Impact of hand hygiene on the infectious risk in nursing home residents: A systematic review

Hand hygiene compliance in nursing home wards: The effects of feedback with lights on alcohol-based hand rub dispensers

BACKGROUND

Hand hygiene (HH) among health care workers (HCWs) is crucial in preventing infections in nursing homes. However, HH compliance (HHC) among HCWs remains low. This study aimed to investigate the effect of feedback lights on HCWs' HHC.

METHODS

A 5-month interventional study was conducted in 3 wards in a nursing home in Denmark. During the intervention period, a green light with a smiley appeared on the alcohol-based hand rub (ABHR) dispensers when HCWs used the ABHR, acknowledging HCWs for using the ABHR. HHC was monitored using an automatic HH monitoring system (AHHMS).

RESULTS

A total of 64 HCWs were enrolled. The AHHMS collected 23,696 HH opportunities in apartments and dirty utility rooms. Overall, HHC in the apartments increased from 50% at baseline (95% CI: 48, 53) to 56% (95% CI: 54, 58) during the intervention. However, the increased HHC level was not sustained during follow-up.

CONCLUSIONS

The AHHMS enabled the assessment of the intervention. We found a significant effect of light-guided feedback in the apartments. However, the increased HHC was not sustained after the light was switched off.

Using contact network dynamics to implement efficient interventions against pathogen spread in hospital settings: A modelling study

BACKGROUND

Long-term care facilities (LTCFs) are hotspots for pathogen transmission. Infection control interventions are essential, but the high density and heterogeneity of interindividual contacts within LTCF may hinder their efficacy. Here, we explore how the patient-staff contact structure may inform effective intervention implementation.

METHODS AND FINDINGS

Using an individual-based model (IBM), we reproduced methicillin-resistant Staphylococcus aureus colonisation transmission dynamics over a detailed contact network recorded within a French LTCF of 327 patients and 263 staff over 3 months. Simulated baseline cumulative colonisation incidence was 21 patients (prediction interval: 11, 31) and 35 staff (prediction interval: 19, 54). We examined the potential impact of 3 types of interventions against transmission (reallocation reducing the number of unique contacts per staff, reinforced contact precautions, and hypothetical vaccination protecting against acquisition), targeted towards specific populations. All 3 interventions were effective when applied to all nurses or healthcare assistants (median reduction in MRSA colonisation incidence up to 35%), but the benefit did not exceed 8% when targeting any other single staff category. We identified "supercontactor" individuals with most contacts ("frequency-based," overrepresented among nurses, porters, and rehabilitation staff) or with the longest cumulative time spent in contact ("duration-based," overrepresented among healthcare assistants and patients in elderly care or persistent vegetative state (PVS)). Targeting supercontactors enhanced interventions against pathogen spread in the LTCF. With contact precautions, targeting frequency-based staff supercontactors led to the highest incidence reduction (20%, 95% CI: 19, 21). Vaccinating a mix of frequency- and duration-based staff supercontactors led to a higher reduction (23%, 95% CI: 22, 24) than all other approaches. Although based on data from a single LTCF, when varying epidemiological parameters to extend to other pathogens, our results suggest that targeting supercontactors is always the most effective strategy, indicating this approach could be applied to prevent transmission of other nosocomial pathogens.

CONCLUSIONS

By characterising the contact structure in hospital settings and identifying the categories of staff and patients more likely to be supercontactors, with either more or longer contacts than others, interventions against nosocomial spread could be more effective. We find that the most efficient implementation strategy depends on the intervention (reallocation, contact precautions, vaccination) and target population (staff, patients, supercontactors). Importantly, both staff and patients may be supercontactors, highlighting the importance of including patients in measures to prevent pathogen transmission in LTCF.

Hand hygiene compliance in nursing home wards: the effect of increased accessibility of alcohol-based hand rub

BACKGROUND

Elderly nursing home residents are vulnerable to infection from micro-organisms. Hand hygiene is considered one of the most important measures to prevent transmission.

AIM

To determine the effect of increased accessibility to alcohol-based hand rub (ABHR) in nursing home wards by monitoring hand hygiene compliance (HHC) among healthcare workers (HCWs).

