‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene

Adapting the WHO hand hygiene 'reminders in the workplace' to improve acceptability for healthcare workers in maternity settings worldwide: a mixed methods study

INTRODUCTION

Hand hygiene is key in preventing healthcare-associated infections, but it is challenging in maternity settings due to high patient turnover, frequent emergencies and volume of aseptic procedures. We sought to investigate if adaptions to the WHO hand hygiene reminders could improve their acceptability in maternity settings globally, and use these findings to develop new reminders specific to maternity settings.

METHODS

Informed by Sekhon et al's acceptability framework, we conducted an online survey, semi-structured interviews and a focus group examining the three WHO central hand hygiene reminders ('your five moments of hand hygiene', 'how to hand wash' and 'how to hand rub') and their acceptability in maternity settings. A convergent mixed-methods study design was followed. Findings were examined overall and by country income status. A WHO expert working group tested the integrated findings, further refined results and developed recommendations to improve acceptability for use in the global maternity community. Findings were used to inform the development of two novel and acceptable hand hygiene reminders for use in high-income country (HIC) and low- and middle-income country (LMIC) maternity settings.

RESULTS

Participation in the survey (n=342), semi-structured interviews (n=12) and focus group (n=7) spanned 51 countries (14 HICs and 37 LMICs). The highest scoring acceptability constructs were clarity of the intervention (intervention coherence), confidence in performance (self-efficacy), and alignment with personal values (ethicality). The lowest performing were perceived difficulty (burden) and how the intervention made the participant feel (affective attitude). Overfamiliarity reduced acceptability in HICs (perceived effectiveness). In LMICs, resource availability was a barrier to implementation (opportunity cost). Two new reminders were developed based on the findings, using inclusive female images, and clinical examples from maternity settings.

CONCLUSION

Following methodologically robust adaptation, two novel and inclusive maternity-specific hand hygiene reminders have been developed for use in both HIC and LMICs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of a multimodal prevention strategy on dialysis-associated infection events in outpatients receiving haemodialysis: The DIPS stepped wedge, cluster-randomized trial

OBJECTIVES

Patients with haemodialysis catheters are susceptible to dialysis-associated infections, particularly bloodstream infections. There have been few systematic attempts to reduce this burden. Our study aimed to investigate the effect of a multimodal prevention strategy on dialysis-associated infection events (DAIE) among haemodialysis outpatients.

METHODS

A multicentre, stepped wedge, cluster-randomized controlled trial was done from October 2019 to September 2021. Outpatient dialysis facilities entered into the intervention phase in three randomly assigned clusters, at three predefined time points. The multimodal prevention strategy consisted of infection surveillance and hand hygiene (HH) compliance observation with active feedback and teaching aseptic procedures, and a patient flyer. The primary outcome was incidence rates of different DAIE, such as bloodstream infections, intravenous antimicrobial starts, and local access-site infections per 1000 dialysis. As secondary outcome, we analysed the HH compliance change.

RESULTS

A total of 43 haemodialysis outpatient facilities with 11 251 patients and 1 413 457 proceeded haemodialysis were included in the DIPS-trial. Incidence rates were 0.71 DAIE per 1000 dialysis (95% CI, 0.65-0.78) in the control and 0.31 (95% CI, 0.27-0.36) in the intervention group. The univariable analysis yielded an incidence rate ratio (IRR) of 0.44 (95% CI, 0.33-0.59) for DAIE. Especially in patients with a central venous catheter, we saw a significant decrease in DAIE in the intervention group (IRR 0.4; 95% CI, 0.28-0.58). The HH observation combined with feedback and intensified training, resulted in an increase of HH compliance from 58-65%.

DISCUSSION

A multimodal prevention strategy showed a significant preventive effect on DAIE among haemodialysis outpatients. This reduction also applied to bloodstream infections, especially in patients with a central venous catheter.

Indication-based and patient-based hand hygiene performance among nurses working at a university hospital

The traditional method of monitoring hand hygiene (HH) based on specific indications does not ensure that HH is performed for all required indications during patient care. This study aimed to compare HH performance rates (HHPRs) based on specific indications versus overall patient care among nurses at a university hospital. The study retrospectively analyzed HH monitoring data for 1398 indications from 543 patients and 190 nurses. Observations were conducted continuously, tracking a single healthcare worker from before patient contact until the end of the contact within a 30-min period. The indication-based HHPR was found to be 89.1%, while the patient-based HHPR was 78.1%. In the context of patient-based HHPR, the lowest rates were observed among nurses in the emergency room (48.3%) and those with less than 1 year of work experience (66.7%). Moreover, the largest discrepancy between indication-based and patient-based HHPR was noted among emergency room nurses with less than 1 year of experience. This significant difference underscores the need for patient-based HH monitoring, particularly for nurses in emergency settings and those with limited experience.

Interaction between overconfidence effects and training formats in nurses' education in hand hygiene

BACKGROUND

Undergraduate training in hand hygiene is a keystone of infection control. Several studies have shown overconfidence effects in hand hygiene practices, which can impair metacognition. We hypothesized that overconfidence might be prevalent in the early education stages of nursing students and that these effects could be reduced through frequent interactive learning formats, such as learning groups.

METHODS

We conducted a multicenter cross-sectional questionnaire with 196 German nursing students, including general, surgical, and anesthetic nursing specializations.

RESULTS

Overconfidence was observed in nursing students across all specialties and years of education. The cluster analyses showed three different types of learners: two characterized by overconfidence and one demonstrating justifiable confidence. Furthermore, the moderation analysis indicated that providing feedback and promoting metacognition regarding students' learning achievements could mitigate overplacement, particularly through the frequent implementation of interactive teaching formats.

DISCUSSION

Despite some limitations, these findings highlight the prevalence of overconfidence effects in nursing students, the presence of different learning profiles, and the importance of incorporating feedback within interactive learning formats concerning hand hygiene. Accordingly, educators need to be trained and supervised to deliver these learning formats and provide feedback to students effectively.

Hand hygiene in emergencies: Multiprofessional perceptions from a mixed methods based online survey in Germany

Introduction

Despite high vulnerability to infection, hand disinfection compliance in emergencies is low. This is regularly justified as the disinfection procedure delays life support, and instead, wearing disposable gloves is preferred. Simulation studies showed higher achievable compliance than detected in real-life situations. This study aimed to explore healthcare providers' attitudes toward hand disinfection and using gloves in emergencies.

Methods

We conducted an anonymous online survey in Germany on the attitude and subjective behavior in the five moments of hand hygiene in a closed environment and an open convenience sampling survey. Statistics included paired student's t-tests corrected for multiple testing. For qualitative analysis, we employed a single-coder approach.

Results

In 400 participants, we detected low priority of WHO-1 (before touching a patient) and WHO-2 (before clean/aseptic procedure) hand hygiene moments, despite knowing the risks of omission of hand disinfection. For all moments, self-assessment exceeded the assessment of colleagues (p < 0.001). For WHO-3, we detected a lower disinfection priority for wearing gloves compared to contaminated bare hands. Qualitative analyses revealed five themes: basic conditions, didactic implementations, cognitive load, and uncertainty about feasibility and efficacy.

Discussion

Considering bias, the study's subjective nature, the unknown role of emergency-related infections contributing to hospital-acquired infections, and different experiences of healthcare providers, we conclude that hand disinfection before emergencies is de-prioritized and justified by the emergency situation regardless of the objective feasibility.

Conclusion

This study reveals subjective and objective barriers to implementation of WHO-1 and WHO-2 moments of hand disinfection to be further evaluated and addressed in educational programs.

Should automated electronic hand-hygiene monitoring systems be implemented in routine patient care? Systematic review and appraisal with Medical Research Council Framework for Complex Interventions

Manual hand-hygiene audit is time-consuming, labour-intensive and inaccurate. Automated hand-hygiene monitoring systems (AHHMSs) offer advantages (generation of standardized data, avoidance of the Hawthorne effect). World Health Organization Guidelines for Hand Hygiene published in 2009 suggest that AHHMSs are a possible alternative. The objective of this review was to assess the current state of the literature for AHHMSs and offer recommendations for use in real-world settings. This was a systematic literature review, and publications included were from the time that PubMed commenced until 19th November 2023. Forty-three publications met the criteria. Using the Medical Research Council's Framework for Developing and Evaluating Complex Interventions, two were categorized as intervention development studies. Thirty-nine were evaluations. Two described implementation in real-world settings. Most were small scale and short duration. AHHMSs in conjunction with additional intervention (visual or auditory cue, performance feedback) could increase hand hygiene compliance in the short term. Impact on infection rates was difficult to determine. In the few publications where costs and resources were considered, time devoted to improving hand hygiene compliance increased when an AHHMS was in use. Health workers' opinions about AHHMSs were mixed. In conclusion, at present too little is known about the longer-term advantages of AHHMSs to recommend uptake in routine patient care. Until more longer-term accounts of implementation (over 12 months) become available, efforts should be made to improve direct observation of hand hygiene compliance to improve its accuracy and credibility. The Medical Research Council Framework could be used to categorize other complex interventions involving use of technology to prevent infection to help establish readiness for implementation.

