Workload even affects hand hygiene in a highly trained and well-staffed setting: a prospective 365/7/24 observational study

Application of the behaviour-centred design to understand facilitators and deterrents of hand hygiene among healthcare providers: findings from a formative phase of a cluster randomised trial in the Kampala Metropolitan area

BACKGROUND

Hand hygiene is known to reduce healthcare-associated infections. However, it remains suboptimal among healthcare providers. In this study, we used the Behaviour-centered Design approach to explore the facilitators and deterrents to hand hygiene among healthcare providers in the Kampala Metropolitan area, Uganda.

METHODS

We conducted a formative qualitative study as part of a cluster randomised trial in 19 healthcare facilities (HCFs). The study used 19 semi-structured and 18 key informant interviews to collect data on hand hygiene status and facilitators and deterrents of hand hygiene. Research assistants transcribed verbatim and used a thematic framework aided by Nvivo 14.0. to undertake analysis. We used thick descriptions and illustrative quotes to enhance the credibility and trustworthiness of our findings.

RESULTS

About 47.4% of the HCFs had sufficient hand hygiene infrastructure, and 57.9% did not report total compliance with hand hygiene during patient care. The physical facilitator for hand hygiene was the presence of constant reminders such as nudges, while the biological included the frequency of patient contact and the nature of clinical work. The only biological deterrent was the heavy workload in HCFs. The executive brain facilitators included knowledge of workplace health risks, infection prevention and control (IPC) guidelines, and a positive attitude. A negative attitude was the executive brain deterrent to hand hygiene. Recognition, rewards, and fear of infections were the only motivated brain facilitators. Behavioural setting facilitators included proximity to functional hand hygiene infrastructure, the existence of active IPC committees, good leadership, and the availability of a budget for hand hygiene supplies. Behavioural setting deterrents included the non-functionality and non-proximity to hand hygiene infrastructure and inadequate supplies.

CONCLUSIONS

The study revealed low compliance with hand hygiene during the critical moments of patient care and inadequacy of hand hygiene infrastructure. The deterrents to hand hygiene included a heavy workload, negative attitude, inadequate supplies, non-functionality, and long distance to hand washing stations. Facilitators included constant reminders, fear of infections, frequency of patient contact and nature of clinical work, positive attitude, knowledge of IPC guidelines, recognition and reward, good leadership, availability of budgets for hand hygiene supplies, availability and proximity to hand hygiene supplies and infrastructure and active IPC committees.

TRIAL REGISTRATION

ISRCTN Registry with number ISRCTN98148144. The trial was registered on 23/11/2020.

Drastic hourly changes in hand hygiene workload and performance rates: a multicenter time series analysis

BACKGROUND

High hand hygiene (HH) workload is a commonly cited barrier to optimal HH performance. The objective of this study was to assess trends of HH workload as defined by HH opportunities (HHO) and performance rates over different time scales using automated HH monitoring system data.

METHODS

This multi-year retrospective observational study was conducted in 58 inpatient units located in 10 North American hospitals. HHO and HH rates were analyzed by time series mixed effects general additive model.

RESULTS

Median HH rates peaked at 50.0 between 6-7 am with a trough of 38.2 at 5 pm. HHO over hours in a day were highest at 184 per hospital unit per hour at 10 am with a trough of 49.0 between 2-3 am. Median rates for day and night shifts were 40.8 and 45.5 respectively (p=0.078). Weekend day shift had the lowest median rate (39.4) compared to any other 12-hour shift (p<0.1018). The median rates and HHO varied little across days in a week and months.

CONCLUSIONS

HH workload and performance rates were negatively correlated and changed drastically over hours in a day. Hospitals should consider HH workload in the development and timely delivery of improvement interventions.

[Automated surveillance and risk prediction with the aim of risk-stratified infection control and prevention (RISK PRINCIPE)]

Healthcare-associated infections (HCAIs) represent an enormous burden for patients, healthcare workers, relatives and society worldwide, including Germany. The central tasks of infection prevention are recording and evaluating infections with the aim of identifying prevention potential and risk factors, taking appropriate measures and finally evaluating them. From an infection prevention perspective, it would be of great value if (i) the recording of infection cases was automated and (ii) if it were possible to identify particularly vulnerable patients and patient groups in advance, who would benefit from specific and/or additional interventions.To achieve this risk-adapted, individualized infection prevention, the RISK PRINCIPE research project develops algorithms and computer-based applications based on standardised, large datasets and incorporates expertise in the field of infection prevention.The project has two objectives: a) to develop and validate a semi-automated surveillance system for hospital-acquired bloodstream infections, prototypically for HCAI, and b) to use comprehensive patient data from different sources to create an individual or group-specific infection risk profile.RISK PRINCIPE is based on bringing together the expertise of medical informatics and infection medicine with a focus on hygiene and draws on information and experience from two consortia (HiGHmed and SMITH) of the German Medical Informatics Initiative (MII), which have been working on use cases in infection medicine for more than five years.

