Behavioural considerations for hand hygiene practices: the basic building blocks

Identification of essential contents and a standard framework for the development of an Infection Prevention and Control manual for healthcare facilities: A scoping review

BACKGROUND

Several international organizations have outlined the components of infection prevention and control (IPC) programs. To successfully implement an IPC program, hospital staff may adopt a manual that provides support for implementing the IPC measures, even requiring significant efforts. This study aims to identify essential aspects and develop a standardized structure for an IPC manual. The IPC manual framework can be customized and utilized by any health care facility, thereby facilitating adherence to international and national legislation.

METHODS

The study was conducted using the Joanna Briggs Institute methodology for scoping reviews. Reporting followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews standard. The search for evidence was performed on PubMed and Web of Science. Methodological quality was evaluated blindly by 2 reviewers using the Critical Appraisal Skills Program checklist.

RESULTS

Nineteen papers were included in the review. Data extraction considered the most recent guidelines and the categorization into the 8 Core Components established by the World Health Organization. Through the literature review, the essential elements and challenges of an IPC hospital manual were identified, and a framework was proposed.

CONCLUSIONS

By incorporating these essential elements into their IPC manual, health care facilities can establish a robust IPC framework. A potential future development stemming from this work could involve the creation of a standardized national IPC manual tailored for hospital settings.

Health Science Students' Perceptions of Hand Hygiene Education and Practice in a South African University: Introducing the University Hand Hygiene Improvement Model

Hand hygiene serves as a critical preventative measure against the spread of acquired infections in healthcare facilities and is an integral component of patient safety programs. While healthcare students in training are typically introduced to the principles underlying hand hygiene, the translation of this understanding into practice is often lacking, and compliance has remained low. This study aimed to evaluate health science students' in biomedical sciences, chiropractic and emergency medical care, environmental health, complementary medicine, medical imaging and radiation sciences, nursing, optometry, podiatry, and sports and movement studies perceptions regarding hand hygiene education (knowledge and attitude) and practice at a university in South Africa. Consenting students were asked to complete an online questionnaire that tested their knowledge, practices, and skills in handwashing. The ANOVA analysis results suggested significant differences in hand hygiene scores across departments and years of study. The multiple regression analyses confirmed these findings, suggesting that the department of study significantly influenced all aspects of hand hygiene, while the year of study affected hand hygiene skills, and age group influenced hand hygiene practices. Based on these findings, a conceptual model, the University Hand Hygiene Improvement Model (UHHIM), was proposed to enhance the teaching and learning of hand hygiene at the university level. The model underscores the necessity of targeted education, continuous monitoring, and feedback, and the pivotal roles of hand hygiene facilitators and student participation in enhancing hand hygiene behaviors.

A systematic review of nudges on hand hygiene against the spread of COVID-19

The COVID-19 pandemic has posed the greatest threat to global health over the last three years. Due to the temporary shortage of appropriate vaccines, a systematic change in human behaviour is necessary to keep the spread of the virus under control, increasing the quality of basic hygiene practices, such as systematic hand hygiene. Nudges are increasingly used in public health interventions to promote critical preventive hygiene behaviours. This review aimed to investigate the effect and the characteristics of nudges on hand hygiene, as a COVID-19 preventive measure. We systematically reviewed the relevant literature from January 2008 to November 2020. A total of 15 articles met the inclusion criteria. The findings of this review showed that most of the nudging interventions had a positive effect on hand hygiene. Nudges should be included in the existing and future public health interventions to prevent the spread of COVID-19 and future pandemics, rather than being an alternative and unconventional tool for public health policies.

The effect of education based on health belief model on hand hygiene behavior in the staff of Tehran dentistry centers: A quasi-experimental intervention study

Background and Aims

Considering the increasing prevalence of dental services in the community and the impossibility of identifying each infected patient, hand sanitation is the most critical factor in controlling infection in these centers. Therefore, this study aimed to determine the effect of educational intervention on the hand health behavior of the staff of Tehran dentistry clinics based on the health belief model (HBM).

Methods

In this quasi-experimental study in 2017, 128 employees of the health centers were selected through a multistage sampling method and they were placed in two groups of intervention and control (each 64 people). The data was collected using a questionnaire devised by the researcher. The validity and reliability of the questionnaire were determined. The questionnaire consisted of demographics, knowledge, structures of the HBM, and behavior variables. Then, the intervention was administered based on HBM-based education. Data were analyzed by SPSS16 and independent t test, χ ², and repeated measurement analysis of variance.

Results

Before the intervention, the two intervention and control groups did not differ significantly in terms of demographic variables, mean scores of knowledge, constructs of HBM, and hand hygiene behavior (p > 0.05), while the intervention group was scored higher significantly compared to the control one after the intervention (p < 0.001).

Conclusion

According to the findings, the HBM can be used as a framework for designing educational interventions to improve hand hygiene behavior to control infection in health centers.

Interactive Interventions Can Improve Hand Hygiene and Aseptic Techniques During Perioperative Care-Experience From the "Safe Hands" Project

PURPOSE

This paper evaluates a theory-driven, interactive hand hygiene (HH) intervention, the Safe Hands project, based on theories of organizational learning and culture including leadership support, dialogue and co-creation.

DESIGN

This prospective quasi-experimental study used unobtrusive overt observations to evaluate adherence to HH recommendations after implementing an infection-prevention intervention.

METHODS

The primary outcome was differences in HH practices "Before aseptic/clean procedure" (WHO moment 2), "After body fluid exposure risk" (WHO moment 3) and performance of aseptic techniques. One operating room (OR) department served as the study hospital and the other as the control hospital, both at Swedish university hospitals. Adherence to HH guidelines was measured 4 times during 2015 to 2017.

FINDINGS

The intervention site displayed a significant improvement in adherence to HH guidelines and aseptic techniques. WHO 2; from 23.8% to 36.2%, (P = .014), WHO 3; from 22.2% to 42.3%, (P = .002), and aseptic techniques; from 17.5% to 31.6%, (P = .003). No changes in adherence were identified at the control site. The use of contaminated gloves decreased post intervention at the study operating department.

CONCLUSIONS

This study shows that implementing tailored interventions that are underpinned by theories from organizational learning and culture can improve adherence to hand hygiene in a complex setting as the OR up to 6 months post-intervention. The interprofessional co-creation of standards operating procedures addressing specific care procedures and emphasizing the importance of aseptic techniques can be an acceptable and feasible way to reduce the risks of contaminating medical devices and patients during perioperative care.

Acculturation of hygiene norms among immigrants to Sweden

Hygiene norms in Sweden are generally loose compared to most other countries. Does this looseness affect the hygiene norms among people who immigrate to Sweden from other countries? In a study of hygiene norms among immigrants to Sweden, the change in the physical environment and material living conditions, acculturation to Swedish culture and norms, and selection effects were all expected to lead immigrant hygiene norms to be closer to Swedish looseness. However, in a sample of 447 immigrants from 12 different countries, immigrants reported hygiene norms that were even stricter than those found in their countries of origin. We propose an explanation based on a combination of uncertainty about prevailing hygiene norms and the social risk and stigma associated with being perceived as unhygienic. We conclude that acculturation processes may rely on mechanisms that are domain specific.

Make it a habit: how habit strength, goal importance and self-control predict hand washing behaviour over time during the COVID-19 pandemic

OBJECTIVE

Hand washing has been at the core of recommendations and guidelines that aim to curb infectious diseases in general, and COVID-19 in particular. As hand washing comes down to an individual's behaviour, we aimed to study how individual psychological variables influence hand washing over time during the COVID-19 pandemic.

DESIGN

Over the course of 20 weeks, participants answered questions about their hand washing behaviour, goal importance, habit strength and self-control. Participants from an experimental and a control condition completed a baseline and final measurement, and the experimental condition was invited to bi-weekly measurements through reminders.

MAIN OUTCOME MEASURE

Hand washing behaviour over the past 14 days was assessed by self-report at baseline and final measurement, and additionally repeatedly over the course of 20 weeks in the experimental condition.

RESULTS

Hand washing behaviour decreased over time, but this decrease was buffered by habit strength and goal importance. The decrease was smaller in the experimental condition that received reminders every 2 weeks.

CONCLUSION

Sending personal reminders on hand washing behaviour contributes to hand washing behaviour. Moreover, taking habit strength and goal importance, and to a lesser extent self-control into account is important when designing interventions to promote hand washing behaviour.

Smart Hand Sanitisers in the Workplace: A Survey of Attitudes towards an Internet of Things Technology

An online survey was circulated to employees from a wide range of organisations to gauge attitudes towards the idea of using smart hand sanitisers in the workplace. The sanitisers are capable of real-time monitoring and providing feedback that varies according to the hand hygiene behaviour of users. In certain circumstances, the sanitisers can monitor individuals, making it possible to identify workers whose hand hygiene falls below a certain standard. The survey was circulated between July and August 2021 during the COVID-19 pandemic. Data gathered from 314 respondents indicated support for some features of the technology, but also indicated concern about invasions of privacy and the possibility of coercion. Attitudes towards the possible implementation of the technology varied significantly according to certain characteristics of the sample, but particularly with age. Respondents above the median age were more likely to support the use of data in ways that could facilitate the promotion and enforcement of hand hygiene practices.