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.

Knowledge, Attitudes, and Practices of Hand Hygiene, Mask Use, and Social Distancing among Public Hospital and Polyclinic Nurses in Barbados during the Coronavirus 2019 Pandemic

BACKGROUND

Nurses are essential members of the healthcare workforce and were among the first-line carers for patients in community and hospital settings during the COVID-19 pandemic. As a result, they were at a heightened risk of infection, resulting in several reported deaths among nursing staff. Several preventive measures were adopted to contain the spread of the COVID-19 virus. This study aims to explore the knowledge, attitudes, and practices (KAP) of nurses regarding hand hygiene, mask wearing, and social distancing measures in healthcare settings in Barbados during the COVID-19 pandemic.

METHOD

An online survey of nurses working in public hospitals and polyclinics (public primary care clinics) in Barbados from March 2021 to December 2021 was conducted. A nonsystematic convenience sampling method was employed to recruit nurses who were readily available and willing to participate. A questionnaire captured the sociodemographic information and knowledge and practices related to hand hygiene, the use of face masks, and social distancing. Each correct response received one mark. Overall knowledge scores were categorized as poor (<60%), average (60-80%), or good (>80-100%).

RESULTS

Of the 192 participants, the majority were female (82.8%) and had >5 years of experience (82%). The findings revealed that 45.8% had poor knowledge of hand hygiene, and that the knowledge of 43.8% of respondents was average. Multivariable logistic regression showed that, after adjustment for age and gender, registered nurses had 2.1 times increased odds (95% confidence interval 1.0, 4.2) of having good knowledge compared to other nursing categories. Regarding mask wearing, 53.6% of nurses had average knowledge, and 27.1% had good knowledge. Multivariable logistic regression showed that, after adjustment for age and gender, registered nurses had 3.3 times increased odds (95% confidence interval 1.5, 7.4) of having good knowledge compared to nursing assistants. A total of 68.6% of respondents followed the correct steps of handwashing every time, and 98.3% wore a mask in public places. More than half of the nurses (51.2%) kept a safe distance from others to avoid spreading SARS-CoV-2; one-third were in a crowded place(s) in the past three months, and 55.8% usually followed guidelines for social isolation as recommended by the WHO.

CONCLUSIONS

The study identified knowledge deficiencies related to hand hygiene and wearing masks among nurses. It is imperative to provide additional training on infection control measures.

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.

To Analyze and Evaluate the Rate of Compliance of Hand Hygiene Practices in a Tertiary Care Hospital: Initiation of Quality Improvement Program and Clinical Audit

INTRODUCTION

Health care as a service organization is associated with hospital-acquired infection which is drawing attention. There are concerns raised by patients, attenders, stake holders, insurers, government agencies, and regulatory bodies. The study aims to evaluate the awareness and the rate of compliance with hand hygiene.

METHODS

The audit methodology implemented is a concurrent medical record audit. The period of the audit was conducted for 6 months. A random sampling method was incorporated. The sample size was determined as 20% of the staff had been involved.

RESULTS

The Total average level of awareness of hand hygiene and adherence to policy is 93.6%. The average of all the 3 categories of compliance at 5 levels of hand hygiene in percentage is 82.3%.

DISCUSSION

Hand hygiene practices if stringently implemented will minimize the cross-transmission of infection in health care facilities. By knowing the awareness level and compliance level are measured with standardized training modules.

APPLICATIONS

Create awareness on hand hygiene and provide training with respect to the effectiveness of implementation. Incorporate hand hygiene steps as well as in the audit process.

CONCLUSIONS

There is a requirement for training with respect to the effectiveness of the implementation of the techniques. The level of care and quality of services can be made better by incorporating quality improvement programs (QIPs). By regular audits, we can raise the service quality and benchmark it.

Supporting patients and their carers to participate in infection prevention and control activities: The views of patients, family members, and hospital staff from Bangladesh, Indonesia, and South Korea

BACKGROUND

Hand hygiene reminders for healthcare workers (HCWs) are commonly used to empower patients. However, this approach overlooks the role of family carers in delivering direct contact care in Asian countries. Limited knowledge exists regarding empowerment strategies for patients and their family carers in infection prevention and control (IPC) recommendations. This study aimed to provide a comprehensive exploration of IPC empowerment within the context of family involvement in care provision across Bangladesh, Indonesia, and South Korea.

METHODS

In-depth interviews were conducted in 5 tertiary-level hospitals in Bangladesh, Indonesia, and South Korea. A total of 64 participants were interviewed through 57 interviews, including 6 group interviews, comprising 2 groups: (1) patients and their family and private carers; and (2) HCWs.

RESULTS

The study identified barriers to engaging patients and family carers in IPC measures. These included concerns about the patient-HCW hierarchical relationship, lack of knowledge about healthcare-associated infection, IPC, and patient zone, perceptions of IPC as a barrier to family connections, and disempowerment of patients in IPC due to family bonds.

CONCLUSIONS

This study provides diverse perspectives on IPC empowerment, revealing challenges faced by patients, family carers, and HCWs. The interlaced relationship established by social norms of family carer provision hinders the empowerment of family carers. Acknowledging the cultural influence on health care arrangements and its implication for IPC empowerment is crucial in mitigating these barriers.

Perioperative Urinary Catheter Use and Association to (Gram-Negative) Surgical Site Infection after Spine Surgery

This study evaluates potential associations between the perioperative urinary catheter (UC) carriage and (Gram-negative) surgical site infections (SSIs) after spine surgery. It is a retrospective, single-center, case-control study stratifying group comparisons, case-mix adjustments using multivariate logistic regression analyses. Around half of the patients (2734/5485 surgeries) carried a UC for 1 day (median duration) (interquartile range, 1-1 days). Patients with perioperative UC carriage were compared to those without regarding SSI, in general, and Gram-negative, exclusively. The SSI rate was 1.2% (67/5485), yielding 67 revision surgeries. Gram-negative pathogens caused 16 SSIs. Seven Gram-negative episodes revealed the same pathogen concomitantly in the urine and the spine. In the multivariate analysis, the UC carriage duration was associated with SSI (OR 1.1, 95% confidence interval 1.1-1.1), albeit less than classical risk factors like diabetes (OR 2.2, 95%CI 1.1-4.2), smoking (OR 2.4, 95%CI 1.4-4.3), or higher ASA-Scores (OR 2.3, 95%CI 1.4-3.6). In the second multivariate analysis targeting Gram-negative SSIs, the female sex (OR 3.8, 95%CI 1.4-10.6) and a UC carriage > 1 day (OR 5.5, 95%CI 1.5-20.3) were associated with Gram-negative SSIs. Gram-negative SSIs after spine surgery seem associated with perioperative UC carriage, especially in women. Other SSI risk factors are diabetes, smoking, and higher ASA scores.

COVID-19 on the spectrum: a scoping review of hygienic standards

The emergence of COVID-19 in Wuhan, China, rapidly escalated into a worldwide public health crisis. Despite numerous clinical treatment endeavors, initial defenses against the virus primarily relied on hygiene practices like mask-wearing, meticulous hand hygiene (using soap or antiseptic solutions), and maintaining social distancing. Even with the subsequent advent of vaccines and the commencement of mass vaccination campaigns, these hygiene measures persistently remain in effect, aiming to curb virus transmission until the achievement of herd immunity. In this scoping review, we delve into the effectiveness of these measures and the diverse transmission pathways, focusing on the intricate interplay within the food network. Furthermore, we explore the virus's pathophysiology, considering its survival on droplets of varying sizes, each endowed with distinct aerodynamic attributes that influence disease dispersion dynamics. While respiratory transmission remains the predominant route, the potential for oral-fecal transmission should not be disregarded, given the protracted presence of viral RNA in patients' feces after the infection period. Addressing concerns about food as a potential viral vector, uncertainties shroud the virus's survivability and potential to contaminate consumers indirectly. Hence, a meticulous and comprehensive hygienic strategy remains paramount in our collective efforts to combat this pandemic.

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.

Hand hygiene compliance and associated factors among healthcare workers in selected tertiary-care hospitals in Bangladesh

BACKGROUND

Hand hygiene (HH) is a fundamental element of patient safety. Adherence to HH among healthcare workers (HCWs) varies greatly depending on a range of factors, including risk perceptions, institutional culture, auditing mechanisms, and availability of HH supplies.

AIMS

This study aimed to evaluate HH compliance and associated factors among HCWs in selected tertiary-care hospitals in Bangladesh.