Central aspects when implementing an electronic monitoring system for assessing hand hygiene in clinical settings: A grounded theory study

Background

New technologies, such as electronic monitoring systems, have been developed to promote increased adherence to hand hygiene among healthcare workers. However, challenges when implementing these technologies in clinical settings have been identified.

Aim

The aim of this study was to explore healthcare workers' experiences when implementing an electronic monitoring system to assess hand hygiene in a clinical setting.

Method

Interviews with healthcare workers (registered nurses, nurse assistants and leaders) involved in the implementation process of an electronic monitoring system (n = 17) were conducted and data were analyzed according to the grounded theory methodology formulated by Strauss and Corbin.

Results

Healthcare workers' experiences were expressed in terms of leading and facilitating, participating and contributing, and knowing and confirming. These three aspects were merged together to form the core category of collaborating for progress. Leaders were positive and committed to the implementation of the electronic monitoring system, endeavouring to enable facilitation and support for their co-workers (registered nurses and nurse assistants). At the same time, co-workers were positive about the support they received and contributed by raising questions and demands for the product to be used in clinical settings. Moreover, leaders and co-workers were aware of the objective of implementing the electronic monitoring system.

Conclusion

We identified dynamic collective work between leaders and co-workers during the implementation of the electronic monitoring system. Leadership, participation and knowledge were central aspects of enhancing a collaborative process. We strongly recommend involving both ward leaders and users of new technologies to promote successful implementation.

An outbreak of multi-drug-resistant Acinetobacter baumannii on a burns ICU and its control with multi-faceted containment measures

BACKGROUND

Patients in burns centres are at high risk of acquiring multi-drug-resistant organisms (MDROs) due to the reduced skin barrier and long hospital stay.

METHODS

This study reports the investigation and control of an outbreak of MDR Acinetobacter baumannii in a burns centre. The 27 patients hospitalized in the centre during the outbreak were screened regularly, and a total of 132 environmental samples were analysed to identify a potential source. Fourier-transform infra-red (FT-IR) spectroscopy and multi-locus sequence typing were applied to characterize the outbreak strain.

RESULTS

Between August and November 2022, the outbreak affected eight patients, with 11 infections and three potentially related fatal outcomes. An interdisciplinary and multi-professional outbreak team implemented a bundle strategy with repetitive admission stops, isolation precaution measures, patient screenings, enhanced cleaning and disinfection, and staff education. FT-IR spectroscopy suggested that the outbreak started from a patient who had been repatriated 1 month previously from a country with high prevalence of MDR A. baumannii. Environmental sampling did not identify a common source. Acquisition of the outbreak strain was associated with a higher percentage of body surface area with burn lesions ≥2a [per percent increase: odds ratio (OR) 1.05, 95% confidence interval (CI) 0.99-1.12; P=0.09], and inversely associated with a higher nurse-to-patient ratio (per 0.1 increase: OR 0.34, 95% CI 0.10-1.12; P=0.06).

CONCLUSIONS

Burn patients with a higher percentage of body surface area with burn lesions ≥2a are at high risk of colonization and infection due to MDROs, particularly during periods of high workload. A multi-faceted containment strategy can successfully control outbreaks due to MDR A. baumannii in a burns centre.

Whole-genome sequencing links cases dispersed in time, place, and person while supporting healthcare worker management in an outbreak of Panton-Valentine leucocidin meticillin-resistant Staphylococcus aureus; and a review of literature

This is a report on an outbreak of Panton-Valentine leucocidin-producing meticillin-resistant Staphylococcus aureus (PVL-MRSA) in an intensive care unit (ICU) during the COVID-19 pandemic that affected seven patients and a member of staff. Six patients were infected over a period of ten months on ICU by the same strain of PVL-MRSA, and a historic case identified outside of the ICU. All cases were linked to a healthcare worker (HCW) who was colonized with the organism. Failed topical decolonization therapy, without systemic antibiotic therapy, resulted in ongoing transmission and one preventable acquisition of PVL-MRSA. The outbreak identifies the support that may be needed for HCWs implicated in outbreaks. It also demonstrates the role of whole-genome sequencing in identifying dispersed and historic cases related to the outbreak, which in turn aids decision-making in outbreak management and HCW support. This report also includes a review of literature of PVL-MRSA-associated outbreaks in healthcare and highlights the need for review of current national guidance in the management of HCWs' decolonization regimen and return-to-work recommendations in such outbreaks.

