Hand hygiene compliance: are we kidding ourselves?

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.

A Cross-Sectional, Questionnaire-Based Survey on Air Infection Control among Romanian People

(1) Background: Infection control should be one of the main objectives in the comprehensive medical approach. (2) Methods: A cross-sectional study was conducted from June-July 2022. A questionnaire including 22 questions with multiple answers was applied online to 202 subjects selected at random. The questionnaire collected data on the subjects' knowledge about protective measures against airborne infections. For this study, a descriptive statistic was performed. Pearson's Chi-square test was used for data comparison. (3) Results: Only 61.39% (124) of the subjects consider that protective equipment is mandatory for the dental team, 40.10% (81) know to a very large extent and 44.06% (89) to a large extent that when talking, a respiratory infection can be transmitted. A rather large percentage of the subjects take into account the cost of the protective mask to a very large extent 39.60% (80). Only 30.20% (61) of the subjects would vaccinate to a very large extent and 24.75% (50) to a large extent against micro-organisms transmitted by air p > 0.05. (4) Conclusions: Most people know the aspects related to air decontamination, the priority being the promotion of control methods of airborne infections, and it is necessary to improve the level of knowledge on a large scale within the population.

Comparison of two electronic hand hygiene systems using real-time feedback via wireless technology to improve hand hygiene compliance in an intensive care unit

BACKGROUND

Most hand hygiene (HH) intervention studies use a quasi-experimental design, are primarily uncontrolled before-and-after studies, or are controlled before-and-after studies with a nonequivalent control group. Well-funded studies with improved designs and HH interventions are needed.

OBJECTIVES

To evaluate healthcare worker (HCW) HH compliance with alcohol-based hand rub (ABHR) through direct observation (human observer), 2 electronic technologies, a radio frequency identification (RFID) badge system, and an invasive device sensor.

METHODS

In our controlled experimental study, 2,269 observations were made over a 6-month period from July 1 to December 30, 2020, in a 4-bed intensive care unit. We compared HH compliance between a basic feedback loop system with RFID badges and an enhanced feedback loop system that utilized sensors on invasive devices.

RESULTS

Real-time feedback by wireless technology connected to a patient's invasive device (enhanced feedback loop) resulted in a significant increase in HH compliance (69.5% in the enhanced group vs 59.1% in the basic group; P = .0001).

CONCLUSION

An enhanced feedback loop system connected to invasive devices, providing real-time alerts to HCWs, is effective in improving HH compliance.

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.

An interventional implementation project: hand hygiene improvement

Background

Good hand hygiene is the most effective basic measure for preventing hospital-acquired infections. This research project, which originated from a project report on improving hand hygiene at a general hospital in Hangzhou, Zhejiang, China, aimed to investigate the effectiveness of hand hygiene improvement among the hospital staff.

Methods

Since 2017, a hand hygiene improvement project involving the staff of a 2,500-bed general teaching hospital in Zhejiang, China, has been carried out. This study summarized the implementation and effectiveness of the project, which is based on the five factors of systematic evaluation. The research summary was divided into three phases: phase I (December 2017 to August 2018), phase 2 (September 2018 to April 2019), and phase 3 (May 2019 to December 2019). The data of hand hygiene compliance rates of different groups of professionals in the different research periods were statistically analyzed.

Results

The results showed that continuous intervention led to a gradual increasing trend (Ptrend<0.001) in the hand hygiene implementation rate with as the intervention time and phases progressed. The hand hygiene compliance rates differed significantly during different phases (76.61%, 79.95%, and 83.34% in phases 1, 2, and 3, respectively, P<0.001). At the same time, the compliance rates of hand hygiene at each phase differed significantly between different professions (P<0.001, the compliance rate of hand hygiene among nurses was the highest and lowest among workers). The compliance rate of hand hygiene for different professions during the three phases were: nurses, 84.73%; doctors, 78.35%; interns, 77.62%; and other hospital workers, 72.79%.

Conclusions

The hand hygiene compliance rate was effectively improved among the hospital staff after the implementation of the hand hygiene improvement project. In this hospital, the project yielded remarkable results. Hand hygiene must be continuously practiced and improved to develop good habits. Effective and detailed planning as well as key factors, such as hand hygiene facilities, information monitoring, the active participation and response of employees, training and education, and supervision and feedback, could help to guarantee the effectiveness of the project.

Hand hygiene compliance among healthcare workers in Ghana’s health care institutions: An observational study

Objective

To assess hand hygiene compliance in selected primary hospitals in Ghana.

