31), the use of alcohol-based hand rub before a procedure from 1.7% to 33.3% p<.001), and the use of alcohol-based hand rub after procedure from 0% to 30% p<.00l). After the intervention the mean score for the knowledge test increased insignificantly from 59.3% to 65.3%, (mean difference = 6.1%, 95% CI; -4.69 to 16.88).

CONCLUSION

The criterion-based audit process identified substandard care for infection prevention at the labour ward. An intervention of discussing baseline findings and a short training session and introducing alcohol-based hand rub resulted in improvements on infection prevention performance.

Developing theory-informed knowledge translation strategies to facilitate the use of patient-reported outcome measures in interdisciplinary low back pain clinical practices in Quebec: mixed methods study

Background

There is a growing interest among healthcare providers (HCPs) to use Patient Reported Outcome Measures (PROMs) in clinical care. PROMs can help improve patient-care provider communication and may be used to inform the need for interdisciplinary care for Low Back Pain (LBP). However, PROM implementation to support clinical decision-making is complex and requires knowledge translation (KT) interventions that will overcome barriers to using PROMs in interdisciplinary clinical settings.

Objectives

to 1) identify potential barriers and enablers to using PROMs in primary care LBP clinical practice from the perspective of healthcare team members, and 2) develop a theory-based tailored KT intervention to facilitate the use of PROMs in interdisciplinary clinical practice.

Methods

We invited 25 HCPs working in an interdisciplinary team to complete a self-administered survey designed based on the Theoretical Domain Framework (TDF) to identify the barriers and enablers to using PROM scores in LBP clinical practice. The questionnaire consisted of 30 questions rated on a 5-point Likert scale (quantitative) and included open-ended questions (qualitative). Quantitative and qualitative data were analysed to estimate the frequency of barriers and enablers. Findings were then reviewed by a panel of four KT experts who mapped behaviour change techniques to barriers identified that informed the design of a KT intervention.

Results

Eighteen HCPs responded to the survey. Factors identified as likely to restrict the use of PROM scores included knowledge, skills, social/professional role and identity, goals, decision processes, beliefs about consequences, environmental context and resources, behavioural regulation, and social influence. A multi-component evidence-based KT intervention was proposed by the panel of experts to address these barriers: a training workshop; educational materials; and use of PROM score reports to HCPs that were all delivered by an opinion leader.

Conclusion

The routine use of PROMs in clinical practice may optimize the quality of LBP care and improve patients’ outcomes. The proposed multi-component KT intervention is expected to be an effective strategy to increase HCPs’ ability to integrate PROMs into clinical decision-making and to engage patients in their care.

Assessment and management of the risk of SARS-CoV-2 infection in an IVF laboratory

Research question

The study set out to identify corrective measures aimed at reducing the risk of aerosol-mediated viral infection within an IVF laboratory.

Design

A failure modes and effect analysis (FMEA) was conducted by a multidisciplinary IVF team. A schematic representation of new protocols and procedures adopted during COVID-19 emergency has been defined, including directives about the behaviour to adopt when entering the clinic and the laboratory, in case of face-to-face contact with patients and between staff members. In addition, the risk of cross-contamination between samples belonging to different patients during cell handling and manipulation has been evaluated. Potential failure modes for each phase of the emergency have been analysed, focusing on possible sources of error. Risk priority numbers have been calculated as products of Occurrence × Severity × Detection scores.

Results

Except for cell–cell contamination, which was considered highly unlikely, failure modes during patient–staff, staff–staff and staff–cell interactions were estimated as carrrying a moderate to high risk of infection. The main corrective measures entailed precautionary logistic measures, the implementation of additional personal protective equipment and changes in the IVF laboratory procedures and scheduling of the daily routine. Some procedures were also revised, aiming to increase staff's awareness and caution.

Conclusions

Standard laboratory protocols are insufficient to face a virus whose transmission is aerosol mediated. The measures outlined in this FMEA should thus be considered not only for facing this pandemic, but also for the future to promptly manage any aerosol-mediated virus infection, whose impact on the management of an IVF laboratory might be less severe than COVID-19 although not completely negligible.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

BACKGROUND

In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed.

OBJECTIVES

To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020.

SELECTION CRITERIA

We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate.

MAIN RESULTS

Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants) coveralls were more difficult to doff than isolation gowns (very low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to more water-repellent material but may have greater user satisfaction (MD -0.46, 95% CI -0.84 to -0.08, scale of 1 to 5). According to three studies that tested more recently introduced full-body PPE ensembles, there may be no difference in contamination. Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4) and to fewer contamination spots (MD -5, 95% CI -8.08 to -1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol-based hand rub. Training The use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only.

AUTHORS' CONCLUSIONS

We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training. We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

BACKGROUND

In epidemics of highly infectious diseases, such as Ebola, severe acute respiratory syndrome (SARS), or coronavirus (COVID-19), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Personal protective equipment (PPE) can reduce the risk by covering exposed body parts. It is unclear which type of PPE protects best, what is the best way to put PPE on (i.e. donning) or to remove PPE (i.e. doffing), and how to train HCWs to use PPE as instructed.

OBJECTIVES

To evaluate which type of full-body PPE and which method of donning or doffing PPE have the least risk of contamination or infection for HCW, and which training methods increase compliance with PPE protocols.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to 20 March 2020.

SELECTION CRITERIA

We included all controlled studies that evaluated the effect of full-body PPE used by HCW exposed to highly infectious diseases, on the risk of infection, contamination, or noncompliance with protocols. We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training on the same outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias in included trials. We conducted random-effects meta-analyses were appropriate.

MAIN RESULTS

Earlier versions of this review were published in 2016 and 2019. In this update, we included 24 studies with 2278 participants, of which 14 were randomised controlled trials (RCT), one was a quasi-RCT and nine had a non-randomised design. Eight studies compared types of PPE. Six studies evaluated adapted PPE. Eight studies compared donning and doffing processes and three studies evaluated types of training. Eighteen studies used simulated exposure with fluorescent markers or harmless microbes. In simulation studies, median contamination rates were 25% for the intervention and 67% for the control groups. Evidence for all outcomes is of very low certainty unless otherwise stated because it is based on one or two studies, the indirectness of the evidence in simulation studies and because of risk of bias. Types of PPE The use of a powered, air-purifying respirator with coverall may protect against the risk of contamination better than a N95 mask and gown (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.17 to 0.43) but was more difficult to don (non-compliance: RR 7.5, 95% CI 1.81 to 31.1). In one RCT (59 participants), people with a long gown had less contamination than those with a coverall, and coveralls were more difficult to doff (low-certainty evidence). Gowns may protect better against contamination than aprons (small patches: mean difference (MD) -10.28, 95% CI -14.77 to -5.79). PPE made of more breathable material may lead to a similar number of spots on the trunk (MD 1.60, 95% CI -0.15 to 3.35) compared to more water-repellent material but may have greater user satisfaction (MD -0.46, 95% CI -0.84 to -0.08, scale of 1 to 5). Modified PPE versus standard PPE The following modifications to PPE design may lead to less contamination compared to standard PPE: sealed gown and glove combination (RR 0.27, 95% CI 0.09 to 0.78), a better fitting gown around the neck, wrists and hands (RR 0.08, 95% CI 0.01 to 0.55), a better cover of the gown-wrist interface (RR 0.45, 95% CI 0.26 to 0.78, low-certainty evidence), added tabs to grab to facilitate doffing of masks (RR 0.33, 95% CI 0.14 to 0.80) or gloves (RR 0.22, 95% CI 0.15 to 0.31). Donning and doffing Using Centers for Disease Control and Prevention (CDC) recommendations for doffing may lead to less contamination compared to no guidance (small patches: MD -5.44, 95% CI -7.43 to -3.45). One-step removal of gloves and gown may lead to less bacterial contamination (RR 0.20, 95% CI 0.05 to 0.77) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28) than separate removal. Double-gloving may lead to less viral or bacterial contamination compared to single gloving (RR 0.34, 95% CI 0.17 to 0.66) but not to less fluorescent contamination (RR 0.98, 95% CI 0.75 to 1.28). Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4) and to fewer contamination spots (MD -5, 95% CI -8.08 to -1.92). Extra sanitation of gloves before doffing with quaternary ammonium or bleach may decrease contamination, but not alcohol-based hand rub. Training The use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7). A video lecture on donning PPE may lead to better skills scores (MD 30.70, 95% CI 20.14 to 41.26) than a traditional lecture. Face-to-face instruction may reduce noncompliance with doffing guidance more (odds ratio 0.45, 95% CI 0.21 to 0.98) than providing folders or videos only.