METHODS

An 11-month intervention study was conducted in a Danish six-ward nursing home. Data were collected using an automatic hand hygiene monitoring system (AHHMS). After a baseline period, one extra ABHR dispenser was placed in each of the 150 apartments. Baseline HHC was compared with the HHC during an immediate intervention period and a long-term intervention period.

FINDINGS

A total of 159 HCWs were included. The AHHMS registered 341,078 hand hygiene opportunities. Overall baseline HHC was 31% (95% confidence interval: 30-32). A significant +18% absolute immediate effect (first five months) (95% CI: 17-19; P < 0.0001) and +13 percentage points (95% CI: 11-14; P < 0.0001) long-term effect (another four months) were recorded. HCWs working day shifts and short-term employees had a higher baseline HHC than HCWs working evening/night shifts. However, HCWs working night shifts achieved the greatest long-term effect with a mean +27 percentage point difference (P < 0.0001).

CONCLUSION

Placing an additional ABHR dispenser strategically within staff workflow significantly increased HHC among HCWs, demonstrating a noteworthy effect. The study is the first to report the effect on nursing home dispenser accessibility as a single intervention and to show a significant unmet potential.

Patient Safety in Nursing Homes From an Ecological Perspective: An Integrated Review

OBJECTIVES

The aims of the study were to identify the systemic factors affecting the characteristics and safety of older adults living in nursing homes and the resulting resident outcomes and to explore the relationship between them through an integrated literature review.

METHODS

A literature search was conducted from April 22 to May 6, 2021, in the PubMed, Embase, Cochrane CENTRAL, CIHNAL, RISS, NDL, and KoreaMed databases. The following key words and MeSH terms were used for the search: "nursing home," "skilled nursing facility," "long-term care facility," and "patient safety" or "safety."

RESULTS

Forty-seven qualifying articles were finally selected. Three domains were derived as personal factors, 12 as facility factors, and one as a policy factor. The interrelationships between them could result in positive or negative resident outcomes. The relationship between them was also reconstructed from an ecological perspective.

CONCLUSIONS

The results demonstrated that the safety and quality of life of older adults living in nursing homes were affected by both individual and institutional factors.

Impact of multimodal interventions targeting behavior change on hand hygiene adherence in nursing homes: An 18-month quasi-experimental study

BACKGROUND

Nursing home residents are vulnerable and frail, and hand hygiene adherence is often too low to prevent transmission of infections. This study's aim was to investigate whether interventions targeting behavior change can improve hand hygiene adherence in nursing homes.

METHODS

Over 18 months, 22 nursing home wards participated in this quasi-experimental study. Three intervention wards were selected based on the mean values of hand hygiene adherence, infections, and antibiotic use. Multimodal interventions targeting behavior change, including education, UV-light boxes, and posters, were implemented.

RESULTS

Hand hygiene adherence increased to 60.9% in the intervention wards and decreased to 51.3% in the control wards. The control wards experienced lower adherence in all indications of WHO's "My five moments for hand hygiene."

DISCUSSION

Interventions should target proper hand hygiene before patient contact and glove use because health care workers have low adherence in these areas. The findings indicate that the type of intervention is less important than attention to hand hygiene and activating workers' motivation. Using a behavior change approach and continuous reinforcement is important because the effects of interventions diminish over time.

CONCLUSIONS

Our findings showed that multimodal interventions targeting behavior change may increase hand hygiene adherence.

Visibility and Accessibility of Hand Hygiene Stations and Fatigue Among Nurses Working in Long-Term Care (LTC) During the COVID-19 Pandemic

OBJECTIVES

Evaluate the relationship between nurses' perception of the long-term care (LTC) environment, specifically having visible and accessible hand hygiene stations (HHS), and nurses' fatigue during the COVID-19 pandemic.

BACKGROUND

LTC nurses experience not only heavy workloads and fatigue but also a high risk of infection during the COVID-19 pandemic. Few studies have evaluated the relationship between safety measures such as having visible and accessible HHS and nurses' fatigue.

METHODS

The cross-sectional COVID-19 Impact on Nurses Study (COINS) was an online survey distributed to members of the American Association of Post-Acute Care Nursing through the REDCap survey platform, between June 1, 2020, and January 31, 2021. Logistic regression modeling was conducted to identify the relationship between nurses' perception of having visible and accessible HHS and fatigue among LTC nurses.

