Hand hygiene and healthcare system change within multi-modal promotion: a narrative review

[Factors that influence the use of sepsis-related competencies in health professionals and how they promote their patients' sepsis knowledge: Results of a mixed methods study with health professionals]

BACKGROUND

Sepsis is a life-threatening and relatively common emergency which is often recognized too late or not at all. Therefore, the "SepsisWissen" (SepsisKnowledge) project aimed to bring about changes in health care professionals' behavior in the area of sepsis prevention and early detection. It addressed the health care professionals themselves (e. g., their own vaccination, hygiene and early detection behavior) and their patient counseling behavior. To promote this behavior, the SepsisWissen campaign included offers such as trainings or print products. The subsequent core question is: From the health professionals' perspective, which barriers and facilitators affect their own application of sepsis competence and their promotion of their patients' sepsis competence?

METHODS

This paper was based on a cross-sectional mixed-methods study part of "SepsisWissen" withPart a) was analyzed using qualitative oriented content analysis based on Mayring, part b) was analyzed descriptively. The interviewees included physicians, nurses, pharmacists, assistants to physicians and pharmacists and, additionally, one paramedic in the quantitative sample. Some of them had attended "SepsisWissen" trainings.

RESULTS

The qualitative data analysis identified 41 conducive and hindering factors, which can be assigned to the following eight major topics: 1) syndrome sepsis; 2) predisposing factors for health professionals' own acquisition and application of sepsis competence; 3) enabling factors for health professionals themselves; 4) behavior and lifestyle of patients; 5) reinforcing factors for patients; 6) public health education; 7) political, administrative, and organizational context; 8) environmental factors. In the qualitative and quantitative surveys, the suggestion to improve the sepsis competence of the population and to reduce misinformation, respectively, through public education (e.g., via schools or the media).

DISCUSSION

Sepsis training for health professionals was considered as a facilitating factor for taking potential sepsis symptoms and patients' respective statements more seriously. Future training formats should convey more explicitly how health professionals can better communicate their own sepsis knowledge to their patients. They request instruments to support their communication, such as checklists for lay persons. According to the interviews, health workers themselves need recurring external reminders for the topic of sepsis. Organizational and political conditions should be improved. From the health professionals' point of view, it is essential to offer better reimbursement for prevention and counseling services and to allocate adequate time resources for both.

CONCLUSION

Health professionals could increase their potential to apply and promote sepsis competence if general conditions were optimized. From their perspective, it is most important to relieve them of some of their patient counselling burden by initiating more public education.

Linezolid and vancomycin for nosocomial infections in pediatric patients: a systematic review

OBJECTIVE

To investigate the effectiveness of linezolid and vancomycin for the treatment of nosocomial infections in children under 12 years old.

DATA SOURCES

This is a systematic review in which five randomized clinical trials about the effectiveness of linezolid and vancomycin, involving a total of 429 children with nosocomial infections, were evaluated. They were searched in scientific databases: PubMed, Bvs, and SciELO.

SUMMARY OF FINDINGS

The main nosocomial infections that affected children were bacteremia, skin, and soft tissue infections followed by nosocomial pneumonia. Most infections were caused by Gram-positive bacteria, which all studies showed infections caused by Staphylococcus aureus, with methicillin-resistant S. aureus (MRSA) and methicillin-resistant coagulase-negative staphylococci strains being isolated. Both linezolid and vancomycin showed high therapeutic efficacy against different types of nosocomial infections, ranging from 84.4% to 94% for linezolid and 76.9% to 90% for vancomycin. Patients receiving linezolid had lower rates of rash and red man syndrome compared to those receiving vancomycin. However, despite the adverse reactions, antimicrobials can be safely administered to children to treat nosocomial infections caused by resistant Gram-positive bacteria.

CONCLUSION

Both linezolid and vancomycin showed good efficacy in the treatment of bacterial infections caused by resistant Gram-positive bacteria in hospitalized children. However, linezolid stands out regarding its pharmacological safety. Importantly, to strengthen this conclusion, further clinical trials are needed to provide additional evidence.

Nurses' preferences for interventions to improve infection prevention and control behaviors based on systems engineering initiative to patient safety model: a discrete choice experiment

BACKGROUND

The evidence of preferences for infection prevention and control (IPC) intervention from system perspective was lacked. This study aimed to elicit nurses' preferences for the intervention designed to improve IPC behaviors based on the Systems Engineering Initiative to Patient Safety (SEIPS) model using Discrete Choice Experiment (DCE).

METHODS

A DCE was conducted among nurses who were on active duty and willing to participate from July 5th to 10th, 2021 in a tertiary hospital in Ganzhou City, Jiangxi Province, using convenience sampling. A self-administered questionnaire included scenarios formed by six attributes with varying levels based on SEIPS model: person, organization, tools and technology, tasks, internal environment and external environment. A conditional logit and latent class logit model were performed to analyze the data.

RESULTS

A total of 257 valid questionnaires were analyzed among nurses. The results from the latent class logit model show that nurses' preferences can be divided into three classes. For nurses in multifaceted-aspect-preferred class (41.9%), positive coefficients were obtained in those six attributes. For person-preferred class (19.7%), only person was positively significant. For environment-preferred class (36.4%), the most important attribute were tasks, tools and technology, internal environment and external environment.

CONCLUSIONS

This finding suggest that nurses have three latent-class preferences for interventions. Multifaceted interventions to improve IPC behaviors based on the SEIPS model are preferred by most nurses. Moreover, relevant measured should be performed targeted the latent class of person-preferred and external-environment-preferred nurses.