Design

A cross-sectional health facility-based observational study was conducted in primary health care facilities in five regions in Ghana. A total of 546 healthcare workers including doctors, nurses, midwives and laboratory personnel from 106 health facilities participated in the study.

Main outcome measures

The main outcome measures included availability of hand hygiene materials and alcohol job aids; compliance with moments of hand hygiene; and compliance with steps in hygienic hand washing. These were assessed using descriptive statistics.

Results

The mean availability of hand hygiene material and alcohol job aids was 75% and 71% respectively. This was described as moderately high, but less desirable. The mean hand hygiene compliance with moments of hand hygiene was 51%, which was also described asmoderately high, but less desirable. It was observed that, generally, hand hygiene was performed after procedures than before. However, the mean compliance with steps in hygienic hand washing was 86%, which was described as high and desirable.

Conclusion

Healthcare workers are generally competent in performance of hygienic hand washing. However, this does not seem to influence compliance with moments of hand hygiene. Efforts must therefore be made to translate the competence of healthcare workers in hygienic hand washing into willingness to comply with moments of hand hygiene, especially contact with patients.

Ways in which healthcare interior environments are associated with perceived safety against infectious diseases and coping behaviours

BACKGROUND

Global pandemic outbreaks are a cause of fear. Healthcare workers (HCWs), especially those fighting the pathogens at the front line, are at higher risk of being infected while they treat patients. In addition, various environmental fomites in hospitals, which may carry infectious agents, can increase the risk of acquiring an infectious disease.

AIM

In order to deliver the best healthcare practice, it is critical that HCWs feel safe and protected against infectious diseases. The aim of this study was to improve understanding of HCWs' hand hygiene (HH) behaviours and perceptions of infectious diseases from a psychological perspective.

METHODS

Environmental features were observed in three departments, and questionnaires were used to determine perceived safety against infectious diseases among HCWs and the coping behaviours they used (e.g. avoidance and disinfection).

FINDINGS

This study found that an increase in the number of HH stations at convenient locations would increase HH compliance and perceived safety against infectious diseases among HCWs. In response to the current research gap in psychological aspects associated with HH, this study found that HCWs' coping behaviours can be predicted by their perceived likelihood of contamination and perceived vulnerability.

CONCLUSIONS

The study findings should be interpreted with care, and further studies with more academic rigor are needed.

Hand Hygiene Compliance in the ICU: A Systematic Review

OBJECTIVES

To synthesize the literature describing compliance with World Health Organization hand hygiene guidelines in ICUs, to evaluate the quality of extant research, and to examine differences in compliance levels across geographical regions, ICU types, and healthcare worker groups, observation methods, and moments (indications) of hand hygiene.

DATA SOURCES

Electronic searches were conducted in August 2018 using Medline, CINAHL, PsycInfo, Embase, and Web of Science. Reference lists of included studies and related review articles were also screened.

STUDY SELECTION

English-language, peer-reviewed studies measuring hand hygiene compliance by healthcare workers in an ICU setting using direct observation guided by the World Health Organization's "Five Moments for Hand Hygiene," published since 2009, were included.

DATA EXTRACTION

Information was extracted on study location, research design, type of ICU, healthcare workers, measurement procedures, and compliance levels.

DATA SYNTHESIS

Sixty-one studies were included. Most were conducted in high-income countries (60.7%) and in adult ICUs (85.2%). Mean hand hygiene compliance was 59.6%. Compliance levels appeared to differ by geographic region (high-income countries 64.5%, low-income countries 9.1%), type of ICU (neonatal 67.0%, pediatric 41.2%, adult 58.2%), and type of healthcare worker (nursing staff 43.4%, physicians 32.6%, other staff 53.8%).

CONCLUSIONS

Mean hand hygiene compliance appears notably lower than international targets. The data collated may offer useful indicators for those evaluating, and seeking to improve, hand hygiene compliance in ICUs internationally.

Hand hygiene compliance monitoring: Do video-based technologies offer opportunities for the future?