Measuring the Self-Efficacy of Health Professionals for Practicing Hand Hygiene and Using Gloves: Development and Validation of an Instrument

Adherence to hand hygiene procedures and the use of gloves is a problem that deserves to be analyzed from an individual and organizational point of view. For this, we aim to develop and validate an instrument for measuring the self-efficacy of health professionals for practicing hand hygiene and using gloves. We evaluated the metric properties of validity and reliability for measuring the self-efficacy of health professionals for practicing hand hygiene and using gloves. Fifteen health and education professionals formed the judges committee to construct the instrument for measuring the self-efficacy of health professionals for practicing hand hygiene and using gloves. Moreover, 362 nursing professionals participated in this study that was carried out from 2017 to 2020. The construct validity by known groups was confirmed by comparing the means of self-efficacy of the self-efficacy of health professionals for practicing hand hygiene and using gloves with the variables sex and unit of activity. The convergent construct validity showed a weak correlation between the scores of the self-efficacy of health professionals for practicing hand hygiene and using gloves instrument, and the perceived general self-efficacy scale. This instrument is easy to apply and can be used in the assessment of behavioral determinants, regarding hand hygiene and the use of gloves, in other health professionals, considering the generalization and scope of the items.

Nursing care for patients carrying multi-drug resistant organisms: Experiences, intention to use protective equipment and ability to comply with measures

AIMS

The aims of the study were to explore the impact of caring for patients carrying multi-drug resistant organisms on nursing staff and identify factors predicting their intention to use personal protective equipment and their ability to comply with advised infection prevention and control measures.

BACKGROUND

Carriage of multi-drug resistant organisms and corresponding infection prevention and control measures have a major impact on patients. Limited research has been done to investigate the impact of caring for these patients on nursing staff.

DESIGN

A cross-sectional design.

METHODS

Online survey among Dutch nursing staff in various healthcare settings. Prediction analyses were conducted using random forest. The STROBE checklist was used preparing the manuscript.

RESULTS

974 respondents were included. The majority of nursing staff reported to have experience in caring for patients carrying multi-drug resistant organisms. Relevant dilemmas in daily practice were identified. Important predictors of the intention to use protective equipment were practicing hand hygiene, usable protocols, favourable attitudes and perceptions, as well as knowledge. Important predictors of the ability to comply with advised measures were usable and findable protocols, a suitable work environment and practicing hand hygiene.

CONCLUSION

We have gained comprehensive insight into experiences, attitudes, perceptions, knowledge and dilemmas in daily practice of nursing staff caring for patients carrying multi-drug resistant organisms. To enhance their intention to use protective equipment and their ability to comply with advised measures, activities should focus on improving hand hygiene and the usability of protocols. Additionally, efforts are needed to improve knowledge, provide better resources and a more supportive work environment. All of which need to be specifically tailored to each healthcare setting.

RELEVANCE TO CLINICAL PRACTICE

The results can be used in the development of interventions to improve nursing care while reducing the unfavourable impact on nursing staff and supporting adherence to advised measures.

Evaluating methods for the use and decontamination of needleless connectors: A qualitative inquiry

BACKGROUND

Needleless connectors (NCs) are essential devices designed to provide safe, needle-free connection between venous access devices, syringes and infusions. There is a variety of designs, and associated decontamination products and practices; the resulting confusion can cause detrimental patient outcomes. This study aimed to explore nurses' attitudes, techniques, and practices around the use and decontamination of NCs in clinical practice.

METHODS

Qualitative inquiry was conducted with seven focus groups of 4-6 participants each in the cancer and surgical units of a large tertiary hospital in Australia between January and March 2019. Participants comprised nurses who had taken part in a recent clinical trial of NC decontamination. Focus group sessions were recorded, transcribed and synthesised using content analysis.

RESULTS

Seven focus groups were conducted (total, N = 30 participants), lasting 16-20 min. Six major themes were identified surrounding needleless connector use and decontamination: 'safety and utility'; 'terminology and technological understanding'; 'clinical practice determinants'; 'decontamination procedures and influencers'; 'education and culture'; and 'research and innovation'.

CONCLUSION

The participants articulated positive attitudes towards needleless connector use for needle-stick and infection prevention, however rationales for care and maintenance practices demonstrated limited understanding of guidelines (e.g., disinfection time) and specific NC function (e.g., positive, negative pressure). The findings indicated the need for targeted, standardised needleless connector education, to enhance staff confidence, improve consistency of care and ensure patient safety.

Translating a theory-based positive deviance approach into an applied tool: Mitigating barriers among health professionals (HPs) regarding infection prevention and control (IPC) guidelines

Background

Although a wide range of intervention programs and methods have been implemented to increase health professionals’ (HPs) adherence with infection prevention and control (IPC) guidelines and decrease the incidence of healthcare associated infections (HAIs), a significant discrepancy remains between the guidelines and their implementation in practice.

Objectives

This study proposes an applied tool based on the integrated theoretical framework of the positive deviance (PD) approach for developing more effective interventions to mitigate this discrepancy.

Methods

A qualitative study guided by the PD approach based on data from two sources: (1) in-depth archival analysis of systematic review articles, and (2) integration and synthesis of findings based on an extensive empirical study we conducted, involving 250 HPs (nurses, physicians, support staff and cleaning staff) from three governmental hospitals in Israel, over 35 months (January 2017 to November 2020).

Results

The barriers faced by HPs were classified into four main categories: (1) individual-motivational, (2) social-cultural, (3) organizational, and (4) work environment and resource-centered. For each barrier, we constructed a set of questions based on the PD approach. For each question, we adapted and applied methodological tools (e.g., in-depth interviews, focus groups, social network maps, video clips and simulations) to help solve the problem.

Conclusion

Translating a theory-based approach into an applied tool that offers step-by-step actions can help researchers and practitioners adopt and implement the approach within intervention programs to mitigate barriers.

Hospital-Acquired Pneumonia

Pneumonia acquired during hospitalization is called nosocomial pneumonia (NP). Nosocomial pneumonia is divided into two types. Hospital-acquired pneumonia (HAP) refers to hospital-acquired pneumonia, whereas ventilator-associated pneumonia (VAP) refers to ventilator-associated pneumonia. Most clinical literature stresses VAP’s importance and associated mortality and morbidity, whereas HAP is not given enough attention even while being the most common cause of NP. HAP, like VAP, carries a high mortality and morbidity. HAP is the commonest cause of mortality from hospital-acquired infections. HAP is a common determinant for intensive care unit (ICU) admits with respiratory failure. Recent research has identified definite risk factors responsible for HAP. If these are prevented or modified, the HAP incidence can be significantly decreased with improved clinical outcomes and lesser utilization of the health care resources. The prevention approach will need multiple strategies to address the issues. Precise epidemiological data on HAP is deficient due to limitations of the commonly used diagnostic measures. The diagnostic modalities available in HAP are less invasive than VAP. Recent infectious disease society guidelines have stressed the importance of HAP by removing healthcare-associated pneumonia as a diagnosis. Specific differences exist between HAP and VAP, which are gleaned over in this chapter.

When do children avoid infection risks: Lessons for schools during the COVID-19 pandemic

The physical closing of schools because of COVID-19 has disrupted both student learning and family logistics. There is significant pressure for in-person learning to remain open for all children. However, as is expected with outbreaks of novel infections, vaccines and other pharmaceutical therapeutics may not be instantly available. This raises serious public health questions about the risks to children and society at large. The best protective measures for keeping young children in school focus on behaviors that limit transmission. It is therefore critical to understand how we can engage children in age-appropriate ways that will best support their ability to adhere to protocols effectively. Here, we synthesize published studies with new results to investigate the earliest ages at which children form an understanding of infection risk and when they can translate that understanding effectively to protective action.

Environmental cleaning and infection prevention and control: The role of Patient Service Assistants

BACKGROUND

In Australia, Patient Service Assistants are an integral part of all health care settings, yet there is a paucity of studies considering their understandings and perceptions of their role about infection prevention and control. The aim in this study was to explore haematology Personal Service Assistants' experience, understanding and perceptions of their role in improving patient safety through environmental cleaning.

METHODS

A qualitative exploratory descriptive design was utilised to collect data from cleaning staff via focus groups. Three semi-structured focus groups were conducted.