A Multifaceted Approach to the "Bare below the Elbow" Concept and Hand Hygiene Compliance among Healthcare Professionals-Multicenter Population-Based Study

Nosocomial infections remain an important issue for patient safety concerns. Since hospital infections are mainly connected with healthcare professionals' routines, an increase in hand hygiene effectiveness through compliance with the "bare below the elbow" (BBE) concept could reduce the number of nosocomial infections. Therefore, this study aims to evaluate hand hygiene and to investigate healthcare professionals' compliance with the BBE concept. We performed our study on a group of 7544 hospital professionals involved in patient care. During the national preventive action, questionnaires, demographic data, and hand hygiene preparations were recorded. Hand disinfection was verified by COUCOU BOX, containing a UV camera. We noted that 3932 (52.1%) persons complied with the BBE rules. Nurses and non-medical personnel were significantly more often classified as BBE rather than non-BBE (2025; 53.3% vs. 1776; 46.7%, respectively, p = 0.001 and 1220; 53.7% vs. 1057; 46.3%, p = 0.006). Different proportions were demonstrated for the groups of physicians-non-BBE (783; 53.3%) compared to BBE (687; 46.7%) (p = 0.041). Healthcare workers from the BBE group statistically more often disinfected their hands correctly (2875/3932; 73.1%) compared to the non-BBE group (2004/3612; 55.5%) (p < 0.0001). This study demonstrates the positive impact of compliance with the BBE concept on effective hand disinfection and patient safety. Therefore, education and infection-prevention actions should be popularized to improve the BBE policy's effectiveness as well.

Direct hand hygiene observations and feedback increased hand hygiene compliance among nurses and doctors in medical and surgical wards - an eight-year observational study

BACKGROUND

The improvement of hand hygiene compliance (HHC) is critical to preventing healthcare-associated infections (HCAIs). The present study explored how direct observation and feedback influences HHC among nurses and doctors in surgical and medical wards, and whether these actions impact HCAI incidence.

METHODS

In this longitudinal observational study, HHC and the incidence of HCAIs were observed in six medical and seven surgical wards in a tertiary hospital in Finland from May 2013 to Dec 2020. Data of the observations of five hand hygiene (HH) moments were collected from the hospital HH and the HCAI monitoring registries. For statistical analyses a multivariable logistic regression analysis and a Poisson regression model were used.

FINDINGS

HH monitoring included 24 614 observations among nurses and 6 396 observations among doctors. In medical wards, HHC rates increased 10.8% - from 86.2% to 95.5%, and HCAI incidence decreased from 15.9 to 13.5 per 1000 patient days (p<0.0001). In surgical wards, HHC increased 32.7% - from 67.6% to 89.7%, and HCAI incidence decreased from 13.7 to 12.0 per 1000 patient days (p< 0.0001). The overall HHC increased significantly among nurses (17.8%) and doctors (65.8%). The HHC was better among nurses than doctors (in medical wards; OR 3.36; 95% CI 2.90-3.90, p<0.001 and in surgical wards; OR 9.85; 95% CI 8.97-10.8, p<0.001).

CONCLUSION

Direct observations and feedback of HH increased significantly HHC among nurses and doctors over an eight-year period. During the same period, the incidence of HCAIs significantly decreased in both medical and surgical wards.

Improvement of Hand Hygiene Compliance Using the Plan-Do-Study-Act Method: Quality Improvement Project From a Tertiary Care Institute in Bihar, India

Background

Hospital-acquired infections (HAIs) are the most severe complications of intensive care stay, especially in pediatric patients. Proper hand hygiene (HH) is the cheapest, simplest, but often neglected method to prevent HAIs. The World Health Organization (WHO) has formulated and promoted a standardized recommendation for HH. Both the WHO and the Centers for Disease Control and Prevention (CDC) recommend the use of soap and water for handwashing whenever there is visible dirt on the hands. In all other situations, an alcohol-based hand rub is an effective alternative. The quality improvement (QI) methodology has been widely followed in many countries to improve basic and advanced healthcare systems. The QI strategy follows the plan-do-study-act (PDSA) method.

Methodology

This quasi-experimental (pre- and post-intervention), prospective, QI study was conducted at the neonatal intensive care unit and pediatric intensive care unit of the pediatrics department in a tertiary care hospital in Bihar, India. A QI team was formed. The study was divided into four phases. WHO charts for assessing HH compliance were used for observation and data collection. The EQUATOR Checklist (Squire Checklist) was used to accurately report the QI work. Epi Info™ (version 7.2.5) was used for statistical analysis. The chi-square test was used to measure the statistical difference between pre- and post-intervention HH compliance (proportions).

Results

In the pre-intervention phase, a total of 106 HH opportunities were observed. The HH compliance at this stage was 40.6%. The QI team conducted several meetings, and a root cause analysis was performed with the help of the Fishbone diagram. It was decided to target three probable causes, namely, (a) less awareness, (b) inconvenient locations of hand rub dispensers, and (c) forgetfulness. The QI team decided to run three PDSA cycles. In the last phase, 212 HH opportunities were observed with a compliance percentage of 69.8%. There was a significant improvement when data of pre- and post-intervention HH compliance were compared in all categories of healthcare workers (HCWs), except doctors, where the improvement was not statistically significant. When the cumulative data of all subtypes of HCWs were analyzed, there was a significant improvement (p < 0.0001). Run charts and box plots were used for the easy depiction of the results.

Conclusions

Adopting proper HH methods remains the most effective way of preventing nosocomial infections, especially in intensive care units. We used the WHO model of HH in our study. The pre-intervention HH compliance was 40.6%. QI methodology using root cause analysis and implementation of three PDSA cycles were used to increase the HH compliance percentage. Post-intervention HH compliance increased to 69.8% and the effect was sustained. The study highlights the usefulness of the QI methodology in bringing small but important changes in clinical practice for better patient care.

