Educating healthcare workers to optimal hand hygiene practices: addressing the need

A Multifaceted Approach to the "Bare below the Elbow" Concept and Hand Hygiene Compliance among Healthcare Professionals-Multicenter Population-Based Study

Nosocomial infections remain an important issue for patient safety concerns. Since hospital infections are mainly connected with healthcare professionals' routines, an increase in hand hygiene effectiveness through compliance with the "bare below the elbow" (BBE) concept could reduce the number of nosocomial infections. Therefore, this study aims to evaluate hand hygiene and to investigate healthcare professionals' compliance with the BBE concept. We performed our study on a group of 7544 hospital professionals involved in patient care. During the national preventive action, questionnaires, demographic data, and hand hygiene preparations were recorded. Hand disinfection was verified by COUCOU BOX, containing a UV camera. We noted that 3932 (52.1%) persons complied with the BBE rules. Nurses and non-medical personnel were significantly more often classified as BBE rather than non-BBE (2025; 53.3% vs. 1776; 46.7%, respectively, p = 0.001 and 1220; 53.7% vs. 1057; 46.3%, p = 0.006). Different proportions were demonstrated for the groups of physicians-non-BBE (783; 53.3%) compared to BBE (687; 46.7%) (p = 0.041). Healthcare workers from the BBE group statistically more often disinfected their hands correctly (2875/3932; 73.1%) compared to the non-BBE group (2004/3612; 55.5%) (p < 0.0001). This study demonstrates the positive impact of compliance with the BBE concept on effective hand disinfection and patient safety. Therefore, education and infection-prevention actions should be popularized to improve the BBE policy's effectiveness as well.

Evaluation of knowledge, attitude, and practice regarding hand hygiene practices among inpatients of kalinga institute of medical sciences Bhubaneswar: A preliminary study

Background:

Health-care-associated infection or nosocomial infection is defined as patients getting an infection on admission to the hospital if they were not infected or incubating the infection before admission. Hand hygiene is the most important measure that can avoid the transmission of germs and can prevent health-care-associated infections.

Materials and Methods:

A hospital-based cross-sectional study was conducted between June 2020 to July 2021 with the objective to evaluate knowledge, attitude, and practice of hand hygiene among the inpatients of Kalinga Institute of Medical Sciences, Bhubaneswar. A predesigned structured questionnaire was used for data collection. Knowledge and attitude of the participants were assessed using prevalidated 9 point and 6 point scale. Practice of the health-care providers (HCPs) toward health hygiene observed by the patients was also assessed using 6 point scale.

Results:

Majority of the participants had average knowledge score (56.7%) and average attitude score (62.0%) on hand hygiene, whereas their observation on the practice of hand hygiene among HCPs has given bad score (50.7%). Males have significantly good knowledge (P = 0.0001) and attitude score (P = 0.00097) compared to female. Similarly higher educational level participants had significantly good knowledge (P = 0.0002) and attitude score (P = 0.0053) on hand hygiene.

Conclusions:

The findings of this study indicate that there is insufficient hand hygiene awareness among the inpatients in a tertiary care hospital population mainly among the female and less educated participants. Hence, development of community-based hand hygiene promotion programs for the general public are the need of the hour.

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

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

Identifying interventions to improve hand hygiene compliance in the intensive care unit through co-design with stakeholders

Background: Despite the effectiveness of hand hygiene (HH) for infection control, there is a lack of robust scientific data to guide how HH can be improved in intensive care units (ICUs).  The aim of this study is to use the literature, researcher, and stakeholder opinion to explicate potential interventions for improving HH compliance in the ICU, and provide an indication of the suitability of these interventions. Methods: A four-phase co-design study was designed. First, data from a previously completed systematic literature review was used in order to identify unique components of existing interventions to improve HH in ICUs. Second, a workshop was held with a panel of 10 experts to identify additional intervention components. Third, the 91 intervention components resulting from the literature review and workshop were synthesised into a final list of 21 hand hygiene interventions. Finally, the affordability, practicability, effectiveness, acceptability, side-effects/safety, and equity of each intervention was rated by 39 stakeholders (health services researchers, ICU staff, and the public). Results: Ensuring the availability of essential supplies for HH compliance was the intervention that received most approval from stakeholders. Interventions involving role models and peer-to-peer accountability and support were also well regarded by stakeholders. Education/training interventions were commonplace and popular. Punitive interventions were poorly regarded. Conclusions: Hospitals and regulators must make decisions regarding how to improve HH compliance in the absence of scientific consensus on effective methods. Using collective input and a co-design approach, the guidance developed herein may usefully support implementation of HH interventions that are considered to be effective and acceptable by stakeholders.