RESULTS

Seven Patient Service Assistants participated in the study out of 11 employed. Two key themes emerged from the thematic analysis: (1) Playing a major role in Infection Prevention and Control, and (2) prioritising good interpersonal relationships over promoting infection prevention and control. Patient Service Assistants emphasised the importance of their involvement in keeping the ward clean, including patients' rooms and surroundings, to prevent cross infection. Most participants underlined the dilemmas they faced when visitors and/or informal cleaning employees or casual ward staff did not adhere to ward infection prevention and control norms.

CONCLUSION

Patient Service Assistants were employing key infection prevention and control principles in their ward cleaning routine, with the aim of achieving a safer patient environment although they were reluctant to challenge observed practice deviations. The role of Patient Service Assistants highlights the widely held misconception that patient safety is solely dependent on healthcare workers.

What are the predictors of hand hygiene compliance in the intensive care unit? A cross-sectional observational study

Background:

Although appropriate hand hygiene (HH) practices are recognised as the most effective preventative strategy for infection, adherence is suboptimal. Previous studies in intensive care units (ICUs) have found differences in HH compliance between those moments that protect the patient, and those that protect the healthcare provider. However, such studies did not control for other variables known to impact HH compliance.

Aim:

To examine HH among healthcare workers (HCWs) in ICU settings, and identify whether there is a statistical difference in HH compliance between patient-protective and self-protective moments, while controlling for other variables known to influence HH compliance (i.e. professional role, unit and shift time).

Methods:

A cross-sectional observational study was conducted in four ICUs across three Irish hospitals. Compliance was assessed according to the WHO’s ‘five moments for hand hygiene’. HCW professional role, total number of ‘opportunities’ for HH and whether compliance was achieved were recorded.

Results:

A total of 712 HH opportunities were recorded, with an overall compliance rate of 56.9%. Logistic regression analysis revealed that physicians, allied healthcare professionals and auxiliary staff were less likely than nurses to engage in HH. HCWs were more likely to comply during night shifts compared to morning shifts, and with self-protective as compared to patient-protective HH moments.

Conclusion:

The information provided in this study provides a data-driven approach that ICUs can use to tailor HH interventions to where, when and for whom they are most required.

Stepwise interventions for improving hand hygiene compliance in a level 3 academic neonatal intensive care unit in north India

OBJECTIVE

We evaluated effect of sequentially introducing four WHO-recommended interventions to promote hand-hygiene compliance in tertiary-care NICU.

STUDY DESIGN

Four dedicated research nurses directly observed doctors and nurses to record success in hand-hygiene opportunities at randomly selected NICU beds and randomly sampled time-slots in four phases (of 4-weeks each): I-Baseline, II-Self-directed learning; III-Participatory learning; IV-Closed-Circuit Television (CCTV); and V-CCTV-plus (with feedback).

FINDINGS

Hand-hygiene compliance changed from 61.8% (baseline) to 77% (end) with overall relative change: 24.6% (95% CI 18, 32; p value= 0.003); compared with preceding phase, relative changes of 21% (15, 28; <0.001), 4% (0, 8; 0.008), -10% (-13, -6; <0.001), and 10% (5, 15; <0.001) during phases II, III, IV, and V, respectively were observed. Rise in hand-hygiene compliance was higher for after-WHO-moments (12.7%; upto 2.5-folds for moment 5, <0.001) compared to before-WHO-moments (5.2%). Educational interventions, feedback and monitoring WHO moments can improve hand-hygiene compliance significantly among health-care providers in NICU.

An exploratory qualitative study of caregivers' knowledge, perceptions and practices related to hospital hygiene in rural Niger

Background

The risk of healthcare-associated infections is exacerbated by poor hygiene practices in health care facilities and can contribute to increased patient morbidity and mortality. In low-income settings, caregivers play a key role in maintaining proper hygiene during inpatient stays. We aimed to explore caregivers' knowledge, perceptions and practices related to hospital hygiene in a rural, sub-Saharan African setting.

Methods

We conducted an exploratory qualitative study among caregivers of children admitted to an inpatient therapeutic feeding center in Madarounfa, Niger. Individual interviews with 28 caregivers of hospitalized children were conducted to explore their knowledge, perceptions and practices of hygiene in the health facility.

Findings

Caregivers described a broad understanding of hygiene and reported knowledge of its importance in the hospital, particularly to prevent disease transmission and protect child health. Hygiene was perceived as a collective rather than individual responsibility. Caregivers reported on the poor hygiene practice of others and cited a lack of space and hygiene materials as barriers to correct hygiene practice. Caregivers described educational sessions and informal sharing with other caregivers as tools to gain knowledge and improve practice.

Conclusion

This exploratory study is unique in describing the perspective of caregivers in a low-resource hospital setting, a group often underrepresented when designing health interventions to improve hospital hygiene. Our findings suggest a strong knowledge of hospital hygiene among caregivers in this setting, with positive perception of its importance in health promotion. Poor individual practice was reported but may be improved through additional education and provision of hygiene materials.

Patient, staff empowerment and hand hygiene bundle improved and sustained hand hygiene in hospital wards

AIM

We piloted a hand hygiene (HH) project in a ward, focusing on World Health Organization moments 1 and 4. Our aim was to design highly reliable interventions to achieve >90% compliance.

METHODS

Baseline HH compliance was 57 and 67% for moments 1, 4, respectively, in 2015. After the pilot ward showed sustained improvement, we launched the 'HH bundle' throughout the hospital. This included: (i) appointment of HH champions; (ii) verbal/visual bedside reminders; (iii) patient empowerment; (iv) hand moisturisers; (v) tagging near-empty handrub (HR) bottles. Other hospital-wide initiatives included: (vi) Smartphone application for auditing; (vii) 'Speak up for Patient Safety' Campaign in 2017 for staff empowerment; (viii) making HH a key performance indicator.

RESULTS

Overall HH compliance increased from a baseline median of 79.6-92.6% in end-2019. Moments 1 and 4 improved from 71 to 92.7% and from 77.6 to 93.2%, respectively. Combined HR and hand wash consumption increased from a baseline median of 82.6 ml/patient day (PD) to 109.2 mL/PD. Health-care-associated rotavirus infections decreased from a baseline median of 4.5 per 10 000 PDs to 1.5 per 10 000 PDs over time.

CONCLUSIONS

The 'HH Bundle' of appointing HH champions, active reminders and feedback, patient education and empowerment, availability of hand moisturisers, tagging near-empty hand rub bottles together with hospital-wide initiatives including financial incentives and the 'Speak Up for Patient Safety' campaign successfully improved the overall HH compliance to >90%. These interventions were highly reliable, sustained over 4 years and also reduced health-care-associated rotavirus infection rates.

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.

Hand hygiene behavior among Sri Lankan medical students during COVID-19 pandemic

BACKGROUND

Poor compliance with hand hygiene practices among medical students poses a risk for cross-infection. It has become more critical during the COVID-19 pandemic than ever before. This study aimed to determine the knowledge, attitudes, practices of hand hygiene among final-year medical students. It also explored reported hand hygiene behavior before the COVID-19 pandemic and the need for educational strategies to correct the deficiencies.

METHODS

A concurrent mixed-method approach was used. In the quantitative strand, a cross-sectional online survey was carried out via a Google form. Mann-Whitney U test and Chi-squared test were used for comparisons. In the qualitative strand, twelve participants were interviewed, based on a semi-structured interview guide and audio recorded. Transcribed data were evaluated with thematic content analysis.

RESULTS

A total of 225 final-year medical students were studied in the quantitative strand. Most were females. The mean score for knowledge was 3.35 ± 0.795 out of six. Of them, 31.6 % of participants scored below 3 points (< 50 % of the total). Most (78.9 %) had positive attitudes (score of > 80 %). Only 36.4 % reported "adequate" hand hygiene performance in all eight dimensions of the behavior domain. Noticeably, fewer participants reported to clean their hands after checking blood pressure (55.6 %), and only 66.2 % stated carrying a hand sanitizer in their pocket. Significant correlations were not found between reported behavior and attitudes (p = 0.821) or knowledge (p = 0.794). The qualitative strand with 12 respondents revealed the positive influence of both hierarchical and non-hierarchal role models. Time constraints, skin irritation, and workload pressures were the main barriers. Frequent reminders, supervision, and interactive teaching were suggested as methods to improve hand hygiene compliance. They also stated that increased enthusiasm was noted on hand hygiene during the COVID-19 pandemic compared to the pre-pandemic period.

CONCLUSIONS

Most of the participants had positive attitudes towards hand hygiene. Yet, a considerable gap between attitudes and knowledge and reported hand hygiene behavior was evident. Coupling educational programs that use cognitive and behavioral methods, including role modeling, supervision, and frequent reminders, is recommended to bridge the knowledge-attitude-behavior gap.

Knowledge of infection prevention and control among healthcare workers and factors influencing compliance: a systematic review

BACKGROUND

Knowledge of infection prevention and control (IPC) procedures among healthcare workers (HCWs) is crucial for effective IPC. Compliance with IPC measures has critical implications for HCWs safety, patient protection and the care environment.