AUTHORS' CONCLUSIONS

We found low- to very low-certainty evidence that covering more parts of the body leads to better protection but usually comes at the cost of more difficult donning or doffing and less user comfort, and may therefore even lead to more contamination. More breathable types of PPE may lead to similar contamination but may have greater user satisfaction. Modifications to PPE design, such as tabs to grab, may decrease the risk of contamination. For donning and doffing procedures, following CDC doffing guidance, a one-step glove and gown removal, double-gloving, spoken instructions during doffing, and using glove disinfection may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than folder-based training. We still need RCTs of training with long-term follow-up. We need simulation studies with more participants to find out which combinations of PPE and which doffing procedure protects best. Consensus on simulation of exposure and assessment of outcome is urgently needed. We also need more real-life evidence. Therefore, the use of PPE of HCW exposed to highly infectious diseases should be registered and the HCW should be prospectively followed for their risk of infection.

Comparison of knowledge, attitudes and hand hygiene behavioral intention in medical and nursing students

Introduction

Hand hygiene is crucial to prevent cross infection. Healthcare students are in a prime position to learn hand hygiene skills. The aim of this study was to analyze hand hygiene behavioral intentions of healthcare students before and after contact with the patient and to compare the knowledge of and attitude towards hand hygiene between medical and nursing students.

Methods

In a descriptive survey research design, convenience selection of a sample of medical students (n=657) and nursing students (n=303) was done from modules taught by the Department of Preventive Medicine and Public Health in both Medicine and Nursing undergraduate degrees in four Spanish universities. The hand hygiene Questionnaire, a validated instrument to evaluate behavior, knowledge, and attitudes, was used.

Results

A significantly lower percentage of students reported always or almost always carrying out hand hygiene before contact with the patient or invasive procedures in comparison to the percentage complying after contact with secretions or with the patient. Although hand hygiene knowledge appears acceptable, its importance is not sufficiently valued.

Conclusions

There are deficiencies in behavioral intention, knowledge, and attitudes related to hand hygiene in medical and nursing students. Better results are observed among nursing students, especially those who have received specific training.

Nurses' knowledge, behaviour and compliance concerning hand hygiene in nursing homes: a cross-sectional mixed-methods study

Background

Effective hand hygiene is one of the most important measures for protecting nursing home residents from nosocomial infections. Infections with multi-resistant bacteria’s, associated with healthcare, is a known problem. The nursing home setting differs from other healthcare environments in individual and organisational factors such as knowledge, behaviour, and attitude to improve hand hygiene and it is therefore difficult to research the influential factors to improve hand hygiene. Studies have shown that increasing knowledge, behaviour and attitudes could enhance hand hygiene compliance in nursing homes. Therefore, it may be important to examine individual and organisational factors that foster improvement of these factors in hand hygiene. We aim to explore these influences of individual and organisational factors of hand hygiene in nursing home staff, with a particular focus on the function of role modelling by nursing managers.

Methods

We conducted a mixed-methods study surveying 165 nurses and interviewing 27 nursing managers from nursing homes in Germany.

Results

Most nurses and nursing managers held the knowledge of effective hand hygiene procedures. Hygiene standards and equipment were all generally available but compliance to standards also depended upon availability in the immediate work area and role modelling. Despite a general awareness of the impact of leadership on staff behaviour, not all nursing managers fully appreciated the impact of their own consistent role modelling regarding hand hygiene behaviours.

Conclusion

These results suggest that improving hand hygiene should focus on strategies that facilitate the provision of hand disinfectant materials in the immediate work area of nurses. In addition, nursing managers should be made aware of the impact of their role model function and they should implement this in daily practice.

Evaluating the effectiveness of the "Germ-Free Hands" intervention for improving the hand hygiene practices of public health students

PURPOSE

This quasi-experimental study sought to assess the effectiveness of a multidisciplinary intervention called "Germ-Free Hands" to improve the hand hygiene practices of students attending Thailand's Sirindhorn College of Public Health (SCPH).

METHODS

The intervention was developed and implemented at SCPH and incorporated education, training, a workshop, and performance feedback. The intervention targeted behavioral antecedents specified by the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB). Handwashing determinants (knowledge, beliefs, attitudes, subjective norms, perceived behavioral control, and intentions) and hand hygiene behaviors were assessed at baseline, immediately post-intervention, and 3 months post-intervention for the intervention group at (n=60) at the Suphanburi campus of SCPH and a matched control group (n=60) of students at the Ubonratchathani campus. Data analysis included descriptive statistics, independent samples t-tests, two-way measures of analysis of variance, and a generalized estimating equation to compare handwashing practices by self-reports between two groups.

RESULTS

The "Germ-Free Hands" intervention produced significant improvements in the intervention group's handwashing knowledge, behavioral and control beliefs, subjective norm scores, intentions, and behaviors, as compared to the control group. However, the intervention had no significant impact on normative beliefs, attitudes, or perceived behavioral control. Reported improvements also decreased 3 months post-intervention, and the number of bacterial colonies on students' hands increased over the course of the study.

CONCLUSION

This study adds to the evidence that multidisciplinary interventions can be effective at improving handwashing rates. However, education and training must be continuous, rather than delivered as a one-time program, in order to have sustained results. Participants may also require more in-depth instruction in correct handwashing and drying techniques to remove bacteria effectively and prevent recolonization.

Personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff

BACKGROUND

In epidemics of highly infectious diseases, such as Ebola Virus Disease (EVD) or Severe Acute Respiratory Syndrome (SARS), healthcare workers (HCW) are at much greater risk of infection than the general population, due to their contact with patients' contaminated body fluids. Contact precautions by means of personal protective equipment (PPE) can reduce the risk. It is unclear which type of PPE protects best, what is the best way to remove PPE, and how to make sure HCW use PPE as instructed.

OBJECTIVES

To evaluate which type of full body PPE and which method of donning or doffing PPE have the least risk of self-contamination or infection for HCW, and which training methods increase compliance with PPE protocols.

SEARCH METHODS

We searched MEDLINE (PubMed up to 15 July 2018), Cochrane Central Register of Trials (CENTRAL up to 18 June 2019), Scopus (Scopus 18 June 2019), CINAHL (EBSCOhost 31 July 2018), and OSH-Update (up to 31 December 2018). We also screened reference lists of included trials and relevant reviews, and contacted NGOs and manufacturers of PPE.

SELECTION CRITERIA

We included all controlled studies that compared the effects of PPE used by HCW exposed to highly infectious diseases with serious consequences, such as Ebola or SARS, on the risk of infection, contamination, or noncompliance with protocols. This included studies that used simulated contamination with fluorescent markers or a non-pathogenic virus.We also included studies that compared the effect of various ways of donning or doffing PPE, and the effects of training in PPE use on the same outcomes.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data and assessed risk of bias in included trials. We planned to perform meta-analyses but did not find sufficiently similar studies to combine their results.