Hand hygiene is universally recognised as the primary measure to reduce healthcare-associated infections. Studies have convincingly demonstrated a link between increased hand hygiene compliance and reductions in rates of healthcare-associated infections. Direct observation is considered the gold standard method for monitoring hand hygiene compliance. Despite the acknowledged benefits of this approach, recent literature has highlighted a range of issues impacting on the reliability and validity of this data collection technique. The rise of technology in healthcare provides opportunity for alternative methods that promise advantages over direct human observation. There have been no published examples of systems that are able to capture data consistent with all the WHO '5 Moments for Hand Hygiene'. In this paper we explore current human-based auditing practises for monitoring hand hygiene compliance and raise for discussion and debate video-based technologies to monitor hand hygiene compliance. We raise questions regarding hybrid approaches that incorporate both direct human observation and indirect video-based surveillance, and the possible advantages and disadvantages therein for monitoring hand hygiene compliance. We suggest that such methods have the potential to ameliorate, or minimise, the inherent biases associated with direct observation, notably the Hawthorne Effect. Future research into the utility of a hybrid approach to auditing, including the technical specifications, efficacy, cost effectiveness and acceptability of such a model is warranted.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Psychometric evaluation of a measure of factors influencing hand hygiene behaviour to inform intervention

BACKGROUND

Although the hand hygiene (HH) procedure is simple, the related behaviour is complex and is not readily understood, explained or changed. There is a need for practical tools to provide data that can guide healthcare managers and practitioners not only on the 'what' (the standards that must be met), but also the 'how' (guidance on how to achieve the standards).

AIM

To develop a valid questionnaire to evaluate attitudes to the factors that influence engagement in HH behaviour that can be readily completed, administered and analysed by healthcare professionals to identify appropriate intervention strategies. Construct validity was assessed using confirmatory factor analysis, predictive validity was assessed through comparison with self-reported HH behaviour, and convergent validity was assessed through direct unit-level observation of HH behaviour.

METHODS

The Capability, Opportunity, Motivation-Behaviour (COM-B) model was used to design a 25-item questionnaire that was distributed to intensive care unit (ICU) personnel in Ireland. Direct observation of HH behaviour was carried out at two ICUs.

FINDINGS

In total, 292 responses to the survey (response rate 41.0%) were included in the analysis. Confirmatory factor analysis resulted in a 17-item questionnaire. Multiple regression revealed that a model including capability, opportunity and motivation was a significant predictor of self-reported behavioural intention [F(3,209)=22.58, P<0.001]. However, the opportunity factor was not found to make a significant contribution to the regression model.

CONCLUSION

The COM-B HH questionnaire is reliable and valid, and provides data to support the development and evaluation of HH interventions that meet the needs of specific healthcare units.

Hand hygiene compliance and accuracy in a university dental teaching hospital

Objective

This study aimed to evaluate compliance with guidelines on hand hygiene by examining five handwashing categories in postgraduate year (PGY) dentists at a university teaching hospital and to evaluate the accuracy rates of handwashing.

Methods

Through direct observation, trained PGY dentists were monitored throughout their daily care routine of before contact with patients, before using an instrument, after contact with patients, upon direct exposure to patients’ fluids, and while touching the patients’ surrounding area. Hand hygiene opportunities were considered complete in each category. A total of 16,597 hand hygiene opportunities across 37 individuals were observed from July to October 2012 and from September to October 2013.

Results

The overall handwashing compliance rate was 34.7%. The handwashing compliance rate was higher during work in oral surgery services (92.8%) than during work in general clinical practice (34.2%). The accuracy rate of handwashing was also higher during work in oral surgery services (87.5%) than during work in general clinical practice (51.0%). Similar results were obtained across all five handwashing categories.

Conclusions

Handwashing compliance and accuracy rates are low in PGY dentists. More education and continuous monitoring are suggested to improve handwashing compliance, as well as the correct handwashing procedures for dentists.

Interventions to increase hand hygiene compliance in a tertiary university hospital over a period of 5 years: An iterative process of information, training and feedback

AIMS AND OBJECTIVE

To explore whether an iterative process of information and training paired with a feedback system to observed healthcare professionals and the respective management improves hand hygiene (HH) compliance.

BACKGROUND

Healthcare-associated infections are a major risk for patient safety, and adherence to the "My five moments" (M5M) for HH varies significantly within organisations as well as within healthcare professional groups. Identified barriers in a baseline survey revealed the need of more information, training, repetitive compliance measurements and feedback to all healthcare professionals.

DESIGN

A quality improvement project using the method of direct observation of healthcare professionals in nonsurgical and surgical wards.

METHODS

Between 2013 and 2017, 6,009 healthcare professionals were informed and trained, and HH compliance measurements were performed by hygiene experts. Compliance measurement results were documented in an online tool to give an immediate feedback to observed healthcare professionals. Additionally, a report was forwarded to the management of the respective department to raise awareness. Compliance rates per year were descriptively summarised. The research and reporting methodology followed SQUIRE 2.0.

