Evaluation of a training programme on knowledge and compliance of nurse assistants' hand hygiene in nursing homes

Hand Scrubbing and Donning of Sterile Surgical Gloves: An Observational Clinical Audit of Novice Dental Surgeons

Background The most critical factors in the satisfactory recovery of a patient post-surgery are obedience to sterilization and aseptic protocol. Using aseptic principles, the standard hand scrubbing and gloving procedure prevents contamination of the surgical site and aids in infection control.  Methods Eighty dental interns were observed during minor oral surgical procedures for hand scrubbing and donning sterile surgical gloves, following the steps and guidelines provided by World Health Organization (WHO). The dental interns were evaluated, and in order to enhance their understanding of hand scrubbing and donning surgical gloves, desensitization programs were conducted through lectures using PowerPoint presentations. After one week, the participants were observed and evaluated again. This program made the participants aware of asepsis and infection control in clinical practice. Results Prior to intervention, only 37.14% of young dental surgeons performed proper conventional hand hygiene practices. After the intervention, this percentage increased to 62.142%, indicating a significant improvement. Regarding the donning of sterile surgical gloves, 43.75% of participants followed the standard steps before the intervention. After the intervention, the percentage raised to 86.25% indicating substantial growth. Conclusion Observations before and after the evaluation demonstrated significant changes in the acceptance rates for the fundamental criteria of hand hygiene and donning sterile surgical gloves. Adhering to both procedures according to WHO guidelines will help to reduce the risk of infections and raise awareness about asepsis in the practice among young dental surgeons.

Compliance to hand hygiene and its determinant factors among Community Health Care Providers in Community Clinics: an observational study in Bangladesh

Background

Healthcare-associated infections caused by poor hand hygiene (HH) practices can affect both the care seekers and the health care providers (HCPs) while providing primary health care. No study has been conducted on the compliance of HH practices among the primary level HCPs in Bangladesh.

Objective

The study aimed to assess the compliance rates of HH and its determinant factors among Community Health Care Providers (CHCPs) in Community Clinics (CC).

Methods

A cross-sectional study was conducted from September 2019 to February 2020 among 150 randomly selected CHCPs with functional HH facilities in Patuakhali district, Bangladesh. Structured interviews and observation tools were used to collect data.

Results

Good HH compliance among CHCPs was found to be 16.7% (95% CI: 11.3-21.3). Out of all 1218 possible HH opportunities, only 255 (20.9%) resulted in any HH action. Presence of 70% alcohol-based hand sanitiser at the point of care (aOR: 6.4, 95% CI: 1.1-38.3), HH training (aOR: 4.6, 95% CI: 1.1-18.9), displayed visual cues (aOR: 4.4, 95% CI: 1.1-17.7), knowledge about HH (aOR: 3.8, 95% CI: 1.1-13.6) and number of HH opportunities (aOR: 0.6, 95% CI: 0.4-0.8) were factors associated with HH compliance.

Discussion

Overall HH compliance among CHCPs was relatively low. It was recommended to implement multimodal HH improvement strategies, including a continuous training program, supply of alcohol-based hand rub, reminder, provision of five moments of HH in the training modules and feedback on HH performance.

Effect of infection control training course on knowledge and practices of medical interns in a large academic hospital in Egypt: an intervention study

Health care-associated infections are reported among the top causes of hospital deaths worldwide. Their prevention is a first priority for patient safety in acute care hospitals. Education and training is recommended as a core component for effective infection prevention and control programs. This study aimed to assess the effect of an infection control training course on the knowledge and practices of medical interns in a large academic hospital in Egypt. The study included 268 medical interns who were getting their practical training at Tanta University Hospitals, Egypt during the study period. Knowledge and practices regarding infection control measures were assessed using a predesigned questionnaire sheet and an observational checklist before and after intervention by infection control training course based on Egyptian national guide for infection control. The data have been analyzed through the application of descriptive frequency, percentages, mean of scores, and the inferential analysis that includes paired t test and Monte Carlo test. The level of statistical significance was adopted at p≤0.05. There was a statistically significant (p < 0.0001) increase in total knowledge score (65.4±13.9 versus 80.2 ±13.2) and total practices score (65±11.3 versus 108±7.9) of infection control measures among studied participants before intervention compared with after intervention. A significant strong positive correlation was detected (r= 0.8, p= 0.0001) between total knowledge and practice scores after intervention by training course. There is a strong positive correlation between knowledge and practices so intervention by infection control training course using teaching multimedia and role play significantly improves the knowledge and practice levels of the studied medical interns.

HAND HYGIENE COMPLIANCE IN THE PREVENTION OF HOSPITAL ACQUIRED INFECTIONS: A SYSTEMATIC REVIEW

BACKGROUND

Healthcare worker's (HCW) hands are known to be a primary source of transmission of hospital-acquired infections (HAIs). Thus, practicing hand hygiene (HH) and adhering to HH guidelines are both expected to decrease the risk of transmission but there is no consensus on the optimal hand hygiene compliance (HHC) rate that HCWs should aim for.

AIM

The objective of this study was to systematically review the published literature to determine an optimal threshold of HCW HHC rate associated with the lowest incidence rate of HAIs.

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. We searched online databases using a comprehensive search criterion for randomized controlled trials and non-randomized controlled studies, investigating the impact of HCW's HHC rate on HAI rates in patients of all ages, within healthcare facilities in high income countries.

FINDINGS

Of the 8,093 articles citations and abstracts screened, 35 articles were included in the review. Most studies reported overall HAIs per 1000 patient-days and device-associated HAIs per 1000 device-days. Most studies reported HHC rates between 60%-70%. Lower incidence HAI rates seemed to be achieved with HHC rates of approximately 60%. Studies included were not originally designed to assess the impact of HHC on HAI rates but risk of bias was assessed as per our predetermined exposure and outcome criterion. 11 (31%) of studies were deemed at low risk of bias.