An Intra-COVID-19 Assessment of Hand Hygiene Facility, Policy and Staff Compliance in Two Hospitals in Sierra Leone: Is There a Difference between Regional and Capital City Hospitals?

Although hand hygiene (HH) is the most effective intervention to reduce the spread of infections, there are limited data on HH facilities, policy, and compliance in sub-Saharan Africa. This cross-sectional study is aimed at assessing HH using the WHO HH self-assessment framework, HH technical reference manual, and a modified infection control self-assessment tool in two hospitals in Sierra Leone. Only 10% and 9% of regional and capital city hospitals had running tap water, respectively. Veronica buckets were the resources for HH in 89% of units in the regional hospital and 92% of units in capital city hospital. Constant supply of soap and alcohol-based hand rub was available in 82% and 68%; and 74% and 79% of units in the capital city and regional hospitals, respectively. Only 10% of the units in both hospitals had hand-drying facilities and functional sinks. Overall HH compliance for the two hospitals was 18.6% and was higher in the regional (20.8%) than the capital city (17.0%) hospitals. The HH levels for the capital city and regional hospitals were 277.5 and 262.5 respectively. Despite the COVID-19 pandemic, there are still challenges with HH compliance in Sierra Leone. It is, therefore, necessary to strengthen the HH multi-modal strategy.

Hand hygiene in health care: 20 years of ongoing advances and perspectives

Health-care-associated infections are the most prevalent adverse events of hospital care, posing a substantial threat to patient safety and burden on society. Hand hygiene with alcohol-based hand rub is the most effective preventive strategy to reduce health-care-associated infections. Over the past two decades, various interventions have been introduced and studied to improve hand hygiene compliance among health-care workers. The global implementation of the WHO multimodal hand hygiene improvement strategy and constant efforts to replace the use of soap and water with alcohol-based hand rub have led to a faster and more efficient hand cleaning method. These strategies have strongly contributed to the success of behaviour change and a subsequent decrease in health-care-associated infections and cross-transmission of multidrug-resistant organisms worldwide. The WHO multimodal behaviour change strategy requires a series of elements including system change as a prerequisite for behaviour, change, education, monitoring and performance feedback, reminders in the workplace, and an institutional safety climate. Successful adoption of the promotion strategy requires adaptation to available resources and sociocultural contexts. This Review focuses on the major advances and challenges in hand hygiene research and practices in the past 20 years and sets out various ways forward for improving this lifesaving action.

The Golden Hour: Sustainability and Clinical Outcomes of Adequate Time to Antibiotic Administration in Children with Cancer and Febrile Neutropenia in Northwestern Mexico

PURPOSE

Time to antibiotic administration (TTA) is a commonly used standard of care in pediatric cancer settings in high-income countries. Effective interventions to improve outcomes in cancer patients with febrile neutropenia (FN) often address timely and appropriate antibiotic administration. We assessed the effectiveness of a locally adapted multimodal strategy in decreasing TTA in a resource-constrained pediatric cancer center in Mexico.

METHODS

We conducted a prospective observational study between January 2014 and April 2019. A three-phase (phase I: execution, phase II: consolidation, phase III: sustainability) multimodal improvement strategy that combined system change, FN guideline development, education, auditing and monitoring, mentoring, and dissemination was implemented to decrease TTA in inpatient and ambulatory areas. Sustainability factors were measured by using a validated tool during phases I and III.

RESULTS

Our population included 105 children with cancer with 204 FN events. The baseline assessment revealed that only 50% of patients received antibiotics within 60 minutes of prescription (median time: inpatient, 75 minutes; ambulatory, 65 minutes). After implementing our improvement strategy, the percentage of patients receiving antibiotics within 60 minutes of prescription increased to 88%. We significantly decreased median TTA in both clinical areas during the three phases of the study. In phase III (sustainability), the median TTA was 40 minutes (P = .023) in the inpatient area and 30 minutes (P = .012) in the ambulatory area. The proportion of patients with sepsis decreased from 30% (baseline) to 5% (phase III) (P = .001).

CONCLUSION

Our results demonstrate that locally adapted multimodal interventions can reduce TTA in resource-constrained settings. Mentoring and dissemination were novel components of the multimodal strategy to improve FN-associated clinical outcomes. Improving local infrastructure, ongoing monitoring systems, and leadership engagement have been key factors to achieving sustainability during the 5-year period.

Standardized aseptic dressing change procedure: Optimizations and adherence in a prospective pre- and postintervention cohort study

BACKGROUND

The "HygArzt" project investigated the effectiveness of hygiene measures introduced by an infection prevention link physician (PLP).

OBJECTIVE

To investigate whether the introduction of a standardized aseptic dressing change concept (ADCC) by a PLP can increase hand hygiene adherence and adherence to specific process steps during an aseptic dressing change (ADC) in a trauma surgery and orthopedic department.

METHODS

We defined 4 required hand disinfection indications: (1) before the preparation of ADC equipment, (2) immediately before the ADC, (3) before the clean phase, and (4) after the ADC. A process analysis of the preintervention phase (331 ADCs) was used to develop a standardized ADCC. The ADCC was introduced and iteratively adopted during the intervention phase. The effect was evaluated during the postintervention phase (374 ADCs).

RESULTS

Hand hygiene adherence was significantly increased by the introduction of the ADCC for all indications: (1) before the preparation of the ADC equipment (from 34% before to 85% after, P <.001), (2) immediately before an ADC (from 32% before to 85% after; P < .001), (3) before the clean phase (from 42% before to 96% after; P < .001), and (4) after an ADC (from 74% before to 99% after; P < .001). Overall hand hygiene adherence was analyzed before the indications for an ADC (from 9.6% before to 74% after; P < .001). The same strategy was applied to the following process parameters: use of a clean work surface, clean withdrawal of equipment from the dressing trolley, and appropriate waste disposal.