RESULTS

The majority of LTC nurse respondents (78.35%) reported having moderate to very severe fatigue. Nurses who reported not having enough visible and accessible HHS in their work environment have statistically significantly higher odds (odds ratio [OR] = 0.37, 95% confidence interval [CI] [0.20, 0.70], p = .002) of reporting experiencing moderate to very severe fatigue compared to nurses who perceived there was adequate HHS. The logistic regression is significant while controlling for sociodemographic differences, guilt for family and patients, support from work, and confidence in the future of LTC.

CONCLUSIONS

This study reveals the LTC environment that incorporates better considerations of more visible and accessible HHS might mitigate nurses' fatigue during the pandemic. A conceptual framework has been proposed for future studies.

Healthcare-related infections within nursing homes (NHS): A qualitative study of care practices based on a systemic approach

Background

Infectious events, often related to healthcare practice, occur frequently within Nursing Homes (NHs), representing one of the main causes for morbidity, hospital admissions and mortality. The aims of this study are the analysis of care delivery problems and contributory factors of healthcare-related infections in a sample of NHs. This research could help identify organizational, technological and behavioural aspects, to implement improvement actions and reduce the impact of infections in long-term care.

Methods

The study is a qualitative research with a systemic approach, based on the analysis of interactions in real practice between human factors, technologies and organizational structure and processes in 7 NHs in Tuscany (Italy), through extensive and structured observations of daily practices. The collected data were analyzed by applying clinical and ergonomic competences, comparing the data collected with established safe practices. The study was conducted by a nurse and a psychologist

Results

From the data several problems related to infection control emerge. Buildings are often not suitable for confined spaces, room ventilation, natural light and rapid emergency response. Hand washing is not sufficient, use of antibiotics is usually not adequate. The microclimate is often not adequate, hygienic procedures are not always flawless. Staff members are in small numbers.

Discussions

This study highlights high risk of contracting infections related to NHs. The study shows that dedicated infection prevention guidance are needed, to develop a local plan integrated with hospital setting, customized to needs of guests and characteristics of long-term care facilities, supported by a deep understanding of daily practices.

Interventions on Socioeconomic and Racial Inequities in Respiratory Pandemics: a Rapid Systematic Review

Purpose of Review

Racial and socioeconomic inequities in respiratory pandemics have been consistently documented, but little official guidance exists on effective action to prevent these. We systematically reviewed quantitative evaluations of (real or simulated) interventions targeting racial and socioeconomic inequities in respiratory pandemic outcomes.

Recent Findings

Our systematic search returned 10,208 records, of which 5 met inclusion criteria, including observational (n = 1), randomized trial (n = 1), and simulation (n = 3) studies. Interventions studied included vaccination parity, antiviral distribution, school closure, disinfection, personal protective equipment, and paid sick leave, with a focus on Black (n = 3) and/or Latinx (n = 4) or low-SES (n = 2) communities. Results are suggestive that these interventions might be effective at reducing racial and/or SES disparities in pandemics.

Summary

There is a dearth of research on strategies to reduce pandemic disparities. We provide theory-driven, concrete suggestions for incorporating equity into intervention research for pandemic preparedness, including a focus on social and economic policies.

Updates on Infection Control in Alternative Health Care Settings

Patients increasingly receive care from a large spectrum of different settings, placing them at risk for exposure to pathogens by many different sources. Each health care environment has its own specific challenges, and thus infection control programs must be tailored to each specific setting. High-turnover outpatient settings may require additional considerations, such as establishing patient triage and follow-up protocols, and broadened cleaning and disinfection procedures. In nursing homes, infection control programs should focus on surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs.

The effect of a hand hygiene intervention on infections in residents of nursing homes: a cluster randomized controlled trial

BACKGROUND

The primary goal of hand hygiene is to reduce infectious disease rates. We examined if a nursing home's participation in a hand hygiene intervention resulted in residents having fewer healthcare associated infections (HAIs) when compared to nursing homes without the hand hygiene intervention.

METHODS

This study is a part of a cluster randomized controlled trial (RCT) in 33 nursing homes to improve hand hygiene (HANDSOME). The incidence of five illnesses was followed over 13 months: gastroenteritis, influenza-like illness, pneumonia, urinary tract infections and infections from methicillin-resistant Staphylococcus aureus (MRSA). Incidence rates per study arm were reported for baseline (October-December 2016) and two follow-up periods (January-April 2017, May-October 2017). HAI rates were compared in a Poisson multilevel analysis, correcting for baseline differences (the baseline infection incidence and the size of the nursing home), clustering of observations within nursing homes, and period in the study.