MAIN RESULTS

We included 17 studies with 1950 participants evaluating 21 interventions. Ten studies are Randomised Controlled Trials (RCTs), one is a quasi RCT and six have a non-randomised controlled design. Two studies are awaiting assessment.Ten studies compared types of PPE but only six of these reported sufficient data. Six studies compared different types of donning and doffing and three studies evaluated different types of training. Fifteen studies used simulated exposure with fluorescent markers or harmless viruses. In simulation studies, contamination rates varied from 10% to 100% of participants for all types of PPE. In one study HCW were exposed to Ebola and in another to SARS.Evidence for all outcomes is based on single studies and is very low quality.Different types of PPEPPE made of more breathable material may not lead to more contamination spots on the trunk (Mean Difference (MD) 1.60 (95% Confidence Interval (CI) -0.15 to 3.35) than more water repellent material but may have greater user satisfaction (MD -0.46; 95% CI -0.84 to -0.08, scale of 1 to 5).Gowns may protect better against contamination than aprons (MD large patches -1.36 95% CI -1.78 to -0.94).The use of a powered air-purifying respirator may protect better than a simple ensemble of PPE without such respirator (Relative Risk (RR) 0.27; 95% CI 0.17 to 0.43).Five different PPE ensembles (such as gown vs. coverall, boots with or without covers, hood vs. cap, length and number of gloves) were evaluated in one study, but there were no event data available for compared groups.Alterations to PPE design may lead to less contamination such as added tabs to grab masks (RR 0.33; 95% CI 0.14 to 0.80) or gloves (RR 0.22 95% CI 0.15 to 0.31), a sealed gown and glove combination (RR 0.27; 95% CI 0.09 to 0.78), or a better fitting gown around the neck, wrists and hands (RR 0.08; 95% CI 0.01 to 0.55) compared to standard PPE.Different methods of donning and doffing proceduresDouble gloving may lead to less contamination compared to single gloving (RR 0.36; 95% CI 0.16 to 0.78).Following CDC recommendations for doffing may lead to less contamination compared to no guidance (MD small patches -5.44; 95% CI -7.43 to -3.45).Alcohol-based hand rub used during the doffing process may not lead to less contamination than the use of a hypochlorite based solution (MD 4.00; 95% CI 0.47 to 34.24).Additional spoken instruction may lead to fewer errors in doffing (MD -0.9, 95% CI -1.4 to -0.4).Different types of trainingThe use of additional computer simulation may lead to fewer errors in doffing (MD -1.2, 95% CI -1.6 to -0.7).A video lecture on donning PPE may lead to better skills scores (MD 30.70; 95% CI 20.14,41.26) than a traditional lecture.Face to face instruction may reduce noncompliance with doffing guidance more (OR 0.45; 95% CI 0.21 to 0.98) than providing folders or videos only.There were no studies on effects of training in the long term or on resource use.The quality of the evidence is very low for all comparisons because of high risk of bias in all studies, indirectness of evidence, and small numbers of participants.

AUTHORS' CONCLUSIONS

We found very low quality evidence that more breathable types of PPE may not lead to more contamination, but may have greater user satisfaction. Alterations to PPE, such as tabs to grab may decrease contamination. Double gloving, following CDC doffing guidance, and spoken instructions during doffing may reduce contamination and increase compliance. Face-to-face training in PPE use may reduce errors more than video or folder based training. Because data come from single small studies with high risk of bias, we are uncertain about the estimates of effects.We still need randomised controlled trials to find out which training works best in the long term. We need better simulation studies conducted with several dozen participants to find out which PPE protects best, and what is the safest way to remove PPE. Consensus on the best way to conduct simulation of exposure and assessment of outcome is urgently needed. HCW exposed to highly infectious diseases should have their use of PPE registered and should be prospectively followed for their risk of infection in the field.

Participatory approach to quality development in infection prevention and control (IPC) in Nigerian health facilities

The development of an educational concept of a training programme for infection prevention and control (IPC) was seen as a key issue to successfully address the complexity of change processes of professional IPC routines in clinical procedures. Therefore, the Nigeria Centre for Disease Control (NCDC), Nigeria, and the Robert Koch Institute (RKI), Germany established an interdisciplinary project framework, involving knowledge and competences from different disciplines and professions like health professionals, epidemiologists and educators (MAURICE project). A multi-module training programme for health care workers to improve IPC standards was developed and implemented based on the participatory approach and a systemic view for organizational change.

Implementation science in low-resource settings: using the interactive systems framework to improve hand hygiene in a tertiary hospital in Ghana

Quality issue

Low-resource clinical settings often face obstacles that challenge the implementation of recommended evidence-based practices (EBPs). Implementation science approaches are useful in identifying barriers and developing strategies to address them.

Initial assessment

Ridge Regional Hospital (RRH), a tertiary referral hospital in Accra, Ghana experienced a spike in rates of neonatal sepsis and launched a quality improvement (QI) initiative that identified poor adherence to hand hygiene in the neonatal intensive care unit as a potential source of infections.

Choice of solution

A multi-modal change package of World Health Organization-recommended solutions was created to address this issue.

Implementation

To ensure that the outputs of the QI effort were adopted within the organization, leaders at RRH and Kybele, Inc. used an implementation science framework called the ‘Interactive Systems Framework for Dissemination and Implementation’ (ISF) to create a package of locally acceptable implementation strategies. The ISF has never been used before to guide implementation in low-resource settings.

Evaluation

Hand hygiene compliance rose from 67% to 92% overall, including a 36% increase during the night shifts—a group of healthcare workers with typically very low levels of compliance.

Lessons learned

The drastic improvement in adherence to hand hygiene suggests the potential value of the joint use of QI and implementation science to promote the creation and application of contextually appropriate EBPs in low-resource settings. Our results also suggest that using an implementation framework such as the ISF could rapidly increase the uptake of other evidence-based interventions in low-resource settings.

Interventions to improve hand hygiene compliance in emergency departments: a systematic review

The emergency department (ED) is where hand hygiene problems are significant as the procedures in the ED are often high risk and invasive. To date, there have been no comprehensive reviews on hand hygiene in EDs. The aim of this study was to investigate hand hygiene compliance (HHC) rate, factors affecting the HHC rate, and intervention strategies to improve HHC in EDs. Electronic databases were used to search for research published from 1948 to January 2018. The databases included ovidMEDLINE, ovidEMBASE, the Cochrane Library, CINAHL, Koreamed, and Kmbase. All study designs were included. Two reviewers independently extracted the data and assessed the bias risk using reliable and validated tools. A narrative synthesis was performed. Twenty-four studies, including 12 cross-sectional surveys and 12 interventional studies, were included. Of the 12 interventional studies reviewed, only 33% (N = 4) reported HHC rates of more than 50%. Factors that influenced HHC included types of healthcare worker, hand hygiene indication, ED crowding, positive attitudes towards HHC, patient location, auditing hand hygiene, and type of shift. Almost all of the studies (83.3%) applied multimodal or dual interventions to improve HHC. A range of strategies, including education, monitoring and providing feedback, campaigns, and cues, effectively improved HHC. The review findings indicate that there is a room for improvement in HHC in EDs. Future randomized controlled trials are necessary to determine which intervention modalities are most effective and sustainable for HHC improvement.

Cleaning Staff's Attitudes about Hand Hygiene in a Metropolitan Hospital in Australia: A Qualitative Study

Background: In 2009, the National Hand Hygiene Initiative (NHHI) was implemented in hospitals across Australia with the aim of improving hand hygiene practices and reducing healthcare-associated infections. Audits conducted post-implementation showed the lowest rates of compliance with hand hygiene practices are among operational staff including hospital cleaners. There is limited information about hand hygiene issues in hospital cleaners to inform development of evidence-based interventions to improve hand hygiene compliance in this group. Aim: This qualitative study was undertaken to explore the attitudes of hospital cleaning staff regarding hand hygiene and the National Hand Hygiene Initiative. Methodology: Focus groups were conducted with 12 cleaning staff at a large Australian hospital implementing the National Hand Hygiene Initiative. Findings: Hospital cleaners recognise the importance of hand hygiene in preventing healthcare-associated infections. Cleaners cite peer support, leadership, and the recognition and reward of those excelling in hand hygiene as strong motivators. Barriers to optimal hand hygiene practice include the presence of multiple conflicting guidelines, hand hygiene “overload” and a lack of contextualised education programs. This exploratory qualitative study reveals three themes about attitudes of hospital cleaning staff towards hand hygiene. These themes are: (1) “The culture of hand hygiene: It’s drummed into us”; (2) “Reminders and promotion for hand hygiene: We just need a big ‘Please wash your hands’ sign”; and (3) “The personal value of hand hygiene: Like he said, it’s second nature to us”. Conclusion: Hand-hygiene messages and training need to be more consistent and contextualised to achieve improvements in hand hygiene practices in hospital cleaning staff in Australia.

Family Experiences and Perspectives on Infection Prevention in Pediatric Long-Term Care

PURPOSE

Residents of pediatric long-term care facilities (pLTCF) are particularly vulnerable to healthcare-associated infections. The aims of this qualitative study were to (a) explore perspectives on infection prevention among families visiting children in pLTCF and (b) identify facilitators of and barriers to optimal hand hygiene.

DESIGN AND METHODS

Semistructured, in-depth interviews with 10 family members visiting two New York City metropolitan area facilities were analyzed to identify themes.