AIMS

To discuss the body of available literature regarding HCWs' knowledge of IPC and highlight potential factors that may influence compliance to IPC precautions.

DESIGN

A systematic review. A protocol was developed based on the Preferred Reporting Items for Systematic reviews and Meta-Analysis [PRISMA] statement.

DATA SOURCES

Electronic databases (PubMed, CINAHL, Embase, Proquest, Wiley online library, Medline, and Nature) were searched from 1 January 2006 to 31 January 2021 in the English language using the following keywords alone or in combination: knowledge, awareness, healthcare workers, infection, compliance, comply, control, prevention, factors. 3417 papers were identified and 30 papers were included in the review.

RESULTS

Overall, the level of HCW knowledge of IPC appears to be adequate, good, and/or high concerning standard precautions, hand hygiene, and care pertaining to urinary catheters. Acceptable levels of knowledge were also detected in regards to IPC measures for specific diseases including TB, MRSA, MERS-CoV, COVID-19 and Ebola. However, gaps were identified in several HCWs' knowledge concerning occupational vaccinations, the modes of transmission of infectious diseases, and the risk of infection from needle stick and sharps injuries. Several factors for noncompliance surrounding IPC guidelines are discussed, as are recommendations for improving adherence to those guidelines.

CONCLUSION

Embracing a multifaceted approach towards improving IPC-intervention strategies is highly suggested. The goal being to improve compliance among HCWs with IPC measures is necessary.

Motivating healthcare professionals (nurses, nurse assistants, physicians) to integrate new practices for preventing healthcare-associated infections into the care continuum: turning Positive Deviance into positive norms

Background

The literature examining healthcare-associated infections (HAI) points to two main problems in conforming to infection prevention and control (IPC) guidelines among healthcare professionals (HP). One is the discrepancy between HPs’ behavioral intentions and their implementation in practice. The other refers to how HPs maintain these practices after the intervention stage ends. The method proposed in this study seeks to address both these issues by using the Positive Peviance (PD) approach to focus on the dissemination stage of interventions. The study seeks to offer a method for disseminating 27 PD practices to 135 HPs, among them nurses, nurse assistants and physicians, so as to help them maintain IPC guidelines, offer feedback on the dissemination process and examine the impact of the dissemination stage on changes in their behavior.

Methods

The theoretical model underlying this qualitative research was the Recognition-Primed dDecision (RPD) model, which we implemented in the field of healthcare-associated infections (HAIs). Moreover, we used the Discovery & Action Dialogue (DAD) and Think Aloud (TA) techniques to describe the methodological development of simulations for HPs. Feedback from the HP demonstrators underwent content analysis, while descriptive statistics were used to characterize behavioral changes.

Results

HPs’ information processing regarding infection prevention shifts from peripheral/automatic processing to intuition and analytical/central processing, turning PD practices into positive norms. The HPs personally experienced finding a solution and made repeated corrections until they overcame the barriers. Most of the HPs (69.4%) reported that the practices were fully implemented, together with additional practices.

Conclusions

Implementation of the dissemination stage indicates that in order for HPs to integrate and assimilate practices that are not in the official guidelines, merely observing simulations is not sufficient. Rather, each staff member must personally carry out the procedures.

The COVID-19 pandemic as a factor of hospital staff compliance with the rules of hand hygiene: assessment of the usefulness of the "Clean Care is a Safer Care" program as a tool to enhance compliance with hand hygiene principles in hospitals

Introduction

Hand cleansing and disinfection is the most efficient method for reducing the rates of hospital-acquired infections which are a serious medical and economic problem. Striving to ensure the maximum safety of the therapeutic process, we decided to promote hand hygiene by implementing the educational program titled "Clean Care is a Safer Care". The occurrence of the COVID-19 pandemic affected the compliance with procedures related to the sanitary regime, including the frequency and accuracy of hand decontamination by medical personnel.

Objective

The objective of the study was to assess the usefulness of the educational program titled "Clean Care is a Safer Care" as a tool for increasing compliance with hand hygiene principles.

Methods

We monitored the compliance with the hygiene procedure before implementation of the program as well as during the hand hygiene campaign by means of direct observation as well as the disinfectant consumption rates.

Results

In the initial self-assessment survey, the hospital had scored 270/500 points (54%). Preliminary audit revealed the hygiene compliance rate at the level of 49%. After broad-scaled educational efforts, the semi-annual audit revealed an increase in hand hygiene compliance rate up to 81% (hospital average) while the final audit carried out after one year of campaigning revealed a compliance rate of 77%. The final score for the hospital increased to 435/500 points.

Conclusions

COVID-19 pandemic dramatically increased accuracy of proper hand hygiene procedures and consumption of disinfectant agents. The educational program has succeeded to reach its goal; however, long-term educational efforts are required to maintain and improve the quality of provided services.

Hand Hygiene Compliance at Critical Points of Care

BACKGROUND

Most articles on hand hygiene report either overall compliance or compliance with specific hand hygiene moments. These moments vary in the level of risk to patients if healthcare workers (HCWs) are noncompliant. We assessed how task type affected HCWs' hand hygiene compliance.

METHODS

We linked consecutive tasks individual HCWs performed during the Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) study into care sequences and identified task pairs-2 consecutive tasks and the intervening hand hygiene opportunity. We defined tasks as critical and/or contaminating. We determined the odds of critical and contaminating tasks occurring, and the odds of hand hygiene compliance using logistic regression for transition with a random effect adjusting for isolation precautions, glove use, HCW type, and compliance at prior opportunities.

RESULTS

Healthcare workers were less likely to do hand hygiene before critical tasks than before other tasks (adjusted odds ratio [aOR], 0.97 [95% confidence interval {CI}, .95-.98]) and more likely to do hand hygiene after contaminating tasks than after other tasks (aOR, 1.12 [95% CI, 1.10-1.13]). Nurses were more likely to perform both critical and contaminating tasks, but nurses' hand hygiene compliance was better than physicians' (aOR, 0.94 [95% CI, .91-.97]) and other HCWs' compliance (aOR, 0.87 [95% CI, .87-.94]).

CONCLUSIONS

Healthcare workers were more likely to do hand hygiene after contaminating tasks than before critical tasks, suggesting that habits and a feeling of disgust may influence hand hygiene compliance. This information could be incorporated into interventions to improve hand hygiene practices, particularly before critical tasks and after contaminating tasks.

Hand hygiene and the sequence of patient care

OBJECTIVE

To determine whether the order in which healthcare workers perform patient care tasks affects hand hygiene compliance.

DESIGN

For this retrospective analysis of data collected during the Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) study, we linked consecutive tasks healthcare workers performed into care sequences and identified task transitions: 2 consecutive task sequences and the intervening hand hygiene opportunity. We compared hand hygiene compliance rates and used multiple logistic regression to determine the adjusted odds for healthcare workers (HCWs) transitioning in a direction that increased or decreased the risk to patients if healthcare workers did not perform hand hygiene before the task and for HCWs contaminating their hands.

SETTING

The study was conducted in 17 adult surgical, medical, and medical-surgical intensive care units.

PARTICIPANTS

HCWs in the STAR*ICU study units.

RESULTS

HCWs moved from cleaner to dirtier tasks during 5,303 transitions (34.7%) and from dirtier to cleaner tasks during 10,000 transitions (65.4%). Physicians (odds ratio [OR]: 1.50; P < .0001) and other HCWs (OR, 2.15; P < .0001) were more likely than nurses to move from dirtier to cleaner tasks. Glove use was associated with moving from dirtier to cleaner tasks (OR, 1.22; P < .0001). Hand hygiene compliance was lower when HCWs transitioned from dirtier to cleaner tasks than when they transitioned in the opposite direction (adjusted OR, 0.93; P < .0001).

CONCLUSIONS

HCWs did not organize patient care tasks in a manner that decreased risk to patients, and they were less likely to perform hand hygiene when transitioning from dirtier to cleaner tasks than the reverse. These practices could increase the risk of transmission or infection.

A two-component intervention to improve hand hygiene practices and promote alcohol-based hand rub use among people who inject drugs: a mixed-methods evaluation

Background

Inconsistent hand hygiene puts people who inject drugs (PWID) at high risk of infectious diseases, in particular skin and soft tissue infections. In healthcare settings, handwashing with alcohol-based hand rubs (ABRH) is recommended before aseptic procedures including intravenous injections. We aimed to evaluate the acceptability, safety and preliminary efficacy of an intervention combining ABHR provision and educational training for PWID.

Methods

A mixed-methods design was used including a pre-post quantitative study and a qualitative study. Participants were active PWID recruited in 4 harm reduction programmes of France and followed up for 6 weeks. After baseline assessment, participants received a face-to-face educational intervention. ABHR was then provided throughout the study period. Quantitative data were collected through questionnaires at baseline, and weeks 2 (W2) and 6 (W6) post-intervention. Qualitative data were collected through focus groups with participants who completed the 6-week study.