RESULTS

In total, 84 compliance measurements with 19,295 "M5M for HH" were observed in 49 wards. Overall, mean HH compliance increased from 81.9 ± 5.2% in 2013 to 94.0 ± 3.6% in 2017. Physicians' HH compliance rate improved from 69.0 ± 16.6% to 89.3 ± 6.6%, that of nurses from 86.0 ± 6.9% to 96.4 ± 3.1%, and that of others from 60.5 ± 27.9% to 83.8 ± 20.2%. All M5M for HH (#1-#5) increased over the study period (#1: +16.9%; #2: +20.5%; #3: +7.6%; #4: +5.9%; #5: +12.7%).

CONCLUSIONS

Results demonstrated that an iterative process of information, training, observation and feedback over a period of 5 years can be successful in increasing HH compliance. Positive trends were observed for HH compliance rates across all healthcare professional groups as well as for all M5M for HH.

Strategies to improve hand hygiene compliance among healthcare workers in adult intensive care units: a mini systematic review

BACKGROUND

Hand hygiene compliance among healthcare workers (HCWs) in intensive care units (ICUs) is disconcertingly low.

AIM

To identify the effective intervention(s) for increasing HH compliance among HCWs in adult ICUs.

METHODS

Two major electronic databases, OVID Medline and CINAHL, were searched by using a combination of MeSH terms and text words (e.g. hand hygiene, hand washing, compliance, adher*, improve*, develop* and intensive care unit) for relevant articles. This was supplemented by Google Scholar and hand searching of included bibliographies. Data from identified articles were then abstracted, quality-assessed, and combined into a summary effect.

FINDINGS

Of 89 titles and abstracts that were identified, 14 articles were finally included. Overall study quality was good. However, variations in design, setting, sample size, and intervention(s) tested precluded a meta-analysis; hence a narrative synthesis was conducted. The interventions included education, observation, provision of supplies, improving access and directive support; tested singly or in combination; resulted in positive outcomes in all but one study. A combination of administrative support, 'supplies', education and training, reminders, surveillance, and performance feedback raised the compliance from a baseline of 51.5% to a record 80.1%; but no set of intervention(s) could improve the compliance to the desired near-100% level.

CONCLUSION

Available data suggest that multi-modal interventions are effective in raising the compliance to a 'plateau' level but not up to the desired standard. Methodologically appropriate trials of combined interventions could enhance the evidence about interventions to improve hand hygiene compliance among ICU staff.

Hand hygiene compliance rates: Fact or fiction?

BACKGROUND

The mandatory national hand hygiene program requires Australian public hospitals to use direct human auditing to establish compliance rates. To establish the magnitude of the Hawthorne effect, we compared direct human audit rates with concurrent automated surveillance rates.

METHODS

A large tertiary Australian teaching hospital previously trialed automated surveillance while simultaneously performing mandatory human audits for 20 minutes daily on a medical and a surgical ward. Subtracting automated surveillance rates from human audit rates provided differences in percentage points (PPs) for each of the 3 quarterly reporting periods for 2014 and 2015.

RESULTS

Direct human audit rates for the medical ward were inflated by an average of 55 PPs in 2014 and 64 PPs in 2015, 2.8-3.1 times higher than automated surveillance rates. The rates for the surgical ward were inflated by an average of 32 PPs in 2014 and 31 PPs in 2015, 1.6 times higher than automated surveillance rates. Over the 6 mandatory reporting quarters, human audits collected an average of 255 opportunities, whereas automation collected 578 times more data, averaging 147,308 opportunities per quarter. The magnitude of the Hawthorne effect on direct human auditing was not trivial and produced highly inflated compliance rates.

CONCLUSIONS

Mandatory compliance necessitates accuracy that only automated surveillance can achieve, whereas daily hand hygiene ambassadors or reminder technology could harness clinicians' ability to hyperrespond to produce habitual compliance.

Safe removal of gloves from contact precautions: The role of hand hygiene

BACKGROUND

Routine hand hygiene effectively removes methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin resistant Enterococcus (VRE) from the ungloved hands of healthcare workers (HCWs) who are caring for patients under contact precautions, when exposure to bodily fluids is not expected.

METHODS

HCWs' ungloved hands were cultured after hand hygiene with alcohol-based hand rub (ABHR) or soap-and-water wash after routine clinical care of patients known to be colonized or infected with MRSA or VRE.