RESULTS

There was statistically significantly more gastroenteritis (p < 0.001) and statistically significantly less influenza-like illness (p < 0.01) in the intervention arm when compared to the control arm. There were no statistically significant differences or pneumonia, urinary tract infections, and MRSA infections in the intervention arm when compared to the control arm. In a sensitivity analysis, gastroenteritis was no longer statistically significantly higher in the intervention arm (p = 0.92).

CONCLUSIONS

As in comparable studies, we could not conclusively demonstrate the effectiveness of an HH intervention in reducing HAIs among residents of nursing homes, despite the use of clearly defined outcome measures, a standardized reporting instrument, and directly observed HH in a multicenter cluster RCT. Trial registration Netherlands Trial Register, trial NL6049 (NTR6188). Registered October 25, 2016, https://www.trialregister.nl/trial/6049 .

Observational study of compliance with infection control practices among healthcare workers in subsidized and private residential care homes

Background

The elderly population in Hong Kong is rapidly growing, and the need for residential care homes (RCHs) is increasing. The risk of being infected with micro-organisms increases among the frail and the vulnerable elderly population as their immunity system begins to deteriorate. Furthermore, the residents in RCHs are at high risk of healthcare-associated infections (HAIs) due to the confined living environments and individual co-morbidities. In relation to this, infection control practice (ICP) is considered a crucial and effective approach in preventing HAIs. This study aimed to observe the daily ICP of healthcare workers in RCH settings.

Methods

An observational study was conducted to observe daily ICP among healthcare workers in private and subsidized RCHs. Each RCH was separated into different units based on the location (common area and bedroom area) and nature of residents for successive days. The ICP episodes were observed until 200 opportunities in each unit. The ICP episodes were recorded by an electronic tool called “eRub,” which is an ICP checklist based on international guidelines.

Results

The most frequent observed ICP episodes were hand hygiene (n = 1053), the use of gloves (n = 1053) and respiratory protection (n = 1053). The overall compliance of hand hygiene was poor, with only 15% of participants performing this during the “five moments for hand hygiene.” Furthermore, the observations showed that 77.9% improperly performed the use of gloves, and 31.8% failed to wear a mask during the care provision for the elderly. However, the results showed that most healthcare workers can wear the mask in a proper way when they should. Generally, the personal care workers were the worst in terms of hand hygiene and use of gloves compared with the other types of healthcare workers.

Conclusions

Despite the fact that the practice of hand hygiene, the use of gloves, and respiratory protection were the important elements of ICP, overall compliance to these elements was still poor. Personal care workers had the most frequent contact with the residents, but they had the worst compliance rate. Hence, continued monitoring and training among healthcare workers is needed, particularly personal care workers, in this healthcare service setting.

Improvement of hand hygiene adherence among staff in long-term care facilities for elderly in Japan

INTRODUCTION

Hand hygiene is crucial for infection control in long-term care facilities for elderly (LTCFEs), because it can be easily implemented in the low-resource settings of LTCFEs. This study investigated the actual status of hand hygiene adherence in LTCFEs, identified the factors inhibiting its appropriate implementation, and evaluated the effectiveness of a hand hygiene promotion program.

METHODS

In this before-and-after study, participants were staff members (n = 142) at two LTCFEs in Gunma Prefecture, Japan. We modified the World Health Organization's "five moments for hand hygiene" and assessed participants' hand hygiene adherence rates in four situations: (1) Before touching around a resident's mucous membrane area; (2) Before medical practice or clean/aseptic procedures; (3) After body fluid exposure/risk or after touching around a resident's mucous membrane area; and (4) After touching a resident's contaminated environments. The study was divided into four phases. In Phase 1, participants self-assessed their hand hygiene adherence using a questionnaire. In Phase 2, we objectively assessed participants' pre-intervention adherence rates. In Phase 3, an intervention comprising various hand hygiene promotion measures, such as education and hands-on training on hand hygiene practices and timings, was implemented. In Phase 4, participants' post-intervention adherence rates were objectively measured.