CONCLUSIONS

Although HHC is part of HCW's code of conduct, very high HHC rates were difficult to reach. In observational studies, HHC and HAI followed a negative relationship up to about 60%. Due to flaws in study design, causality could not be inferred; only general trends could be discussed. Given the limitations, there is a need for high-quality evidence to support the implementation of specified targets of HHC rates.

Implementation of a multimodal infection control strategy in the nursing home

The main cause of morbidity and mortality among residents of nursing homes (NHs) is healthcare-associated infections (HAIs). We conducted infection control intervention by applying the WHO multimodal strategy for one year from January to December 2018 in the one NH in South Korea. Healthcare workers (HCWs) in NH were observed by infection control nurse from February to December 2018. Hand hygiene (HH) compliance according WHO 5 moments and type of HH, glove use were measured as main outcomes. During the intervention period, a total of 1,461 cases were observed. HH compliance among HCWs increased from 12.6% to 55.2% after the intervention. According to WHO 5 moments, HH before touching a patient and after touching a patient saw significant improvements. Further, glove misuse decreased significantly from 45.9% to 25.4%. The multifaceted infection control program in the NH group significantly improved the HH compliance of HCWs.

Hand Hygiene Compliance and Influencing Factors Among Nursing Assistants in Nursing Homes

The current study explored compliance with hand hygiene and related influencing factors among nursing assistants (NAs) in nursing homes. A descriptive observational research design was used. Seven nursing homes in Chongqing, China, including hospital-affiliated, public, and private, were selected. A hand hygiene observation tool was used to assess NAs' (N = 237) hand hygiene practice (N = 2,370 opportunities). NAs' overall compliance rate was 3.6%: 6.8%, 3.1%, and 1.9% at hospital-affiliated, public, and private nursing homes, respectively. Compliance rate between two opportunities, after contact with residents and after contact with residents' surroundings, differed significantly (p = 0.002 and 0.038, respectively). The highest and lowest compliance rates occurred after bodily fluid exposure (8.3%; odds ratio [OR] = 0.37, 95% confidence interval [CI] [0.218, 0.627], p < 0.001) and before resident contact (1.2%; OR = 3.142, 95% CI [1.265, 7.805], p = 0.014), respectively. Working experience and educational background were the two major influencing factors for hand hygiene. It is urgent to improve NAs' hand hygiene accordingly. [Journal of Gerontological Nursing, 47(4), 45-52.].

Strengthening International Research in Long-Term Care: Recommended Common Data Elements to Support Clinical Staff Training

The purpose of this study is to develop candidate common data element (CDE) items related to clinical staff training in long-term care (LTC) homes that can be used to enable international comparative research. This paper is part of the WE-THRIVE (Worldwide Elements to Harmonize Research in Long-Term Care Living Environments) group's initiative which aims to improve international academic collaboration. We followed best practices to develop CDEs by conducting a literature review of clinical staff (i.e., Regulated Nurses, Health Care Aides) training measures, and convening a subgroup of WE-THRIVE experts to review the literature review results to develop suitable CDEs. The international expert panel discussed and critically reflected on the current knowledge gaps from the literature review results. The panel proposed three candidate CDEs which focused on the presence of and the measurement of training. These three proposed CDEs seek to facilitate international research as well as assist in policy and decision-making regarding LTC homes worldwide. This study is a critical first step to develop candidate CDE items to measure staff training internationally. Further work is required to get feedback from other researchers about the proposed CDEs, and assess the feasibility of these CDEs in high and low resourced settings.

Synergistic Effect of Combination Interventions for Methicillin-Resistant Staphylococcus aureus Transmission Control in Nursing Homes: A Computation Modelling Evaluation with Heterogeneous Contact Mixing

The endemic threat of methicillin-resistant Staphylococcus aureus (MRSA) in nursing homes poses a serious and escalating challenge to public health administration in infection control. Nursing homes are considered as major reservoirs for MRSA colonization, with considerable high levels of colonization prevalence. We employed a computation model to evaluate effects of three intervention scenarios on MRSA colonization prevalence rate in nursing homes. Simulations were conducted using a deterministic compartmental model featuring heterogeneous contact matrix between residents and health-care workers (HCWs). Contact parameters were derived from a nursing home survey. Three intervention scenarios were simulated: (1) hand-hygiene compliance by HCWs, (2) screening-and-isolation upon admission, and (3) implementing both interventions at the same time. For every 10% reduction in average contamination duration in HCWs, the estimated average reduction in prevalence rate was 1.29 percentage point compared with the prevalence rate before the intervention was implemented. Screening-and-isolation intervention resulted in an average reduction of 19.04 percentage point in prevalence rate (S.D. = 1.58; 95% CI = 18.90-19.18). In intervention scenario 3, synergistic effects were observed when implementing hand-hygiene compliance by HCWs and screening-and-isolation together. Our results provide evidence showing that implementing multiple interventions together has a synergistic effect on colonization prevalence reduction.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Increased hand hygiene compliance in nursing homes after a multimodal intervention: A cluster randomized controlled trial (HANDSOME)

OBJECTIVE

To assess the effect of a multimodal intervention on hand hygiene compliance (HHC) in nursing homes.

DESIGN, SETTING, AND PARTICIPANTS

HHC was evaluated using direct, unobtrusive observation in a cluster randomized controlled trial at publicly funded nursing homes in the Netherlands. In total, 103 nursing home organizations were invited to participate; 18 organizations comprising 33 nursing homes (n = 66 nursing home units) participated in the study. Nursing homes were randomized into a control group (no intervention, n = 30) or an intervention group (multimodal intervention, n = 36). The primary outcome measure was HHC of nurses. HHC was appraised at baseline and at 4, 7, and 12 months after baseline. Observers and nurses were blinded.

INTERVENTION

Audits regarding hand hygiene (HH) materials and personal hygiene rules, 3 live lessons, an e-learning program, posters, and a photo contest. We used a new method to teach the nurses the WHO-defined 5 moments of HH: Room In, Room Out, Before Clean, and After Dirty.