CONCLUSIONS

A PLP sufficiently implemented a standardized concept for aseptic dressing change during an iterative improvement process, which resulted in a significant improvement in hand hygiene and adherence to other specific ADCC process steps.

Addressing the global challenge of access to supplies during COVID-19

The current COVID-19 pandemic has presented unprecedented challenges for health care facilities worldwide. Global production and shipping routes were disrupted, and health care institutions, even in high resource areas, found themselves lacking the basic supplies for effective infection prevention and control. One major hurdle was the global access to supplies, particularly N95/FFP2 masks and alcohol-based hand rub (ABHR) for performing hand hygiene.

This chapter explores how the lack of masks and ABHR were addressed through local production and the disinfection and reuse of disposable N95 masks. Although the global situation is no longer dire, the pandemic is currently still underway, and access to sufficient and high-quality supplies still is an important challenge faced by health care institutions.

Previously, local production was mainly promoted by the World Health Organization (WHO) as a social business venture for helping developing countries. Disposable mask reuse was barely studied until this pandemic, because there was never really a need to. Thus the literature in these fields are mostly quite new. This chapter reviews the introduction and state of the art of the field, the evidence for hand hygiene and masking in the literature, the global situation since the pandemic and strategies that countries have taken to adapt. It then concentrates further on the specifics of local production, both for ABHR and for masks, and on the issues surrounding mask reuse. The chapter concludes with putting these technologies in the larger context of the pandemic, and how learning how the world tried to implement solutions can teach us lessons for future emergencies.

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.

Effective Hand Preparation for Surgical Procedures in Low- and Middle-Income Countries

Background: The burden of healthcare-associated infections (HAIs) is greatest in low- and middle-income countries (LMICs); surgical site infections (SSIs) are the most common HAI in LMICs. Hand hygiene is the single most effective strategy for reducing HAIs and the transmission of antimicrobial drug-resistant pathogens. Similarly, effective surgical hand preparation is a critical step in the prevention of SSIs in the surgical patient. Methods: Surgical hand preparation (SHP) is a seemingly simple activity that is easily overlooked. Performed properly, however, along with other measures, it has the potential to reduce SSIs in LMICs. The article reviews the current state of surgical hand preparation in LMICs. Results: Alcohol-based handrubs (ABHRs) have received wide acceptance by healthcare workers for both hand hygiene and SHP; when mixed with emollients, ABHRs retain efficacy against microorganisms and gain skin tolerability and user acceptability. Healthcare institutions in many LMICs face difficulties obtaining the products needed to ensure effective SHP using ABHRs. Conclusion: The ABHRs are the most efficacious surgical hand preparation products available today. They are cost-effective and can safely be prepared locally in hospitals, even in LMICs. The challenge of access to ABHRs should be addressed by national and local governments, through advocacy by healthcare workers coupled with continued lobbying and campaigns by the World Health Organization. Effective surgical hand preparation, like hand hygiene, saves lives.

World Health Organization Framework: Multimodal Hand Hygiene Strategy in Piedmont (Italy) Health Care Facilities

OBJECTIVES

In 2009, the World Health Organization (WHO) introduced the "Hand Hygiene Self-Assessment Framework" (HHSAF) to evaluate the level of the application of the Multimodal Hand Hygiene Improvement Strategy (MHHIS), which defines preventive interventions, standards, and tools conceived to improve hand hygiene in healthcare facilities. The aim of our study was to evaluate the implementation of the MHHIS in Piedmont healthcare units in 2014 using the HHSAF document.

METHODS

Our surveillance was performed through collection and analysis of the data from 50 Piedmont healthcare facilities recorded through the HHSAF in 2014. The HHSAF describes the hand hygiene level evaluating the following 5 parameters: system changes, education/staff training, evaluation and feedback, reminders in the workplace, and promotion of an institutional safety climate.

RESULTS

We reported that 70.4% of the healthcare facilities involved in the study achieved the intermediate hand hygiene level, 19% the advanced level, and 11% the basic level. No facility exhibited an inadequate level of WHO multimodal implementation. Only 55% of the healthcare units provided information about hand hygiene to patients, and only 15% actively involved patients and their families.

CONCLUSIONS

The implementation of the MHHIS has achieved important results all over the world in terms of hand hygiene. Piedmont has reached an overall good level, particularly in terms of the supply and availability of hand washing products and staff education. Our results revealed, however, some critical issues related to direct and indirect monitoring of hand hygiene, providing reminders and the active involvement of patients, family members, and caregivers.

Hand antisepsis without decreasing efficacy by shortening the rub-in time of alcohol-based handrubs to 15 seconds

BACKGROUND

A previous study among neonatal intensive care unit (NICU) nurses showed that the antibacterial efficacy of alcohol-based handrubs (ABHR) can be achieved in 15 s instead of 30 s with a significant increase in the frequency of hand antisepsis. This study aimed to examine 15-s vs 30-s antisepsis performance by measuring microbial load on fingertips and compliance among nurses in a low-risk gynaecological ward.

METHODS

An independent trained observer monitored the frequency and compliance with hand antisepsis during shifts in a crossover design. Fingertips including thumbs were rinsed in soy broth before hand rubbing at the beginning of a shift and then hourly to determine the bacterial load. Performance activity was assigned to the contamination class of the Fulkerson scale. Immediately before the lunch break, volunteers cleaned their hands for a randomly determined application time of 15 or 30 s.

RESULTS

Examination of bacterial load on fingertips revealed no difference between 15 vs 30 s application time. Controlled hand antisepsis before the lunch break also showed no difference in efficacy for either test series. Participants rubbing for 15 s were more likely to perform hand antisepsis compared with those rubbing for 30 s (P=0.2). The compliance increased from 54.7% to 69.5% in the 15-s trial.