FINDINGS

"Everyone follows the rules" and "infections are inevitable" were primary themes. Participants reported "common sense" as a facilitator and "distraction" as a major barrier to prevention practices.

CONCLUSION

Current education for visitors may be inadequate to improve infection prevention behaviors.

CLINICAL RELEVANCE

Nurse-led education strategies for infection prevention should be tested and modified for families visiting pLTCF.

Validity of hand hygiene compliance measurement by observation: A systematic review

BACKGROUND

Hand hygiene is monitored by direct observation to improve practice, but this approach can potentially cause information, selection, and confounding bias, threatening the validity of findings. The aim of this study was to identify and describe the potential biases in hand hygiene compliance monitoring by direct observation; develop a typology of biases and propose improvements to reduce bias; and increase the validity of compliance measurements.

METHODS

This systematic review of hospital-based intervention studies used direct observation to monitor health care workers' hand hygiene compliance.

RESULTS

Seventy-one publications were eligible for review. None was free of bias. Selection bias was present in all studies through lack of data collection on the weekends (n = 61, 86%) and at night (n = 46, 65%) and observations undertaken in single-specialty settings (n = 35, 49%). We observed inconsistency of terminology, definitions of hand hygiene opportunity, criteria, tools, and descriptions of the data collection. Frequency of observation, duration, or both were not described or were unclear in 58 (82%) publications. Observers were trained in 56 (79%) studies. Inter-rater reliability was measured in 26 (37%) studies.

CONCLUSIONS

Published research of hand hygiene compliance measured by direct observation lacks validity. Hand hygiene should be measured using methods that produce a valid indication of performance and quality. Standardization of methodology would expedite comparison of hand hygiene compliance between clinical settings and organizations.

"We have to clean ourselves to ensure that our children are healthy and beautiful": findings from a qualitative assessment of a hand hygiene poster in rural Uganda

Background

Neonatal sepsis is a major cause of mortality worldwide, with most deaths occurring in low-income countries. The World Health Organisation (WHO) ‘5 Moments for Hand Hygiene’ poster has been used to reduce hospital-acquired infections, but there is no similar tool to prevent community-acquired newborn infections in low-resource settings. This assessment, part of the BabyGel Pilot study, evaluated the acceptability of the ‘Newborn Moments for Hand Hygiene in the Home’ poster. This was an educational tool which aimed to remind mothers in rural Uganda to clean their hands to prevent neonatal infection.

Methods

The BabyGel pilot was a cluster randomised trial that assessed the post-partum use of alcohol-based hand rub (ABHR) to prevent neonatal infections in Mbale, Uganda. Fifty-five women in 5 village clusters received the ABHR and used it from birth to 3 months postnatally, with use guided by the new poster. Following the study, 5 focus group discussions (FGDs) were conducted consisting of 6–8 purposively sampled participants from intervention villages. FGDs were audio-recorded, transcribed then translated into English. Transcripts were inductively coded using ATLAS.ti® and qualitatively analysed using thematic content analysis.

Results

Most mothers reported that they understood the message in the poster (“The picture shows me you must use these drugs to keep your baby healthy”) and that they could adhere to the moments from the poster. Some participants used the information from the poster to encourage other caregivers to use the ABHR (“after explaining to them, they liked it”). Other potential moments for hand hygiene were introduced by participants, such as after tending to domestic animals and gardening.

Conclusion

The poster was well-received, and participants reported compliance with the moments for hand hygiene (although the full body wipe of the baby has since been removed). The poster will be adapted into a sticker format on the ABHR bottle. More focus could be put into an education tool for other caregivers who wish to hold the baby. Overall, the study demonstrated the acceptability of an adapted version of the WHO Moments for Hand Hygiene poster in the introduction of an intervention in the community.

Trial registration

ISRCTN67852437, registered 02/03/2015.

Trial funding

Medical Research Council/ Wellcome Trust/ DfID (Global Health Trials Scheme).

An Intervention Study for the Prevention and Control of Health Care-Associated Infection in the Critical Cares Area of a Tertiary Care Hospital in Saudi Arabia

INTRODUCTION

Healthcare-associated infections (HAIs) are an infection that patients acquire during receiving treatment and care for the medical or surgical problem.

OBJECTIVE

The objective of this study is to find the patterns of HAIs cases in the hospital and to know the impact of the intervention on prevention and control of health care associated infection.

METHODOLOGY

This was prospective interventional study.

RESULTS

The majority of cases of HAIs was reported from intensive care unit 47%. The most common site involved due to HAIs was catheter-associated urinary tract infection followed by central line-associated bloodstream infection. During the study period, around 28% reduction of cases were reported. During 6 months period (March to August 2016), around 540 cases were admitted in the critical care areas out of that 32 cases were reported as HAIs (5.9%) for the same period from (March to August 2017) was (3.4%), that difference came to be a statistically significant (χ2 = 4.12, P = 0.042, df = 1).

CONCLUSION

This small study showed that strict implementation of care bundles with good compliance of hand hygiene, Personal protective equipment and antibiotic stewardship are helpful for prevention and control of hospital acquired infections. This study also demonstrated significant (28%) reduction of hospital acquired infections during the study period.

Health care-associated infections - an overview

Health care-associated infections (HCAIs) are infections that occur while receiving health care, developed in a hospital or other health care facility that first appear 48 hours or more after hospital admission, or within 30 days after having received health care. Multiple studies indicate that the common types of adverse events affecting hospitalized patients are adverse drug events, HCAIs, and surgical complications. The US Center for Disease Control and Prevention identifies that nearly 1.7 million hospitalized patients annually acquire HCAIs while being treated for other health issues and that more than 98,000 patients (one in 17) die due to these. Several studies suggest that simple infection-control procedures such as cleaning hands with an alcohol-based hand rub can help prevent HCAIs and save lives, reduce morbidity, and minimize health care costs. Routine educational interventions for health care professionals can help change their hand-washing practices to prevent the spread of infection. In support of this, the WHO has produced guidelines to promote hand-washing practices among member countries.

Promoting the use of self-management in novice chiropractors treating individuals with spine pain: the design of a theory-based knowledge translation intervention

Background

Clinical practice guidelines generally recommend clinicians use self-management support (SMS) when managing patients with spine pain. However, even within the educational setting, the implementation of SMS remains suboptimal. The objectives of this study were to 1) estimate the organizational readiness for change toward using SMS at the Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario from the perspective of directors and deans, 2) estimate the attitudes and self-reported behaviours towards using evidence-based practice (EBP), and beliefs about pain management among supervisory clinicians and chiropractic interns, 3) identify potential barriers and enablers to using SMS, and 4) design a theory-based tailored Knowledge Translation (KT) intervention to increase the use of SMS.

Methods

Mixed method design. We administered three self-administered questionnaires to assess clinicians’ and interns’ attitudes and behaviours toward EBP, beliefs about pain management, and practice style. In addition, we conducted 3 focus groups with clinicians and interns based on the Theoretical Domain Framework (TDF) to explore their beliefs about using SMS for patients with spine pain. Data were analysed using deductive thematic analysis by 2 independent assessors. A panel of 7 experts mapped behaviour change techniques to key barriers identified informing the design of a KT intervention.

Results

Participants showed high level of EBP knowledge, positive attitude of EBP, and moderate frequency of EBP use. A number of barrier factors were identified from clinicians (N = 6) and interns (N = 16) corresponding to 7 TDF domains: Knowledge; Skills; Environmental context and resources; Emotion; Beliefs about Capabilities; Memory, attention & decision making; and Social Influence. To address these barriers, the expert panel proposed a multifaceted KT intervention composed of a webinar and online educational module on a SMS guided by the Brief Action Planning, clinical vignettes, training workshop, and opinion leader support.

Conclusion

SMS strategies can help maximizing the health care services for patients with spine pain. This may in turn optimize patients’ health. The proposed theory-based KT intervention may facilitate the implementation of SMS among clinicians and interns.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2241-1) contains supplementary material, which is available to authorized users.

Effect of electronic real-time prompting on hand hygiene behaviors in health care workers

BACKGROUND

Poor hand hygiene by health care workers is a major cause of nosocomial infections. This research evaluated the ability of an electronic monitoring system with real-time prompting capability to change hand hygiene behaviors.