Identifying interventions to improve hand hygiene compliance in the intensive care unit through co-design with stakeholders

Background: Despite the effectiveness of hand hygiene (HH) for infection control, there is a lack of robust scientific data to guide how HH can be improved in intensive care units (ICUs).  The aim of this study is to use the literature, researcher, and stakeholder opinion to explicate potential interventions for improving HH compliance in the ICU, and provide an indication of the suitability of these interventions. Methods: A four-phase co-design study was designed. First, data from a previously completed systematic literature review was used in order to identify unique components of existing interventions to improve HH in ICUs. Second, a workshop was held with a panel of 10 experts to identify additional intervention components. Third, the 91 intervention components resulting from the literature review and workshop were synthesised into a final list of 21 hand hygiene interventions. Finally, the affordability, practicability, effectiveness, acceptability, side-effects/safety, and equity of each intervention was rated by 39 stakeholders (health services researchers, ICU staff, and the public). Results: Ensuring the availability of essential supplies for HH compliance was the intervention that received most approval from stakeholders. Interventions involving role models and peer-to-peer accountability and support were also well regarded by stakeholders. Education/training interventions were commonplace and popular. Punitive interventions were poorly regarded. Conclusions: Hospitals and regulators must make decisions regarding how to improve HH compliance in the absence of scientific consensus on effective methods. Using collective input and a co-design approach, the guidance developed herein may usefully support implementation of HH interventions that are considered to be effective and acceptable by stakeholders.

Nurses' perceptions of the sustainability of a standardised assessment for preventing complications in a ICU: a qualitative study

Background: Quality improvement projects have been widely adopted to prevent complications in the ICU. Objective: This paper describes nurses' perceptions of implementation strategies and the potential sustainability of a practice change intervention to prevent complications in a Malaysian ICU. Design: A participatory action research using five focus group discussions were undertaken with 19 nurses in a single ICU in regional Malaysia. Focus group transcripts were analysed using thematic analysis. Results: The main themes derived from the interviews were: [1] Empowering staff to embrace evidence-based practices; [2] Staff knowledge, attitudes, and beliefs that impact on behaviour; and [3] management support and leadership are influential in staff behaviours (acceptance & perseverance of change process). Discussion: Resistance to change was recognized as a barrier to adopting evidence based recommendations. There is a need to improve nurses' knowledge, attitude and awareness of the importance of assessment for VAP, CRBSI and PIs in the ICU.

Hand hygiene compliance and associated factors among health care providers in Central Gondar zone public primary hospitals, Northwest Ethiopia

Background

Poor hand hygiene compliance is one in all the leading contributory factors to healthcare-associated infections. This is an important source of complications across the continuum of care and poses a serious threat to people admitted to hospitals. However, the magnitude and associated factors of hand hygiene compliance in public primary hospitals were not well investigated in Ethiopia. Therefore, this study was conducted to assess hand hygiene compliance and associated factors among health care providers in Central Gondar Zone public primary hospitals, Northwest Ethiopia.

Methods

An Institutional based cross-sectional study was conducted from March to April 2019 among health care providers. The data were collected using self-administered questionnaires and observational checklists. Using Epi Info 3.1, data was entered and analyzed using SPSS version 23. The data were analyzed using descriptive statistics and logistic regression models. A p-value less than 0.05 with 95% confidence interval was used to declare statistical significance.

Results

Of 335 study participants, 50 (14.9%), had good hand hygiene compliance. Training on hand hygiene (AOR = 8.07, 95%CI: 2.91, 22.39), availability of adequate soap and water for hand hygiene (AOR = 5.10, 95%CI: 1.93, 13.52), availability of alcohol-based hand rub (AOR = 3.23, 95%CI: 1.32, 7.92), knowledge about hand hygiene (AOR = 6.74, 95%CI: 2.96, 15.34) and attitude towards hand hygiene (AOR = 2.15, 95%CI: 1.04, 4.46) were factors associated with hand hygiene compliance.