DISCUSSION

Shortening the duration for hand antisepsis did not decrease efficacy. Shortening the application time to 15 s should be considered within the critical components of a successful multimodal intervention strategy to improve hand-hygiene compliance in clinical practice.

Chlorhexidine-based decolonization to reduce healthcare-associated infections and multidrug-resistant organisms (MDROs): who, what, where, when, and why?

Body surface decolonization with chlorhexidine bathing and nasal mupirocin has become a simple solution for prevention of healthcare-associated infections. The clinical trial evidence for this practice will be reviewed to understand who benefits from this practice, for what reasons, and at what times. The method of bathing and nasal decolonization will also be discussed as proper application is needed for maximal effectiveness. Finally, the conflict between current effectiveness and future potential for fueling resistance is considered.

The effect of incorporating covert observation into established overt observation-based hand hygiene promotion programs

BACKGROUND

Covert observation (CO) is reliable for measuring hand hygiene compliance (HHC). However, the benefit of adding CO to overt observation (OO) is uncertain. We evaluated whether incorporating CO into an OO-based hand hygiene (HH) promotion program improves HH rate.

METHODS

Health care worker's HH activities were observed through 5 monitoring sessions (2 in phases 1 and 2 and 1 in phase 3) of simultaneous CO and OO. An intervention was applied-barrier identification interview-only in phase 2.

RESULTS

Overall HHC was 91.0% for OO, and 49.3% for CO. HHC in phase 1 was not changed by repeated CO (34.7% and 34.0%, P = .70). HHC based on CO increased to 66.9% in phase 2 after the application of an intervention (P < .01), but decreased to 57.5% in phase 3 (P < .01). HHC based on OO increased significantly between only the first and second sessions in phase 2 (90.8% and 94.5%, respectively, P = .01).

DISCUSSION

Although CO did not significantly change behavior, HHC with CO responded promptly to the application and cessation of a new intervention.

CONCLUSIONS

CO reflects HHC change more reliably than does OO. However, it is uncertain whether CO will improve HHC.

Improvement of hand hygiene compliance among health care workers in intensive care units

Aim

Hand hygiene (HH) is an essential component in preventing healthcare associated infections. The purpose of this study was to evaluate HH compliance among health care workers (HCWs) in intensive care units at Beni-Suef university hospital, Egypt before and after an intervention educational program.

Methods

Data were collected by using the standardized WHO method for direct observation ‘‘Five moments for HH’’ approach. Observations were conducted in six ICUs before intervention (March to April 2017) and after the intervention (July to August 2017). The study included 608 opportunities (observations) among 177 HCWs collected before and 673 opportunities among 163 HCWs collected after the intervention.

Results

Overall HH compliance increased significantly from 30.9 (95% CI: 27.2-34.6%) before intervention to 69.5 (95% CI: 65.2-72.6%) post intervention; with the highest HH compliance rate among nurses compared to physicians and workers (P = 0.001). Significantly higher HH compliance rates were observed after body fluid exposure, before aseptic procedures, and after patient contact compared to before patient contact and after patient surrounding contact (P = 0.001). In binary logistic regression analyses a statistically significant difference was shown (P = 0.047) for HH compliance among events before and after patient contact (OR = 1.399, 95% CI: 1.004-1.948).

Conclusions

The interventional educational program improved the HH compliance among ICUs-HCWs at Beni-Suef university hospital. The hospital should conduct monthly observational monitoring for the ICUs units sharing the findings to spread best practices. Provision of sustained training programs to help efficient and effective HH for care delivery is mandatory.

Prevention Strategies for Recurrent Community-Associated Staphylococcus aureus Skin and Soft Tissue Infections

PURPOSE OF REVIEW

Staphylococcus aureus skin and soft tissue infections (SSTI) are a major source of morbidity. More than half of patients experiencing SSTI will have at least one recurrent infection. These infections frequently cluster in households. Given the burden these infections pose to patients and healthcare, prevention strategies are of major clinical importance and represent an active area of research. Bacterial colonization is frequently an early and critical step in the pathogenesis of infection. As such, strategies to prevent reinfection have aimed to decrease staphylococcal colonization of the skin and mucus membranes, a process referred to as decolonization.

RECENT FINDINGS

Treatment of acute SSTI with incision and drainage and systemic antibiotics is the mainstay of therapy for healing of the acute infection. Systemic antibiotics also provide benefit through reduced incidence of recurrent SSTI. Education for patients and families regarding optimization of personal and household hygiene measures, and avoidance of sharing personal hygiene items, is an essential component in prevention efforts. For patients experiencing recurrent SSTI, or in households in which multiple members have experienced SSTI, decolonization should be recommended for all household members. A recommended decolonization regimen includes application of intranasal mupirocin and antiseptic body washes with chlorhexidine or dilute bleach water baths. For patients who continue to experience recurrent SSTI, periodic decolonization should be considered. Personal decolonization with topical antimicrobials and antiseptics reduces the incidence of recurrent S. aureus SSTI. Future avenues for investigation include strategies for household environmental decontamination as well as manipulation of the host microbiota.

Uncovering the hidden microbiota in hospital and built environments: New approaches and solutions

IMPACT STATEMENT

Research concerning the microbiome of indoor environments like hospitals, houses or buildings could have several implications for human health. Today, there is an ongoing shift in the paradigm of microbial analysis, from single isolated bacterial samples to entire microbiome profiles using high-throughput DNA sequencing methods. The use of sequencing methods in several studies has revealed an unprecedented microbial diversity in indoor environments, leading to a larger comprehension of the entire microbiome context. Here, we present a review of these microbiome studies using high-throughput DNA sequencing, including some new approaches and ideas that can be broadly applied in microbial tracking and epidemiological surveillance of indoor environments.