Estimating the effect of practicing nursing professionals density on cumulative carbapenem-resistance prevalence in gram-negative invasive Isolates: a 30 European country observational modeling study

Background

The burden of antimicrobial-resistance, specifically carbapenem-resistance in gram-negative bacteria (CRGN), presents a serious public health threat worldwide. In Europe, Southern and Eastern countries (SEC) display a higher CRGN-prevalence as compared to Northern and Western countries (NWC). Since SEC also display lower nurse-density on average, we hypothesized that the occurrence of CRGN might correlate with nurse understaffing and therefore aimed at quantifying a potential independent effect of nurse-density on total CRGN in Europe.

Methods

A 30-country cross-sectional study was conducted. Cumulative six-year CRGN-prevalence (2011–2016) in four gram-negative bacterial species was determined based on > 700 k clinical invasive isolates (EARS-net). We performed multivariable log-linear regression to provide estimations of the effect of nurse-density while adjusting to various health-system variables.

Results

Multivariable analysis (adj.-R² ~ 93%) suggested an average 0.4% [95%-CI 0.2–1.0%] CRGN-increase due to a decrement of one practicing nurse per week of hospital-stay of one population individual. Our modeling provided CRGN-estimations in two non-EARS-net countries (Switzerland and Turkey), which were almost equal to empirically estimated values (CAESAR-Network). Furthermore, a nurse-density-dependent moderation of the inter-species distribution balance was a likely pathway of the observed effect. These observations were specific for CRGN, in contrast to other resistance types in the same species.

Conclusions

This is the first attempt of quantifying potential nurse-density effects on antimicrobial-resistance at national level. Our results suggest an increase in CRGN by decreasing nurse-density. Nurse-density is thus a novel factor that might improve our understanding of the unbalanced CRGN-distribution among sub-European regions. Consequently, integrating nurse-density in future AMR-policies could be beneficial.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01076-0.

Risk stratification for selecting empiric antibiotherapy during and after COVID-19

PURPOSE OF REVIEW

SARS-CoV-2 deeply modified the risk of bacterial infection, bacterial resistance, and antibiotic strategies. This review summarized what we have learned.

RECENT FINDINGS

During the COVID-19 pandemic, we observed an increase in healthcare-acquired infection and multidrug-resistant organism-related infection, triggered by several factors: structural factors, such as increased workload and ongoing outbreaks, underlying illnesses, invasive procedures, and treatment-induced immunosuppression. The two most frequently healthcare-acquired infections described in patients hospitalized with COVID-19 were bloodstream infection, related or not to catheters, health-acquired pneumonia (in ventilated or nonventilated patients). The most frequent species involved in bacteremia were Gram-positive cocci and Gram-negative bacilli in health-acquired pneumonia. The rate of Gram-negative bacilli is particularly high in late-onset ventilator-associated pneumonia, and the specific risk of Pseudomonas aeruginosa- related pneumonia increased when the duration of ventilation was longer than 7 days. A specificity that remains unexplained so far is the increase in enterococci bacteremia.

SUMMARY

The choice of empiric antibiotimicrobials depends on several factors such as the site of the infection, time of onset and previous length of stay, previous antibiotic therapy, and known multidrug-resistant organism colonization. Pharmacokinetics of antimicrobials could be markedly altered during SARS-CoV-2 acute respiratory failure, which should encourage to perform therapeutic drug monitoring.

Compliance with hand disinfection in the surgical area of an orthopedic university clinic: results of an observational study

Background

Hand hygiene using alcoholic hand rub solution is essential for the prevention of surgical site infections. There are several opportunities for hygienic hand disinfection (termed “hand hygiene” in the following) during immediate pre-, intra- and postoperative orthopedic patient care. However, the level of hand hygiene compliance among surgical and anesthesia staff in this context is unclear. Therefore, we conducted an observational study in operating theatres of an orthopedic university clinic in northern Germany during July and August 2020.

Methods

One trained person directly and comprehensively observed hand hygiene compliance of surgical and anesthesia staff according to the WHO “My 5 moments for hand hygiene” model (WHO-5). In addition to cross-tabulations with Chi² tests, multiple logistic regression models were used to study associations between occupational group, medical specialty, and compliance (both overall and for each WHO-5 indication). Models were adjusted for hand hygiene opportunities being associated with female or male healthcare workers, being located within or outside the operation room, and occurring in adult or pediatric surgery.

Results

In total, 1145 hand hygiene opportunities during 16 surgeries were observed. The overall compliance was 40.8% (95% CI 37.9–43.6%), with a larger difference between surgical versus anesthesia staff (28.4% vs. 46.1%, p < 0.001) than between physicians versus nurses (38.5% vs. 42.9%, p = 0.13). Adjusting for sex, place of observation, and adult versus pediatric operation theatre, logistic regression analyses revealed a significant interaction between medical specialty and occupational group (p < 0.001). In particular, the odds for compliance were higher for anesthesiologists (47.9%) than for surgeons (19.6%) (OR = 4.8, 95% CI 3.0–7.6). In addition, compliance was higher in pediatric surgery (OR = 1.9, 95% CI 1.4–2.6). In general, WHO-5-stratified results were in line with these overall patterns.