METHODS

Handwashing activity was measured by counting dispenser activations on a single nursing unit before, during, and after installation of the system. The effect of changing the prompt duration on hand hygiene performance was determined by a cluster-randomized trial on 3 nursing units with 1 acting as control. Sustainability of performance and participation was observed on 4 nursing units over a year. All staff were eligible to participate.

RESULTS

Between June 2015 and December 2016, a total of 459,376 hand hygiene opportunities and 330,740 handwashing events from 511 staff members were recorded. Dispenser activation counts were significantly influenced by use of the system (χ²[3] = 75.76; P < .0001). Hand hygiene performance dropped from 62.61% to 24.94% (odds ratio, 0.36; 95% confidence interval, 0.34-0.38) when the prompting feature was removed. Staff participation had a negative trajectory of -0.72% (P < .001), whereas change in average performance was -0.18% (P < .001) per week for the year.

CONCLUSIONS

Use of electronic monitoring with real-time prompts of 20 seconds' duration nearly doubles handwashing activity and causes handwashing to occur sooner after entering a patient room. These improvements are sustainable over a year.

How a smiley protects health: A pilot intervention to improve hand hygiene in hospitals by activating injunctive norms through emoticons

Hand hygiene practice in hospitals is unfortunately still widely insufficient, even though it is known that transmitting pathogens via hands is the leading cause of healthcare-associated infections. Previous research has shown that improving knowledge, providing feedback on past behaviour and targeting social norms are promising approaches to improve hand hygiene practices. The present field experiment was designed to direct people on when to perform hand hygiene and prevent forgetfulness. This intervention is the first to examine the effect of inducing injunctive social norms via an emoticon-based feedback system on hand hygiene behaviour. Electronic monitoring and feedback devices were installed in hospital patient rooms on top of hand-rub dispensers, next to the doorway, for a period of 17 weeks. In the emoticon condition, screens at the devices activated whenever a person entered or exited the room. Before using the alcohol-based hand-rub dispenser, a frowny face was displayed, indicating that hand hygiene should be performed. If the dispenser was subsequently used, this picture changed to a smiley face to positively reinforce the correct behaviour. Hand hygiene behaviour in the emoticon rooms significantly outperformed the behaviour in three other tested conditions. The strong effect in this field experiment indicates that activating injunctive norms may be a promising approach to improve hand hygiene behaviour. Theoretical and practical implications of these findings are discussed.

Influence of Handprint Culture Training on Compliance of Healthcare Workers with Hand Hygiene

OBJECTIVE

We aimed to study the effect of visual observation of bacterial growth from handprints on healthcare workers' (HCWs) compliance with hand hygiene (HH).

SETTINGS

Medical and postoperative cardiac surgery units.

DESIGN

Prospective cohort study.

SUBJECT

The study included 40 HCWs.

INTERVENTION

Each HCW was interviewed on 3 separate occasions. The 1st interview was held to obtain a handprint culture before and after a session demonstrating the 7 steps of HH using alcohol-based hand rub, allowing comparison of results before and after HH. A 2nd interview was held 6 weeks later to obtain handprint culture after HH. A 3rd interview was held to obtain a handprint culture before HH. One month before implementation of handprint cultures and during the 12-week study period, monitoring of HCWs for compliance with HH was observed by 2 independent observers.

MAIN RESULTS

There was a significant improvement in HH compliance following handprint culture interview (p < 0.001). The frequency of positive cultures, obtained from patients with suspected healthcare-associated infections, significantly declined (blood cultures: p = 0.001; wound cultures: p = 0,003; sputum cultures: p = 0.005).

CONCLUSION

The visual message of handprint bacterial growth before and after HH seems an effective method to improve HH compliance.

Hospital-based interventions: a systematic review of staff-reported barriers and facilitators to implementation processes

BACKGROUND

Translation of evidence-based interventions into hospital systems can provide immediate and substantial benefits to patient care and outcomes, but successful implementation is often not achieved. Existing literature describes a range of barriers and facilitators to the implementation process. This systematic review identifies and explores relationships between these barriers and facilitators to highlight key domains that need to be addressed by researchers and clinicians seeking to implement hospital-based, patient-focused interventions.

METHODS

We searched MEDLINE, PsychInfo, Embase, Web of Science, and CINAHL using search terms focused specifically on barriers and facilitators to the implementation of patient-focused interventions in hospital settings. To be eligible, papers needed to have collected formal data (qualitative or quantitative) that specifically assessed the implementation process, as experienced by the staff involved.

RESULTS

Of 4239 papers initially retrieved, 43 papers met inclusion criteria. Staff-identified barriers and facilitators to implementation were grouped into three main domains: system, staff, and intervention. Bi-directional associations were evident between these domains, with the strongest links evident between staff and intervention.

CONCLUSIONS

Researchers and health professionals engaged in designing patient-focused interventions need to consider barriers and facilitators across all three identified domains to increase the likelihood of implementation success. The interrelationships between domains are also crucial, as resources in one area can be leveraged to address barriers in others. These findings emphasize the importance of careful intervention design and pre-implementation planning in response to the specific system and staff context in order to increase likelihood of effective and sustainable implementation.

TRIAL REGISTRATION

This review was registered on the PROSPERO database: CRD42017057554  in February 2017.

Iterative co-creation for improved hand hygiene and aseptic techniques in the operating room: experiences from the safe hands study

BACKGROUND

Hand hygiene and aseptic techniques are essential preventives in combating hospital-acquired infections. However, implementation of these strategies in the operating room remains suboptimal. There is a paucity of intervention studies providing detailed information on effective methods for change. This study aimed to evaluate the process of implementing a theory-driven knowledge translation program for improved use of hand hygiene and aseptic techniques in the operating room.

METHODS

The study was set in an operating department of a university hospital. The intervention was underpinned by theories on organizational learning, culture and person centeredness. Qualitative process data were collected via participant observations and analyzed using a thematic approach.

RESULTS

Doubts that hand-hygiene practices are effective in preventing hospital acquired infections, strong boundaries and distrust between professional groups and a lack of psychological safety were identified as barriers towards change. Facilitated interprofessional dialogue and learning in "safe spaces" worked as mechanisms for motivation and engagement. Allowing for the free expression of different opinions, doubts and viewing resistance as a natural part of any change was effective in engaging all professional categories in co-creation of clinical relevant solutions to improve hand hygiene.

CONCLUSION

Enabling nurses and physicians to think and talk differently about hospital acquired infections and hand hygiene requires a shift from the concept of one-way directed compliance towards change and learning as the result of a participatory and meaning-making process. The present study is a part of the Safe Hands project, and is registered with ClinicalTrials.gov (ID: NCT02983136 ). Date of registration 2016/11/28, retrospectively registered.

Behavioral Interventions to Reduce Infections in Pediatric Long-term Care Facilities: The Keep It Clean for Kids Trial

Children in pediatric long-term care facilities (pLTCF) represent a highly vulnerable population and infectious outbreaks occur frequently, resulting in significant morbidity, mortality, and resource use. The purpose of this quasi-experimental trial using time series analysis was to assess the impact of a 4-year theoretically based behavioral intervention on infection prevention practices and clinical outcomes in three pLTCF (288 beds) in New York metropolitan area including 720 residents, ages 1 day to 26 years with mean lengths of stay: 7.9-33.6 months. The 5-pronged behavioral intervention included explicit leadership commitment, active staff participation, work flow assessments, training staff in the World Health Organization "'five moments of hand hygiene (HH)," and electronic monitoring and feedback of HH frequency. Major outcomes were HH frequency, rates of infections, number of hospitalizations associated with infections, and outbreaks. Mean infection rates/1000 patient days ranged from 4.1-10.4 pre-intervention and 2.9-10.0 post-intervention. Mean hospitalizations/1000 patient days ranged from 2.3-9.7 before and 6.4-9.8 after intervention. Number of outbreaks/1000 patient days per study site ranged from 9-24 pre- and 9-18 post-intervention (total = 95); number of cases/outbreak ranged from 97-324 (total cases pre-intervention = 591 and post-intervention = 401). Post-intervention, statistically significant increases in HH trends occurred in one of three sites, reductions in infections in two sites, fewer hospitalizations in all sites, and significant but varied changes in the numbers of outbreaks and cases/outbreak. Modest but inconsistent improvements occurred in clinically relevant outcomes. Sustainable improvements in infection prevention in pLTCF will require culture change; increased staff involvement; explicit administrative support; and meaningful, timely behavioral feedback.