Results

Among the 59 participants included, 48 (81%) and 43 (73%) attended W2 and W6 visits, respectively. ABHR acceptability was high and adoption rates were 50% (W2) and 61% (W6). Only a minority of participants reported adverse skin reactions (ranging from 2 to 6%). Preliminary efficacy of the intervention was shown through increased hand hygiene frequency (multivariable linear mixed model: coef. W2 = 0.58, p = 0.002; coef. W6 = 0.61, p = 0.002) and fewer self-reported injecting-related infections (multivariable logistic mixed model: AOR W6 = 0.23, p = 0.021). Two focus groups were conducted with 10 participants and showed that young PWID and those living in unstable housing benefited most from the intervention.

Conclusions

ABHR for hand hygiene prior to injection are acceptable to and safe for PWID, particularly those living in unstable housing. The intervention’s educational component was crucial to ensure adoption of safe practices. We also provide preliminary evidence of the intervention’s efficacy through increased hand hygiene frequency and a reduced risk of infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-05895-1.

Hand-washing promotion for preventing diarrhoea

BACKGROUND

Diarrhoea accounts for 1.8 million deaths in children in low- and middle-income countries (LMICs). One of the identified strategies to prevent diarrhoea is hand washing.

OBJECTIVES

To assess the effects of hand-washing promotion interventions on diarrhoeal episodes in children and adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases, the World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), and metaRegister of Controlled Trials (mRCT) on 8 January 2020, together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Individually-randomized controlled trials (RCTs) and cluster-RCTs that compared the effects of hand-washing interventions on diarrhoea episodes in children and adults with no intervention.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial eligibility, extracted data, and assessed risks of bias. We stratified the analyses for child day-care centres or schools, community, and hospital-based settings. Where appropriate, we pooled incidence rate ratios (IRRs) using the generic inverse variance method and a random-effects model with a 95% confidence interval (CI). We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 29 RCTs: 13 trials from child day-care centres or schools in mainly high-income countries (54,471 participants), 15 community-based trials in LMICs (29,347 participants), and one hospital-based trial among people with AIDS in a high-income country (148 participants). All the trials and follow-up assessments were of short-term duration. Hand-washing promotion (education activities, sometimes with provision of soap) at child day-care facilities or schools prevent around one-third of diarrhoea episodes in high-income countries (incidence rate ratio (IRR) 0.70, 95% CI 0.58 to 0.85; 9 trials, 4664 participants, high-certainty evidence) and may prevent a similar proportion in LMICs, but only two trials from urban Egypt and Kenya have evaluated this (IRR 0.66, 95% CI 0.43 to 0.99; 2 trials, 45,380 participants; low-certainty evidence). Only four trials reported measures of behaviour change, and the methods of data collection were susceptible to bias. In one trial from the USA hand-washing behaviour was reported to improve; and in the trial from Kenya that provided free soap, hand washing did not increase, but soap use did (data not pooled; 3 trials, 1845 participants; low-certainty evidence). Hand-washing promotion among communities in LMICs probably prevents around one-quarter of diarrhoea episodes (IRR 0.71, 95% CI 0.62 to 0.81; 9 trials, 15,950 participants; moderate-certainty evidence). However, six of these nine trials were from Asian settings, with only one trial from South America and two trials from sub-Saharan Africa. In seven trials, soap was provided free alongside hand-washing education, and the overall average effect size was larger than in the two trials which did not provide soap (soap provided: RR 0.66, 95% CI 0.58 to 0.75; 7 trials, 12,646 participants; education only: RR 0.84, 95% CI 0.67 to 1.05; 2 trials, 3304 participants). There was increased hand washing at major prompts (before eating or cooking, after visiting the toilet, or cleaning the baby's bottom) and increased compliance with hand-hygiene procedure (behavioural outcome) in the intervention groups compared with the control in community trials (data not pooled: 4 trials, 3591 participants; high-certainty evidence). Hand-washing promotion for the one trial conducted in a hospital among a high-risk population showed significant reduction in mean episodes of diarrhoea (1.68 fewer) in the intervention group (mean difference -1.68, 95% CI -1.93 to -1.43; 1 trial, 148 participants; moderate-certainty evidence). Hand-washing frequency increased to seven times a day in the intervention group versus three times a day in the control arm in this hospital trial (1 trial, 148 participants; moderate-certainty evidence). We found no trials evaluating the effects of hand-washing promotions on diarrhoea-related deaths or cost effectiveness.

AUTHORS' CONCLUSIONS

Hand-washing promotion probably reduces diarrhoea episodes in both child day-care centres in high-income countries and among communities living in LMICs by about 30%. The included trials do not provide evidence about the long-term impact of the interventions.

Perceptions of Nigerian healthcare workers towards hand hygiene: a qualitative study

Introduction

hand hygiene (HH) is an effective measure to reduce healthcare-associated infections and the growing burden of antimicrobial resistance. There is a need to understand the perceptions of healthcare workers towards its practice and the use of alcohol-based hand rubs (ABHR) to make recommendations to promote HH. Our study aimed to explore the perceptions of Nigerian healthcare workers towards HH and the use and availability of ABHR to suggest potential interventions to improve its practice as qualitative evidence in this field is limited in Nigeria.

Methods

a qualitative study design was utilized to understand the perceptions of healthcare workers towards HH and the use of ABHR at Adeoyo Maternity Hospital, Ibadan, Nigeria. Purposive sampling was used to recruit nineteen healthcare workers who were interviewed. Thematic content analysis was used to analyze the data generated.

Results

five themes emerged including discrepancies in what constitutes HH practice as participants, motivation for HH practice, a good knowledge of timing as regards practice, barriers to good practice and evidence of poor practice.

Conclusion

while many healthcare workers know about HH and self-reported compliance towards it seems to be high, knowledge gaps, lack of resources, absence of regulations and poor working conditions were impediments to the successful implementation of HH practices. We recommend that hospitals institute well-articulated HH regulations, continuous education and training of healthcare workers. Hospitals should also ensure adequate provision of resources for hand hygiene and institute a continuous monitoring and feedback program to evaluate compliance with regulations.

Exploring determinants of hand hygiene among hospital nurses: a qualitative study

BACKGROUND

The present research is a qualitative one aiming to determine factors affecting hand-hygiene behavior of the nursing staff in Shariati Hospital of Tehran, Iran.

METHODS

This was a qualitative study performed using content analysis approach. Considering the aim of the study, 16 in-depth semi-structured interviews were held with the nursing staff of Shariati Hospital of Tehran University of Medical Sciences. A convenient sampling was performed and continued until data saturation and until no new codes and categories were obtained. Data were analyzed through a qualitative content analysis based on the Graham and landsman method. Directed qualitative content analysis was done in order to analyze the data.

RESULTS

The results of this study revealed 3 main themes in the Theory of Planned Behavior (TPB) (attitude, subjective norms and perceived behavioral control) and 8 main themes in the outside the framework (environment, perceptions, life style, morality, education, organizational culture, salience and personality).

CONCLUSION

Due to the other factors also found in this study, an integration of theories and models for designing of interventions is recommended to increase adherence to hand hygiene behavior.

Evolution and associated factors of hand hygiene compliance in a pediatric tertiary hospital

BACKGROUND

The objective is to know the evolution of the Degree of Compliance with Recommendations (DCR) on hand hygiene (HH) and its associated factors in the pediatric care areas (PCAs) of a tertiary hospital.

METHODS

Observational, cross-sectional study, repeated over time, with direct observation of the DCR on HH during the daily activity of health care workers. Over 13 years, 9226 HH opportunities were observed. Associations between DCR, PCA and other variables (eg, age, sex, and professional position) were examined using χ² and adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

DCR on HH in 9 PCAs was 64.3% (95% CI, 63.3-65.3), and in the group of non-pediatric areas it was 49.6% (95% CI, 49.1-50.1). The areas with the highest degree of compliance were Oncology 72.8% (95% CI, 69.2-76.4), Neonatology 73.2% (95% CI, 71.3-75.1), and Neonatal intensive care unit 70.0% (95% CI, 67.5-72.6). These were the areas with the strongest association with HH compliance, with aOR:2.8 (95% CI, 2.2-3.6); aOR, 3.0 (95% CI, 2.6-3.6) aOR:2.6 (95% CI, 2.1-3.1), respectively. Other associated factors were the indications "after an activity," aOR, 1.6 (95% CI, 1.5-1.8) and the availability of pocket-size alcohol-based solution, aOR, 2.1(95% CI, 1.9-2.3).

CONCLUSIONS

The DCR on HH in PCAs is higher than in other areas, although there is still margin for improvement. We have identified modifiable factors that have an independent association with HH compliance in PCAs. Focusing on modifiable factors will increase compliance with HH with the ultimate goal of reducing healthcare associated infections.