Conclusion

The overall level of hand hygiene compliance among health care providers was poor. Training, availability of adequate soap and water, availability of alcohol-based hand rub, knowledge on hand hygiene, and attitude of health care providers were significantly associated with hand hygiene compliance.

Associations Between Hand Hygiene Education and Self-Reported Hand-Washing Behaviors Among Korean Adults During MERS-CoV Outbreak

BACKGROUND

Hand washing is an effective way to prevent transmission of infectious diseases. Education and promotional materials about hand washing may change individuals' awareness toward hand washing. Infectious disease outbreak may also affect individuals' awareness.

AIMS

Our study aimed to examine associations between hand-washing education and self-reported hand-washing behaviors among Korean adults during the year of the Middle East respiratory syndrome (MERS) outbreak.

METHODS

Data from the 2015 Community Health Survey were used for this study. The total study population comprised 222,599 individuals who were older than 20 years of age. A multiple linear regression model was used to investigate associations between hand hygiene education and self-reported hand-washing behaviors. Subgroup analyses stratified by age, sex, income, and MERS outbreak regions were also performed.

RESULTS

Individuals who received hand-washing education or saw promotional materials related to hand washing had significantly higher scores for self-reported use of soap or sanitizer (β = 0.177, P < .0001) and self-reported frequency of hand washing (β = 0.481, P < .0001) than those who did not have such experiences. The effect of hand-washing education on self-reported behavior change was greater among older adults, women, and lower income earners. The effect of hand hygiene education on self-reported use of soap or sanitizer was similar regardless of whether the participants lived in MERS regions.

CONCLUSION

Our findings emphasize the importance of education or promotions encouraging hand washing, especially for older adults, women, and lower income earners. In addition, MERS outbreak itself affected individuals' awareness of hand-washing behaviors. Well-organized campaigns that consider these factors are needed to prevent infectious diseases.

Educational sessions may not be enough to improve knowledge about hand hygiene: Assessing the knowledge about hand hygiene of health workers before and after an educational workshop in Sudan

Background: In an attempt to defeat the high prevalence of health care associated infections, by raising the awareness about hand hygiene, we implemented a quasi-experimental study as part of a quality improvement project to evaluate the efficacy of focused educational workshop on knowledge about hand hygiene among health care workers in Sudan. Methods: Seventy-three participants were recruited from two public hospitals and one private hospital in Khartoum, Sudan in September 2017. The knowledge before and after the educational workshop was assessed for each participant using the World Health Organization hygiene associated infection questionnaire. We analyzed data using SPSS v22 and used McNemar’s test to compare knowledge before and after the workshop. Results: Around 40% of participants worked in general ward and 85% of them were women. Almost 70% were midwives or nurses. The mean age of participants was 28.4 years. We compared the knowledge of hand hygiene between nurses and doctors before the workshop, and the results showed that nurses had better knowledge in almost all aspects of hand hygiene. When we compared the knowledge before and immediately after the workshop for all participants, we found that there was no significant improvement in almost all aspects of knowledge about hand hygiene (P>0.05). Conclusion: Comparing the knowledge before and after the workshop, we found no significant improvement in almost all aspects of hand hygiene. Of note, nurses’ knowledge about hand hygiene was consistently higher than doctors.  Additional studies are needed to identify the optimal design of educational sessions.

An educational intervention to improve hand hygiene compliance in Vietnam

Background

Hand hygiene compliance is the basis of infection control programs. In developing countries models to improve hand hygiene compliance to reduce healthcare acquired infections are required. The aim of this study was to determine hand hygiene compliance following an educational program in an obstetric and gynecological hospital in Vietnam.

Methods

Health care workers from neonatal intensive care, delivery suite and a surgical ward from Hung Vuong Hospital, Ho Chi Minh City, Vietnam undertook a 4-h educational program targeting hand hygiene. Compliance was monitored monthly for six months following the intervention. Hand hygiene knowledge was assessed at baseline and after six months of the study.

Results

There were 7124 opportunities over 370 hand hygiene recording sessions with 1531 opportunities at baseline and 1620 at 6 months following the intervention. Hand hygiene compliance increased significantly from baseline across all sites (43.6% [95% Confidence interval CI: 41.1–46.1] to 63% [95% CI: 60.6–65.3]; p < 0.0001). Health care worker hand hygiene compliance increased significantly after intervention (p < 0.0001). There were significant improvements in knowledge scores from baseline to 2 months post educational intervention with mean difference standard deviations (SD): 1.5 (2.5); p < 0.001).