How a smiley protects health: A pilot intervention to improve hand hygiene in hospitals by activating injunctive norms through emoticons

Hand hygiene practice in hospitals is unfortunately still widely insufficient, even though it is known that transmitting pathogens via hands is the leading cause of healthcare-associated infections. Previous research has shown that improving knowledge, providing feedback on past behaviour and targeting social norms are promising approaches to improve hand hygiene practices. The present field experiment was designed to direct people on when to perform hand hygiene and prevent forgetfulness. This intervention is the first to examine the effect of inducing injunctive social norms via an emoticon-based feedback system on hand hygiene behaviour. Electronic monitoring and feedback devices were installed in hospital patient rooms on top of hand-rub dispensers, next to the doorway, for a period of 17 weeks. In the emoticon condition, screens at the devices activated whenever a person entered or exited the room. Before using the alcohol-based hand-rub dispenser, a frowny face was displayed, indicating that hand hygiene should be performed. If the dispenser was subsequently used, this picture changed to a smiley face to positively reinforce the correct behaviour. Hand hygiene behaviour in the emoticon rooms significantly outperformed the behaviour in three other tested conditions. The strong effect in this field experiment indicates that activating injunctive norms may be a promising approach to improve hand hygiene behaviour. Theoretical and practical implications of these findings are discussed.

Hand hygiene compliance and behavioural determinants in a paediatric intensive care unit: An observational study

BACKGROUND

Hand hygiene is considered the single most effective means of reducing healthcare-associated infections, but improving and sustaining hand hygiene compliance remains a great challenge.

OBJECTIVES

To compare hand hygiene compliance before and after interventions to promote adherence in a paediatric intensive care unit (PICU) and to identify predictors of intention to perform the behaviour "hand hygiene during patient care in the PICU".

METHODS

A before and after study was conducted in three phases. Based on the World Health Organization guideline for hand hygiene compliance monitoring, 1261 hand hygiene opportunities were directly observed during routine patient care by two observers simultaneously, in a nine-bed PICU in Brazil, before and after infrastructure and educational interventions. To identify predictors of healthcare professionals' intention to perform the behaviour hand hygiene during patient care, a data collection instrument was designed based on the Theory of Planned Behaviour. Statistical analyses were undertaken using Chi-square test or the Fisher's exact test and regression analysis. A significance level of 5% (p < 0.05) was applied to all analyses.

RESULTS

The hand hygiene compliance rate increased significantly from 27.3% in the "pre-intervention phase" to 33.1% in "phase 1-post-intervention," to 37.0% in "phase 2-post-intervention" (p = .010). Perceived social pressure (p = .026) was a determinant factor of intention to perform the behaviour.

CONCLUSIONS

Hand hygiene compliance raised significantly after infrastructure, educational, and performance feedback interventions. However, despite the significant effect of the implemented interventions, the overall hand hygiene compliance rate was low. Perceived social pressure characterised a determinant factor of intention to perform the behaviour "hand hygiene during patient care in the PICU", reinforcing the need for behaviour determinants analysis when designing promotional interventions.

Innovation Implementation in the Context of Hospital QI: Lessons Learned and Strategies for Success

In 1999, the Institute of Medicine reported that 98,000 people die each year due to medical errors. In the following years, the focus on hospital quality was intensified nationally, with policymakers providing evidence-based practice guidelines for improving health care quality. However, these innovations (evidence-based guidelines) that were being produced at policy levels were not translating to clinical practice at the hospital organizational level easily, and stark variations continued to persist, in the quality of health care. Circa 2009, nearly a decade after the release of the IOM report, the health care organizational literature began referring to this challenge as "innovation implementation failure" in health care organizations (HCOs), ie, failure to implement an evidence-based practice that is new to a HCO. This stream of literature drew upon management research to explain why innovation implementation failure occurs in HCOs and what could be done to prevent it. This paper conducts an integrative review of the literature on "innovation implementation" in hospitals and health systems over the last decade, since the spotlight was cast on "innovation implementation failure" in HCOs. The review reveals that while some studies have retrospectively sought to identify the key drivers of innovation implementation, through surveys and interviews of practitioners (the "what"), other studies have prospectively sought to understand how innovation implementation occurs in hospitals and health systems (the "how"). Both make distinctive contributions to identifying strategies for success in innovation implementation. While retrospective studies have helped identify the key drivers of innovation implementation, prospective studies have shed light on how these drivers could be attained, thereby helping to develop context-sensitive management strategies for success. The literature has called for more prospective research on the implementation and sustainability of health care innovations. This paper summarizes the lessons learned from the literature, discusses the relevance of management research on innovation implementation in HCOs, and identifies future research avenues.

Association of national and hospital factors to hospitals' alcohol-based handrub consumption in Europe: results of the European PROHIBIT study

OBJECTIVES

Hand hygiene is considered the most effective way to reduce the transmission of (multidrug-resistant) organisms and to prevent healthcare-associated infections. Hand rubbing with alcohol-based handrub (AHR) has become the reference standard for hand hygiene. Data on AHR consumption are easy to obtain and can serve as an approximation for hand hygiene compliance. As described earlier, AHR consumption varies among European hospitals. In the current study the role of various hospital and country indicators for AHR consumption is analysed.

METHODS

As part of the European Prevention of Hospital Infections by Intervention and Training (PROHIBIT) project hospital-based data on infection prevention and control (IPC) structure and organization and hospital-wide AHR consumption were obtained from acute care hospitals. National indicators such as income, public health expenditure, national hand hygiene campaigns, IPC training and the six Hofstede dimensions were identified. Univariable and multivariable linear regression analyses using generalized linear models were performed to estimate the association between AHR consumption and indicators at both hospital and country levels.