METHODS

During September 2020 to May 2021, we conducted non-participatory observations at 10 tertiary-care hospitals using the WHO's '5-moments for hand hygiene tool' to record HH compliance among physicians, nurses and cleaning staff. We also performed semi-structured interviews to determine the key barriers to complying with HH.

RESULTS

We observed 14,668 hand hygiene opportunities. The overall HH compliance was 25.3%, the highest among nurses (28.5%), and the lowest among cleaning staff (9.9%). HCWs in public hospitals had significantly higher odds of complying with HH practices than those in private hospitals (adjusted odds ratio: 1.73, 95% CI: 1.55-1.93). The odds of performing HH after touching a patient were 3.36 times higher compared with before touching a patient (95% CI: 2.90-3.90). The reported key barriers to performing HH were insufficient supplies (57.9%), skin reactions (26.3%), workload (26.3%) and lack of facilities (22.7%). Overall, observed HH supplies were available in 81.7% of wards for physicians and 95.1% of wards for nurses, however, no designated HH facilities were found for the cleaning staff.

CONCLUSIONS

HH compliance among HCWs fell significantly short of the standard for safe patient care. Inadequate HH supplies demonstrate a lack of prioritizing, promoting and investing in infection prevention and control.

Quality Improvement Project to Improve Hand Hygiene Compliance in a Level III Neonatal Intensive Care Unit

This quality improvement project aimed to improve hand hygiene (HH) compliance in a Level III Neonatal Intensive Care Unit. The project was conducted over three Plan-Do-Study-Act (PDSA) cycles, with each cycle lasting two months. The interventions included healthcare worker (HCW) education on HH, repetition of education, and immediate feedback to HCWs. Compliance data were collected through covert observations of HCWs in the NICU. The overall compliance rate increased from 31.56% at baseline to 46.64% after the third PDSA cycle. The HH compliance was noted to be relatively low after touching patient care surroundings, at entry and exit from the NICU main unit, before wearing gloves and after removing gloves, at baseline and throughout the three PDSA cycles. HCW education alone did not result in significant improvements, highlighting the need for additional interventions. The study underscores the importance of involving NICU leadership and providing immediate feedback to promote HH compliance. Further efforts should focus on addressing the false sense of security associated with glove usage among HCWs, individual rewards and involving the healthcare staff in the shared goal of increasing HH compliance. Consideration of workload metrics and their impact on compliance could steer future interventions.

Preventing Multidrug-Resistant Bacterial Transmission in the Intensive Care Unit with a Comprehensive Approach: A Policymaking Manual

Patients referred to intensive care units (ICU) commonly contract infections caused by multidrug-resistant (MDR) bacteria, which are typically linked to complications and high mortality. There are numerous independent factors that are associated with the transmission of these pathogens in the ICU. Preventive multilevel measures that target these factors are of great importance in order to break the chain of transmission. In this review, we aim to provide essential guidance for the development of robust prevention strategies, ultimately ensuring the safety and well-being of patients and healthcare workers in the ICU. We discuss the role of ICU personnel in cross-contamination, existing preventative measures, novel technologies, and strategies employed, along with antimicrobial surveillance and stewardship (AMSS) programs, to construct effective and thoroughly described policy recommendations. By adopting a multifaceted approach that combines targeted interventions with broader preventive strategies, healthcare facilities can create a more coherent line of defense against the spread of MDR pathogens. These recommendations are evidence-based, practical, and aligned with the needs and realities of the ICU setting. In conclusion, this comprehensive review offers a blueprint for mitigating the risk of MDR bacterial transmission in the ICU, advocating for an evidence-based, multifaceted approach.

Using community theater to improve demand for vaccination services in the Niger Delta Region of Nigeria

INTRODUCTION

Despite abundant evidence showing immunization as a lifesaving public health measure, a large proportion of Nigerian children are still not or fully vaccinated. Lack of awareness and distrust of the immunization process by caregivers are some of the reasons for poor immunization coverage which need to be addressed. This study aimed at improving vaccination demand, acceptance and uptake in Bayelsa and Rivers State, both in the Niger Delta Region (NDR) of Nigeria through a human-centered process of trust building, education and social support.

METHODS

A quasi-experimental intervention christened Community Theater for Immunization (CT4I) was deployed in 18 selected communities between November 2019 and May 2021 in the two states. In the intervention localities, relevant stakeholders including the leadership of the health system, community leaders, health workers and community members were engaged and actively involved in the design and performance of the theaters. The content for the theater showcased real stories, using a human-centered design (HCD) of ideation, co-creation, rapid prototyping, feedback collection and iteration. Pre- and post-intervention data on the demand and utilization of vaccination services were collected using a mixed method.

RESULTS

In the two states, 56 immunization managers and 59 traditional and religious leaders were engaged. Four broad themes implicating user and provider factors emerged from the 18 focus group discussions as responsible for low immunization uptake in the communities. Of the 217 caregivers trained on routine immunization and theater performances, 72% demonstrated a knowledge increase at the post-test. A total of 29 performances attended by 2,258 women were staged with 84.2% of the attendees feeling satisfied. At the performances, 270 children received vaccine shots (23% were zero-dose). There was a 38% increase in the proportion of fully immunized children in the communities and 9% decline in the proportion of zero-dose children from baseline.

CONCLUSION

Both demand- and supply-side factors were identified as responsible for poor vaccination in the intervention communities. Our intervention demonstrates that caregivers will demand immunization services if they are engaged through community theater using a human-centered design (HCD). We recommend a scaling up of HCD to address the challenge of vaccine hesitancy.

Safe infant feeding in healthcare facilities: Assessment of infection prevention and control conditions and behaviors in India, Malawi, and Tanzania

Infants need to receive care in environments that limit their exposure to pathogens. Inadequate water, sanitation, and hygiene (WASH) environments and suboptimal infection prevention and control practices in healthcare settings contribute to the burden of healthcare-associated infections, which are particularly high in low-income settings. Specific research is needed to understand infant feeding preparation in healthcare settings, a task involving multiple behaviors that can introduce pathogens and negatively impact health. To understand feeding preparation practices and potential risks, and to inform strategies for improvement, we assessed facility WASH environments and observed infant feeding preparation practices across 12 facilities in India, Malawi, and Tanzania serving newborn infants. Research was embedded within the Low Birthweight Infant Feeding Exploration (LIFE) observational cohort study, which documented feeding practices and growth patterns to inform feeding interventions. We assessed WASH-related environments and feeding policies of all 12 facilities involved in the LIFE study. Additionally, we used a guidance-informed tool to carry out 27 feeding preparation observations across 9 facilities, enabling assessment of 270 total behaviors. All facilities had 'improved' water and sanitation services. Only 50% had written procedures for preparing expressed breastmilk; 50% had written procedures for cleaning, drying, and storage of infant feeding implements; and 33% had written procedures for preparing infant formula. Among 270 behaviors assessed across the 27 feeding preparation observations, 46 (17.0%) practices were carried out sub-optimally, including preparers not handwashing prior to preparation, and cleaning, drying, and storing of feeding implements in ways that do not effectively prevent contamination. While further research is needed to improve assessment tools and to identify specific microbial risks of the suboptimal behaviors identified, the evidence generated is sufficient to justify investment in developing guidance and programing to strengthen infant feeding preparation practices to ensure optimal newborn health.

WHO "My Five Moments for hand hygiene" in anaesthesia induction: a video-based analysis reveals novel system challenges and design opportunities

BACKGROUND

Anaesthesia induction is a fast-paced, complex activity that involves a high density of hand-to-surface exposures. Hand hygiene (HH) adherence has been reported to be low, which bears the potential for unnoticed pathogen transmission between consecutive patients. Therefore, we aimed to study the fit of the WHO's five moments of HH concept to the anaesthesia induction workflow.

METHODS

We analysed video recordings of 59 anaesthesia inductions according to the WHO HH observation method considering each hand-to-surface exposure of every involved anaesthesia provider. Binary logistic regression was used to determine risk factors for non-adherence, i.e., professional category, gender, task role, gloves, holding of objects, team size and HH moment. Additionally, we re-coded half of the videos for self-touching behaviour for quantitative and qualitative analysis.

RESULTS

Overall, 2240 HH opportunities were met by 105 HH actions (4.7%). The drug administrator role (OR=2.2), the senior physician status (OR=2.1), donning (OR=2.6) and doffing (OR=3.6) of gloves were associated with higher HH adherence. Notably, 47.2% of all HH opportunities were caused by self-touching behaviour. Provider clothes, face, and patient skin were the most frequently touched surfaces.

CONCLUSIONS

The high density of hand-to-surface exposures, a high cognitive load, prolonged glove use, carried mobile objects, self-touching, and personal behaviour patterns were potential causes for non-adherence. A purpose-designed HH concept based on these results, involving the introduction of designated objects and provider clothes to the patient zone, could mitigate HH adherence and microbiologic safety.