Conclusions

A simple educational model was implemented in a Vietnamese hospital that revealed good hand hygiene compliance for an extended period of time. Hand hygiene knowledge increased during the intervention. This hand hygiene model could be used in developing countries were resources are limited.

Determinants of success and sustainability of the WHO multimodal hand hygiene promotion campaign, Italy, 2007-2008 and 2014

A national hand hygiene promotion campaign based on the World Health Organization (WHO) multimodal, Clean Care is Safer Care campaign was launched in Italy in 2007. One hundred seventy-five hospitals from 14 of 20 Italian regions participated. Data were collected using methods and tools provided by the WHO campaign, translated into Italian. Hand hygiene compliance, ward infrastructure, and healthcare workers’ knowledge and perception of healthcare-associated infections and hand hygiene were evaluated before and after campaign implementation. Compliance data from the 65 hospitals returning complete data for all implementation tools were analysed using a multilevel approach. Overall, hand hygiene compliance increased in the 65 hospitals from 40% to 63% (absolute increase: 23%, 95% confidence interval: 22–24%). A wide variation in hand hygiene compliance among wards was observed; inter-ward variability significantly decreased after campaign implementation and the level of perception was the only item associated with this. Long-term sustainability in 48 of these 65 hospitals was assessed in 2014 using the WHO Hand Hygiene Self-Assessment Framework tool. Of the 48 hospitals, 44 scored in the advanced/intermediate categories of hand hygiene implementation progress. The median hand hygiene compliance achieved at the end of the 2007–2008 campaign appeared to be sustained in 2014.

Interventions to Improve Hand Hygiene Compliance in the ICU: A Systematic Review

OBJECTIVES

To synthesize the literature describing interventions to improve hand hygiene in ICUs, to evaluate the quality of the extant research, and to outline the type, and efficacy, of interventions described.

DATA SOURCES

Systematic searches were conducted in November 2016 using five electronic databases: Medline, CINAHL, PsycInfo, Embase, and Web of Science. Additionally, the reference lists of included studies and existing review papers were screened.

STUDY SELECTION

English language, peer-reviewed studies that evaluated an intervention to improve hand hygiene in an adult ICU setting, and reported hand hygiene compliance rates collected via observation, were included.

DATA EXTRACTION

Data were extracted on the setting, participant characteristics, experimental design, hand hygiene measurement, intervention characteristics, and outcomes. Interventional components were categorized using the Behavior Change Wheel. Methodological quality was examined using the Downs and Black Checklist.

DATA SYNTHESIS

Thirty-eight studies were included. The methodological quality of studies was poor, with studies scoring a mean of 8.6 of 24 (SD= 2.7). Over 90% of studies implemented a bundled intervention. The most frequently employed interventional strategies were education (78.9%), enablement (71.1%), training (68.4%), environmental restructuring (65.8%), and persuasion (65.8%). Intervention outcomes were variable, with a mean relative percentage change of 94.7% (SD= 195.7; range, 4.3-1155.4%) from pre to post intervention.

CONCLUSIONS

This review demonstrates that best practice for improving hand hygiene in ICUs remains unestablished. Future research employing rigorous experimental designs, careful statistical analysis, and clearly described interventions is important.

Factors that influence hand hygiene practice amongst occupational therapy students

Purpose

Hand hygiene is the single most important intervention to reduce the risk of acquiring infection. All healthcare workers and healthcare students have a responsibility to prevent transmission of infection. The purpose of this study is to investigate students’ attitudes to hand hygiene following university-based education and practice placement. Students attended a lecture, completed an e-learning module, participated in a practical session using a ultra-violet light hand inspection cabinet and engaged in clinical placement.

Design/methodology/approach

In all, 64 students participated in a multimodal hand hygiene education programme before clinical placement, with each student completing an in-class questionnaire after placement. Data were analysed using descriptive and comparative statistics. Students rated educational methods that had most influence on them. Their preference was for a practical hand hygiene education session. Students were also influenced by the therapist they were on placement with. They were least influenced by the didactic college presentation.

Findings

This study highlights that students may be influenced by different methods of education at different stages in their course and that placement may be an important influencing factor in the earlier years of occupational therapy education.

