Hand Hygiene, an Update

Too much ado about data: Continuous remote monitoring of water temperatures, circulation and throughput can assist in the reduction of hospital-associated waterborne infections

BACKGROUND

National and international guidance provides advice on maintenance and management of water systems in healthcare buildings, however, healthcare-associated waterborne infections (HAWI) are increasing. This narrative review identifies parameters critical to water quality in healthcare buildings and assesses if remote sensor monitoring can deliver safe water systems thus reducing HAWI.

METHOD

A narrative review was performed using the following search terms 1) consistent water temperature AND waterborne pathogen control OR nosocomial infection 2) water throughput AND waterborne pathogen control OR nosocomial infection 3) remote monitoring of in-premise water systems AND continuous surveillance for temperature OR throughput OR flow OR use. Databases employed were PubMed, CDSR (Clinical Study Data Request) and DARE (Database of Abstracts of Reviews of Effects) from Jan 2013 - Mar 2024.

FINDINGS

Single ensuite-patient rooms, expansion of wash-hand basins, widespread glove use, alcohol gel and wipes have increased water system stagnancy resulting in amplification of waterborne pathogens and transmission risk of Legionella, Pseudomonas and Non-Tuberculous Mycobacteria. Manual monitoring does not represent temperatures across large complex water systems. This review deems that multiple point continuous remote sensor monitoring is effective at identifying redundant and low use outlets, hydraulic imbalance and inconsistent temperature delivery across in-premise water systems.

CONCLUSION

As remote monitoring becomes more common there will be greater recognition of failures in temperature control, hydraulics and balancing in water systems and there remains much to learn as we adopt this developing technology within our hospitals.

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.

Updates and future directions regarding hand hygiene in the healthcare setting: insights from the 3rd ICPIC alcohol-based handrub (ABHR) task force

Healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) pose threats to global health. Effective hand hygiene is essential for preventing HAIs and the spread of AMR in healthcare. We aimed to highlight the recent progress and future directions in hand hygiene and alcohol-based handrub (ABHR) use in the healthcare setting. In September 2023, 42 experts in infection prevention and control (IPC) convened at the 3rd International Conference on Prevention and Infection Control (ICPIC) ABHR Taskforce in Geneva, Switzerland. The purpose of this meeting was to provide a synthesis of recent evidence and formulate a research agenda on four critical areas for the implementation of effective hand hygiene practices: (1) ABHR formulations and hand rubbing techniques, (2) low-resource settings and local production of ABHR, (3) hand hygiene monitoring and technological innovations, and (4) hand hygiene standards and guidelines.

Effects of light-guided nudges on health care workers' hand hygiene behavior

BACKGROUND

Hospital-acquired infections are the most frequent adverse events in health care and can be reduced by improving the hand hygiene compliance (HHC) of health care workers (HCWs). We aimed to investigate the effect of nudging with sensor lights on HCWs' HHC.

METHODS

An 11-month intervention study was conducted in 2 inpatient departments at a university hospital. An automated monitoring system (Sani NudgeTM) measured the HHC. Reminder and feedback nudges with lights were displayed on alcohol-based hand rub dispensers. We compared the baseline HHC with HHC during periods of nudging and used the follow-up data to establish if a sustained effect had been achieved.

RESULTS

A total of 91 physicians, 135 nurses, and 15 cleaning staff were enrolled in the study. The system registered 274,085 hand hygiene opportunities in patient rooms, staff restrooms, clean rooms, and unclean rooms. Overall, a significant, sustained effect was achieved by nudging with lights in relation to contact with patients and patient-near surroundings for both nurses and physicians. Furthermore, a significant effect was observed on nurses' HHC in restrooms and clean rooms. No significant effect was found for the cleaning staff.

CONCLUSIONS

Reminder or feedback nudges with light improved and sustained physicians' and nurses' HHC, and constitute a new way of changing HCWs' hand hygiene behavior.

Effects of data-driven feedback on nurses' and physicians' hand hygiene in hospitals - a non-resource-intensive intervention in real-life clinical practice

Background

Hand hygiene (HH) by healthcare workers (HCWs) is one of the most important measures to prevent hospital-acquired infections. However, HCWs struggle to adhere to HH guidelines. We aimed to investigate the effect of a non-resource intensive intervention with group and individual feedback on HCWs HH in a real-life clinical practice during the COVID-19 pandemic.

Methods

In 2021, an 11-month prospective, interventional study was conducted in two inpatient departments at a Danish university hospital. An automated hand hygiene monitoring system (Sani Nudge™) was used to collect data. HH opportunities and alcohol-based hand rub events were measured. Data were provided as HH compliance (HHC) rates. We compared HHC across 1) a baseline period, 2) an intervention period with weekly feedback in groups, followed by 3) an intervention period with weekly individual feedback on emails, and 4) a follow-up period.