RESULTS

Data from 232 hospitals from 22 European countries were analysed. Multivariate risk factor analysis showed independent associations between AHR consumption and private and university-affiliated hospitals (multiplicative effect, 95% CI: 1.76, 1.21-2.55; and 1.39, 1.17-1.64, respectively), high-income countries (3.61, 2.94-4.43), and countries offering national curricula for the training of IPC nurses (3.77, 2.32-6.13). However, no cultural dimension was independently associated with AHR consumption.

CONCLUSION

Country indicators such as high-income, national training on IPC, and hospital type and status are positively associated with AHR consumption in Europe.

Does hospital ownership influence hand hygiene compliance?

The issue as to whether hospital ownership has an impact on the quality of care has long been a serious concern. Hand hygiene (HH) compliance is regarded as an important indicator of the quality of care in the control of hospital-acquired infections. However, little information is available on whether hospital ownership influences HH compliance. In this study, of 229 hospitals selected from Hubei province in China, 152 were public and 77 were private hospitals. A total of 23 652 healthcare workers (HCWs) were surveyed, using a convenience sampling. HH compliance, the WHO's "My Five Moments for hand hygiene" (5MHH), among HCWs, together with the factors of hospital ownership, training frequency, bed occupancy rates, etc. were collected. Univariate analysis and ordinal logistic regression analysis were used to analyze factors affecting HH compliance. Overall, HH compliance rates were 67% and 79% for public and private hospitals, respectively. The HH compliance rates of HCWs and 5MHH were between 55% and 95%, and influenced by hospital ownership (P<0.05), excluding compliance rate at the moment after body fluid exposure, and other influence factors included training frequency and bed occupancy rate (P<0.05). HH compliance is better in private than in public hospitals. Hospital ownership is a significant factor affecting HH compliance, in addition to training frequency and bed occupancy rate.

TWOC around the clock: a multimodal approach to improving catheter care

BACKGROUND

Urinary tract infections (UTI) are the second-largest group of healthcare-associated infections (HCAI). The Saving Lives Urinary Catheter Care Bundle was introduced to reduce catheter-associated urinary tract infections (CAUTI). In response, we implemented a catheter care group to examine ways to improve catheter care in an acute hospital NHS Trust.

METHODS

We adopted a multimodal approach, revolving around four components: (1) Catheter Care Pathway; (2) HOUDINI checklist; (3) catheter magnets; and (4) use of bladder ultrasound scanners.

RESULTS

The yearly CAUTI prevalence survey showed an annual reduction in CAUTI from 2012-2013 to 2014-2015 (3.5% to 2.4%). Evaluations of the multimodal approach have highlighted limitations, leading to priorities being established around provision of tools, education, and use of measurement and feedback.

CONCLUSIONS

Our multimodal approach demonstrates CAUTI rate improvements are achievable, directly benefiting patients. However, long-term maintenance of multimodal components is required to ensure sustained benefit. Engagement and accountability have emerged as significant challenges to the effectiveness and longevity of the catheter care group. We suggest greater emphasis on such challenges if long-term national or international improvement is to be achieved.

A joint, multilateral approach to improve compliance with hand hygiene in 4 countries within the Baltic region using the World Health Organization's SAVE LIVES: Clean Your Hands model

BACKGROUND

The aim of this prospective multicenter study was to explore the usefulness of a modified World Health Organization (WHO) hand hygiene program to increase compliance with hand hygiene among health care workers (HCWs) in Latvia, Lithuania, Saint Petersburg (Russia), and Sweden and to provide a basis for continuing promotion of hand hygiene in these countries. The study was carried out in 2012. Thirteen hospitals participated, including 38 wards.

METHODS

Outcome data were handrub consumption, compliance with hand hygiene measured with a modified WHO method, and assessment of knowledge among HCWs. Interventions were education of the nursing staff, posters and reminders in strategic places in the wards, and feedback of the results to nursing staff in ward meetings.

RESULTS

Feedback of results was an effective tool for education at the ward level. The most useful outcome measurement was handrub consumption, which increased by at least 50% in 30% of the wards. In spite of this, handrub consumption remained at a low level in many of the wards.

CONCLUSIONS

There are several reasons for this, and the most important were self-reported nursing staff shortage and fear of adverse effects from using alcoholic handrub and verified skin irritation.

Improving hand hygiene compliance among healthcare workers: an intervention study in a Hospital in Guizhou Province, China

OBJECTIVE

Hand hygiene (HH) is a critical component for controlling hospital-acquired infection (HAI). The present study was designed to develop an intervention approach to improve compliance with HH among healthcare workers in a hospital setting.

METHODS

The HH intervention study was conducted in Guizhou Provincial People's Hospital, Guiyang, China and organized by its Department of HAI Management. It was an observational, prospective, quasiexperimental (before-after intervention) study. The study was divided into two phases: the baseline phase and the intervention phase. The investigative team included clinical monitoring staff and infection control practitioners who received a series of instructions on HH compliance, monitoring skills, and measurement of the use of HH products.

RESULTS

Based on 27,852 observations in a 17-month period, the rate of compliance with HH improved from 37.78% at baseline to 75.90% after intervention. Significant improvement in compliance and an increase in consumption of HH products was observed after intervention. The per patient-day consumption of alcohol-based hand rub products and handwash agents increased by 4.75mL and 4.55mL, respectively. The consumption of paper towels increased 3.41 sheets per patient-day. During the same period, the prevalence rate of HAI decreased 0.83%.

CONCLUSIONS

This study demonstrates that a significant improvement in compliance with HH can be achieved through a systemic, multidimensional intervention approach involving all categories of healthcare workers in a hospital setting, which may result in a decrease of the HAI rate.