Conclusions

Hygienic hand disinfection compliance was approximately 41%. Notably, surgeons performed worse than anesthesiologists did. These results indicate that hand hygiene compliance in orthopedic surgery needs to be improved. Tailored interventions promise to be an appropriate way to address each occupational group’s specific needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01058-2.

Hand hygiene improvement of individual healthcare workers: results of the multicentre PROHIBIT study

BACKGROUND

Traditionally, hand hygiene (HH) interventions do not identify the observed healthcare workers (HWCs) and therefore, reflect HH compliance only at population level. Intensive care units (ICUs) in seven European hospitals participating in the "Prevention of Hospital Infections by Intervention and Training" (PROHIBIT) study provided individual HH compliance levels. We analysed these to understand the determinants and dynamics of individual change in relation to the overall intervention effect.

METHODS

We included HCWs who contributed at least two observation sessions before and after intervention. Improving, non-changing, and worsening HCWs were defined with a threshold of 20% compliance change. We used multivariable linear regression and spearman's rank correlation to estimate determinants for the individual response to the intervention and correlation to overall change. Swarm graphs visualized ICU-specific patterns.

RESULTS

In total 280 HCWs contributed 17,748 HH opportunities during 2677 observation sessions. Overall, pooled HH compliance increased from 43.1 to 58.7%. The proportion of improving HCWs ranged from 33 to 95% among ICUs. The median HH increase per improving HCW ranged from 16 to 34 percentage points. ICU wide improvement correlated significantly with both the proportion of improving HCWs (ρ = 0.82 [95% CI 0.18-0.97], and their median HH increase (ρ = 0.79 [0.08-0.97]). Multilevel regression demonstrated that individual improvement was significantly associated with nurse profession, lower activity index, higher nurse-to-patient ratio, and lower baseline compliance.

CONCLUSIONS

Both the proportion of improving HCWs and their median individual improvement differed substantially among ICUs but correlated with the ICUs' overall HH improvement. With comparable overall means the range in individual HH varied considerably between some hospitals, implying different transmission risks. Greater insight into improvement dynamics might help to design more effective HH interventions in the future.

Nurses' perceptions on the effects of high nursing workload on patient care in an intensive care unit of a referral hospital in Malawi: a qualitative study

BACKGROUND

The Malawi health system has taken numerous actions to reduce high nurse workloads, despite this, shortage of nurses especially in critical care settings still persists due to lack of prioritisation of critical care. Therefore, it is important to understand the effects of high nursing workload in Intensive Care Unit (ICU). This study aimed at exploring the perceptions of nurses regarding the effects of high nursing workload on patient care in ICU at Queen Elizabeth Central Hospital.

METHODS

This qualitative descriptive study was conducted in a general ICU at Queen Elizabeth Central Hospital in Blantyre, Malawi. A purposive sample of 12 nurses working in the ICU was selected. Participants included full-time nurses working in the ICU. A total of 10 In-depth interviews were conducted to collect data upon which data saturation was reached. A semi-structured interview guide was used for data collection. Data was analysed manually using thematic analysis method by Braun & Clarke.

RESULTS

Study findings indicated that high nursing workload compromises the delivery of quality nursing care to critically ill patients, compromises patient safety and has negative impact on nurses' wellbeing.

CONCLUSION

The study findings portray that nurses are aware of the negative effects that high nursing workload has on patient care. The study findings support the need for more ICU nurses in order to reduce nurse workloads and the need for nurse managers and policy makers to develop strategies to manage nurse workloads and its effects on patient care.

Correlation between Overconfidence and Learning Motivation in Postgraduate Infection Prevention and Control Training