A methodology for using Lambda phages as a proxy for pathogen transmission in hospitals

BACKGROUND

One major concern in hospitalized patients is acquiring infections from pathogens borne on surfaces, patients, and healthcare workers (HCWs). Fundamental to controlling healthcare-associated infections is identifying the sources of pathogens, monitoring the processes responsible for their transmission, and evaluating the efficacy of the procedures employed for restricting their transmission.

AIM

To present a method using the bacteriophage Lambda (λ) to achieve these ends.

METHODS

Defined densities of multiple genetically marked λ phages were inoculated at known hotspots for contamination on high-fidelity mannequins. HCWs then entered a pre-sanitized simulated hospital room and performed a series of patient care tasks on the mannequins. Sampling occurred on the scrubs and hands of the HCWs, as well as previously defined high-touch surfaces in hospital rooms. Following sampling, the rooms were decontaminated using procedures demonstrated to be effective. Following the conclusion of the simulation, the samples were tested for the presence, identity, and densities of these λ phages.

FINDINGS

The data generated enabled the determination of the sources and magnitude of contamination caused by the breakdown of established infection prevention practices by HCWs. This technique enabled the standardized tracking of multiple contaminants during a single episode of patient care. Unlike other biological surrogates, λ phages are susceptible to common hospital disinfectants, and allow for a more accurate evaluation of pathogen transmission.

CONCLUSION

Whereas our application of these methods focused on healthcare-associated infections and the role of HCW behaviours in their spread, these methods could be employed for identifying the sources and sites of microbial contamination in other settings.

Wireless Body Area Network for Preventing Self-Inoculation Transmission of Respiratory Viral Diseases

This paper proposes an idea of Wireless Body Area Networks (WBANs) based on Bluetooth Low-Energy (BLE) standards to recognize and alarm a gesture of touching the face, and in effect, to prevent self-inoculation of respiratory viral diseases, such as COVID-19 or influenza A, B, or C. The proposed network comprises wireless modules placed in bracelets and a necklace. It relies on the received signal strength indicator (RSSI) measurements between the bracelet and necklace modules. The measured signal is cleared of noise using the exponential moving average (EMA). Next, we use a classification algorithm based on a Least-Squares Support Vector Machine (LSSVM) in order to detect facial touches. When the results of the classification indicate that the hand is moving toward the face, an alarm is sent through the neck module and the vibrator embedded in the wrist module is switched on. Based on the performed tests, it can be concluded that the proposed solution is characterized by high accuracy and reliability. It should be useful, especially for individuals who are regularly exposed to the risk of respiratory infections.

The power of feedback: Implementing a comprehensive hand hygiene observer program

BACKGROUND

Hand hygiene (HH) is a fundamental component of infection prevention within all healthcare settings. We implemented a hospital-wide program built on overt HH observation, real-time feedback, and thematic analysis of HH misses.

METHODS

A robust observer training program was established to include foundational training in the WHO's My Five Moments of HH. Observational data from 2011 to 2019 were analyzed by unit, provider type, and thematic analyses of misses.

RESULTS

During the study period, we conducted 160,917 hospital-wide observations on 29 units (monthly average of 1,490 observations). Institutional compliance remained above 95% from 2013 to 2019. Thematic analysis revealed "touching self" and "touching phone" as common, institution-wide reasons for HH misses.

DISCUSSION

Overt observations facilitated communication between HH program and healthcare staff to better understand workflow and educate staff on HH opportunities. This program is an integral part of the Infection Prevention team and has been deployed to collect supplemental data during clusters and outbreaks investigations.

CONCLUSIONS

In addition to having rich HH data, successes of this program, include increased awareness of IPC practices, enhanced communication about patient safety, enriched dialog and feedback around HH misses, and relationship building among program observers, unit staff and leaders.

Developing a design-based concept to improve hand hygiene in the neonatal intensive care unit

BACKGROUND

Hand hygiene (HH) is the most critical measure in the prevention of nosocomial infections in the neonatal intensive care unit (NICU). Improving and sustaining adequate HH compliance rates, however, remains a significant challenge. Using a behavioral change framework and nudge theory, we developed a design-based concept aimed at facilitating and stimulating HH behavior.

METHODS

Concept development was initiated by selecting a theoretical framework after which contextual field studies aimed at discovering causes for poor compliance were conducted. Potential solutions were brainstormed upon during focus group sessions. Low-fidelity prototypes were tested regarding feasibility, usability, and acceptability. A final concept was crafted drawing from findings from each design phase.

RESULTS

Complying with recommended HH guidelines is unrealistic and infeasible due to frequent competing (clinical) priorities requiring HH. The concept "Island-based nursing," where a patient room is divided into two geographical areas, namely, the island and general zone, was created. HH must be performed upon entering and exiting the island zone, and after exposure to any surface within the general zone. Reminding of HH is prompted by illuminated demarcation of the island zone, serving as the concept's nudge.

CONCLUSIONS

Island zone demarcation facilitates and economizes HH indications in an innovative and intuitive manner.

IMPACT

Although hand hygiene (HH) is the single most important element in the prevention of nosocomial infections in neonates, improving and sustaining adequate HH compliance rates remains a significant challenge. Complying with recommended HH guidelines was found to be unrealistic and infeasible due to the significant amount of time required for HH in a setting with a high workload and many competing (clinical) priorities. The concept of "Island-based nursing," under which the primary HH indication is upon entering and exiting the island zone, facilitates and economizes HH indications in an innovative and user-friendly manner.

Indications for hand and glove disinfection in Advanced Cardiovascular Life Support: A manikin simulation study

Background and aim

There are no investigations on hand hygiene during cardiopulmonary resuscitation (CPR), even though these patients are at high risk for healthcare-associated infections. We aimed to evaluate the number of indicated hand hygiene per CPR case in general and the fraction that could be accomplished without delay for other life-saving techniques through standardized observations.

Materials and methods

In 2022, we conducted Advanced Cardiovascular Life Support (ACLS) courses over 4 days, practicing 33 ACLS case vignettes with standard measurements of chest compression fractions and hand hygiene indications. A total of nine healthcare workers (six nurses and three physicians) participated.

Results

A total of 33 training scenarios resulted in 613 indications for hand disinfection. Of these, 150 (24%) occurred before patient contact and 310 (51%) before aseptic activities. In 282 out of 310 (91%) indications, which have the highest impact on patient safety, the medication administrator was responsible; in 28 out of 310 (9%) indications, the airway manager was responsible. Depending on the scenario and assuming 15 s to be sufficient for alcoholic disinfection, 56-100% (mean 84.1%, SD ± 13.1%) of all indications could have been accomplished without delaying patient resuscitation. Percentages were lower for 30-s of exposure time.

Conclusion

To the best of our knowledge, this is the first study investigating the feasibility of hand hygiene in a manikin CPR study. Even if the feasibility is overestimated due to the study setup, the fundamental conclusion is that a relevant part of the WHO indications for hand disinfection can be implemented without compromising quality in acute care, thus increasing the overall quality of patient care.

Hygiene Behavior and COVID-19 Pandemic: Opportunities of COVID-19-Imposed Changes in Hygiene Behavior

In Ethiopia, the WHO strategies to stop coronavirus transmission were implemented rapidly. As a result, there was a rapid change in hygiene behavior, which are basic for preventing COVID-19 and other contagious diseases. This research was designed to examine the sustainability of the COVID-19 imposed hygiene behaviors for future challenges. The study was conducted in 2 major nexus areas in Addis Ababa. The data were collected using a questionnaire and spot-check from 622 respondents selected by systematic random sampling. The questionnaire was given at every 15th interval in several spots of the site. Observational hygiene-check was done through observing key personal hygiene conditions. Proportion, χ2 test, and Poisson's regression were applied for the analysis. The χ2-test analyses showed that the hand washing frequency before, during, and post-COVID-19 was statistically significant (P < .005). Findings from the spot-check also show that the hands of 76.8%, the nails of 68.7%, and the hairs of 70.7% of the respondents were clean. The major driving factors for the rapid changes in hygiene behavior were the awareness developed (95%), the fear and panic (90%), and increased access to water and soap (63%). Nevertheless, the major reasons for failing to continue the COVID-19-imposed good hygiene practice in the post-COVID-19 times include the decline in infection and death rates (26%) and the decline in facility access (20%). Hand washing frequency significantly changed during the COVID-19 pandemic indicating that the practice as part of the preventive strategy was successful. However, as this was mainly due to the fear and panic in the community, the COVID-19 imposed hand washing practice did not bring real and sustainable behavioral changes. This indicates that for long-lasting changes in hygiene behavior, continuous and better approach need to be introduced.