Assessing user acceptance towards automated and conventional sink use for hand decontamination using the technology acceptance model

Hand hygiene (HH) prevents harmful contaminants spreading in settings including domestic, health care and food handling. Strategies to improve HH range from behavioural techniques through to automated sinks that ensure hand surface cleaning. This study aimed to assess user experience and acceptance towards a new automated sink, compared to a normal sink. An adapted version of the technology acceptance model (TAM) assessed each mode of handwashing. A within-subjects design enabled N = 46 participants to evaluate both sinks. Perceived Ease of Use and Satisfaction of Use were significantly lower for the automated sink, compared to the conventional sink (p < 0.005). Across the remaining TAM factors, there was no significant difference. Participants suggested design features including jet strength, water temperature and device affordance may improve HH technology. We provide recommendations for future HH technology development to contribute a positive user experience, relevant to technology developers, ergonomists and those involved in HH across all sectors. Practitioner Summary: The need to facilitate timely, effective hand hygiene to prevent illness has led to a rise in automated handwashing systems across different contexts. User acceptance is a key factor in system uptake. This paper applies the technology acceptance model as a means to explore and optimise the design of such systems.

Implementation strategies for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

A key function of health systems is implementing interventions to improve health, but coverage of essential health interventions remains low in low-income countries. Implementing interventions can be challenging, particularly if it entails complex changes in clinical routines; in collaborative patterns among different healthcare providers and disciplines; in the behaviour of providers, patients or other stakeholders; or in the organisation of care. Decision-makers may use a range of strategies to implement health interventions, and these choices should be based on evidence of the strategies' effectiveness.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of implementation strategies for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on alternative implementation strategies and informing refinements of the framework for implementation strategies presented in the overview.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of implementation strategies on professional practice and patient outcomes and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the review findings. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 39 of them in this overview. An additional four reviews provided supplementary information. Of the 39 reviews, 32 had only minor limitations and 7 had important methodological limitations. Most studies in the reviews were from high-income countries. There were no studies from low-income countries in eight reviews.Implementation strategies addressed in the reviews were grouped into four categories - strategies targeting:1. healthcare organisations (e.g. strategies to change organisational culture; 1 review);2. healthcare workers by type of intervention (e.g. printed educational materials; 14 reviews);3. healthcare workers to address a specific problem (e.g. unnecessary antibiotic prescription; 9 reviews);4. healthcare recipients (e.g. medication adherence; 15 reviews).Overall, we found the following interventions to have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects.1.Strategies targeted at healthcare workers: educational meetings, nutrition training of health workers, educational outreach, practice facilitation, local opinion leaders, audit and feedback, and tailored interventions.2.Strategies targeted at healthcare workers for specific types of problems: training healthcare workers to be more patient-centred in clinical consultations, use of birth kits, strategies such as clinician education and patient education to reduce antibiotic prescribing in ambulatory care settings, and in-service neonatal emergency care training.3. Strategies targeted at healthcare recipients: mass media interventions to increase uptake of HIV testing; intensive self-management and adherence, intensive disease management programmes to improve health literacy; behavioural interventions and mobile phone text messages for adherence to antiretroviral therapy; a one time incentive to start or continue tuberculosis prophylaxis; default reminders for patients being treated for active tuberculosis; use of sectioned polythene bags for adherence to malaria medication; community-based health education, and reminders and recall strategies to increase vaccination uptake; interventions to increase uptake of cervical screening (invitations, education, counselling, access to health promotion nurse and intensive recruitment); health insurance information and application support.

AUTHORS' CONCLUSIONS

Reliable systematic reviews have evaluated a wide range of strategies for implementing evidence-based interventions in low-income countries. Most of the available evidence is focused on strategies targeted at healthcare workers and healthcare recipients and relates to process-based outcomes. Evidence of the effects of strategies targeting healthcare organisations is scarce.

Interventions to improve hand hygiene compliance in patient care

BACKGROUND

Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure. This is an update of a previously published review.

OBJECTIVES

To assess the short- and long-term success of strategies to improve compliance to recommendations for hand hygiene, and to determine whether an increase in hand hygiene compliance can reduce rates of health care-associated infection.

SEARCH METHODS

We conducted electronic searches of the Cochrane Register of Controlled Trials, PubMed, Embase, and CINAHL. We conducted the searches from November 2009 to October 2016.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series analyses (ITS) that evaluated any intervention to improve compliance with hand hygiene using soap and water or alcohol-based hand rub (ABHR), or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened citations for inclusion, extracted data, and assessed risks of bias for each included study. Meta-analysis was not possible, as there was substantial heterogeneity across studies. We assessed the certainty of evidence using the GRADE approach and present the results narratively in a 'Summary of findings' table.

MAIN RESULTS

This review includes 26 studies: 14 randomised trials, two non-randomised trials and 10 ITS studies. Most studies were conducted in hospitals or long-term care facilities in different countries, and collected data from a variety of healthcare workers. Fourteen studies assessed the success of different combinations of strategies recommended by the World Health Organization (WHO) to improve hand hygiene compliance. Strategies consisted of the following: increasing the availability of ABHR, different types of education for staff, reminders (written and verbal), different types of performance feedback, administrative support, and staff involvement. Six studies assessed different types of performance feedback, two studies evaluated education, three studies evaluated cues such as signs or scent, and one study assessed placement of ABHR. Observed hand hygiene compliance was measured in all but three studies which reported product usage. Eight studies also reported either infection or colonisation rates. All studies had two or more sources of high or unclear risks of bias, most often associated with blinding or independence of the intervention.Multimodal interventions that include some but not all strategies recommended in the WHO guidelines may slightly improve hand hygiene compliance (five studies; 56 centres) and may slightly reduce infection rates (three studies; 34 centres), low certainty of evidence for both outcomes.Multimodal interventions that include all strategies recommended in the WHO guidelines may slightly reduce colonisation rates (one study; 167 centres; low certainty of evidence). It is unclear whether the intervention improves hand hygiene compliance (five studies; 184 centres) or reduces infection (two studies; 16 centres) because the certainty of this evidence is very low.Multimodal interventions that contain all strategies recommended in the WHO guidelines plus additional strategies may slightly improve hand hygiene compliance (six studies; 15 centres; low certainty of evidence). It is unclear whether this intervention reduces infection rates (one study; one centre; very low certainty of evidence).Performance feedback may improve hand hygiene compliance (six studies; 21 centres; low certainty of evidence). This intervention probably slightly reduces infection (one study; one centre) and colonisation rates (one study; one centre) based on moderate certainty of evidence.Education may improve hand hygiene compliance (two studies; two centres), low certainty of evidence.Cues such as signs or scent may slightly improve hand hygiene compliance (three studies; three centres), low certainty of evidence.Placement of ABHR close to point of use probably slightly improves hand hygiene compliance (one study; one centre), moderate certainty of evidence.

AUTHORS' CONCLUSIONS

With the identified variability in certainty of evidence, interventions, and methods, there remains an urgent need to undertake methodologically robust research to explore the effectiveness of multimodal versus simpler interventions to increase hand hygiene compliance, and to identify which components of multimodal interventions or combinations of strategies are most effective in a particular context.

Hand hygiene technique quality evaluation in nursing and medicine students of two academic courses

Objective:

because they are health professionals, nursing and medical students' hands during internships can function as a transmission vehicle for hospital-acquired infections.

Method:

a descriptive study with nursing and medical degree students on the quality of the hand hygiene technique, which was assessed via a visual test using a hydroalcoholic solution marked with fluorescence and an ultraviolet lamp.

Results:

546 students were assessed, 73.8% from medicine and 26.2% from nursing. The area of the hand with a proper antiseptic distribution was the palm (92.9%); areas not properly scrubbed were the thumbs (55.1%). 24.7% was very good in both hands, 29.8% was good, 25.1% was fair, and 20.3% was poor. The worst assessed were the male, nursing and first year students. There were no significant differences in the age groups.

Conclusions:

hand hygiene technique is not applied efficiently. Education plays a key role in setting a good practice base in hand hygiene, theoretical knowledge, and in skill development, as well as good practice reinforcement.

Changing the paradigm: messages for hand hygiene education and audit from cluster analysis

BACKGROUND

Hand hygiene is considered to be the foremost infection prevention measure. How healthcare workers accept and make sense of the hand hygiene message is likely to contribute to the success and sustainability of initiatives to improve performance, which is often poor.