Introduction: Training in hand hygiene for health care workers is essential to reduce hospital-acquired infections. Unfortunately, training in this competency may be perceived as tedious, time-consuming, and expendable. In preceding studies, our working group detected overconfidence effects in the self-assessment of hand hygiene competencies. Overconfidence is the belief of being better than others (overplacement) or being better than tests reveal (overestimation). The belief that members of their profession are better than other professionals is attributable to the clinical tribalism phenomenon. The study aimed to assess the correlation of overconfidence effects on hand hygiene and their association with four motivational dimensions (intrinsic, identified, external, and amotivation) to attend hand hygiene training. Methods: We conducted an open online convenience sampling survey with 103 health care professionals (physicians, nurses, and paramedics) in German, combining previously validated questionnaires for (a) overconfidence in hand hygiene and (b) learning motivation assessments. Statistics included parametric, nonparametric, and cluster analyses. Results: We detected a quadratic, u-shaped correlation between learning motivation and the assessments of one’s own and others’ competencies. The results of the quadratic regressions with overplacement and its quadratic term as predictors indicated that the model explained 7% of the variance of amotivation (R² = 0.07; F(2, 100) = 3.94; p = 0.02). Similarly, the quadratic model of clinical tribalism for nurses in comparison to physicians and its quadratic term explained 18% of the variance of amotivation (R² = 0.18; F(2, 48) = 5.30; p = 0.01). Cluster analysis revealed three distinct groups of participants: (1) “experts” (n₁ = 43) with excellent knowledge and justifiable confidence in their proficiencies but still motivated for ongoing training, and (2) “recruitables” (n₂ = 43) who are less competent with mild overconfidence and higher motivation to attend training, and (3) “unawares” (n₃ = 17) being highly overconfident, incompetent (especially in assessing risks for incorrect and omitted hand hygiene), and lacking motivation for training. Discussion: We were able to show that a highly rated self-assessment, which was justified (confident) or unjustified (overconfident), does not necessarily correlate with a low motivation to learn. However, the expert’s learning motivation stayed high. Overconfident persons could be divided into two groups: motivated for training (recruitable) or not (unaware). These findings are consistent with prior studies on overconfidence in medical and non-medical contexts. Regarding the study’s limitations (sample size and convenience sampling), our findings indicate a need for further research in the closed populations of health care providers on training motivation in hand hygiene.

Electronic Monitoring Systems for Hand Hygiene: Systematic Review of Technology

BACKGROUND

Hand hygiene is one of the most effective ways of preventing health care-associated infections and reducing their transmission. Owing to recent advances in sensing technologies, electronic hand hygiene monitoring systems have been integrated into the daily routines of health care workers to measure their hand hygiene compliance and quality.

OBJECTIVE

This review aims to summarize the latest technologies adopted in electronic hand hygiene monitoring systems and discuss the capabilities and limitations of these systems.

METHODS

A systematic search of PubMed, ACM Digital Library, and IEEE Xplore Digital Library was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were initially screened and assessed independently by the 2 authors, and disagreements between them were further summarized and resolved by discussion with the senior author.

RESULTS

In total, 1035 publications were retrieved by the search queries; of the 1035 papers, 89 (8.60%) fulfilled the eligibility criteria and were retained for review. In summary, 73 studies used electronic monitoring systems to monitor hand hygiene compliance, including application-assisted direct observation (5/73, 7%), camera-assisted observation (10/73, 14%), sensor-assisted observation (29/73, 40%), and real-time locating system (32/73, 44%). A total of 21 studies evaluated hand hygiene quality, consisting of compliance with the World Health Organization 6-step hand hygiene techniques (14/21, 67%) and surface coverage or illumination reduction of fluorescent substances (7/21, 33%).

CONCLUSIONS

Electronic hand hygiene monitoring systems face issues of accuracy, data integration, privacy and confidentiality, usability, associated costs, and infrastructure improvements. Moreover, this review found that standardized measurement tools to evaluate system performance are lacking; thus, future research is needed to establish standardized metrics to measure system performance differences among electronic hand hygiene monitoring systems. Furthermore, with sensing technologies and algorithms continually advancing, more research is needed on their implementation to improve system performance and address other hand hygiene-related issues.

Observational Study of Hand Hygiene Compliance at a Trauma Hospital in Iraqi Kurdistan

Healthcare-associated infections, commonly caused by poor hand hygiene, represent a significant source of disease and economic burden for healthcare systems, especially those in resource-limited settings. The few existing studies on hand hygiene compliance in resource-limited hospital settings suggest that compliance is insufficient. The difference in compliance rates between units in resource-limited trauma hospitals is largely unknown. We aimed to assess hand hygiene compliance rates among healthcare workers at a trauma hospital in Iraqi Kurdistan and compare the levels of compliance between the emergency room (ER), the intensive care unit (ICU), and the acute care ward (ACW). We carried out overt observations in 2018 using the validated World Health Organization ‘five moments for hand hygiene’ observational tool. We observed a total of 622 hand hygiene opportunities performed by 149 healthcare workers. Hand hygiene compliance was defined as handwashing with soap and water or the use of alcohol-based hand rub, in accordance with the ‘five moments for hand hygiene’ concept. Overall, the hand hygiene compliance rate was found to be 6.8% (95% confidence interval 5.0–9.1). Compliance was significantly lower in the ER (1.0%), compared with the ICU (8.1%) (p = 0.0012), and the ACW (11.1%) (p < 0.0001). In all three units, the availability of alcohol-based hand rub and handwashing sinks was insufficient in relation to the number of patient beds. We conclude that the overall level of hand hygiene compliance was low, with the lowest level of compliance in the ER. Our findings call for improved resource allocation and strengthened hand hygiene routines. These relatively simple measures could potentially lower the incidence of healthcare-associated infections and improve the mortality and morbidity of patients in already overburdened healthcare systems.