Research limitations/implications

This study highlights the importance of the availability of a multimodal educational approach and clinical placement to promote increased compliance with hand hygiene amongst students.

Practical implications

University healthcare course curricula should include multimodal approaches to the education of hand hygiene. While hand hygiene e-learning modules are beneficial, they should be used in conjunction with a multimodal educational strategy that incorporates practical elements. The influence of the therapist on a students’ behaviour should be utilised to improve both student and professionals hand hygiene adherence.

Originality/value

Original piece of work that is not widely discussed in Occupational Therapy literature.

Use of a simulation intervention to examine differences in nursing students' hand hygiene knowledge, beliefs, and behaviors

BACKGROUND

Although hand hygiene remains an essential aspect of quality care, adherence to best patient safety practices continues to pose major challenges.

OBJECTIVES

The objectives of this study are to examine hand hygiene knowledge, beliefs, practices, perceived importance and behaviors using Social Cognitive Theory and simulation-based intervention.

DESIGN

Participants were taken from a convenience sample of 131 undergraduate nursing students enrolled in a nursing fundamentals course at an urban university in the midwestern United States, and then randomly assigned to their respective groups. Using an experimental pretest-posttest design, control and intervention groups received the same lecture pertaining to hand hygiene and 3 data collection points where van de Mortel's Hand Hygiene Questionnaire (HHQ) was administered. In addition, the intervention group viewed a 6.5min video related to healthcare acquired infection and participated in 4 simulated situations requiring hand hygiene, based on World Health Organization guidelines. For all students, the hand hygiene technique was assessed through the use of Glo Germ, followed by handwashing and photography under ultraviolet light (posttest only). Image illumination was analyzed using image processing software. Microbiological sampling plates (pretest-posttest) were assessed quantitatively by colony counting.

RESULTS

Study findings did not support differences in the intervention group for the 5 hypothesized relationships. Social desirability responding and negative item confusion were found to occur with the HHQ in the student population. There was a significant difference in the UV hand photographs, with students in the afternoon having lower values than students in the morning.

CONCLUSIONS

Given the study results, there were no definitive educational recommendations to teach hand hygiene to nursing students. Future research should continue to further examine multi-focal modalities to enhance adherence to hand hygiene practices, as well as control for extraneous mediating or moderating variables found in educational settings.

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Staff Knowledge, Awareness, Perceptions, and Beliefs About Infection Prevention in Pediatric Long-term Care Facilities

BACKGROUND

The burden of healthcare-associated infection worldwide is considerable, and there is a need to improve surveillance and infection control practices such as hand hygiene.

OBJECTIVES

The aims of this study were to explore direct care providers' knowledge about infection prevention and hand hygiene, their attitudes regarding their own and others' hand hygiene practices, and their ideas and advice for improving infection prevention efforts.

METHODS

This exploratory study included interviews with direct care providers in three pediatric long-term care facilities. Two trained nurse interviewers conducted semistructured interviews using an interview guide with open-ended questions. Two other nurse researchers independently transcribed the audio recordings and conducted a thematic analysis using a strategy adapted from the systematic text condensation approach.

RESULTS

From 31 interviews, four major thematic categories with subthemes emerged from the analysis: (a) hand hygiene products; (b) knowledge, awareness, perceptions, and beliefs; (c) barriers to infection prevention practices; and (d) suggested improvements. There was confusion regarding hand hygiene recommendations, use of soap or sanitizer, and isolation precaution policies. There was a robust "us" and "them" mentality between professionals.

DISCUSSION

One essential driver of staff behavior change is having expectations that are meaningful to staff, and many staff members stated that they wanted more in-person staff meetings with education and hands-on, practical advice. Workflow patterns and/or the physical environment need to be carefully evaluated to identify systems and methods to minimize cross-contamination. Further studies need to evaluate if personal sized containers of hand sanitizer (e.g., for the pocket, attached to a belt or lanyard) would facilitate improvement of hand hygiene in these facilities.

Strategies to prevent healthcare-associated infections through hand hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Demographic characteristics of patients and their assessment of selected hygienic practices of hospital personnel in the context of safety climate of hospitalization

BACKGROUND

Hand hygiene (HH) is a key factor in hospital infection prevention and patient safety. The objectives of this article were to examine patients' observations concerning compliance with selected procedures for hospital hygiene among medical personnel and assess the correlation between patients' key demographic characteristics and their awareness and sense of safety associated with hospitalization.