Silica nanoparticles with encapsulated DNA (SPED) to trace the spread of pathogens in healthcare

Background

To establish effective infection control protocols, understanding pathogen transmission pathways is essential. Non-infectious surrogate tracers may safely explore these pathways and challenge pre-existing assumptions. We used silica nanoparticles with encapsulated DNA (SPED) for the first time in a real-life hospital setting to investigate potential transmission routes of vancomycin-resistant enterococci in the context of a prolonged outbreak.

Methods

The two study experiments took place in the 900-bed University Hospital Zurich, Switzerland. A three-run ‘Patient experiment’ investigated pathogen transmission via toilet seats in a two-patient room with shared bathroom. First, various predetermined body and fomite sites in a two-bed patient room were probed at baseline. Then, after the first patient was contaminated with SPED at the subgluteal region, both patients sequentially performed a toilet routine. All sites were consequently swabbed again for SPED contamination. Eight hours later, further spread was tested at predefined sites in the patient room and throughout the ward. A two-run ‘Mobile device experiment’ explored the potential transmission by mobile phones and stethoscopes in a quasi-realistic setting. All SPED contamination statuses and levels were determined by real-time qPCR.

Results

Over all three runs, the ‘Patient experiment’ yielded SPED in 59 of 73 (80.8%) predefined body and environmental sites. Specifically, positivity rates were 100% on subgluteal skin, toilet seats, tap handles, and entertainment devices, the initially contaminated patients’ hands; 83.3% on patient phones and bed controls; 80% on intravenous pumps; 75% on toilet flush plates and door handles, and 0% on the initially not contaminated patients’ hands. SPED spread as far as doctor’s keyboards (66.6%), staff mobile phones (33.3%) and nurses’ keyboards (33.3%) after eight hours. The ‘Mobile device experiment’ resulted in 16 of 22 (72.7%) positive follow-up samples, and transmission to the second patient occurred in one of the two runs.

Conclusions

For the first time SPED were used to investigate potential transmission pathways in a real hospital setting. The results suggest that, in the absence of targeted cleaning, toilet seats and mobile devices may result in widespread transmission of pathogens departing from one contaminated patient skin region.

Paradoxes of pandemic infection control: Proximity, pace and care within and beyond SARS-CoV-2

From the adoption of mask-wearing in public settings to the omnipresence of hand-sanitising, the SARS-CoV-2 pandemic has brought unprecedented cultural attention to infection prevention and control (IPC) in everyday life. At the same time, the pandemic threat has enlivened and unsettled hospital IPC processes, fracturing confidence, demanding new forms of evidence, and ultimately involving a rapid reassembling of what constitutes safe care. Here, drawing on semi-structured interviews with 63 frontline healthcare workers from two states in Australia, interviewed between September 2020 and March 2021, we illuminate some of the affective dimensions of IPC at a time of rapid change and evolving uncertainty. We track how a collective sense of risk and safety is relationally produced, redefining attitudes and practices around infective risk, and transforming accepted paradigms of care and self-protection. Drawing on Puig de la Bellacasa's formulation, we propose the notion of IPC as a multidimensional matter of care. Highlighting the complex negotiation of space and time in relation to infection control and care illustrates a series of paradoxes, the understanding of which helps illuminate not only how IPC works, in practice, but also what it means to those working on the frontline of the pandemic.

Effectiveness and sustainability of the WHO multimodal hand hygiene improvement strategy in the University Hospital Bouaké, Republic of Côte d'Ivoire in the context of the COVID-19 pandemic

Introduction

The most frequent adverse events in healthcare are healthcare-associated infections, whose burden is highest in resource-limited settings. In addition, low resource settings often lack Hand Hygiene (HH) knowledge and reliable supply to disinfectant, a necessity emphasized by the past West African Ebola Epidemic and the ongoing COVID-19 pandemic. PASQUALE aims to increase patient safety by introducing the WHO multimodal HH strategy in the University Hospital Bouaké, Côte d’Ivoire.

Methods

Assessment of HH knowledge, perception and compliance was performed 12 months before, right after the intervention and at a ten months interval using questionnaires for knowledge and perception and direct observation for compliance. The intervention consisted of a HH training and the introduction of local production of alcohol-based hand-rub. In the absence of a control group, the effectiveness of the intervention was assessed by a before-and-after study.

Results

Baseline knowledge score was 14/25, increased significantly to 17/25 (p < 0.001) upon first and decreased to 13/25 in second follow-up. Compliance showed a significant increase from 12.7% to 36.8% (p < 0.001) in first and remained at 36.4% in second follow-up. Alcohol-based hand-rub production and consumption almost doubled after first confirmed COVID-19 case in Côte d’Ivoire.

Conclusion

The WHO HH improvement strategy is an effective and pandemic-adaptable method to increase long-term HH compliance. This study emphasizes that the implementation of the strategy to build a robust system is of utmost importance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-01032-4.

A multi-centre study of the effects of direct observation of hand hygiene practices on alcohol-based handrub consumption

Introduction

The World Health Organization recommends monitoring alcohol-based handrub (ABHR) consumption and direct observation of hand hygiene practices to ensure compliance. In Japan monitoring of ABHR consumption is widely performed. However, direct observation is not common, particularly in small facilities and non-acute-care facilities. Hence, the current study aimed to evaluate the longitudinal effects of direct observation of hand hygiene practices and monitoring of ABHR consumption with provision of feedback to healthcare personnel on ABHR consumption and hand hygiene compliance.

Methods

We conducted a 4-year prospective intervention study. Monitoring of ABHR consumption and direct observation of hand hygiene practices with monthly feedback to healthcare personnel was implemented in 17 facilities. These consisted of 11 acute-care facilities of varying sizes and six non-acute-care facilities. A generalized linear mixed model analysis was performed to assess factors associated with ABHR consumption.

Results

All facilities implemented ABHR consumption monitoring within one month of starting the study. However, the mean time required to implement direct observation of hand hygiene practices was 24.7 (±19.1) months. The ABHR consumption increased significantly (P<0.0001) in all medical facilities after implementing the direct observation. Multivariable regression analysis showed the hospital ward type, duration of ABHR consumption monitoring, and duration of direct observation of hand hygiene practices were independently associated with ABHR consumption.

Conclusions

Direct observation of hand hygiene practices with feedback should be implemented more widely in combination with ABHR consumption monitoring to help increase hand hygiene compliance.

A controlled before-and-after study of a multi-modal intervention to improve hand hygiene during the peri-natal period in Cambodia

Adequate hand hygiene practices throughout the continuum of care of maternal and newborn health are essential for infection prevention. However, the hand hygiene compliance of facility-based birth attendants, parents and other caregivers along this continuum is low and behavioural-science informed interventions targeting the range of caregivers in both the healthcare facility and home environments are scarce. We assessed the limited efficacy of a novel multimodal behaviour change intervention, delivered at the facility, to improve the hand hygiene practices among midwives and caregivers during childbirth through the return to the home environment. The 6-month intervention was implemented in 4 of 8 purposively selected facilities and included environmental restructuring, hand hygiene infrastructure provision, cues and reminders, and participatory training. In this controlled before-and-after study, the hand hygiene practices of all caregivers present along the care continuum of 99 women and newborns were directly observed. Direct observations took place during three time periods; labour, delivery and immediate aftercare in the facility delivery room, postnatal care in the facility ward and in the home environment within the first 48 h following discharge. Multilevel logistic regression models, adjusted for baseline measures, assessed differences in hand hygiene practices between intervention and control facilities. The intervention was associated with increased odds of improved practice of birth attendants during birth and newborn care in the delivery room (Adjusted odds ratio [AOR] = 4.7; 95% confidence interval [CI] = 2.7, 7.7), and that of parental and non-parental caregivers prior to newborn care in the post-natal care ward (AOR = 9.2; CI = 1.3, 66.2); however, the absolute magnitude of improvements was limited. Intervention effects were not presented for the home environment due COVID-19 related restrictions on observation duration at endline which resulted in too low observation numbers to warrant testing. Our results suggest the potential of a facility-based multimodal behaviour change intervention to improve hand hygiene practices that are critical to maternal and neonatal infection along the continuum of care.

Hand Hygiene Practices during the COVID-19 Pandemic in Northern Italy: Assessment of Compliance Rates Measured by Direct Observation and Alcohol-Based Handrub Usage

Hand hygiene (HH) is among the most effective measures for reducing the transmission of healthcare-associated infections and SARS-CoV-2. We aimed to assess HH practices among healthcare workers (HCWs) of three hub hospitals in Northern Italy during the COVID-19 pandemic, by assessing HH compliance measured by direct observation and alcohol-based handrub usage. An observational study was conducted over a period of three months, between February and April 2021. HH compliance audits were conducted using the WHO My 5 Moments for HH approach. Multivariable logistic regression was used to evaluate independent predictors of HH compliance: ward type, HCW category and HH indication. Spearman correlation was used to investigate the relationship between HH compliance and alcohol-based handrub consumption. In total, 2880 HH opportunities were observed, with an overall compliance of 68%. Significant differences were found in compliance rates across ward types, HCW categories and HH indications. The mean alcohol-based handrub usage among included wards was 41.63 mL/PD. No correlation was identified between compliance rates and alcohol-based handrub consumption (ρ 0.023, p 0.943). This study provided a snapshot of HH practices in a pandemic context, which could be useful as a reference for future studies.