RESULTS

Although most participants reported high hand hygiene adherence rate in the self-assessment (93.1%), the pre-intervention evaluation revealed otherwise (16.8%). Participants' post-intervention adherence rates increased for all four situations (77.3%).

CONCLUSION

The intervention program helped increase participants' hand hygiene adherence rates, indicating its effectiveness. Similar interventions in other LTCFEs may also improve adherence rates.

Root Cause Analysis to Identify Medication and Non-Medication Strategies to Prevent Infection-Related Hospitalizations from Australian Residential Aged Care Services

Infections are leading causes of hospitalizations from residential aged care services (RACS), which provide supported accommodation for people with care needs that can no longer be met at home. Preventing infections and early and effective management are important to avoid unnecessary hospital transfers, particularly in the Australian setting where new quality standards require RACS to minimize infection-related risks. The objective of this study was to examine root causes of infection-related hospitalizations from RACS and identify strategies to limit infections and avoid unnecessary hospitalizations. An aggregate root cause analysis (RCA) was undertaken using a structured local framework. A clinical nurse auditor and clinical pharmacist undertook a comprehensive review of 49 consecutive infection-related hospitalizations from 6 RACS. Data were collected from nursing progress notes, medical records, medication charts, hospital summaries, and incident reports using a purpose-built collection tool. The research team then utilized a structured classification system to guide the identification of root causes of hospital transfers. A multidisciplinary clinical panel assessed the root causes and formulated strategies to limit infections and hospitalizations. Overall, 59.2% of hospitalizations were for respiratory, 28.6% for urinary, and 10.2% for skin infections. Potential root causes of infections included medications that may increase infection risk and resident vaccination status. Potential contributors to hospital transfers included possible suboptimal selection of empirical antimicrobial therapy, inability of RACS staff to establish on-site intravenous access for antimicrobial administration, and the need to access subsidized medical services not provided in the RACS (e.g., radiology and pathology). Strategies identified by the panel included medication review, targeted bundles of care, additional antimicrobial stewardship initiatives, earlier identification of infection, and models of care that facilitate timely access to medical services. The RCA and clinical panel findings provide a roadmap to assist targeting services to prevent infection and limit unnecessary hospital transfers from RACS.

Improving Hand Hygiene Compliance in Nursing Homes: Protocol for a Cluster Randomized Controlled Trial (HANDSOME Study)

BACKGROUND

Hand hygiene compliance is considered the most (cost-)effective measure for preventing health care-associated infections. While hand hygiene interventions have frequently been implemented and assessed in hospitals, there is limited knowledge about hand hygiene compliance in other health care settings and which interventions and implementation methods are effective.

OBJECTIVE

This study aims to evaluate the effect of a multimodal intervention to increase hand hygiene compliance of nurses in nursing homes through a cluster randomized controlled trial (HANDSOME study).

METHODS

Nursing homes were randomly allocated to 1 of 3 trial arms: receiving the intervention at a predetermined date, receiving the identical intervention after an infectious disease outbreak, or serving as a control arm. Hand hygiene was evaluated in nursing homes by direct observation at 4 timepoints. We documented compliance with the World Health Organization's 5 moments of hand hygiene, specifically before touching a patient, before a clean/aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching patient surroundings. The primary outcome is hand hygiene compliance of the nurses to the standards of the World Health Organization. The secondary outcome is infectious disease incidence among residents. Infectious disease incidence was documented by a staff member at each nursing home unit. Outcomes will be compared with the presence of norovirus, rhinovirus, and Escherichia coli on surfaces in the nursing homes, as measured using quantitative polymerase chain reaction.

RESULTS

The study was funded in September 2015. Data collection started in October 2016 and was completed in October 2017. Data analysis will be completed in 2020.

CONCLUSIONS

HANDSOME studies the effectiveness of a hand hygiene intervention specifically for the nursing home environment. Nurses were taught the World Health Organization's 5 moments of hand hygiene guidelines using the slogan "Room In, Room Out, Before Clean, After Dirty," which was developed for nursing staff to better understand and remember the hygiene guidelines. HANDSOME should contribute to improved hand hygiene practice and a reduction in infectious disease rates and related mortality.

TRIAL REGISTRATION

Netherlands Trial Register (NTR6188) NL6049; https://www.trialregister.nl/trial/6049.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17419.