What distinguishes positive deviance (PD) health professionals from their peers and what impact does a PD intervention have on behaviour change: a cross-sectional study of infection control and prevention in three Israeli hospitals

Past studies using the positive deviance (PD) approach in the field of infection prevention and control (IPC) have primarily focused on impacts on healthcare-associated infection rates. This research aimed to determine if health professionals who exhibit PD behaviours have distinctive socio-cognitive profiles compared to non-PD professionals, and to examine the impact of a PD intervention on healthcare professionals’ (HPs) behavioural changes in maintaining IPC guidelines. In a cross-sectional study among 135 HPs, respondents first filled out a socio-cognitive characteristics questionnaire, and after 5 months were requested to complete a self-reported behavioural change questionnaire. The main findings indicate that socio-cognitive variables such as external locus of control, perceived threat and social learning were significant predictors of a person exhibiting PD behaviours. Almost 70% of HPs reported behavioural change and creating social networks as a result of the PD intervention in maintaining IPC guidelines, 16.9% of them are a ‘PD boosters’ (a new group of HPs who have adopted the positive practices of PDs that were originally identified, and also added additional practices of their own). Social networks can contribute to internalizing and raising personal accountability even among non-PD professionals, by creating a mind map that makes each person believe they are an important node in the network, regardless of their status and role. Health intervention programmes should purposely make visible and prominent social network connections in the hospital system.

Hand hygiene compliance in Dutch general practice offices

BACKGROUND

Hand hygiene (HH) is considered one of the most important measures to prevent healthcare-associated infections (HAI). Most studies focus on HH compliance within the hospital setting, whereas little is known for the outpatient setting. The aim of this study was to evaluate compliance with HH recommendations in general practitioners (GPs) office, based on World Health Organization (WHO) guideline.

METHODS

An observational study was conducted at five Dutch GPs-practices in September 2017. We measured HH compliance through direct observation using WHO's 'five moments of hand hygiene' observation tool. All observations were done by one trained professional.

RESULTS

We monitored a total of 285 HH opportunities for 30 health care workers (HCWs). The overall compliance was 37%. Hand hygiene compliance was 34, 51 and 16% for general practitioners, practice assistants, and nurses, respectively. It varies between 63% after body fluid exposure and no HH performance before-, during and after home visit of a patient (defined as moment 5). The preferred method of HH was soap and water (63%) versus 37% for alcohol-based hand rub (ABHR). The median time of disinfecting hands was 8 s (range 6-11 s) for HCWs in our study.

CONCLUSIONS

HH compliance among HCWs in Dutch GPs was found to be low, especially with regard to home visits. The WHO recommended switch from hand wash to ABHR was not implemented by the majority of HCWs in 5 observed GPs offices.

A mixed-methods sequential explanatory design comparison between COVID-19 infection control guidelines' applicability and their protective value as perceived by Israeli healthcare workers, and healthcare executives' response

Background

Healthcare workers (HCWs) are on the front line of the COVID-19 outbreak, and their constant exposure to infected patients and contaminated surfaces puts them at risk of acquiring and transmitting the infection. Therefore, they must employ protective measures. In practice, HCWs in Israel were not fully prepared for this sudden COVID-19 outbreak. This research aimed to identify and compare: (1) Israeli HCWs’ perceptions regarding the official COVID-19 guidelines’ applicability and their protective value, and (2) HCWs executives’ response to HWCs’ concern regarding personal protective equipment (PPE) shortage.

Methods

A mixed-methods sequential explanatory design consists of: (1) An online survey of 242 HCWs about the application of the guidelines and PPE, and (2) Personal interviews of 15 HCWs executives regarding PPE shortage and the measures they are taking to address it.

Results

A significant difference between the perceived applicability and protective value was found for most of the guidelines. Some of the guidelines were perceived as more applicable than protective (hand hygiene, signage at entrance, alcohol rub sanitizers at entrance, and mask for contact with symptomatic patients). Other were perceived as less applicable than protective (prohibited gathering of over 10 people, maintaining a distance of 2 m’, and remote services).

Conclusions

HCWs need the support of the healthcare authorities not only to provide missing equipment, but also to communicate the risk to them. Conveying the information with full transparency, while addressing the uncertainty element and engaging the HCWs in evaluating the guidelines, are critical for establishing trust.

Improving the impact of non-pharmaceutical interventions during COVID-19: examining the factors that influence engagement and the impact on individuals

BACKGROUND

During an evolving outbreak or pandemic, non-pharmaceutical interventions (NPIs) including physical distancing, isolation, and mask use may flatten the peak in communities. However, these strategies rely on community understanding and motivation to engage to ensure appropriate compliance and impact. To support current activities for COVID-19, the objectives of this narrative review was to identify the key determinants impacting on engagement.

METHODS

An integrative narrative literature review focused on NPIs. We aimed to identify published peer-reviewed articles that focused on the general community (excluding healthcare workers), NPIs (including school closure, quarantine, isolation, physical distancing and hygiene behaviours), and factors/characteristics (including social, physical, psychological, capacity, motivation, economic and demographic) that impact on engagement.

RESULTS

The results revealed that there are a range of demographic, social and psychological factors underpinning engagement with quarantine, school closures, and personal protective behaviours. Aside from the factors impacting on acceptance and compliance, there are several key community concerns about their use that need to be addressed including the potential for economic consequences.

CONCLUSION

It is important that we acknowledge that these strategies will have an impact on an individual and the community. By understanding the barriers, we can identify what strategies need to be adopted to motivate individuals and improve community compliance. Using a behavioural framework to plan interventions based on these key barriers, will also ensure countries implement appropriate and targeted responses.

Assessment of correlates of hand hygiene compliance among final year medical students: a cross-sectional study in the Netherlands

OBJECTIVES

To identify the factors that influence the hand hygiene compliance of final year medical students, using a theoretical behavioural framework.

DESIGN

Cross-sectional survey assessing self-reported compliance and its behavioural correlates.

SETTING

Internships of medical students in the Netherlands.

PARTICIPANTS

322 medical students of the Erasmus Medical Center were recruited over a period of 12 months during the Public Health internship, which is the final compulsory internship after an 18-month rotation schedule in all major specialities.

PRIMARY AND SECONDARY OUTCOME MEASURES

Behavioural factors influencing compliance to hand hygiene guidelines were measured by means of a questionnaire based on the Theory of Planned Behaviour and Social Ecological Models. Multiple linear regression analysis was used to identify the effect of including attitudes, social norms, self-efficacy, knowledge, risk perception and habit on hand hygiene compliance.

RESULTS

We included 313 students in the analysis (response rate 97%). The behavioural model explained 40% of the variance in self-reported compliance (adjusted R²=0.40). Hand hygiene compliance was strongly influenced by attitudes (perceived outcomes of preventive actions), self-efficacy (perception of the ability to perform hand hygiene at the clinical ward) and habit, but was not associated with knowledge and risk perception.

CONCLUSIONS

Targeting medical students' behaviour should focus on the empowerment of these juniors and provide them with evidence on the health benefits of prevention, rather than increasing their factual knowledge of procedures. Clinical teaching environments could help them form good patient safety habits during this vital phase of their career.

Physiotherapy students as a partner for the prevention of healthcare associated infections

Background: Hand hygiene compliances of healthcare students have been examined extensively. However, there has been no study in this area for the students of the department of physiotherapy and rehabilitation. The aim was to evaluate hand hygiene compliance of the department of physiotherapy and rehabilitation students after a briefing on hand hygiene. Methods: Before the summer practice, the students were briefed on hand hygiene. Then their hand hygiene compliance were assessed. Their sociodemographic characteristics, clinical summer practice data, and hand hygiene compliance based on the recommendations commented in the Centers for Disease Control and Prevention Guideline for Hand Hygiene in Health Care Settings were assessed with a questionnaire prepared by the researchers. Results: Of 53 students, 52 met inclusion criteria. The average correct answer rate was 82.69%. Students had inadequacies in selecting suitable hand hygiene techniques and in complying with hand hygiene indications in some situations related to their profession. Moreover, the students suggested that there was a great need for education (n = 24; 39.34%) and improvements in physical conditions (n = 21; 34.43%). Conclusions: As a conclusion, department of physiotherapy and rehabilitation students were aware of the importance of hand hygiene in terms of prevention of healthcare-associated infections. However, for department of physiotherapy and rehabilitation students, educational programs about hand hygiene is needed in order to gain optimal competence and to be able to protect and improve health care workers and patients safety.

Improving children's and their visitors' hand hygiene compliance

Background

Numerous interventions have tried to improve healthcare workers' hand hygiene compliance. However, little attention has been paid to children's and their visitors' compliance.

Aim

To test whether interactive educational interventions increase children's and visitors' compliance with hand hygiene.