Application Effect of Transparent Supervision Based on Informatization in Prevention and Control of Carbapenem-Resistant Klebsiella pneumoniae Nosocomial Infection

Objective

To explore the effect of transparent supervision model on the prevention and control of carbapenem-resistant Klebsiella pneumoniae (CRKP) nosocomial infection and the value of the autoregressive integrated moving average (ARIMA) model in predicting the incidence of CRKP infection.

Methods

A total of 46,873 inpatients from Jiawang District People's Hospital of Xuzhou between January 2019 and December 2019 (prior to COVID-19 prevention and control) were selected as the preintervention group and 45,217 inpatients from January 2020 to December 2020 (after the COVID-19 prevention and control) as the postintervention group. We performed transparent supervision on CRKP patients detected by the real-time monitoring system for nosocomial infection. Incidence and detection rate of CRKP, utilization rate of special grade hydrocarbon enzyme alkene antibiotics, hand hygiene compliance rate, qualified rate of ATP tests on surface of environmental objects, and execution rate of CRKP core prevention and control were compared between the two groups.

Results

Transparent supervision of CRKP-infected patients was conducted daily from January to December 2020, which resulted in the following: (a) the infection rate of CRKP decreased in a fluctuating manner, and the actual value of hydrocarbon alkene use rate was basically the same as the predicted value with an overall decreasing trend; (b) after the intervention, hand hygiene compliance rate increased from 53.30% to 70.24% (P < 0.001) and the ATP qualified rate increased from 53.77% to 92.24% (P < 0.001); (c) the fitted value of the ARIMA model was in good agreement with the actual value. The incidence of CRKP infection and the utilization rate of carbene antibiotics were also in good agreement with the predicted value. The average relative errors were 11% and 10.78%.

Conclusions

During the COVID-19 outbreak in 2020, the ARIMA model effectively fit and predicted the CRKP infection rate, thereby providing scientific guidance for the prevention and control of CRKP infection. In addition, the transparent supervision intervention model improved the hand hygiene compliance and environmental hygiene qualification rates of medical staff, effectively reducing CRKP cross-infection in the hospital.

Rationale and guidance for strengthening infection prevention and control measures and antimicrobial stewardship programs in Bangladesh: a study protocol

BACKGROUND

Hospital-acquired infections (HAIs) and antimicrobial resistance (AMR) are major global health challenges. Drug-resistant infectious diseases continue to rise in developing countries, driven by shortfalls in infection control measures, antibiotic misuse, and scarcity of reliable diagnostics. These escalating global challenges have highlighted the importance of strengthening fundamental infection prevention and control (IPC) measures and implementing effective antimicrobial stewardship programs (ASP). This study aims to present a framework for enhancing IPC measures and ASP efforts to reduce the HAI and AMR burden in Bangladesh.

METHODS

This implementation approach will employ a mixed-methods strategy, combining both quantitative and qualitative data from 12 tertiary hospitals in Bangladesh. A baseline assessment will be conducted using the Infection Prevention and Control Assessment Framework (IPCAF) developed by the WHO. We will record IPC practices through direct observations of hand hygiene, personal protective equipment (PPE) utilization, and hospital ward IPC infrastructure. Additionally, data on healthcare providers' knowledge, attitudes, and practices regarding IPC and antibiotic prescribing will be collected using both structured questionnaires and qualitative interviews. We will also assist the hospital leadership with establishing and/or strengthening IPC and ASP committees. Based on baseline assessments of each healthcare facility, tailored interventions and quality improvement projects will be designed and implemented. An end-line assessment will also be conducted after 12 months of intervention using the same assessment tools. The findings will be compared with the baseline to determine changes in IPC and antibiotic stewardship practices.

DISCUSSION

Comprehensive assessments of healthcare facilities in low-resource settings are crucial for strengthening IPC measures and ASP activities,. This approach to assessing existing IPC and ASP activities will provide policy-relevant data for addressing current shortfalls. Moreover, this framework proposes identifying institutionally-tailored solutions, which will ensure that response activities are appropriately contextualized, aligned with stakeholder priorities, and offer sustainable solutions.

CONCLUSION

Findings from this study can guide the design and implementation of feasible and sustainable interventions in resource-constrained healthcare settings to address gaps in existing IPC and ASP activities. Therefore, this protocol will be applicable across a broad range of settings to improve IPC and ASP and reduce the burden of hospital-acquired infections and AMR.

Dodging the bundle-Persistent healthcare-associated rhinovirus infection throughout the pandemic

INTRODUCTION

Healthcare-associated viral infections (HAVI) are a common cause of patient harm in the pediatric population. We implemented a HAVI prevention bundle in 2015, which included 6 core elements: caregiver screening, symptom-based isolation, personal protective equipment (PPE), hand hygiene, staff illness procedures, and monitoring of environmental cleanliness. Enhanced bundle elements were introduced at the start of the COVID-19 pandemic, which provided an opportunity to observe the effectiveness of the bundle with optimal adherence to prevention practices, and to measure the impact on respiratory HAVI epidemiology.

METHODS

Respiratory HAVIs were confirmed through review of medical records and application of the National Health Safety Network (NHSN) surveillance criteria for upper respiratory infections (URIs) with predetermined incubation periods for unit attribution. Descriptive statistics of the study population were examined, and comparative analyses were performed on demographic and process metrics. Data analysis was conducted using R statistical software.

RESULTS

We observed an overall decrease in respiratory HAVI of 68%, with prepandemic rates of 0.19 infections per 1,000 patient significantly decreased to a rate of 0.06 per 1,000 patient days in the pandemic period (P < .01). Rhinovirus made up proportionally more of our respiratory HAVI in the pandemic period (64% vs 53%), with respiratory HAVI secondary only to rhinovirus identified during 8 of 16 months in the pandemic period. Compliance with our HAVI prevention bundle significantly improved during pandemic period.

CONCLUSIONS

Enhancement of our HAVI bundle during the COVID-19 pandemic contributed toward significant reduction in nosocomial transmission of respiratory HAVI. Even with prevention practices optimized, respiratory HAVIs secondary to rhinovirus continued to be reported, likely due to the capacity of rhinovirus to evade bundle elements in hospital, and infection prevention efforts at large in the community, leaving vulnerable patients at continued risk.

Comparing human to electronic observers to monitor hand hygiene compliance in an intensive care unit

Objective

We sought to determine whether an electronic hand hygiene (HH) system could monitor HH compliance at similar rates to direct human observation.

Methods

This 4-year proof-of-concept study was conducted in an intensive care unit (ICU) of a private tertiary-care hospital in São Paulo, Brazil, where electronic HH systems were installed in 2 rooms. HH compliance was reported respectively using direct observation and electronic counter devices with an infrared system for detecting HH opportunities.

Results

In phase 1, HH compliance by human observers was 56.3% (564 of 1,001 opportunities), while HH compliance detected by the electronic observer was 51.0% (515 of 1,010 opportunities). In phase 2, human observers registered 484 HH opportunities with a HH compliance rate of 64.7% (313 of 484) versus 70.6% (346 of 490) simultaneously detected by the electronic system. In addition, an enhanced HH electronic system monitored activity 24 hours per day and HH compliance without the presence of a human observer was 40.3% (10,642 of 26,421 opportunities), providing evidence for the Hawthorne effect.

Conclusions

The electronic HH monitoring system had good correlation with human HH observation, but compliance was remarkably lower when human observers were not present due to the Hawthorne effect (25%-30% absolute difference). Electronic monitoring systems can replace direct observation and can markedly reduce the Hawthorne effect.

Female-friendly toilets in schools in Burkina Faso: A mixed-methods study using photo-elicitation

Background

An absence of gender-sensitive sanitation facilities in schools and the negative effects this has on girls has been widely discussed among advocacy groups, though less examined in academic spheres. Drawing on triangulated data, we outline current challenges and respondent-driven solutions to enhance the female-friendly nature of toilets in a context of extreme poverty.

Methods

This mixed-methods study was informed by the tenets of human-centred design. We first quantitatively assessed facilities in 14 secondary schools in the Kossi Province of Burkina Faso. We then collected qualitative data, including 15 focus group discussions and 53 in-depth interviews among schoolgirls, mothers, teachers and key informants. We applied photo-elicitation, a novel method, to explore perceptions of facilities and the desirability and feasibility of interventions to improve gender-friendly sanitation facilities.