METHODS

The study was conducted in January 2012 on a sample of 491 subjects by means of a standardized 10-minute computer-assisted telephone interview survey.

RESULTS

There was a statistically significant correlation between the sense of safety associated with hospitalization declared by patients and their observation of HH practices among health care personnel. A positive correlation was also found between the respondents experiencing personal complications in the form of health care-associated infections themselves or among their family members and the sense of safety associated with hospital treatment.

CONCLUSIONS

Performing HH among hospital staff is one of the factors affecting patients' increased sense of safety during their hospitalization; therefore, HH contributes to the perception of good quality of service provided. Knowledge of the risk of HH does not affect the patients' sense of safety, in contrast with their real-life experiences.

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Harmonizing and supporting infection control training in Europe

Healthcare-associated infection (HCAI), patient safety, and the harmonization of related policies and programmes are the focus of increasing attention and activity in Europe. Infection control training for healthcare workers (HCWs) is a cornerstone of all patient safety and HCAI prevention and control programmes. In 2009 the European Centre for Disease Prevention and Control (ECDC) commissioned an assessment of needs for training in infection control in Europe (TRICE), which showed a substantial increase in commitment to HCAI prevention. On the other hand, it also identified obstacles to the harmonization and promotion of training in infection control and hospital hygiene (IC/HH), mostly due to differences between countries in: (i) the required qualifications of HCWs, particularly nurses; (ii) the available resources; and (iii) the sustainability of IC/HH programmes. In 2013, ECDC published core competencies for infection control and hospital hygiene professionals in the European Union and a new project was launched ['Implementation of a training strategy for infection control in the European Union' (TRICE-IS)] that aimed to: define an agreed methodology and standards for the evaluation of IC/HH courses and training programmes; develop a flexible IC/HH taxonomy; and implement an easily accessible web tool in 'Wiki' format for IC/HH professionals. This paper reviews several aspects of the TRICE and the TRICE-IS projects.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hand hygiene behavior: translating behavioral research into infection control practice

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is patient isolation the single most important measure to prevent the spread of multidrug-resistant pathogens?

Isolation or cohorting of infected patients is an old concept. Its purpose is to prevent the transmission of microorganisms from infected or colonized patients to other patients, hospital visitors, and health care workers, who may subsequently transmit them to other patients or become infected or colonized themselves. Because the process of isolating patients is expensive, time-consuming, often uncomfortable for patients and may impede care, it should be implemented only when necessary. Conversely, failure to isolate a patient with multidrug-resistant microorganisms may lead to adverse outcomes, and may ultimately be expensive when one considers the direct costs of an outbreak investigation and the indirect costs of lost productivity. In this review, we argue that contact precautions are essential to control the spread of epidemic and endemic multidrug-resistant microorganisms, and discuss limitations of some available data.

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

BACKGROUND

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

SUMMARY

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

CONCLUSIONS

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

Features of educational interventions that lead to compliance with hand hygiene in healthcare professionals within a hospital care setting. A BEME systematic review: BEME Guide No. 22

BACKGROUND

In the United Kingdom, there are approximately 300,000 healthcare-associated infections (HCAI) annually, costing an estimated £1 billion. Up to 30% of all HCAI are potentially preventable by better application of knowledge and adherence to infection prevention procedures. Implementation of Department of Health guidelines through educational interventions has resulted in significant and sustained improvements in hand hygiene compliance and reductions in HCAI.

AIM

To determine the features of structured educational interventions that impact on compliance with hand hygiene in healthcare professionals within a hospital care setting.

METHODS

Sixteen electronic databases were searched. Outcomes were assessed using Kirkpatrick's hierarchy and included changes in hand hygiene compliance of healthcare professionals, in service delivery and in the clinical welfare of patients involved.

RESULTS

A total of 8845 articles were reviewed, of which 30 articles met the inclusion criteria. Delivery of education was separated into six groups.

CONCLUSIONS

It was not possible to identify individual features of educational interventions due to each study reporting multicomponent interventions. However, multiple, continuous interventions were better than single interventions in terms of eliciting and sustaining behaviour change. Data were not available to determine the time, nature and type of booster sessions with feedback needed for a permanent change in compliance.