Students' observations of hand hygiene in nursing homes using the five moments of hand hygiene

AIMS AND OBJECTIVES

To use nursing students to observe hand hygiene adherence in nursing homes and to explore whether the students' reflections after observing hand hygiene practices gives them a deeper understanding of the subject matter.

BACKGROUND

Residents in nursing homes worldwide have low tolerance for healthcare-associated infections that require antibiotics, and hand hygiene is the single most effective action to reduce infections.

DESIGN

Observational study using (a) World Health Organization's (WHO) "Five moments for hand hygiene" validated tool to record indications and adherence and (b) an exploratory study of individual reflection notes from students conducted during and after observations.

METHODS

From February 12-15, 2018, 26 nursing students in their second semester of a 3-year bachelor programme participated as observers in five wards in four nursing homes in the Oslo metropolitan area. This study was performed according to the STROBE statement.

RESULTS

Hand hygiene was performed for 57.2% of the 2,393 indications observed and recorded. Adherence differed significantly by type of personnel and by location. Four thematic categories emerged from the reflection notes: (a) practical awareness and introspection; (b) visualisation and enhancement of understanding of practice learning; (c) incorrect hand hygiene practices; and (d) stimulation to increase essential knowledge.

CONCLUSION

Hand hygiene adherence was too low to prevent healthcare-associated infections and to reduce the use of antibiotics. The students' reflection notes indicated more "insight and understanding of the complexity of hand hygiene." We suggest using nursing students in clinical placement as a means of incorporating different interventions as part of their learning skills and become "living reminders" of the importance of hygiene and infection prevention.

RELEVANCE FOR CLINICAL PRACTICE

Improving the student's activity about hygiene and infection prevention in clinical placement may help to raise awareness by healthcare workers in nursing homes.

Implementation of a national quality improvement program to enhance hand hygiene in nursing homes in Taiwan

BACKGROUND/PURPOSE

This study investigated the cause of hand hygiene deficit, and further implemented a quality improvement program using WHO's hand-hygiene strategy to enhance the compliance of hand hygiene in the nursing home in Taiwan.

METHODS

This prospective study was conducted in eleven nursing homes in Taiwan from January 2015 to December 2016. After intervention, we monitor the compliance, and accuracy of hand hygiene. In addition, we also calculated the number of episodes of infection per 1000 resident-days in each nursing home in the intervention period (July-December 2015) and post-intervention period (January-October 2016).

RESULTS

Overall, the consumption of alcohol-based handrubs increased from 10.1 ml per resident-day in intervention period to 12.2 ml per resident-day in post intervention period. The compliance of hand hygiene increased from 74% in intervention period to 79% in post-intervention period and the rate of correct hand hygiene increased from 81% in intervention period to 87% in post-intervention period. Most importantly, the infection density decreased from 2.39 per 1000 resident-day in intervention period to 1.89 per 1000 resident-day.

CONCLUSIONS

A national quality-improvement program using WHO's hand-hygiene strategy to enhance hand hygiene and reduce healthcare associated infection is effective in nursing homes in Taiwan.

Role of Hand Hygiene Ambassador and Implementation of Directly Observed Hand Hygiene Among Residents in Residential Care Homes for the Elderly in Hong Kong

OBJECTIVEMultidrug-resistant organisms (MDROs) are increasingly reported in residential care homes for the elderly (RCHEs). We assessed whether implementation of directly observed hand hygiene (DOHH) by hand hygiene ambassadors can reduce environmental contamination with MDROs.METHODSFrom July to August 2017, a cluster-randomized controlled study was conducted at 10 RCHEs (5 intervention versus 5 nonintervention controls), where DOHH was performed at two-hourly intervals during daytime, before meals and medication rounds by a one trained nurse in each intervention RCHE. Environmental contamination by MRDOs, such as methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Acinetobacter species (CRA), and extended-spectrum β-lactamse (ESBL)-producing Enterobacteriaceae, was evaluated using specimens collected from communal areas at baseline, then twice weekly. The volume of alcohol-based hand rub (ABHR) consumed per resident per week was measured.RESULTSThe overall environmental contamination of communal areas was culture-positive for MRSA in 33 of 100 specimens (33%), CRA in 26 of 100 specimens (26%), and ESBL-producing Enterobacteriaceae in 3 of 100 specimens (3%) in intervention and nonintervention RCHEs at baseline. Serial monitoring of environmental specimens revealed a significant reduction in MRSA (79 of 600 [13.2%] vs 197 of 600 [32.8%]; P<.001) and CRA (56 of 600 [9.3%] vs 94 of 600 [15.7%]; P=.001) contamination in the intervention arm compared with the nonintervention arm during the study period. The volume of ABHR consumed per resident per week was 3 times higher in the intervention arm compared with the baseline (59.3±12.9 mL vs 19.7±12.6 mL; P<.001) and was significantly higher than the nonintervention arm (59.3±12.9 mL vs 23.3±17.2 mL; P=.006).CONCLUSIONSThe direct observation of hand hygiene of residents could reduce environmental contamination by MDROs in RCHEs.Infect Control Hosp Epidemiol 2018;39:571-577.