Results

No school met international water, sanitation and hygiene (WASH) standards for schools. Roughly one third of schools did not have water and, when present, there was no reliable way to use it within the toilet complex. Schoolgirls shared feelings of shame and stress when menstruating at school, and said that they would avoid using school toilets, if possible. Schoolgirls described water access as the most urgent need to address, followed by fostering privacy and facilitating cleanliness within facilities. Mothers and teachers mostly aligned with these priorities, while key informants additionally emphasised the need to raise awareness on both general and menstrual hygiene and to develop maintenance systems. Photo-elicitation engaged and empowered participants to pinpoint priorities and concrete solutions, namely a need for doors and locks, water containers and cleaning materials.

Conclusions

WASH needs in many schools remain unmet. Women and girls should be involved in decision-making across stages of intervention design and implementation. Young women's voices merit greater inclusion in academic literature. Future interventions should enhance access to water and privacy. Future research could explore maintenance and monitoring strategies to develop guidance on sustainable solutions.

Rapid-killing efficacy substantiates the antiseptic property of the synergistic combination of carvacrol and nerol against nosocomial pathogens

Globally, new classes of synthetic and natural antibiotics and antivirulents have continuously been validated for their potential broad-spectrum antagonistic activity with the aim of identifying an effective active molecule to prevent the spread of infectious agents in both food industry and medical field. In view of this, present study is aimed at evaluating the rapid killing efficacy of bioactive molecules Carvacrol (C) and Nerol (N) through British Standard European Norm 1276: phase2/step1 (EN1276) protocol. Active molecules C and N showed broad-spectrum antimicrobial activity against the test strains Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli and Enterococcus hirae at concentration range of 78.125, 625, 156.25 and 312.5 μg/mL, respectively, for C, and 625 μg/mL for N. Whereas, combinatorial approach showed efficient activity with four times reduced concentration of C and N at 78.125 and 156.25 µg/mL, respectively, against test strains. Further, EN1276 results proved the rapid killing efficacy of test strains in 1 min of contact time with significant (> 5 log) growth reduction at 100X concentration of actives. SEM analysis and reduced concentration of protease, lipids and carbohydrate contents of treated group biofilm components ascertained preformed biofilm disruption potential of C + N on polystyrene and nail surfaces. C + N at synergistic concentration exhibited no adverse effect on HaCaT cells at 78.125 µg/mL (C) + 156.25 µg/mL (N). Taken together, based on the observed experimental results, present study evidence the antiseptic/disinfectant ability of C + N and suggest that the combination can preferentially be used in foam-based hand wash formulations.

Understanding short-term transmission dynamics of methicillin-resistant Staphylococcus aureus in the patient room

OBJECTIVE

Little is known about the short-term dynamics of methicillin-resistant Staphylococcus aureus (MRSA) transmission between patients and their immediate environment. We conducted a real-life microbiological evaluation of environmental MRSA contamination in hospital rooms in relation to recent patient activity.

DESIGN

Observational pilot study.

SETTING

Two hospitals, hospital 1 in Zurich, Switzerland, and hospital 2 in Ann Arbor, Michigan, United States.

PATIENTS

Inpatients with MRSA colonization or infection.

METHODS

At baseline, the groin, axilla, nares, dominant hands of 10 patients and 6 environmental high-touch surfaces in their rooms were sampled. Cultures were then taken of the patient hand and high-touch surfaces 3 more times at 90-minute intervals. After each swabbing, patients' hands and surfaces were disinfected. Patient activity was assessed by interviews at hospital 1 and analysis of video footage at hospital 2. A contamination pressure score was created by multiplying the number of colonized body sites with the activity level of the patient.

RESULTS

In total, 10 patients colonized and/or infected with MRSA were enrolled; 40 hand samples and 240 environmental samples were collected. At baseline, 30% of hands and 20% of high-touch surfaces yielded MRSA. At follow-up intervals, 8 (27%) of 30 patient hands, and 10 (6%) of 180 of environmental sites were positive. Activity of the patient explained 7 of 10 environmental contaminations. Patients with higher contamination pressure score showed a trend toward higher environmental contamination.

CONCLUSION

Environmental MRSA contamination in patient rooms was highly dynamic and was likely driven by the patient's MRSA body colonization pattern and the patient activity.

Documentation of adherence to infection prevention best practice in patient records: a mixed-methods investigation

Background

Healthcare-associated infections remain a preventable cause of patient harm in healthcare. Full documentation of adherence to evidence-based best practices for each patient can support monitoring and promotion of infection prevention measures. Thus, we reviewed the extent, nature, and determinants of the documentation of infection prevention (IP) standards in patients with HAI.

Methods

We reviewed electronic patient records (EMRs) of patients included in four annual point-prevalence studies 2013–2016 who developed a device- or procedure-related HAI (surgical site infection (SSI), catheter-associated urinary tract infection (CAUTI), ventilator-associated infection (VAP), catheter-related bloodstream infection (CRBSI)). We examined the documentation quality of mandatory preventive measures published as institutional IP standards. Additionally, we undertook semi-structured interviews with healthcare providers and a two-step inductive (grounded theory) and deductive (Theory of Planned Behaviour) content analysis.

Results

Of overall 2972 surveyed patients, 249 (8.4%) patients developed 272 healthcare-associated infections. Of these, 116 patients met the inclusion criteria, classified as patients with SSI, CAUTI, VAP, CRBSI in 78 (67%), 21 (18%), 10 (9%), 7 (6%), cases, respectively. We found documentation of IP measures in EMRs in 432/1308 (33%) cases. Documentation of execution existed in the study patients’ EMRs for SSI, CAUTI, VAP, CRBSI, and overall, in 261/931 (28%), 27/104 (26%), 46/122 (38%), 26/151 (17%), and 360/1308 (28%) cases, respectively, and documentation of non-execution in 67/931 (7%), 2/104 (2%), 0/122 (0%), 3/151 (2%), and 72/1308 (6%) cases, respectively. Healthcare provider attitudes, subjective norms, and perceived behavioural control indicated reluctance to document IP standards.

Conclusions

EMRs rarely included conclusive data about adherence to IP standards. Documentation had to be established indirectly through data captured for other reasons. Mandatory institutional documentation protocols or technically automated documentation may be necessary to address such shortcomings in patient safety documentation.

Level of Hand Hygiene Compliance and Its Associated Factors Among Health Care Workers at Eka Kotebe General Hospital, Addis Ababa, Ethiopia

BACKGROUND

Poor hand hygiene is an important source of infection, but maintaining hand hygiene is the most important measure to prevent infections. Hand hygiene compliance and its associated factors are not well recognized in Ethiopia. Therefore, this study was intended to determine hand hygiene compliance and its associated factors among health care workers in Eka Kotebe General Hospital.

METHODS

A cross-sectional study was conducted among health care workers at Eka Kotebe General Hospital. A self-administered questionnaire supplemented by a World Health Organization Hand Hygiene Technical Reference Manual was used to collect data. Data was entered using Epi Info 7.2.0.1 and exported to SPSS 23 for analysis. The data were analyzed using descriptive and inferential statistics. Statistical significance was determined using a P-value of ⩽.05 with a 95% confidence interval.

RESULTS

Hand hygiene compliance among healthcare workers was 22.2%. Hand hygiene training (AOR = 2.9, 95% CI: 1.13-7.52), presence of hand hygiene indication poster (AOR = 3.38, 95% CI: 1.18-9.66), hand hygiene promotion by IPC team (AOR = 4.2, 95% CI: 2.53-8.58)), working experience ⩾5 years of a health care providers (AOR = 3.96, 95% CI: 1.12-13.9), being midwife (AOR = 17.1, 95% CI: 2.8-10), being nurse (AOR = 5.3, 95% CI: 2.09-7.8) by profession, and presence of water (AOR = 2.50, 95% CI: 2.20-11.78) were significantly associated factors to hand hygiene compliance.

CONCLUSION

The level of hand hygiene compliance among health care providers was found to be low. Training about hand hygiene, the presence of hand hygiene indication posters, hand hygiene promotion by the IPC team, working experience of health care providers, being a nurse and midwife, and the presence of water were independent predictors of hand hygiene compliance. Health care workers need to be given training on hand hygiene as well as hand hygiene facilities shall be installed and supplied by the hospital in a sustained manner.

Differences in observed and self-reported compliance with the 5 moments for hand hygiene as a function of healthcare workers' empathy

BACKGROUND

Hand hygiene at critical time-points (as established by the WHO model 'Five moments for hand hygiene') remains the leading measure for minimising the risk of healthcare-associated infections. While many interventions have been tested to improve hand hygiene compliance (HHC) of healthcare workers (HCWs), little is known about the relation between HHC and HCW empathy.

AIM

The aim of this study was to investigate the relation between moment-specific HHC rates and HCWs' empathy, at both individual and ward levels.