RESULTS

HHC increased in both arms. The increase after 12 months was larger for units in the intervention arm (from 12% to 36%) than for control units (from 13% to 21%) (odds ratio [OR], 2.10; confidence interval [CI], 1.35-3.28). The intervention arm exhibited a statistically significant increase in HHC at 4 of the 5 WHO-defined HH moments. At follow-up, HHC in the intervention arm remained statistically significantly higher (OR, 1.93; 95% CI, 1.59-2.34) for indications after an activity (from 37% to 39%) than for indications before an activity (from 14% to 27%).

CONCLUSIONS

The HANDSOME intervention is successful in improving HHC in nursing homes.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17419.

Hand hygiene of nursing and midwifery students in Cambodia

AIM

To determine the relationship between knowledge, attitude and the practice of hand hygiene by nursing and midwifery students in Cambodia.

BACKGROUND

Hand hygiene is the most cost-effective means to prevent hospital-acquired infections. Techniques of hand hygiene are simple; however, many researchers have found hand hygiene knowledge, attitude and practice to be poor in many healthcare settings worldwide, especially in developing countries. Cambodia is a developing country in Southeast Asia and data regarding hand hygiene are limited.

METHODS

A cross-sectional descriptive study was conducted to assess the level of knowledge, attitude and practice of hand hygiene. Students in nursing and midwifery programmes were the target population (n = 300). Survey data were collected from January to May 2017. Descriptive statistics, t-tests and correlation coefficients were calculated to assess relationships between student knowledge, attitude and hand hygiene practice.

RESULT

The level of knowledge, attitude and practice of hand hygiene in nursing and midwifery students was moderate. A majority of students had received hand hygiene training. There was no significant difference between nursing and midwifery students in knowledge, attitude and practice of hand hygiene. However, a Pearson correlation of attitude and practice had a weak positive relationship.

CONCLUSION

Both nursing and midwifery students demonstrated moderate levels of knowledge, attitudes and practice of hand hygiene.

IMPLICATION FOR NURSING AND HEALTH POLICY

This study identified a need for hand hygiene training. Developing training programmes to improve attitudes about hand hygiene is strongly recommended. Effective training may contribute to change behaviours of hand hygiene (attitude), improve practice and ultimately reduce hospital-acquired infections.

Nurses' knowledge, behaviour and compliance concerning hand hygiene in nursing homes: a cross-sectional mixed-methods study

Background

Effective hand hygiene is one of the most important measures for protecting nursing home residents from nosocomial infections. Infections with multi-resistant bacteria’s, associated with healthcare, is a known problem. The nursing home setting differs from other healthcare environments in individual and organisational factors such as knowledge, behaviour, and attitude to improve hand hygiene and it is therefore difficult to research the influential factors to improve hand hygiene. Studies have shown that increasing knowledge, behaviour and attitudes could enhance hand hygiene compliance in nursing homes. Therefore, it may be important to examine individual and organisational factors that foster improvement of these factors in hand hygiene. We aim to explore these influences of individual and organisational factors of hand hygiene in nursing home staff, with a particular focus on the function of role modelling by nursing managers.

Methods

We conducted a mixed-methods study surveying 165 nurses and interviewing 27 nursing managers from nursing homes in Germany.

Results

Most nurses and nursing managers held the knowledge of effective hand hygiene procedures. Hygiene standards and equipment were all generally available but compliance to standards also depended upon availability in the immediate work area and role modelling. Despite a general awareness of the impact of leadership on staff behaviour, not all nursing managers fully appreciated the impact of their own consistent role modelling regarding hand hygiene behaviours.

Conclusion

These results suggest that improving hand hygiene should focus on strategies that facilitate the provision of hand disinfectant materials in the immediate work area of nurses. In addition, nursing managers should be made aware of the impact of their role model function and they should implement this in daily practice.

How to make hand hygiene interventions more attractive to nurses: A discrete choice experiment

Background

Better understanding of the characteristics of interventions which are attractive to nurses is required in order to implement effective hand hygiene interventions.

Methods

The intervention characteristics were derived from diffusion of innovation theory (DIT): relative advantage, compatibility, simplicity, trialability, and observability. To identify nurses’ preferences for the five characteristics, a discrete choice experiment (DCE) was conducted. Participants were nurses working at Taiwanese tertiary care hospitals selected through stratified sampling. In addition, the hand hygiene moment (before or after patient contact) was taken into consideration in the DCE to investigate whether nurses’ preferences for the intervention characteristics were the same at different hand hygiene moments.

Results

This survey was conducted between 1 October and 31 December 2014. Among 200 nurses from three Taiwanese tertiary care hospitals, significant preferences for the five intervention characteristics were observed. That is, when an intervention makes the hand hygiene activity more convenient (p<0.001), when nurses participate in the design of the intervention (p<0.001), when an intervention is explained well to nurses before implementing it (p<0.001), when the evidence of hand hygiene is provided at a trial stage to show its effectiveness (p<0.001), and when nurses’ hand hygiene performance is observable to their peers (p<0.001), nurses are more willing to wash their hands with high compliance. In addition, nurses preferred for providing evidence at a trial stage most, and well explanation about the intervention to increase simplicity was least. The rankings of the preference for the five intervention characteristics were the same at different hand hygiene moments (p = 0.453)

Conclusions

The findings suggest policy directions for decision makers aiming to improve overall hand hygiene compliance in healthcare facilities.

Interventions to improve hand hygiene compliance in patient care

BACKGROUND

Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure. This is an update of a previously published review.

OBJECTIVES

To assess the short- and long-term success of strategies to improve compliance to recommendations for hand hygiene, and to determine whether an increase in hand hygiene compliance can reduce rates of health care-associated infection.