Results

We analyzed data from physicians (N=65) and nurses (N=109). In total, 231,022 hygiene opportunities were analyzed. Overall, we observed no significant effect of feedback, regardless of whether it was provided to the group or individuals. We found a trend toward a higher HHC in staff restrooms than in medication rooms and patient rooms. The lowest HHC was found in patient rooms.

Conclusions

The automated hand hygiene monitoring system enabled assessment of the interventions. We found no significant effect of group or individual feedback at the two departments. However, other factors may have influenced the results during the pandemic, such as time constraints, workplace culture, and the degree of leadership support.

Implementation of a quality improvement project using the patient as the observer to improve hand hygiene compliance in ambulatory care practices

BACKGROUND

Monitoring hand hygiene compliance in the ambulatory setting remains a challenge because a healthcare trained observer loses line of sight once the examination room door closes. This quality improvement project focused on the implementation of a hand hygiene compliance improvement programme that is amenable to the routines and work flows of the ambulatory setting.

METHODS

After a review of the literature, nursing leadership and infection prevention implemented the 'patient as the observer' hand hygiene programme across 32 ambulatory practices.

RESULTS

Patients completed 281,000 observations with an overall compliance rate of ≥90%. The average overall compliance rate by role was 91% for providers, 89% for nurses, and 91% for medical assistants/technicians/others. A 92% compliance average was noted 'before caring for you' and 89% 'after caring for you' for providers, 90% and 87% for nurses, and 92% and 89% for medical assistants/technicians/others.

DISCUSSION

This study demonstrated that the implementation of a hand hygiene compliance improvement programme using the patient as the observer can be adopted successfully in the ambulatory setting.

CONCLUSION

Hand hygiene compliance can be monitored effectively in the ambulatory setting with the involvement of the patient as the observer.

Hand hygiene product use by food employees in casual dining and quick-service restaurants

Hand hygiene product usage characteristics by food employees when hand sanitizers are made available are not well understood. To investigate hand hygiene product usage in casual dining and quick-service restaurants, we placed automated monitoring soap and sanitizer dispensers side-by-side at handwash sinks used by food employees in seven restaurants. Dispenses were monitored, and multiple dispenses that occurred within 60 s of each other were considered a single hand hygiene event. This resulted in 186,998 events during the study (149,779 soap only, 21 985 sanitizer only, and 15,234 regimen [defined as soap followed by sanitizer at the same sink within 60 s]) over 15,447 days of use. Soap was the most frequently used hand hygiene method by food employees in both restaurant types. Regimen use, despite being the preferred hand hygiene method by both restaurant chains, was the least used hand hygiene method. When pooled over restaurant types, the median daily usage for soap was statistically significantly highest of all methods at 23.5 dispenses per sink per day (p < 0.0001), the sanitizer median daily usage was 4.27 dispenses per sink per day, and regimen use was statistically significantly lowest of all methods at 4.02 dispenses per sink per day (p < 0.0001). When hand hygiene event types were pooled, casual dining restaurants had similar median hand hygiene event rates (11.4 dispenses per sink per day) compared to quick-service restaurants (11.9 dispenses per sink per day; p = 0.890). The number of events by sink location varied, with sinks located at a warewash station having the highest number of events (19.3 dispenses per sink per day; p < 0.0001), while sinks located by a ready-to-eat food preparation area had the lowest number of events (6.8 dispenses per sink per day; p < 0.0001). These data provide robust baseline benchmarks for future hand hygiene intervention studies in these settings.

Clinical Evaluation of an Electronic Hand Hygiene Monitoring System

BACKGROUND

We aimed to test the accuracy of an electronic hand hygiene monitoring system (EHHMS) during daily clinical activities in different wards and with varying healthcare professions.

METHOD

The accuracy of an EHHMS ([blinded for reviewers]) was assessed during real clinical conditions by comparing events registered by two observers in parallel with events registered by the EHHMS. The events were categorized as true-positive, false-positive, and false-negative registrations. Sensitivity and positive predictive value (PPV) were calculated.

RESULTS

A total of 103 events performed by 25 healthcare workers (9 doctors, 11 nurses, and 5 cleaning assistants) were included in the analyses. The EHHMS had a sensitivity of 100% and a positive predictive value of 100% when measuring alcohol-based hand rub. When looking at the hand hygiene opportunities of all healthcare workers combined taking place in the patient rooms and working rooms, the sensitivity was 75% and the PPV 95%. For doctors' and nurses' taking care of patients in their beds the EHHMS had a sensitivity of 100% and a PPV of 94%.

CONCLUSION

The objective accuracy measures demonstrate that this EHHMS can capture hand hygiene behavior under clinical conditions in different settings with clinical healthcare workers but show less accuracy with cleaning assistants.