METHODS

HHC data was collected via observation and self-report, staffs' empathy levels were measured using an established questionnaire. The survey was conducted on 38 wards of three tertiary-care hospitals in Germany. Observation data was obtained via in-house observations which were conducted up to eight months before or after the survey.

FINDINGS

Evidence for the expected correlation between HCW empathy and moment-specific HHC was found for both observed HHC (Moment 1: r = .483, p = .031; Moment 2: r = 588, p = .006) and self-reported HHC (Moment 1: r = .093, p = .092; Moment 2: r = .145, p = .008). In analyses of variance the critical interaction effect between empathy (i.e., lower vs. higher empathy) and designated time-point of hand hygiene (i.e., before vs. after reference task) was also significant.

CONCLUSION

HCWs' empathy should be considered as an important factor in explaining differences between moment-specific HHC rates. In consequence, empathy comes into focus not only as a crucial factor for high-quality patient care, but as an important contributor to improving HHC, too.

Healthcare-Associated Infection Prevention Interventions for Neonates in Resource-Limited Settings

Healthcare-associated infections (HAIs) and antimicrobial-resistant (AMR) infections are leading causes of neonatal morbidity and mortality, contributing to an extended hospital stay and increased healthcare costs. Although the burden and impact of HAI/AMR in resource-limited neonatal units are substantial, there are few HAI/AMR prevention studies in these settings. We reviewed the mechanism of action and evidence supporting HAI/AMR prevention interventions, including care bundles, for hospitalized neonates in low- and middle-income countries (LMIC).

Prompt control of a Serratia marcescens outbreak in a neonatal intensive care unit informed by whole-genome sequencing and comprehensive infection control intervention package

OBJECTIVE

This report describes a cluster of patients infected by Serratia marcescens in a metropolitan neonatal intensive care unit (NICU) and a package of infection control interventions that enabled rapid, effective termination of the outbreak.

DESIGN

Cross-sectional analytical study using whole-genome sequencing (WGS) for phylogenetic cluster analysis and identification of virulence and resistance genes.

SETTING

NICU in a metropolitan tertiary-care hospital in Sydney, Australia.

PATIENTS

All neonates admitted to the level 2 and level 3 neonatal unit.

INTERVENTIONS

Active inpatient and environmental screening for Serratia marcescens isolates with WGS analysis for identification of resistance genes as well as cluster relatedness between isolates. Planning and implementation of a targeted, multifaceted infection control intervention.

RESULTS

The cluster of 10 neonates colonized or infected with Serratia marcescens was identified in a metropolitan NICU. Two initial cases involved devastating intracranial infections with brain abscesses, highlighting the virulence of this organism. A targeted and comprehensive infection control intervention guided by WGS findings enabled termination of this outbreak within 15 days of onset. WGS examination demonstrated phylogenetic linkage across the cluster, and genomic unrelatedness of later strains identified in the neonatal unit and elsewhere.

CONCLUSIONS

A comprehensive, multipronged, infection control package incorporating close stakeholder engagement, frequent microbiological patient screening, environmental screening, enhanced cleaning, optimization of hand hygiene and healthcare worker education was paramount to the prompt control of Serratia marcescens transmission in this neonatal outbreak. WGS was instrumental in establishing relatedness between isolates and identification of possible transmission pathways in an outbreak setting.

The impact of activating an empathic focus during COVID19 on healthcare workers motivation for hand hygiene compliance in moments serving the protection of others: a randomized controlled trial study

Aim

The "Five moments of hand hygiene" (World Health Organization 2009) can be classified into moments of hand hygiene before and after patient care. Based on research indicating that hand hygiene compliance differs with regard to moments before and after patient care, this research evaluates the effectiveness of an empathy-based intervention in motivating hand hygiene compliance with regard to moments before patient care which protect vulnerable individuals from contamination and infection.

Subjects and method

An online experiment involving 68 healthcare professionals working at a German hospital during the first wave of the COVID-19 pandemic investigates whether instructing healthcare professionals to consider consequences for others (vs for themselves) if they contracted SARS-CoV-2 promotes hand hygiene compliance referring to moments before (vs after) patient care.

Results

In the condition in which healthcare professionals considered consequences for others if they contracted SARS-CoV-2 (other-focus condition), ratings of importance increased (M = 3.49, SD = 1.30) compared to the condition in which healthcare professionals considered consequences for themselves (M = 2.68, SD = 1.24), F(1,66) = 6.87, p = .011, partη2 = .09. Participants in the other-focus condition reported more intentions to comply with "before moments" in the future (M = 3.34, SD = 1.14) compared to participants in the self-focus condition (M = 2.77, SD = 0.80), F(1,66) = 6.15, p = .016, partη2 = .09.

Conclusion

Results indicate that activating an empathic focus in the context of the current pandemic promotes perceived importance and motivation of healthcare professionals to comply with moments aiming at protecting vulnerable others.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10389-022-01725-z.

Multidrug-resistant OXA-48/CTX-M-15 Klebsiella pneumoniae cluster in a COVID-19 Intensive Care Unit: Salient lessons for infection prevention and control during the COVID-19 pandemic

Background

Wards caring for COVID-19 patients, including intensive care units (ICUs), have an important focus on preventing transmission of SARS-CoV-2 to other patients and healthcare workers.

Aim

To describe an outbreak of carbapenemase-producing Enterobacterales (CPE) in a COVID-19 ICU and to discuss key infection control measures enabling prompt termination of the cluster.

Methods

CPE were isolated from clinical specimens and screening swabs from intensive care patients with COVID-19 disease and from environmental screening. Whole-genome sequencing analysis was instrumental in informing phylogenetic relationships.

Findings

Seven clinical isolates and one environmental carbapenemase-producing Klebsiella pneumoniae isolate – all carrying OXA-48, CTX-M-15 and outer membrane porin mutations in ompK35/ompK36 – were identified with ≤1 single nucleotide polymorphism difference, indicative of clonality. A bundle of infection control interventions including careful adherence with contact precautions and hand hygiene, twice weekly screening for multidrug-resistant organisms, strict antimicrobial stewardship, and enhanced cleaning protocols promptly terminated the outbreak.

Conclusion

Prolonged use of personal protective equipment is common with donning and doffing stations at the ward entrance, leaving healthcare workers prone to reduced hand hygiene practices between patients. Minimizing transmission of pathogens other than SARS-CoV-2 by careful adherence to normal contact precautions including hand hygiene, even during high patient contact manoeuvres, is critical to prevent outbreaks of multidrug-resistant organisms. Appropriate antimicrobial stewardship and screening for multidrug-resistant organisms must also be maintained throughout surge periods to prevent medium-term escalation in antimicrobial resistance rates. Whole-genome sequencing is highly informative for multidrug-resistant Enterobacterales surveillance strategies.

Compared hand hygiene compliance among healthcare providers before and after the COVID-19 pandemic: A rapid review and meta-analysis

BACKGROUND

Hand hygiene (HH) is a cost-effective measure to reduce health care-associated infections. The overall characteristics and changes of hand hygiene compliance (HHC) among health care providers during the COVID-19 pandemic provided evidence for targeted HH intervention measures.

AIM

To systematically review the literature and conduct a meta-analysis of studies investigating the rate of HHC and the characteristics of HH during the COVID-19 pandemic.

METHODS

The PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang Data, VIP, and CBM databases were searched. All the original articles with valid HHC data among health care providers during the COVID-19 pandemic (from January 1, 2020 to October 1, 2021) were included. Meta-analysis was performed using a DerSimonian and Laird model to yield a point estimate and a 95% CI for the HHC rate. The heterogeneity of the studies was evaluated using the Cochrane Q test and I2 statistics and a random-effects model was used to contrast between different occupations, the WHO 5-moments of HH and different observation methods. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were followed.

FINDINGS

Seven studies with 2,377 health care providers reporting HHC were identified. The estimated overall HHC was 74%, which was higher than that reported in previous studies (5%-89%). Fever clinic has become a new key place for HHC observation. Nurses had the highest HHC (80%; 95% CI:74%-87%) while auxiliary workers (70%; 95%CI:62%-77%) had the lowest. For the WHO 5-moments, the health care providers had the highest HHC after contact with the body fluids of the patients (91%; 95% CI:88%-94%), while before contact with patient's health care providers had the lowest HHC (68%; 95% CI:62%-74%) which was consistent with before the pandemic. There existed great HHC differences among different monitoring methods (automatic monitoring system:53%; 95% CI:44%-63% versus openly and secretly observation: 91%; 95% CI: 90%-91%).

CONCLUSIONS

During the COVID-19 pandemic, the compliance of health care providers' HH showed a great improvement. The fever clinics have become the focused departments for HH monitoring. The HHC of auxiliary workers and the HH opportunity for "before contact with patients" should be strengthened. In the future, it will be necessary to develop standardized HH monitoring tools for practical work.