SEARCH METHODS

We conducted electronic searches of the Cochrane Register of Controlled Trials, PubMed, Embase, and CINAHL. We conducted the searches from November 2009 to October 2016.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series analyses (ITS) that evaluated any intervention to improve compliance with hand hygiene using soap and water or alcohol-based hand rub (ABHR), or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened citations for inclusion, extracted data, and assessed risks of bias for each included study. Meta-analysis was not possible, as there was substantial heterogeneity across studies. We assessed the certainty of evidence using the GRADE approach and present the results narratively in a 'Summary of findings' table.

MAIN RESULTS

This review includes 26 studies: 14 randomised trials, two non-randomised trials and 10 ITS studies. Most studies were conducted in hospitals or long-term care facilities in different countries, and collected data from a variety of healthcare workers. Fourteen studies assessed the success of different combinations of strategies recommended by the World Health Organization (WHO) to improve hand hygiene compliance. Strategies consisted of the following: increasing the availability of ABHR, different types of education for staff, reminders (written and verbal), different types of performance feedback, administrative support, and staff involvement. Six studies assessed different types of performance feedback, two studies evaluated education, three studies evaluated cues such as signs or scent, and one study assessed placement of ABHR. Observed hand hygiene compliance was measured in all but three studies which reported product usage. Eight studies also reported either infection or colonisation rates. All studies had two or more sources of high or unclear risks of bias, most often associated with blinding or independence of the intervention.Multimodal interventions that include some but not all strategies recommended in the WHO guidelines may slightly improve hand hygiene compliance (five studies; 56 centres) and may slightly reduce infection rates (three studies; 34 centres), low certainty of evidence for both outcomes.Multimodal interventions that include all strategies recommended in the WHO guidelines may slightly reduce colonisation rates (one study; 167 centres; low certainty of evidence). It is unclear whether the intervention improves hand hygiene compliance (five studies; 184 centres) or reduces infection (two studies; 16 centres) because the certainty of this evidence is very low.Multimodal interventions that contain all strategies recommended in the WHO guidelines plus additional strategies may slightly improve hand hygiene compliance (six studies; 15 centres; low certainty of evidence). It is unclear whether this intervention reduces infection rates (one study; one centre; very low certainty of evidence).Performance feedback may improve hand hygiene compliance (six studies; 21 centres; low certainty of evidence). This intervention probably slightly reduces infection (one study; one centre) and colonisation rates (one study; one centre) based on moderate certainty of evidence.Education may improve hand hygiene compliance (two studies; two centres), low certainty of evidence.Cues such as signs or scent may slightly improve hand hygiene compliance (three studies; three centres), low certainty of evidence.Placement of ABHR close to point of use probably slightly improves hand hygiene compliance (one study; one centre), moderate certainty of evidence.

AUTHORS' CONCLUSIONS

With the identified variability in certainty of evidence, interventions, and methods, there remains an urgent need to undertake methodologically robust research to explore the effectiveness of multimodal versus simpler interventions to increase hand hygiene compliance, and to identify which components of multimodal interventions or combinations of strategies are most effective in a particular context.

Implementing a Pilot Trial of an Infection Control Program in Nursing Homes: Results of a Matched Cluster Randomized Trial

BACKGROUND

Hand hygiene is the single-most important nursing home (NH) infection control measure. We piloted a multifaceted hand-washing/surface cleaning intervention in 5 NHs. Our aims were to assess the feasibility of implementing this intervention by assessing staff participation, satisfaction, hand-washing compliance, and whether the intervention was associated with reductions in infection rates, new antimicrobial orders, or overall hospitalization rates.

METHODS

We conducted a randomized, pair-matched pilot intervention in 10 Colorado NHs to reduce infections for all NH residents from October 1, 2015 through May 31, 2016. To evaluate process, we determined online education participation rates, recorded intervention fidelity through weekly reporting measures on microbial surface counts, hand-washing, and infection reporting, and conducted a survey of participating employees. To evaluate potential impacts on clinical outcomes, we collected information on monthly infection log data, new antibiotic orders, and hospitalizations.

RESULTS

Three of 5 sites had education participation rates >90%, the other 2 were poor (13% and 23%). The majority of participation survey respondents (58%) were promoters of the intervention. Directors of nursing reported hygiene hand-washing data for 19.6/24 (81.8%) weeks and microbial surface count data for 20.4/24 (85.1%) weeks. For the first 4 weeks of the study, the bacterial counts averaged 351.4 ± 497.5 relative light units, the mean value for the last 4 weeks was 127.7 ± 85.1 (P value = .12). The number of hand-washing occasions per NH resident was steady over time but differed by treatment facility (P = .03). We observed nonsignificant reductions for total infections (6.7%) and lower respiratory tract infections (19.9%) vs control NHs. There were no significant differences in antimicrobial orders or hospitalization rates pre-post intervention.

CONCLUSIONS

This multifaceted hand-washing and surface cleaning intervention was designed to reduce infection rates among NH residents. In our 10-facility randomized, matched pair pilot study, we observed program compliance and satisfaction along with reductions in surface bacterial counts, but did not observe a statistically significant reduction in infection rates, antimicrobial use, or hospitalizations.

Challenges and Strategies for Prevention of Multidrug-Resistant Organism Transmission in Nursing Homes

PURPOSE OF REVIEW

Nursing home residents are at high risk for colonization and infection with bacterial pathogens that are multidrug-resistant organisms (MDROs). We discuss challenges and potential solutions to support implementing effective infection prevention and control practices in nursing homes.

RECENT FINDINGS

Challenges include a paucity of evidence that addresses MDRO transmission during the care of nursing home residents, limited staff resources in nursing homes, insufficient infection prevention education in nursing homes, and perceptions by nursing home staff that isolation and contact precautions negatively influence the well being of their residents. A small number of studies provide evidence that specifically address these challenges. Their outcomes support a paradigm shift that moves infection prevention and control practices away from a pathogen-specific approach and toward one that focuses on resident risk factors.