Impact of a multicomponent hand hygiene-related intervention on the infectious risk in nursing homes: A cluster randomized trial

BACKGROUND

The aim of this study was to assess the impact of a multifaceted hand hygiene (HH) program on the infectious risk in nursing homes (NHs).

METHODS

This was a 2-arm cluster randomized trial; French NHs were allocated randomly to the intervention (13 NHs) or control (13 NHs) groups. The intervention consisted of implementing a bundle of HH-related measures over 1 year, including increased availability of alcohol-based handrub, HH promotion, staff education, and local work groups. The primary end point was the incidence rate of acute respiratory infections and gastroenteritis reported in the context of clustered cases episodes. Secondary end points were mortality, hospitalization, and antibiotic prescription rates.

RESULTS

Baseline characteristics did not differ between groups. The overall handrub consumption was higher in the intervention group over the 1-year intervention period. Because of underreporting, data on the primary end points were of insufficient quality for analysis. Hospitalizations did not differ between the 2 groups. However, the intervention group showed significantly lower mortality (2.10 vs 2.65 per 100 residents per month, respectively; P = .003) and antibiotic prescriptions (5.0 vs 5.8 defined daily doses per 100 resident days, respectively; P < .001). These results were confirmed by the longitudinal multivariate analysis adjusted for NH and resident characteristics and for seasonality (mortality rate ratio, 0.76).

CONCLUSIONS

A multifaceted HH intervention may have a short-term impact on mortality in NHs. Nevertheless, other strategies may remain necessary to reduce morbidity.

Infection Control in Alternative Health Care Settings: An Update

With changing health care delivery, patients receive care at various settings including acute care hospitals, nursing homes, outpatient primary care and specialty clinics, and at home, exposing them to pathogens in various settings. Various health care settings face unique challenges, requiring individualized infection control programs. Infection control programs in nursing homes should address surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs.

The role of hand hygiene in controlling norovirus spread in nursing homes

Background

Norovirus, the leading cause of gastroenteritis, causes higher morbidity and mortality in nursing homes (NHs) than in the community. Hence, implementing infection control measures is crucial. However, the evidence on the effectiveness of these measures in NH settings is lacking. Using an innovative data-driven modeling approach, we assess various interventions to control norovirus spread in NHs.

Methods

We collected data on resident and staff characteristics and inter-human contacts in a French NH. Based on this data, we developed a stochastic compartmental model of norovirus transmission among the residents and staff of a 100-bed NH. Using this model, we investigated how the size of a 100-day norovirus outbreak changed following three interventions: increasing hand hygiene (HH) among the staff or residents and isolating symptomatic residents.

Results

Assuming a baseline staff HH compliance rate of 15 %, the model predicted on average 19 gastroenteritis cases over 100 days among the residents, which is consistent with published incidence data in NHs. Isolating symptomatic residents was highly effective, leading to an 88 % reduction in the predicted number of cases. The number of expected cases could also be reduced significantly by increasing HH compliance among the staff; for instance, by 75 % when assuming a 60 % HH compliance rate. While there was a linear reduction in the predicted number of cases when HH practices among residents increased, the achieved impact was less important.

Conclusions

This study shows that simple interventions can help control the spread of norovirus in NHs. Modeling, which has seldom been used in these settings, may be a useful tool for decision makers to design optimal and cost-effective control strategies.