Methods

This was a cluster randomised study of hand hygiene compliance before and after the introduction of educational interventions. Observations were compared for different moments of hygiene and times of the day. Qualitative data in the form of questionnaire-based structured interviews were obtained.

Findings

Hand hygiene compliance increased by 24.4% (P < 0.001) following the educational interventions, with children's compliance reaching 40.8% and visitors' being 50.8%. Compliance varied depending on which of the five moments of hygiene was observed (P < 0.001), with the highest compliance being 'after body fluid exposure' (72.7%). Responses from questionnaires showed educational interventions raised awareness of the importance of hand hygiene (69%, 57%) compared to those who had not experienced the educational intervention (50%).

Conclusion

Educational interventions may result in a significant increase in children's and visitors' hand hygiene (P < 0.001).

Hand hygiene - social network analysis of peer-identified and management-selected change agents

Background

Hand hygiene compliance can be improved by strategies fostering collaborative efforts among healthcare workers (HCWs) through change agents. However, there is limited information about how change agents shape the social networks of work teams, and how this relates to organisational culture. The objectives of this study were to describe the influence of peer-identified change agents (PICAs) and management-selected change agents (MSCAs) on hand hygiene, perception of their leadership style by peers, and the role of the organisational culture in the process of hand hygiene promotion.

Methods

This study, stratified in pre-, during, and post-intervention periods, was conducted between February 2017 and March 2018 in two wards at a tertiary care hospital in Malaysia. Hand hygiene promotion was facilitated either by PICAs (study arm 1) or MSCAs (study arm 2), and the two wards were randomly allocated to one of the two interventions. Outcomes were: 1) perceived leadership styles of PICAs and MSCAs by staff, vocalised during question and answer sessions; 2) the social network connectedness and communication patterns between HCWs and change agents by applying social network analysis; and 3) hand hygiene leadership attributes obtained from HCWs in the post-intervention period by questionnaires.

Results

Hand hygiene compliance in study arm 1 and study arm 2 improved by from 48% (95% CI: 44–53%) to 66% (63–69%), and from 50% (44–55%) to 65% (60–69%), respectively. There was no significant difference between the two arms. Healthcare workers perceived that PICAs lead by example, while MSCAs applied an authoritarian top-down leadership style. The organisational culture of both wards was hierarchical, with little social interaction, but strong team cohesion. Position and networks of both PICAs and MSCAs were similar and generally weaker compared to the leaders who were nominated by HCWs in the post-intervention period. Healthcare workers on both wards perceived authoritative leadership to be the most desirable attribute for hand hygiene improvement.

Conclusion

Despite experiencing successful hand hygiene improvement from PICAs, HCWs expressed a preference for the existing top-down leadership structure. This highlights the limits of applying leadership models that are not supported by the local organisational culture.

The devil is in the details: Factors influencing hand hygiene adherence and contamination with antibiotic-resistant organisms among healthcare providers in nursing facilities

BACKGROUND

Antibiotic-resistant organism (ARO) colonization rates in skilled nursing facilities (NFs) are high; hand hygiene is crucial to interrupt transmission. We aimed to determine factors associated with hand hygiene adherence in NFs and to assess rates of ARO acquisition among healthcare personnel (HCP).

METHODS

HCP were observed during routine care at 6 NFs. We recorded hand hygiene adherence, glove use, activities, and time in room. HCP hands were cultured before and after patient care; patients and high-touch surfaces were cultured. HCP activities were categorized as high-versus low-risk for self-contamination. Multivariable regression was performed to identify predictors of hand hygiene adherence.

RESULTS

We recorded 385 HCP observations and paired them with cultures performed before and after patient care. Hand hygiene adherence occurred in 96 of 352 observations (27.3%) before patient care and 165 of 358 observations (46.1%) after patient care. Gloves were worn in 169 of 376 observations (44.9%). Higher adherence was associated with glove use before patient care (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.44-4.54) and after patient care (OR, 3.11; 95% CI, 1.77-5.48). Compared with nurses, certified nurse assistants had lower hand hygiene adherence (OR, 0.31; 95% CI, 0.15-0.67) before patient care and physical/occupational therapists (OR, 0.22; 95% CI, 0.11-0.44) after patient care. Hand hygiene varied by activity performed and time in the room. HCP hands were contaminated with AROs in 35 of 385 cultures of hands before patient care (0.9%) and 22 of 350 cultures of hands after patient care (6.3%).

CONCLUSIONS

Hand hygiene adherence in NFs remain low; it is influenced by job title, type of care activity, and glove use. Hand hygiene programs should incorporate these unique care and staffing factors to reduce ARO transmission.

Prevention of hospital-acquired pneumonia

PURPOSE OF REVIEW

Hospital-acquired pneumonia (HAP) is the leading cause of death from hospital-acquired infection. Little work has been done on strategies for prevention of HAP. This review aims to describe potential HAP prevention strategies and the evidence supporting them. Oral care and aspiration precautions may attenuate some risk for HAP. Oral and digestive decontamination with antibiotics may be effective but could increase risk for resistant organisms. Other preventive measures, including isolation practices, remain theoretical or experimental.

RECENT FINDINGS

Hospital-acquired pneumonia occurs because of pharyngeal colonization with pathogenic organisms and subsequent aspiration of these pathogens.

SUMMARY

Most potential HAP prevention strategies remain unproven.

Inclusion of Real-Time Hand Hygiene Observation and Feedback in a Multimodal Hand Hygiene Improvement Strategy in Low-Resource Settings

Importance

Hand hygiene adherence monitoring and feedback can reduce health care-acquired infections in hospitals. Few low-cost hand hygiene adherence monitoring tools exist in low-resource settings.

Objective

To pilot an open-source application for mobile devices and an interactive analytical dashboard for the collection and visualization of health care workers' hand hygiene adherence data.

Design, Setting, and Participants

This prospective multicenter quality improvement study evaluated preintervention and postintervention adherence with the 5 Moments for Hand Hygiene, as suggested by the World Health Organization, among health care workers from April 23 to May 25, 2018. A novel data collection form, the Hand Hygiene Observation Tool, was developed in open-source software and used to measure adherence with hand hygiene guidelines among health care workers in the inpatient therapeutic feeding center and pediatric ward of Anka General Hospital, Anka, Nigeria, and the postoperative ward of Noma Children's Hospital, Sokoto, Nigeria. Qualitative data were analyzed throughout data collection and used for immediate feedback to staff. A more formal analysis of the data was conducted during October 2018.

Exposures

Multimodal hand hygiene improvement strategy with increased availability and accessibility of alcohol-based hand sanitizer, staff training and education, and evaluation and feedback in near real-time.

Main Outcomes and Measures

Hand hygiene adherence before and after the intervention in 3 hospital wards, stratified by health care worker role, ward, and moment of hand hygiene.

Results

A total of 686 preintervention adherence observations and 673 postintervention adherence observations were conducted. After the intervention, overall hand hygiene adherence increased from 32.4% to 57.4%. Adherence increased in both wards in Anka General Hospital (inpatient therapeutic feeding center, 24.3% [54 of 222 moments] to 63.7% [163 of 256 moments]; P < .001; pediatric ward, 50.9% [132 of 259 moments] to 68.8% [135 of 196 moments]; P < .001). Adherence among nurses in Anka General Hospital also increased in both wards (inpatient therapeutic feeding center, 17.7% [28 of 158 moments] to 71.2% [79 of 111 moments]; P < .001; pediatric ward, 45.9% [68 of 148 moments] to 68.4% [78 of 114 moments]; P < .001). In Noma Children's Hospital, the overall adherence increased from 17.6% (36 of 205 moments) to 39.8% (88 of 221 moments) (P < .001). Adherence among nurses in Noma Children's Hospital increased from 11.5% (14 of 122 moments) to 61.4% (78 of 126 moments) (P < .001). Adherence among Noma Children's Hospital physicians decreased from 34.2% (13 of 38 moments) to 8.6% (7 of 81 moments). Lowest overall adherence after the intervention occurred before patient contact (53.1% [85 of 160 moments]), before aseptic procedure (58.3% [21 of 36 moments]), and after touching a patient's surroundings (47.1% [124 of 263 moments]).

Conclusions and Relevance

This study suggests that tools for the collection and rapid visualization of hand hygiene adherence data are feasible in low-resource settings. The novel tool used in this study may contribute to comprehensive infection prevention and control strategies and strengthening of hand hygiene behavior among all health care workers in health care facilities in humanitarian and low-resource settings.

Visibility and transmission: complexities around promoting hand hygiene in young children - a qualitative study

Background

Effective hand hygiene practice can reduce transmission of diseases such as respiratory tract infections (RTIs) and gastrointestinal infections, especially in young children. While hand hygiene has been widely promoted within Australia, primary care providers’ (PCPs) and parents’ understanding of hand hygiene importance, and their views on hand hygiene in reducing transmission of diseases in the community are unclear. Therefore, the aim of this study was to explore the views of PCPs and parents of young children on their knowledge and practice of hand hygiene in disease transmission.