Making infection prevention education interactive can enhance knowledge and improve outcomes: Results from the Targeted Infection Prevention (TIP) Study

BACKGROUND

The purpose of this study was to assess effectiveness of an interactive educational program in increasing knowledge of key infection prevention and control (IPC) principles with emphasis on indwelling device care, hand hygiene, and multidrug-resistant organisms (MDROs) among nursing home (NH) health care personnel (HCP).

METHODS

We conducted a multimodal randomized controlled study involving HCP at 12 NHs. Ten comprehensive and interactive modules covered common IPC topics. We compared intervention and control scores to assess differences in pretest scores as a result of field interventions, pre- and post-test scores to assess knowledge gain, and magnitude of knowledge gain based on job categories.

RESULTS

We conducted over 200 in-services across 10 topics at six intervention sites over 36 months. There were 4,962 tests returned over the course of the study, ranging from 389-633 per module. Participants were mostly female certified nursing assistants (CNAs). Score improvement was highest for modules emphasizing hand hygiene, urinary catheter care, and MDROs (15.6%, 15.9%, and 22.0%, respectively). After adjusting for cluster study design, knowledge scores were significantly higher after each educational module, suggesting the education delivery method was effective. When compared with CNAs, nursing and rehabilitation personnel scored significantly higher in their knowledge tests.

CONCLUSIONS

Our intervention significantly improved IPC knowledge in HCP, especially for those involved in direct patient care. This increase in knowledge along with preemptive barrier precautions and active surveillance has enhanced resident safety by reducing MDROs and infections in high-risk NH residents.

A quasi-experimental study to determine the effects of a multifaceted educational intervention on hand hygiene compliance in a radiography unit

BACKGROUND

Whilst numerous studies have investigated nurses' compliance with hand hygiene and use of alcohol-based hand rub (ABHR), limited attention has been paid to these issues in allied health staff. Reports have linked infections to breaches in infection control in the radiography unit (RU). With advances in medical imaging, a higher proportion of patients come into contact with RU staff increasing the need for good hand hygiene compliance. This study aimed to evaluate effectiveness on compliance of an intervention to improve awareness of hand hygiene in the RU of a district hospital.

METHODS

A quasi-experimental study design including questionnaires assessing knowledge and attitudes of hand hygiene and direct observation of participants was used to evaluate an educational programme on hand hygiene of the RU of a large district hospital. All healthcare workers (HCW), comprising 76 radiographers, 17 nurses, and nine healthcare assistants (HCA), agreed to participate in the study. Of these, 85 completed the initial and 76 the post-test anonymous questionnaire. The hand hygiene compliance of all 102 HCW was observed over a 3-week period prior to and after the intervention. The 2-month intervention consisted of talks on hand hygiene and benefits of ABHR, provision of visual aids, wall-mounted ABHR dispensers, and personal bottles of ABHR.

RESULTS

Before the intervention, overall hand hygiene compliance was low (28.9 %). Post-intervention, compliance with hand hygiene increased to 51.4 %. This improvement was significant for radiographers and HCA. Additionally, knowledge and attitudes improved in particular, understanding that ABHR can largely replace handwashing and there is a need to perform hand hygiene after environmental contact. The increased use of ABHR allowed HCW to feel they had enough time to perform hand hygiene.

CONCLUSIONS

The educational intervention led to increased awareness of hand hygiene opportunities and better acceptance of ABHR use. The reduced time needed to perform hand rubbing and improved access to dispensers resulted in fewer missed opportunities. Although radiographers and other allied HCW make frequent contact with patients, these may be mistakenly construed as irrelevant with respect to healthcare associated infections. Stronger emphasis on hand hygiene compliance of these staff may help reduce infection risk.

Evidence-based practices to increase hand hygiene compliance in health care facilities: An integrated review

BACKGROUND

Hand hygiene (HH) in health care facilities is a key component to reduce pathogen transmission and nosocomial infections. However, most HH interventions (HHI) have not been sustainable.

AIMS

This review aims to provide a comprehensive summary of recently published evidence-based HHI designed to improve HH compliance (HHC) that will enable health care providers to make informed choices when allocating limited resources to improve HHC and patient safety.

METHODS

The Medline electronic database (using PubMed) was used to identify relevant studies. English language articles that included hand hygiene interventions and related terms combined with health care environments or related terms were included.

RESULTS

Seventy-three studies that met the inclusion criteria were summarized. Interventions were categorized as improving awareness with education, facility design, and planning, unit-level protocols and procedures, hospital-wide programs, and multimodal interventions. Past successful HHIs may not be as effective when applied to other health care environments. HH education should be interactive and engaging. Electronic monitoring and reminders should be implemented in phases to ensure cost-effectiveness. To create hospitalwide programs that engage end users, policy makers should draw expertise from interdisciplinary fields. Before implementing the various components of multimodal interventions, health care practitioners should identify and examine HH difficulties unique to their organizations.

CONCLUSIONS

Future research should seek to achieve the following: replicate successful HHI in other health care environments, develop reliable HHC monitoring tools, understand caregiver-patient-family interactions, examine ways (eg, hospital leadership, financial support, and strategies from public health and infection prevention initiatives) to sustain HHC, and use simulated lab environments to refine study designs.

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

BACKGROUND

In nursing homes, the infectious risk is high, making infection control using approaches such as hand hygiene (HH) a major issue. However, the effectiveness of HH in these settings is not well documented, and HH compliance is low.

METHODS

We systematically searched PubMed, Scopus, Web of Science, and Cochrane Clinical Trials for studies in nursing homes that either described a HH-related intervention or assessed HH compliance and included a measured infectious outcome. Two reviewers independently performed the study selection.

RESULTS

Fifty-six studies met the inclusion criteria and were reviewed. Most were outbreak reports (39%), followed by observational studies (23%), controlled trials (23%), and before-after intervention studies (14%). Thirty-five studies (63%) reported results in favor of HH on at least one of their outcome measures; in addition, the infection control success rate was higher when at least one HH-related intervention (eg, staff education on HH, increased availability of handrub solution) was included (70% vs 30% for no intervention). However, only 25% of randomized trials concluded that HH-related interventions led to a reduction in the infectious risk.