METHODS

A survey of nurses in critical care units in three National Health Service trusts in England was undertaken to explore opinions about hand hygiene, use of alcohol hand rubs, audit with performance feedback, and other key hand-hygiene-related issues. Data were analysed descriptively and subjected to cluster analysis.

RESULTS

Three main clusters of opinion were visualized, each forming a significant group: positive attitudes, pragmatism and scepticism. A smaller cluster suggested possible guilt about ability to perform hand hygiene.

CONCLUSION

Cluster analysis identified previously unsuspected constellations of beliefs about hand hygiene that offer a plausible explanation for behaviour. Healthcare workers might respond to education and audit differently according to these beliefs. Those holding predominantly positive opinions might comply with hand hygiene policy and perform well as infection prevention link nurses and champions. Those holding pragmatic attitudes are likely to respond favourably to the need for professional behaviour and need to protect themselves from infection. Greater persuasion may be needed to encourage those who are sceptical about the importance of hand hygiene to comply with guidelines. Interventions to increase compliance should be sufficiently broad in scope to tackle different beliefs. Alternatively, cluster analysis of hand hygiene beliefs could be used to identify the most effective educational and monitoring strategies for a particular clinical setting.

Hand Hygiene: An Update

The medical field has long recognized the importance of hand hygiene in preventing health care-associated infections, yet studies indicate that this important task is performed only 40% of the time. Health care workers cite several barriers to optimal performance of hand hygiene, but the time required to perform this task is foremost among them. Introduction of alcohol-based hand rubs, bundled interventions, and incorporation of technologies designed to monitor and promote hand hygiene all represent promising advances in this field.

Construct validity-Current issues and recommendations for future hand hygiene research

Health care-associated infection is a leading cause of morbidity and mortality. Hand hygiene is widely regarded as an effective prevention strategy. Often, hand hygiene research is designed and conducted by health care practitioners who may lack formal training in research methods, particularly in the area of social science. In a research context, a construct is a concept that can be measured or observed in some way. A construct can be directly or indirectly measured. For example, height can be directly measured by centimeters, whereas depression can be indirectly measured by a scale of 20 items. Every construct needs to be operationalized by measure(s) to make it a variable. Hence, construct validity refers to the degree of fit between the construct of interest and its operational measure. However, issues with construct validity often weaken the translation from construct to measure(s). This article will (1) describe the common threats to construct validity pertaining to hand hygiene research, (2) identify practical limitations in current research design, and (3) provide recommendations to improve construct validity in future hand hygiene research. By understanding how construct validity may affect hand hygiene research design, there is great potential to improve the validity of future hand hygiene research findings.

Hand hygiene among healthcare workers: A qualitative meta summary using the GRADE-CERQual process

BACKGROUND

Hand hygiene is considered an effective and potentially modifiable infection control behaviour among healthcare workers (HCW). Several meta-studies have been published that compare quantitatively expressed findings, but limited efforts have been made to synthesise qualitative research.

OBJECTIVES

This paper provides the first report of integrated findings from qualitative research reports on hand hygiene compliance among HCW worldwide that employs the GRADE-CERQual process of quality assessment.

METHODS

We conducted database searches and identified 36 reports in which authors conducted qualitative or mixed methods research on hand hygiene compliance among HCW. We used Dedoose analysis software to facilitate extraction of relevant excerpts. We applied the GRADE-CERQual process to describe relative confidence as high, moderate or low for nine aggregate findings.

FINDINGS

Highest confidence findings included that HCW believe they have access to adequate training, and that management and resource support are sometimes lacking. Individual, subjective criteria also influence hand hygiene.

DISCUSSION

These results suggest the need for further investigation into healthcare cultures that are perceived as supportive for infection control. Surveillance processes have potential, especially if information is perceived by HCW as timely and relevant.

Now is the Time for Psychology to Support the Transformation of Academic Health Centers

Psychologists have made important contributions in academic health centers (AHC), but the reputation of psychology as a discipline has been mixed, by turns viewed as a superfluous soft science, or seen as an important contributor to the AHC mission. AHCs currently face exceptional challenges to the viability of AHCs, including: planned alterations from fee-for-service to value-based funding that requires high quality at lower cost; and rising demands to demonstrate competence in trainees. Now more than ever, psychologists can and must help AHCs to meet these challenges.

Exploring the context for effective clinical governance in infection control

BACKGROUND

Effective clinical governance is necessary to support improvements in infection control. Historically, the focus has been on ensuring that infection control practice and policy is based on evidence, and that there is use of surveillance and auditing for self-regulation and performance feedback. There has been less exploration of how contextual and organizational factors mediate an infection preventionists (IP's) ability to engage with evidence-based practice and enact good clinical governance.

METHODS

A cross sectional Web-based survey of IPs in Australia and New Zealand was undertaken. Questions focused on engagement in evidence-based practice and perceptions about the context, culture, and leadership within the infection control team and organization. Responses were mapped against dimensions of Scally and Donaldson's clinical governance framework.

RESULTS

Three hundred surveys were returned. IPs appear well equipped at an individual level to undertake evidence-based practice. The most serious set of perceived challenges to good clinical governance related to a lack of leadership or active resistance to infection control within the organization. Additional challenges included lack of information technology solutions and poor access to specialist expertise and financial resources.

CONCLUSIONS

Focusing on strengthening contextual factors at the organizational level that otherwise undermine capacity to implement evidence-based practice is key to sustaining current infection control successes and promoting further practice improvements.

A Systematic Review on the Effectiveness of Interventions to Improve Hand Hygiene Compliance of Nurses in the Hospital Setting

PURPOSE

The purpose of the present systematic review is to identify the interventions that improve hand hygiene compliance (HHC) specifically among nurses.

METHODS

A systematic review was performed guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses to evaluate the short and long-term effects of interventions to promote hand hygiene practices among nurses in the hospital setting. A search of the Cumulative Index to Nursing and Allied Health Literature, Medline Global Health, and Embase was conducted in addition to studies identified by the most recent systematic review. Six studies met inclusion criteria: three randomized controlled trials (RCTs), one controlled before and after studies (CBAs), and two interrupted times series (ITS).

FINDINGS

One RCT reported effectiveness and 6-month sustainability of the effect related to multimodal-directed and multimodal with team leadership-directed strategies. The other two RCTs found positive effect of education and feedback on compliance; however, compliance rates declined after 1 month. Education was also found to improve HHC up to 3 months postintervention. An electronic reminder and feedback system evaluated by an ITS improved HHC and detected variation in HHC through the day.

CONCLUSIONS

This review showed that single and combined interventions do improve hand hygiene practices among nurses; however, there is a need for more methodologically robust studies to define the most effective and sustainable interventions.

CLINICAL RELEVANCE

Although hand hygiene is the most effective measure to prevent healthcare-associated infections, compliance with hand hygiene remains low. Nurses are among the healthcare providers who spend the most time in direct patient contact. Therefore, there is a need for research to identify the interventions that improve HHC in this group.

Risk behaviours for organism transmission in health care delivery-A two month unstructured observational study

BACKGROUND

Errors in infection control practices risk patient safety. The probability for errors can increase when care practices become more multifaceted. It is therefore fundamental to track risk behaviours and potential errors in various care situations.

OBJECTIVE

The aim of this study was to describe care situations involving risk behaviours for organism transmission that could lead to subsequent healthcare-associated infections.

DESIGN & SETTING

Unstructured nonparticipant observations were performed at three medical wards.

PARTICIPANTS & METHODS

Healthcare personnel (n=27) were shadowed, in total 39h, on randomly selected weekdays between 7:30 am and 12 noon. Content analysis was used to inductively categorize activities into tasks and based on the character into groups. Risk behaviours for organism transmission were deductively classified into types of errors. Multiple response crosstabs procedure was used to visualize the number and proportion of errors in tasks. One-Way ANOVA with Bonferroni post Hoc test was used to determine differences among the three groups of activities.

RESULTS

The qualitative findings gives an understanding of that risk behaviours for organism transmission goes beyond the five moments of hand hygiene and also includes the handling and placement of materials and equipment. The tasks with the highest percentage of errors were; 'personal hygiene', 'elimination' and 'dressing/wound care'. The most common types of errors in all identified tasks were; 'hand disinfection', 'glove usage', and 'placement of materials'. Significantly more errors (p<0.0001) were observed the more multifaceted (single, combined or interrupted) the activity was.