Methods

Using a cross-sectional qualitative research design, we conducted 30 in-depth interviews with PCPs and five focus groups with parents (n = 50) between June 2014 and July 2015 in Melbourne, Australia. Data were thematically analysed.

Results

Participants agreed that hand hygiene practice was important in reducing disease transmissions. However, barriers such as variations of hand hygiene habits, relating visibility to transmission; concerns around young children being obsessed with washing hands; children already being ‘too clean’ and the need to build their immunity through exposure to dirt; and scepticism that hand hygiene practice was achievable in young children, all hindered participants’ motivation to develop good hand hygiene behaviour in young children.

Conclusion

Despite the established benefits of hand hygiene, sustained efforts are needed to ensure its uptake in routine care. To overcome the barriers identified in this study a multifaceted intervention is needed that includes teaching young children good hand hygiene habits, PCPs prompting parents and young children to practice hand hygiene when coming for an RTI consultation, reassuring parents that effective hand hygiene practice will not lead to abnormal psychological behaviour in their children, and community health promotion education campaigns.

The politics and ethics of hospital infection prevention and control: a qualitative case study of senior clinicians' perceptions of professional and cultural factors that influence doctors' attitudes and practices in a large Australian hospital

BACKGROUND

Hospital infection prevention and control (IPC) programs are designed to minimise rates of preventable healthcare-associated infection (HAI) and acquisition of multidrug resistant organisms, which are among the commonest adverse effects of hospitalisation. Failures of hospital IPC in recent years have led to nosocomial and community outbreaks of emerging infections, causing preventable deaths and social disruption. Therefore, effective IPC programs are essential, but can be difficult to sustain in busy clinical environments. Healthcare workers' adherence to routine IPC practices is often suboptimal, but there is evidence that doctors, as a group, are consistently less compliant than nurses. This is significant because doctors' behaviours disproportionately influence those of other staff and their peripatetic practice provides more opportunities for pathogen transmission. A better understanding of what drives doctors' IPC practices will contribute to development of new strategies to improve IPC, overall.

METHODS

This qualitative case study involved in-depth interviews with senior clinicians and clinician-managers/directors (16 doctors and 10 nurses) from a broad range of specialties, in a large Australian tertiary hospital, to explore their perceptions of professional and cultural factors that influence doctors' IPC practices, using thematic analysis of data.

RESULTS

Professional/clinical autonomy; leadership and role modelling; uncertainty about the importance of HAIs and doctors' responsibilities for preventing them; and lack of clarity about senior consultants' obligations emerged as major themes. Participants described marked variation in practices between individual doctors, influenced by, inter alia, doctors' own assessment of patients' infection risk and their beliefs about the efficacy of IPC policies. Participants believed that most doctors recognise the significance of HAIs and choose to [mostly] observe organisational IPC policies, but a minority show apparent contempt for accepted rules, disrespect for colleagues who adhere to, or are expected to enforce, them and indifference to patients whose care is compromised.

CONCLUSIONS

Failure of healthcare and professional organisations to address doctors' poor IPC practices and unprofessional behaviour, more generally, threatens patient safety and staff morale and undermines efforts to minimise the risks of dangerous nosocomial infection.

Effectiveness and core components of infection prevention and control programmes in long-term care facilities: a systematic review

BACKGROUND

Infection prevention and control (IPC) is a measure to prevent healthcare-associated infections in healthcare settings. There is limited evidence of the effectiveness of IPC programmes in long-term care facilities (LTCFs).

AIM

To review and analyse the effectiveness and the components of IPC programmes in LTCFs for older adults.

METHODS

Electronic databases (PubMed, EMBASE, CINAHL and Cochrane CENTRAL) were searched systematically for English-language articles assessing IPC interventions in LTCFs, published over the last decade (2007-2016). The components of IPC programmes were analysed based on the World Health Organization (WHO) manuals for improving IPC activities. Two reviewers independently assessed the quality of studies using the Cochrane risk-of-bias tool and the risk-of-bias assessment tool for non-randomized studies.

FINDINGS

Seventeen studies met the eligibility criteria; 10 studies were randomized trials (58.8%) and the others were non-randomized trials to examine the impact of IPC programmes on infection and/or performance outcomes of healthcare workers. None of the included studies implemented all of the WHO core components. Behavioural change strategies using education, monitoring and feedback were reported to be successful interventions for reducing the threat of healthcare-associated infections. Generally, studies using four or more elements of the WHO multi-modal strategy reported significant reductions in infection rates.

CONCLUSIONS

There is some evidence for the effectiveness of IPC interventions using education, monitoring, feedback and four or more elements of the WHO multi-modal strategy to control healthcare-associated infections in LTCFs.

Reducing Infections "Together": A Review of Socioadaptive Approaches

Reducing healthcare-associated infections often requires the use of both technical and adaptive strategies. The experiences of Semmelweis and Nightingale teach us the importance of social adaptation of technical interventions. Because most infection prevention interventions require widespread participation by healthcare personnel, it is helpful for infectious diseases physicians to learn principles of diffusion of innovations theory and apply them to influence different groups. Comprehensive unit-based program has been successful in reducing device-associated infections. Positive deviance as a socioadaptive approach may be promising. These and other approaches such as social network analysis, relational coordination, link nurses, and stop the line policies need to be further evaluated in future studies. Future research on socioadaptive interventions needs to focus on developing tools and strategies for diagnosing local context and study how these interventions might influence culture of safety. Strategies to sustain momentum of improvement efforts in different healthcare settings need to be refined and further developed through additional research.

Factors for compliance with infection control practices in home healthcare: findings from a survey of nurses' knowledge and attitudes toward infection control

BACKGROUND

Infection is a leading cause of hospitalization among home healthcare patients. Nurses play an important role in reducing infection among home healthcare patients by complying with infection control procedures. However, few studies have examined the compliance of home healthcare nurses with infection control practices or the range of sociocultural and organizational factors that may be associated with compliance.

METHODS

This study analyzed survey responses from nurses at 2 large, certified home healthcare agencies (n = 359), to explore levels of compliance with infection control practices and identify associated demographic, knowledge, and attitudinal correlates.

RESULTS

Nurses reported a high level of infection control compliance (mean = 0.89, standard deviation [SD] = 0.16), correct knowledge (mean = 0.85, SD = 0.09), and favorable attitudes (mean = 0.81, SD = 0.14). Multivariate mixed regression analyses revealed significant positive associations of attitudinal scores with reported level of compliance (P < .001). However, knowledge of inflection control practices was not associated with compliance. Older (P < .05) and non-Hispanic black (P < .001) nurses reported higher compliance with infection control practices than younger and white non-Hispanic nurses.

CONCLUSION

These findings suggest that efforts to improve compliance with infection control practices in home healthcare should focus on strategies to alter perceptions about infection risk and other attitudinal factors.

Beyond the hospital infection control guidelines: a qualitative study using positive deviance to characterize gray areas and to achieve efficacy and clarity in the prevention of healthcare-associated infections

Background

The literature is replete with attempts to design and promote customized guidelines to reduce infections during the care continuum. Paradoxically, these efforts sometimes result in gray areas where many staff members are unaware of what is required of them, which then leads to confusion, frustration, and uncertainty.

We coined the phrase “gray areas” in this context to encompass the variety of situations on the care continuum that are not addressed in the accepted guidelines, and where staff members are unsure of how to proceed.

The purpose of the present study was to characterize the gray areas that were reported by staff and to identify the practices of Positive Deviance (PD) individuals. We define to PD individuals as people who independently develop creative solutions to solve problems not identified by the majority in their community.

Methods

A qualitative constructivist research methodology was used that included personal interviews, observations and video recordings of identified PD practices to enhance infection control. The study was conducted January through March 2018, in two Intensive Care Units (ICU) units at Hadassah Hospital, Jerusalem, Israel. Personal interviews were conducted with 82 staff members from the General ICU (GICU) and Medical ICU (MICU).

Results

The study confirmed that guidelines cannot cover all the different situations that arise during the care continuum and can paradoxically result in the increased spread of hospital infections. Our study found there are numerous individuals who independently develop and implement solutions for gray areas. The creative and practical solutions of PD individuals can address the barriers and difficulties on the care continuum that were encountered by the staff in their communities. For example, inserting a central venous line is a complex practice in the general guidelines, while the PDs provided clear situation-specific solutions not covered in the guidelines.

Conclusions

The recommendations of the present study are to encourage hospital personnel to create their own solutions for various situations on the care continuum, and to disseminate them within their units to achieve a bottom up change, in lieu of investing in new or specific written guidelines.

Electronic supplementary material

The online version of this article (10.1186/s13756-018-0418-x) contains supplementary material, which is available to authorized users.