RESULTS

Two hundred forty samples from 40 HCWs were tested and found to be culture negative for either MRSA or VRE after contact with patients when 3 pumps of ABHR (0/80) or plain soap-and-water wash (0/80) were used. No VRE was observed in any of the 120 samples collected. Two plates (2/40) grew 1 colony-forming unit of MRSA after 2 pumps of ABHR. Two HCWs with positive plates were cultured negative on retesting.

CONCLUSION

We showed that appropriate hand hygiene was effective in removing MRSA and VRE even when gloves were not used for routine clinical care, despite contact with patients known to be colonized with MRSA or VRE. A modified approach to glove use for dry contact with patients on contact precautions might improve patient safety within healthcare settings.

Candidemia in children: Epidemiology, prevention and management

Candidemia is the leading cause of invasive fungal infections in hospitalised children. The highest rates of candidemia have been recorded in neonates and infants <1 year of age. Candidemia is more frequent in neonates and young infants than in adults, and is associated with better clinical outcomes, but higher inpatient costs. Over the last 10 years, a declining trend has been noted in the incidence of paediatric candidemia in the US and elsewhere due to the hospital-wide implementation of central-line insertion and maintenance bundles that emphasise full sterile barrier precautions, chlorhexidine skin preparation during line insertion, meticulous site and tubing care, and daily discussion of catheter necessity. Additional interventions aiming at reducing gut-associated candidemia are required in immunocompromised and critically ill children.

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.

Attitudes and practices of Irish hospital-based physicians towards hand hygiene and hand rubbing using alcohol-based hand rub: a comparison between 2007 and 2015

BACKGROUND

Hand hygiene is the cornerstone of infection prevention and control practices, and reduces healthcare-associated infections significantly. However, international evidence suggests that medical doctors demonstrate poor compliance.

AIM

To explore and compare practices and attitudes towards hand hygiene, particularly hand rubbing using alcohol-based hand rub (ABHR), among hospital-based physicians in Ireland between 2007 and 2015.

METHODS

In 2007, a random sample of doctors in a large teaching hospital was invited to complete a postal survey using a validated questionnaire. In 2015, the study was replicated among all doctors employed in a university hospital group, including the setting of the original study, using an online survey. Data were analysed using SPSS and Survey Monkey.

FINDINGS

Predominately positive and improving attitudes and practices were found, with 86% of doctors compliant with hand hygiene before patient contact in 2015, compared with 58% in 2007. Ninety-one percent of doctors were compliant after patient contact in 2015, compared with 76% in 2007. In 2015, only 39% of respondents reported that they 'almost always' used ABHR for hand hygiene. However, this represents 13.5% more than in 2007. Stated barriers to use of ABHR included dermatological issues, poor acceptance, tolerance and poor availability of ABHR products.

CONCLUSION

Greater awareness of hand hygiene guidelines and greater governance appear to have had a positive impact on practice. However, despite this, practice remains suboptimal and there is scope for substantial improvement. Continued and sustained efforts are required in order to build on progress achieved since the World Health Organization hand hygiene guidelines were published in 2009.

Unit-Specific Rates of Hand Hygiene Opportunities in an Acute-Care Hospital

OBJECTIVE To explore the frequency of hand hygiene opportunities (HHOs) in multiple units of an acute-care hospital. DESIGN Prospective observational study. SETTING The adult intensive care unit (ICU), medical and surgical step-down units, medical and surgical units, and the postpartum mother-baby unit (MBU) of an academic acute-care hospital during May-August 2013, May-July 2014, and June-August 2015. PARTICIPANTS Healthcare workers (HCWs). METHODS HHOs were recorded using direct observation in 1-hour intervals following Public Health Ontario guidelines. The frequency and distribution of HHOs per patient hour were determined for each unit according to time of day, indication, and profession. RESULTS In total, 3,422 HHOs were identified during 586 hours of observation. The mean numbers of HHOs per patient hour in the ICU were similar to those in the medical and surgical step-down units during the day and night, which were higher than the rates observed in medical and surgical units and the MBU. The rate of HHOs during the night significantly decreased compared with day (P92% of HHOs on medical and surgical units, compared to 67% of HHOs on the MBU. CONCLUSIONS Assessment of hand hygiene compliance using product utilization data requires knowledge of the appropriate opportunities for hand hygiene. We have provided a detailed characterization of these estimates across a wide range of inpatient settings as well as an examination of temporal variations in HHOs. Infect Control Hosp Epidemiol 2017;38:411-416.