Utilizing the SEIPS model to guide hand hygiene interventions at a tertiary hospital in Ethiopia

We aimed to apply the Systems Engineering Initiative for Patient Safety (SEIPS) model to increase effectiveness and sustainability of the World Health Organization's (WHOs) hand hygiene (HH) guidelines within healthcare systems. Our cross-sectional, mixed-methods study took place at Jimma University Medical Center (JUMC), a tertiary care hospital in Jimma, Ethiopia, between November 2018 and August 2020 and consisted of three phases: baseline assessment, intervention, and follow-up assessment. We conducted questionnaires addressing HH knowledge and attitudes, interviews to identify HH barriers and facilitators within the SEIPS framework, and observations at the WHO's 5 moments of HH amongst healthcare workers (HCWs) at JUMC. We then implemented HH interventions based on WHO guidelines and results from our baseline assessment. Follow-up HH observations were conducted months later during the Covid-19 pandemic. 250 HCWs completed questionnaires with an average knowledge score of 61.4% and attitude scores indicating agreement that HH promotes patient safety. Interview participants cited multiple barriers to HH including shortages and location of HH materials, inadequate training, minimal Infection Prevention Control team presence, and high workload. We found an overall baseline HH compliance rate of 9.4% and a follow-up compliance rate of 72.1%. Drastically higher follow-up compared to baseline compliance rates were likely impacted by our HH interventions and Covid-19. HCWs showed motivation for patient safety despite low HH knowledge. Utilizing the SEIPS model helped identify institution-specific barriers that informed targeted interventions beyond WHO guidelines aimed at increasing effectiveness and sustainability of HH efforts.

Hand Microbial Flora of Hospitalized Children at the Beginning of Hospitalization and Before Discharge: A Cross-Sectional Study

Background

Hospital infections in pediatric units increase the length of hospital stay and the use of antibiotics, and this causes exposure to more procedures. This study was aimed to determine the microorganisms represented in the hand flora of pediatric patients at the beginning of hospitalization and before discharge.

Methods

The study was designed as a prospective cross-sectional study. This prospective study was performed with 124 pediatric patients. After completion of the admission procedures, an initial sample was taken from the hands of the hospitalized patients. Another sample was taken from the patients just before discharging.

Results

Growth of coagulase-negative staphylococcus (CNS) was observed in the culture samples of 28 patients. Cultures from 23 patients showed different microorganisms such as Staphylococcus aureus, Escherichia coli, and S. epidermis. Examination of final discharge cultures showed CNS in 43 patients, S. aureus in 5 patients, E. coli in 8 patients, Acinetobacter baumannii in 11 patients, and Kocuria rhizophila, K. kristinae, Candida spp., Pseudomonas spp., and Enterococcus in 1 patient.

Conclusion

The cultures from samples obtained at discharge showed the presence of antibiotic-resistant pathogenic microorganisms causing healthcare associated infection.

No increase in compliance before aseptic procedures in German hospitals. A longitudinal study with data from the national surveillance system over four years

BACKGROUND

Hand hygiene plays a crucial role in the prevention of healthcare-associated infections and transmission of pathogens. In 2008 the national campaign 'Aktion Saubere Hände' was launched in Germany. It is based on the World Health Organization (WHO) 'Clean Care is Safer Care' initiative. Direct observation and feedback of the results are key components in the improvement of hand hygiene compliance. In 2014 a voluntary national surveillance electronic tool for the documentation of directly observed compliance to hand hygiene was introduced.

AIM

Description and evaluation of compliance with the WHO model 'my 5 moments' in German hospitals after implementation.

METHODS

Direct observation was performed in the participating hospitals by trained local staff according to the WHO recommendations. We evaluated wards that reported annually at least 150 hand hygiene opportunities (HHOs) of hand hygiene per observation period from January 1^st, 2015 until December 31^st, 2018.

FINDINGS

In all, 1,485,622 HHOs observed on 3337 wards in 525 hospitals were included into analysis. Overall compliance increased from 72% (interquartile range: 61-82) to 76% (66-84). Compliance significantly increased for all individual moments of the WHO model except moment 2. In the multivariate logistic regression analysis the following parameters were independently associated with a high compliance in hand hygiene: intensive care unit, nurse, opportunity observed in 2017 or 2018, as well as all moments except moment 2.

CONCLUSION

Overall compliance in German hospitals increased over time. To improve HH compliance 'before aseptic procedures' appears to be difficult and should be addressed explicitly. Underlying reasons need to be the focus of future investigations.

Clinical experiences with a new system for automated hand hygiene monitoring: A prospective observational study

BACKGROUND

Hand hygiene compliance (HHC) among health care workers remains suboptimal, and good monitoring systems are lacking. We aimed to evaluate HHC using an automated monitoring system.