CONCLUSION

The results of this systematic review suggest that more evidence on HH effectiveness in nursing homes is needed. Future interventional studies should enhance methodologic rigor using clearly defined outcome measures, standardized reporting of findings, and a relevant HH observation tool.

Use of hand hygiene agents as a surrogate marker of compliance in Hungarian long-term care facilities: first nationwide survey

Background

Hand hygiene practice is an important measure for preventing infections in long-term care facilities (LTCFs). However, low compliance with hand hygiene has been reported in a number of studies. The purpose of this study was to provide an overview of the first reference data collected on alcohol-based handrub (ABHR) and antiseptic soap consumption, as surrogate markers for hand hygiene compliance by healthcare workers (HCWs) in Hungarian LTCFs. The objective was to inform stakeholders on the need of hand hygiene improvement in these settings.

Methods

Between 5 May and 30 September 2014, we conducted a nationwide, cross-sectional survey using a standardized self-administered questionnaire; all Hungarian LTCFs were eligible. The Statistical Package for Social Sciences (SPSS) version 20.0 was used for data analysis.

Results

The questionnaire was completed by 354 LTCFs, representing 24 % of all Hungarian LTCFs. In total, the median consumption of ABHR and antimicrobial soap was 15.5 L (IQR, 0–800 L) and 60 L (IQR, 0–1,680 L) per LTCFs, and 2.2 mL (IQR, 0.4–9.1 mL) and 12.1 mL (IQR, 0.7–32.8 mL) per HCWs in 2013, respectively. The estimated number of hand hygiene actions was 0.6 hygienic handrub/HCW per day (IQR, 0–12.8/HCWs) and 2.4 hygienic handwashing/HCW per day (IQR, 0–21.9/HCWs; P = .001), respectively.

Conclusions

This study suggests that non-compliance with hand hygiene is a significant problem in Hungarian LTCFs. Based on our results, there is an urgent need for a nationwide multimodal hand hygiene promotion strategy including education and performance monitoring and feedback in all LTCFs. Furthermore, monitoring of ABHR consumption constitute an additional component of the existing National Nosocomial Surveillance system.

Antimicrobial resistance and stewardship in long-term care settings

Infections and antimicrobial resistance (AMR) in long-term care facilities (LTCFs) are a public health challenge and a future infectious disease threat. More and more data show the dimension and impact of AMR and of inappropriate use of antimicrobials in this setting. Recently, the spread of carbapenemase-producing Enterobacteriaceae has provided new insights into the dangerous role the long-term care sector may play in the AMR problem in a community. Implementation of effective infection and surveillance control programs in LTCFs is challenging, due to scarce resources (personnel, expertise, diagnostic and supportive services), and no or poor coordination of medical care. However, interventions in LTCFs have been proven to be effective: inappropriate use of antibiotics for asymptomatic bacteriuria may be reduced; hand hygiene compliance may be improved; and the transmission of multidrug-resistant organisms may be halted. This paper reviews the most recent epidemiological information on this issue, providing references to valuable intervention programs.

Hand hygiene compliance among the nursing staff in freestanding nursing homes in Taiwan: a preliminary study

This study aimed to explore the hand hygiene compliance among the nursing staff in Taiwanese freestanding nursing homes. A descriptive observational research design was used. A total of 782 opportunities for hand hygiene were observed by one trained research assistant in two freestanding nursing homes. The hand-hygiene observation tool was used to assess hand hygiene practice. The overall hand hygiene compliance among nursing staff in nursing homes was only 11.3%. Results further showed that the compliance was greater after contact with body fluids (odds ratio = 6.9, confidence interval (CI) = 3.75-9.88, P = 0.000) and lower before the performance of aseptic procedures (odds ratio = 0.15, CI = 0.04-0.63, P = 0.003) when compared with other activities. Hand hygiene compliance was relatively low among the nursing staff in freestanding nursing homes in Taiwan. To comprehensively analyze this issue, further research involving a larger number of nursing homes and strategies to improve compliance with hand hygiene among the nursing staff at these institutions is needed.

Types of interventions used to improve hand hygiene compliance and prevent healthcare associated infection

Hand hygiene is regarded as the most effective means of preventing healthcare associated infection. However, systematic reviews provide limited evidence of effectiveness, a finding that is attributed to the poor quality of research designs, dubious outcome measures and flawed approaches to audit. The ability of interventions to improve hand hygiene compliance has not previously been questioned. This review categorises the types of interventions used to promote hand hygiene and discusses their plausibility, taking selected examples from previous systematic searches. Opinion leaders have emphasised the need for interventions to be underpinned by theory. This is an ambitious endeavour for infection control personnel based in National Health Service trusts. However, it is possible to offer pragmatic suggestions to promote compliance. Initiatives are most likely to be successful if needs analysis is undertaken at the outset to address local barriers and identify enablers to compliance, and if interventions are clearly justified by existing evidence, customised according to occupational group, consider health workers’ needs and preferences for training and updating, and avoid punishment.

Hand hygiene deficiency citations in nursing homes

Hand hygiene (HH) is recognized as an effective way to decrease transmission of infections. Little research has been conducted surrounding HH in nursing homes (NHs). In this research, deficiency citations representing potential problems with HH practices by staff as identified in the certification process conducted at almost all US NHs were examined. The aims of the study were to identify potential relationships between these deficiency citations and characteristics of the NH and characteristics of the NH environment. We used a panel of 148,900 observations with information primarily coming from the 2000 through 2009 Online Survey, Certification, And Reporting data (OSCAR). An average of 9% of all NHs per year received a deficiency citation for HH. In the multivariate analyses, for all three caregivers examined (i.e., nurse aides, Licensed Practical Nurses, and Registered Nurses) low staffing levels were associated with receiving a deficiency citation for HH. Two measures of poor quality (i.e., [1] Quality of care deficiency citations and [2] J, K, or L deficiency citations, that is deficiency citations with a high extent of harm and/or more residents affected) were also associated with receiving a deficiency citation for HH. Given the percentage of NHs receiving deficiency citations for potential problems with HH identified in this research, more attention should be placed on this issue.