CONCLUSION

The numbers and types of errors as well as the character of activities performed in care situations described in this study confirm the need to improve current infection control practices. It is fundamental that healthcare personnel practice good hand hygiene however effective preventive hygiene is complex in healthcare activities due to the multifaceted care situations, especially when activities are interrupted. A deeper understanding of infection control practices that goes beyond the sense of security by means of hand disinfection and use of gloves is needed as materials and surfaces in the care environment might be contaminated and thus pose a risk for organism transmission.

Making change easy: A peer-to-peer guide on transitioning to new hand hygiene products

This report summarizes our experiences planning and implementing the transition to a new commercial line of hand hygiene products and their dispensing systems in a large academic health care facility in Toronto, Canada. Our lessons learned are organized into a practical guide made available in 2 different formats: this article and an illustrated peer-to-peer guide (http://www.baycrest.org/wp-content/uploads/HCE-PROG-HH_HighQuality.pdf).

Experiences of hand hygiene among acute care nurses: An interpretative phenomenological analysis

Objective:

Occurrences of healthcare-associated infections are associated with substantial direct and indirect costs. Improvement in hand hygiene among acute care nurses has potential to reduce incidence of healthcare-associated infections. Findings from reviews of intervention research have not conclusively identified components that are more or less efficient or effective. Much prior qualitative research has focused on descriptive analysis of policies and practices rather than providing interpretive explorations of how individuals’ perceptions of hygiene might drive practices.

Methods:

We conducted qualitative interview research with eight nurses in the United States who were employed in various patient-care roles. We analyzed the data using an interpretative phenomenological analysis methodology to explore how nurses described their perceptions of, and experiences with, hygiene. We developed themes that explored individual, workplace, and management influences on perception of hygiene.

Results:

Developed themes include practical hygiene, risky business, and hygiene on trial; the latter theme described the conflict between how nurses perceived their own hygiene practices and how they felt hospital management perceived these practices. Other findings included that participants distinguished between policy-mandated use of sanitizer and a personal sense of cleanliness; the latter was more likely to be associated with scrubbing or removal of contaminants than with use of protectants.

Conclusion:

While participants asserted support for facility hand hygiene policies, their behavior in certain instances might be mediated by broadly defined emergent situations and a belief that it is not currently possible to establish a causal link between an healthcare-associated infections and a specific individual or occurrence. Researchers and infection prevention practitioners might consider soliciting greater input from nurses in planning hand hygiene improvement interventions, to encourage ownership, and emphasizing detailed cases as training content to take advantage of individuals’ sensory responses to hygiene.

A quasi-experimental study to determine the effects of a multifaceted educational intervention on hand hygiene compliance in a radiography unit

BACKGROUND

Whilst numerous studies have investigated nurses' compliance with hand hygiene and use of alcohol-based hand rub (ABHR), limited attention has been paid to these issues in allied health staff. Reports have linked infections to breaches in infection control in the radiography unit (RU). With advances in medical imaging, a higher proportion of patients come into contact with RU staff increasing the need for good hand hygiene compliance. This study aimed to evaluate effectiveness on compliance of an intervention to improve awareness of hand hygiene in the RU of a district hospital.

METHODS

A quasi-experimental study design including questionnaires assessing knowledge and attitudes of hand hygiene and direct observation of participants was used to evaluate an educational programme on hand hygiene of the RU of a large district hospital. All healthcare workers (HCW), comprising 76 radiographers, 17 nurses, and nine healthcare assistants (HCA), agreed to participate in the study. Of these, 85 completed the initial and 76 the post-test anonymous questionnaire. The hand hygiene compliance of all 102 HCW was observed over a 3-week period prior to and after the intervention. The 2-month intervention consisted of talks on hand hygiene and benefits of ABHR, provision of visual aids, wall-mounted ABHR dispensers, and personal bottles of ABHR.

RESULTS

Before the intervention, overall hand hygiene compliance was low (28.9 %). Post-intervention, compliance with hand hygiene increased to 51.4 %. This improvement was significant for radiographers and HCA. Additionally, knowledge and attitudes improved in particular, understanding that ABHR can largely replace handwashing and there is a need to perform hand hygiene after environmental contact. The increased use of ABHR allowed HCW to feel they had enough time to perform hand hygiene.

CONCLUSIONS

The educational intervention led to increased awareness of hand hygiene opportunities and better acceptance of ABHR use. The reduced time needed to perform hand rubbing and improved access to dispensers resulted in fewer missed opportunities. Although radiographers and other allied HCW make frequent contact with patients, these may be mistakenly construed as irrelevant with respect to healthcare associated infections. Stronger emphasis on hand hygiene compliance of these staff may help reduce infection risk.

Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews

OBJECTIVE

To provide an overview of effective interventions aimed at reducing rates of adverse events in hospitals.

DESIGN

Systematic review of systematic reviews.

DATA SOURCES

PubMed, CINAHL, PsycINFO, the Cochrane Library and EMBASE were searched for systematic reviews published until October 2015.

STUDY SELECTION

English-language systematic reviews of interventions aimed at reducing adverse events in hospitals, including studies with an experimental design and reporting adverse event rates, were included. Two reviewers independently assessed each study's quality and extracted data on the study population, study design, intervention characteristics and adverse patient outcomes.

RESULTS

Sixty systematic reviews with moderate to high quality were included. Statistically significant pooled effect sizes were found for 14 types of interventions, including: (1) multicomponent interventions to prevent delirium; (2) rapid response teams to reduce cardiopulmonary arrest and mortality rates; (3) pharmacist interventions to reduce adverse drug events; (4) exercises and multicomponent interventions to prevent falls; and (5) care bundle interventions, checklists and reminders to reduce infections. Most (82%) of the significant effect sizes were based on 5 or fewer primary studies with an experimental study design.

CONCLUSIONS

The evidence for patient-safety interventions implemented in hospitals worldwide is weak. The findings address the need to invest in high-quality research standards in order to identify interventions that have a real impact on patient safety. Interventions to prevent delirium, cardiopulmonary arrest and mortality, adverse drug events, infections and falls are most effective and should therefore be prioritised by clinicians.

Intensive care physicians' and nurses' perception that hand hygiene prevents pathogen transmission: Belief strength and associations with other cognitive factors

Besides habituation, conscious decision-making remains important for healthcare workers' hand hygiene compliance. This study compared 307 physicians and 348 nurses in intensive care at a German university medical centre regarding their belief that hand disinfection prevents pathogen transmission. Physicians perceived less risk reduction ( p < 0.001; variance explained: 4%), a comparison outscored only by lower self-rated guideline knowledge (8%). In both groups, the transmission-preventive belief was associated with high response efficacy, behavioural intention and self-efficacy, but not with self-rated knowledge. Consistent with the Health Action Process Approach, hand hygiene interventions targeting risk reduction beliefs may promote high motivation, but not action control.

Can theoretical intervention improve hand hygiene behavior among nurses?

Background

Hand washing is the best strategy to prevent known nosocomial infections but the nurses’ hand hygiene is estimated to be poor in Iran.

Objective

This study aimed to determine the effectiveness of BASNEF (Behavior, Attitude, Subjective Norms, and Enabling Factors) model on hand hygiene adherence education.

Methods

This controlled quasi-experimental study was conducted on 70 hemodialysis unit nurses (35 case and 35 control) in the health and educational centers of the University of Medical Sciences of Urmia, Iran. To collect the data, a six-part validated and reliable questionnaire was used. The data were analyzed using SPSS version18, using Wilcoxon, Mann–Whitney, chi-square, and Fisher’s exact tests. The significance level was considered P<0.05.

Results

The mean age was 38.4±8.1 years for the intervention group and 40.2±8.0 years for the control group. There was no significant difference between the two groups for any demographic variables. Also, before the intervention, there was no significant difference between the two groups for any components of the BASNEF model. Post-intervention, the attitude, subjective norms, enabling factors, and intention improved significantly in the intervention group (P<0.001), but hand hygiene behavior did not show any significant change in the intervention group (P=0.16).

Conclusion

Despite the improving attitudes and intention, the intervention had no significant effect on hand hygiene behavior among the studied nurses.