METHODS

A prospective, observational study was conducted at 2 Danish university hospitals employing a new monitoring system (Sani nudge). Sensors were located on alcohol-based sanitizers, health care worker name tags, and patient beds measuring hand hygiene opportunities and sanitations.

RESULTS

In total, 42 nurses were included with an average HHC of 52% and 36% in hospitals A and B, respectively. HHC was lowest in patient rooms (hospital A: 45%; hospital B: 29%) and highest in staff toilets (hospital A: 72%; hospital B: 91%). Nurses sanitized after patient contact more often than before, and sanitizers located closest to room exits and in hallways were used most frequently. There was no association found between HHC level and the number of beds in patient rooms. The HHC level of each nurse was consistent over time, and showed a positive correlation between the number of sanitations and HHC levels (hospital A: r = 0.69; hospital B: r = 0.58).

CONCLUSIONS

The Sani nudge system can be used to monitor HHC at individual and group levels, which increases the understanding of compliance behavior.

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.

Human Factors Engineering Contributions to Infection Prevention and Control

OBJECTIVE

This article provides a review of areas that present significant challenges in infection prevention and control and describes human factors engineering (HFE) approaches that have been applied successfully to these areas. In addition, implications and recommendations for HFE use in future research are discussed.

BACKGROUND

Infection prevention and control aims to prevent patients and health care personnel from acquiring preventable infections in healthcare. Effective infection control practices of healthcare-associated infections have recently become even more critical with the emergence of life-threatening infections. HFE could benefit infection prevention and control in addressing older and more recent challenges, but uptake has been limited.

METHOD/RESULTS

This literature review is an integration and synthesis of recently published research that describes HFE-based approaches in infection prevention and control to address the challenges for three specific topics. The results of the review suggests that HFE is in a position to support work in infection prevention and control and improve overall healthcare safety.

CONCLUSION

HFE provides conceptual frameworks and methods that have significant potential to improve infection prevention and control.

APPLICATION

The work reviewed can provide potential solutions for current infection prevention and control challenges by applying HFE based recommendations.

Effect of gloved hand disinfection on hand hygiene before infection-prone procedures on a stem cell ward

BACKGROUND

Hand hygiene compliance even before infection-prone procedures (indication 2, 'before aseptic tasks', according to the World Health Organization (WHO)) remains disappointing.

AIM

To improve hand hygiene compliance by implementing gloved hand disinfection as a resource-neutral process optimization strategy.

METHODS

We performed a three-phase intervention study on a stem cell transplant ward. After baseline evaluation of hand hygiene compliance (phase 1) gloved hand disinfection was allowed (phase 2) and restricted (phase 3) to evaluate and differentiate intervention derived from learning and time effects. The incidence of severe infections as well as of hospital-acquired multidrug-resistant bacteria was recorded by active surveillance.

FINDINGS

Hand hygiene compliance improved significantly from 50% to 76% (P < 0.001) when gloved hand disinfection was allowed. The biggest increase was for infection-prone procedures (WHO 2) from 31% to 65%; P < 0.001. Severe infections decreased by trend (from 6.0 to 2.5 per 1000 patient-days) whereas transmission of multidrug-resistant organisms was not affected.

CONCLUSION

Gloved hand disinfection significantly improved compliance with the hand hygiene, especially in activities relevant to infections and infection prevention. Thus, this process optimization may be an additional, easy implementable, resource-neutral tool for a highly vulnerable patient cohort.

Preventing healthcare-associated infections through human factors engineering

PURPOSE OF REVIEW

Human factors engineering (HFE) approaches are increasingly being used in healthcare, but have been applied in relatively limited ways to infection prevention and control (IPC). Previous studies have focused on using selected HFE tools, but newer literature supports a system-based HFE approach to IPC.

RECENT FINDINGS

Cross-contamination and the existence of workarounds suggest that healthcare workers need better support to reduce and simplify steps in delivering care. Simplifying workflow can lead to better understanding of why a process fails and allow for improvements to reduce errors and increase efficiency. Hand hygiene can be improved using visual cues and nudges based on room layout. Using personal protective equipment appropriately appears simple, but exists in a complex interaction with workload, behavior, emotion, and environmental variables including product placement. HFE can help prevent the pathogen transmission through improving environmental cleaning and appropriate use of medical devices.

SUMMARY

Emerging evidence suggests that HFE can be applied in IPC to reduce healthcare-associated infections. HFE and IPC collaboration can help improve many of the basic best practices including use of hand hygiene and personal protective equipment by healthcare workers during patient care.

Impact of infectious exposures and outbreaks on nurse and infection preventionist workload

BACKGROUND

Staff nurse and infection preventionist (IP) workload increases in response to exposures and outbreaks. Understanding the time burden associated with responding to specific pathogens may improve resource allocation. The purpose of this study was to evaluate workload increases reported by nurses and IPs in response to common exposures and outbreaks.