A short-term, multicomponent infection control program in nursing homes: a cluster randomized controlled trial

OBJECTIVES

To assess the impact of a hygiene-encouragement program on reducing infection rates (primary end point) by 5%.

DESIGN

A cluster randomized study was carried out over a 5-month period.

SETTINGS AND PARTICIPANTS

Fifty nursing homes (NHs) with 4345 beds in France were randomly assigned by stratified-block randomization to either a multicomponent intervention (25 NHs) or an assessment only (25 NHs).

INTERVENTION

The multicomponent intervention was targeted to caregivers and consisted of implementing a bundle of infection prevention consensual measures. Interactive educational meetings using a slideshow were organized at the intervention NHs. The NHs were also provided with color posters emphasizing hand hygiene and a kit that included hygienic products such as alcoholic-based hand sanitizers. Knowledge surveys were performed periodically and served as reminders.

MEASUREMENTS

The primary end point was the total infection rate (urinary, respiratory, and gastrointestinal infections) in those infection cases classified either as definite or probable. Analyses corresponded to the underlying design and were performed according to the intention-to-treat principle. This study was registered (#NCT01069497).

RESULTS

Forty-seven NHs (4515 residents) were included and followed. The incidence rate of the first episode of infection was 2.11 per 1000 resident-days in the interventional group and 2.15 per 1000 resident-days in the control group; however, the difference between the groups did not reach statistical significance in either the unadjusted (Hazard Ratio [HR] = 1.00 [95% confidence interval (CI) 0.89-1.13]; P = .93]) or the adjusted (HR = 0.99 [95% CI 0.87-1.12]; P = .86]) analysis.

CONCLUSION

Disentangling the impact of this type of intervention involving behavioral change in routine practice in caregivers from the prevailing environmental and contextual determinants is often complicated and confusing to interpret the results.

The longitudinal prevalence of MRSA in care home residents and the effectiveness of improving infection prevention knowledge and practice on colonisation using a stepped wedge study design

Objectives To determine the prevalence and health outcomes of meticillin-resistant Staphylococcus aureus (MRSA) colonisation in elderly care home residents. To measure the effectiveness of improving infection prevention knowledge and practice on MRSA prevalence. Setting Care homes for elderly residents in Leeds, UK. Participants Residents able to give informed consent. Design A controlled intervention study, using a stepped wedge design, comprising 65 homes divided into three groups. Baseline MRSA prevalence was determined by screening the nares of residents (n=2492). An intervention based upon staff education and training on hand hygiene was delivered at three different times according to group number. Scores for three assessment methods, an audit of hand hygiene facilities, staff hand hygiene observations and an educational questionnaire, were collected before and after the intervention. After each group of homes received the intervention, all participants were screened for MRSA nasal colonisation. In total, four surveys took place between November 2006 and February 2009. Results MRSA prevalence was 20%, 19%, 22% and 21% in each survey, respectively. There was a significant improvement in scores for all three assessment methods post-intervention (p≤0.001). The intervention was associated with a small but significant increase in MRSA prevalence (p=0.023). MRSA colonisation was associated with previous and subsequent MRSA infection but was not significantly associated with subsequent hospitalisation or mortality. Conclusions The intervention did not result in a decrease in the prevalence of MRSA colonisation in care home residents. Additional measures will be required to reduce endemic MRSA colonisation in care homes.

Common infections in nursing homes: a review of current issues and challenges

Over 1.5 million people live in 16,000 nursing homes in the USA and experience an average of 2 million infections a year. Infections have been associated with high rates of morbidity and mortality, rehospitalization, extended hospital stay and substantial healthcare expenses. Emerging infections and antibiotic-resistant organisms in an institutional environment where there is substantial antimicrobial overuse and the population is older, frailer and sicker, create unique challenges for infection control. This review discusses the common infections, challenges, and a framework for a practical infection prevention program.

Hand-washing behaviour and nurses' knowledge after a training programme

The aim of this study was to evaluate the nurses' hand-washing behaviour and knowledge before and after a training programme. This prospective study involved 200 nurses who participated in hand-washing training at a university hospital in Turkey. The data were collected using a personal information form and pre- and post-test surveys that had been developed by the researchers. During the study, the nurses received 40 min of training on hand washing and a handbook prepared by the researchers. The hand-washing behaviour and knowledge of the nurses were assessed before training and 1 month after the training. To analyse the data, descriptive statistics, a t-test and a Mc Nemar chi-squared test were used. Following the training, there was a significant increase in the frequency of hand washing by the nurses (t = -2.202, P = 0.029), together with an increase in the time allowed for hand washing (P = 0.024, P < 0.05), knowledge of hand-washing practices (t = -16.081, P < 0.05) and quality (t = -10.874, P < 0.05). Planned training programmes for hand washing should be implemented to improve the behaviour and knowledge of nurses.

Nursing home deficiency citations for infection control

BACKGROUND

This study examined the deficiency citation for infection control (ie, F-Tag 441). This information represents potential problems in infection control as identified in the yearly certification process of almost all US nursing homes.

METHODS

The data used came primarily from the Online Survey, Certification, and Reporting data base, which contains information on both deficiency citations and characteristics of nursing homes. The data for each nursing home from 2000 through 2007 were combined, providing a panel of 100,000 observations. Multivariate analyses and generalized estimating equations with a logit link were used.

RESULTS

An average of 15% of all nursing homes received a deficiency citation for infection control each year from 2000 to 2007. In the multivariate analyses, several staffing levels were robust in their significance. For all 3 types of caregiver examined (ie, nurse aides, Licensed Practical Nurses, and Registered Nurses), low staffing levels were associated with receipt of a deficiency citation for infection control.