METHODS

Surveys were distributed to nurses in a New York hospital network and to IPs who attended the 2018 Association for Professionals in Infection Control and Epidemiology annual conference or to IPs who were members of local Association for Professionals in Infection Control and Epidemiology chapters. Respondents were asked to rate their daily workload increase and to rank their most time-consuming activities in response to exposure and outbreak scenarios.

RESULTS

A total of 150 nurses and 228 IPs responded. Among the nurses, >60-minute workload increases were reported for Clostridium difficile (76%), lice or scabies (46%), and influenza (45%). Among the IPs, >60-minute increases were reported for mumps or measles (66%), tuberculosis (64%), and C difficile (50%). Among the nurses, isolation precautions, patient and family education, and staffing changes were the most frequently reported time-consuming activities. Among the IPs, chart review, exposure list compiling, and preventive measures for exposures were the most frequently reported time-consuming activities.

CONCLUSIONS

Organisms that are easier to treat and more difficult to spread, such as scabies or lice, can contribute substantially to nursing workload. Notably, three-quarters of the nurses and one-half of the IPs reported that C difficile adds >1 hour to their daily workload.

High nursing workload is a main associated factor of poor hand hygiene adherence in Beijing, China: An observational study

AIM

The aim of the study was to explore the impact of nurse workloads on adherence to hand hygiene.

BACKGROUND

Adherence to hand hygiene and nursing workloads have been linked to quality of patient care. Therefore, it was important to understand the relationship to safe patient care.

DESIGN

This cross-sectional study was performed from January 2016 to June 2016.

METHODS

Workloads and adherence to hand hygiene for nurses on 3-day shifts in a tertiary hospital were investigated in 2016. Actual hours worked per shift were timed using a stopwatch to assess nursing workloads. Descriptive and inferential statistics and multiple variable regression analysis were used to analyse the data.

RESULTS

Sixty-four nurses from four wards were observed. The average adherence rate of hand hygiene was 26.6% and the average nursing workload per shift was 6.7 hours. Multiple regression revealed that nursing workload was negatively related to adherence rate of hand hygiene.

CONCLUSION

Nurses in this study that had a low rate of adherence with hand hygiene frequently had high workloads. Adherence to hand hygiene was independently associated with actual hours worked per shift.

Do WiFi-based hand hygiene dispenser systems increase hand hygiene compliance?

Innovative methods to ensure better compliance in hand hygiene are urgently needed. The aim of this study was to determine if WiFi-based hand hygiene dispenser-driven self-assessment systems (Wireless Fidelity, WiFi-dispenser) can support the work of infection control teams. Our results suggest that the continuous monitoring of dispenser usage can be a valuable addition to infection prevention and control programs, when used in a bundle in combination with conventional hand hygiene training.

Effectiveness of Hygienic Hand Washing Training on Hand Washing Practices and Knowledge: A Nonrandomized Quasi-Experimental Design

Nurses undertake important responsibilities in patient care and the prevention of hospital-acquired infections. However, adherence to hand hygiene practices among nurses has been reported to be low. This study aims to evaluate the effectiveness of hygienic hand washing training on hand washing practices and knowledge. The study design was a nonrandomized, quasi-experimental study, with pretest-posttest for one group. Pre- and postobservations were also conducted using an observation form on any 5 workdays to evaluate the effectiveness of hygienic hand washing training on hand washing practices. The study was conducted with 63 nurses working at a hospital in Istanbul. Hand Hygiene Knowledge Form scores after hygienic hand washing training were higher than the pretraining scores. The number of the nurses' hand hygiene actions after hand hygiene training increased significantly compared with that before training. The results indicate that training in proper hand washing techniques and hygienic hand washing practices positively affects the knowledge level of nurses and their hand washing behavior. J Contin Educ Nurs. 2018;49(8):360-371.

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.

Safety and Security Concerns of Nurses Working in the Intensive Care Unit: A Qualitative Study

Intensive care units (ICUs) exist to serve as a safe place for critically ill patients to receive care from skilled practitioners. In this qualitative study, ICU nurses shared their perspectives on elements that promote safety and security on their units. After obtaining institutional review board approval, participants participated in telephone interviews with a nurse researcher who has experience as a bedside ICU nurse. Five categories and 14 themes were identified and then confirmed using member checking. Results indicate that participants prefer to provide care in ICUs with no more than 12 to 14 beds and provide the following: visibility of patients and coworkers; more than 1 way to exit; and can be locked in case of emergency or threat. Nearly all respondents mentioned adequate staffing as the most important attribute of a safe, secure care environment for patients and families. More research is needed to identify design features that make the most impact on providing a safe, secure ICU environment.