CONCLUSION

The high number of deficiency citations for infection control problems identified in this study suggests the need for increased emphasis on these programs in nursing homes to protect vulnerable elders.

Impact of a multi-faceted training intervention on the improvement of hand hygiene and gloving practices in four healthcare settings including nursing homes, acute-care geriatric wards and physical rehabilitation units

AIMS

To assess the impact of a multi-faceted training program on the compliance with hand hygiene and gloving practices.

BACKGROUND

Hand hygiene is considered as the cornerstone of the prevention of hospital-acquired infections. Several studies have enhanced the poor effectiveness of training programs in improving hand hygiene compliance.

DESIGN

A before-after evaluation study.

METHODS

The study was conducted in four healthcare settings before and after an intervention program which included the performance feedback of the first evaluation phase, three six-h training sessions, the assessment of hand hygiene performance with teaching boxes and the organisation of one full-day session devoted to institutional communication around hand hygiene in each setting. Hand hygiene compliance and quality of hand rubbing were evaluated. Hand hygiene opportunities were differentiated into extra-series opportunities (before or after a single contact and before the first contact or after the last contact of a series of consecutive contacts) and intra-series opportunities (from the opportunity following the first contact to the opportunity preceding the last in the same series).

RESULTS

Overall, 969 contacts corresponding to 1,470 hand hygiene opportunities (760 during the first phase and 710 during the second) were observed. A significant improvement of observed practices was recorded for the hand hygiene compliance in intra-series opportunities (39·0% vs. 19·0%; p < 10(-5) ), the proportion of gloves worn if indicated (71·4% vs. 52·0%; p < 0·001) and the quality of hand rubbing (85·0% vs. 71·9%; p < 10(-5) ).

CONCLUSIONS

Some of the performances measured for both hand hygiene and gloving practices were improved. We plan to extend this investigation by performing a qualitative study with experts in behavioural sciences to try improving practices for which adherence was still weak after the training program such as hand hygiene in intra-series opportunities.

RELEVANCE TO CLINICAL PRACTICE

This study underscored the usefulness of implementing contextualised training programs, while more traditional courses have shown little impact.

Monitoração da adesão à higienização das mãos: uma revisão de literatura

Pesquisas realizadas demonstram falta de padronização dos métodos de avaliação da aderência dos profissionais de saúde à prática da higienização das mãos. Assim, este estudo de revisão objetivou identificar os diferentes métodos utilizados para avaliação da aderência a essa prática, referendados na literatura por meio de consulta às seguintes bases de dados - Literatura Latino-Americana e do Caribe em Ciências da Saúde, Medical Analysis Retrieval System Online e Scientific Eletronic Library Online nas quais foram identificados 210 estudos, dentre os quais foram selecionados 34 artigos divulgados entre os anos de 2001 a 2010. O estudo apresenta os diferentes métodos adotados para realizar a avaliação da aderência aos procedimentos de higienização das mãos e aponta seus pontos fortes e fragilidades, a fim de subsidiar uma análise crítica por parte dos profissionais de saúde, com o intuito de favorecer a escolha do método mais adequado a cada instituição e realidade.

Interventions to improve hand hygiene compliance in patient care

BACKGROUND

Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure.

OBJECTIVES

To update the review done in 2007, to assess the short and longer-term success of strategies to improve hand hygiene compliance and to determine whether a sustained increase in hand hygiene compliance can reduce rates of health care-associated infection.

SEARCH STRATEGY

We conducted electronic searches of: the Cochrane Central Register of Controlled Trials; the Cochrane Effective Practice and Organisation of Care Group specialised register of trials; MEDLINE; PubMed; EMBASE; CINAHL; and the BNI. Originally searched to July 2006, for the update databases were searched from August 2006 until November 2009.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series analyses meeting explicit entry and quality criteria used by the Cochrane Effective Practice and Organisation of Care Group were eligible for inclusion. Studies reporting indicators of hand hygiene compliance and proxy indicators such as product use were considered. Self-reported data were not considered a valid measure of compliance. Studies to promote hand hygiene compliance as part of a care bundle approach were included, providing data relating specifically to hand hygiene were presented separately. Studies were excluded if hand hygiene was assessed in simulations, non-clinical settings or the operating theatre setting.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed data quality.

MAIN RESULTS

Four studies met the criteria for the review: two from the original review and two from the update. Two studies evaluated simple education initiatives, one using a randomized clinical trial design and the other a controlled before and after design. Both measured hand hygiene compliance by direct observation. The other two studies were both interrupted times series studies. One study presented three separate interventions within the same paper: simple substitutions of product and two multifaceted campaigns, one of which included involving practitioners in making decisions about choice of hand hygiene products and the components of the hand hygiene program. The other study also presented two separate multifaceted campaigns, one of which involved application of social marketing theory. In these two studies follow-up data collection continued beyond twelve months, and a proxy measure of hand hygiene compliance (product use) was recorded. Microbiological data were recorded in one study. Hand hygiene compliance increased for one of the studies where it was measured by direct observation, but the results from the other study were not conclusive. Product use increased in the two studies in which it was reported, with inconsistent results reported for one initiative. MRSA incidence decreased in the one study reporting microbiological data.

AUTHORS' CONCLUSIONS

The quality of intervention studies intended to increase hand hygiene compliance remains disappointing. Although multifaceted campaigns with social marketing or staff involvement appear to have an effect, there is insufficient evidence to draw a firm conclusion. There remains an urgent need to undertake methodologically robust research to explore the effectiveness of soundly designed and implemented interventions to increase hand hygiene compliance.

The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations

The World Health Organization's Guidelines on Hand Hygiene in Health Care have been issued by WHO Patient Safety on 5 May 2009 on the occasion of the launch of the Save Lives: Clean Your Hands initiative. The Guidelines represent the contribution of more than 100 international experts and provide a comprehensive overview of essential aspects of hand hygiene in health care, evidence- and consensus-based recommendations, and lessons learned from testing their Advanced Draft and related implementation tools.