Reducing Staphylococcus aureus bloodstream infections associated with peripheral intravenous cannulae: successful implementation of a care bundle at a large Australian health service

BACKGROUND

Healthcare-associated Staphylococcus aureus bacteraemia (HA-SAB) results in morbidity, mortality, and increased healthcare costs, and these infections are frequently regarded as preventable.

AIM

To implement a multi-modal prevention programme for improved processes regarding peripheral intravenous cannula (PIVC) insertion and maintenance, in order to reduce PIVC-associated HA-SAB events in a large Australian health service.

METHODS

Baseline clinical practice was evaluated for a 12-month pre-intervention period. Measures to reduce HA-SAB risk were introduced between January and September 2013: staff education, improved documentation (including phlebitis scoring), and availability of standardized equipment. Post-intervention auditing was performed during the 27 months following intervention. Baseline and post-intervention HA-SAB and PIVC-associated infection rates were compared. Interrupted time-series and Bayesian change-point analyses were applied to determine the impact of interventions and timing of change.

FINDINGS

Significantly improved documentation regarding PIVC insertion and management was observed in the post-intervention period, with fewer PIVCs left in situ for ≥4 days (2.6 vs 6.9%, P<0.05). During the baseline period a total of 68 HA-SAB events occurred [1.01/10,000 occupied bed-days (OBDs)] and 24 were PIVC-associated (35% of total, rate 0.39 per 10,000 OBDs). In the post-intervention period, a total of 83 HA-SAB events occurred (0.99 per 10,000 OBDs) and 12 were PIVC-associated (14.4% of total, rate 0.14 per 10,000 OBDs). PIVC-associated SAB rates were 63% lower in the post-intervention period compared to baseline (P=0.018) with a change point observed following full bundle implementation in October 2013.

CONCLUSION

A successful multi-modal hospital-wide campaign was introduced to reduce PIVC-associated SAB rates. Evaluation of cost-effectiveness and sustainability is required.

Microbiological Contamination of Drugs during Their Administration for Anesthesia in the Operating Room

Background

The aseptic techniques of anesthesiologists in the preparation and administration of injected medications have not been extensively investigated, but emerging data demonstrate that inadvertent lapses in aseptic technique may be an important contributor to surgical site and other postoperative infections.

Methods

A prospective, open, microbiological audit of 303 cases in which anesthesiologists were asked to inject all bolus drugs, except propofol and antibiotics, through a 0.2-µm filter was performed. The authors cultured microorganisms, if present, from the 0.2-µm filter unit and from the residual contents of the syringes used for drawing up or administering drugs. Participating anesthesiologists rated ease of use of the filters after each case.

Results

Twenty-three anesthesiologists each anesthetized up to 25 adult patients. The authors isolated microorganisms from filter units in 19 (6.3%) of 300 cases (3 cases were excluded), including Staphylococcus capitis, Staphylococcus warneri, Staphylococcus epidermidis, Staphylococcus haemolyticus, Micrococcus luteus/lylae, Corynebacterium, and Bacillus species. The authors collected used syringes at the end of each case and grew microorganisms from residual drug in 55 of these 2,318 (2.4%) syringes including all the aforementioned microorganisms and also Kocuria kristinae, Staphylococcus aureus, and Staphylococcus hominus. Participants’ average rating of ease of use of the filter units was 3.5 out of 10 (0 being very easy and 10 being very difficult).

Conclusions

Microorganisms with the potential to cause infection are being injected (presumably inadvertently) into some patients during the administration of intravenous drugs by bolus during anesthesia. The relevance of this finding to postoperative infections warrants further investigation.

Using medical student observers of infection prevention, hand hygiene, and injection safety in outpatient settings: A cross-sectional survey

BACKGROUND

Health care-associated infection outbreaks have occurred in outpatient settings due to lapses in infection prevention. However, little is known about the overall infection prevention status in outpatient environments.

METHODS

A cross-sectional design was employed to assess infection prevention policies and practices at 15 outpatient sites across New Mexico in 2014 during a medical student outpatient rotation. A standardized infection prevention checklist was completed via staff interview; observations of injection safety practices and hand hygiene behavior were conducted. Aggregate data were analyzed using Excel (Microsoft, Redmond, WA) and Stata (version 12.1, Stata Corp, College Station, TX) statistical software.

RESULTS

Medical practice staff interviews reported a mean of 92.8% (median, 96.7%; range, 75.0%-98.9%) presence of recommended policies and practices. One hundred sixty-three injection safety observations were performed that revealed medication vial rubber septums were disinfected with alcohol 78.4% (95% confidence interval [CI], 71.1%-84.7%) of the time before piercing. Three hundred thirty hand hygiene observations revealed 33.9% (95% CI, 28.8%-39.1%) use of alcohol-based handrub, 29.1% (95% CI, 24.2%-34.0%) use of soap and water, and 37.0% (95% CI, 31.8%-42.4%) use of no hand hygiene.

DISCUSSION AND CONCLUSION

These findings support the need for ongoing infection prevention quality improvement initiatives in outpatient settings and underscore the importance of assessing both self-report and observed behavior of infection prevention compliance.

Compliance with hand hygiene: reference data from the national hand hygiene campaign in Germany

Hand hygiene is a key measure to prevent healthcare-associated infection. To promote hand hygiene nationally the German campaign 'Aktion Saubere Hände' was launched in January 2008, based on the World Health Organization's 'Clean Care is Safer Care' initiative. We report the first results from a full year of data collection on hand hygiene compliance recorded with the help of a renewed observation tool. Data were based on submissions from 109 participating hospitals collected from 576 wards between January 1st and December 31st, 2014. The overall median compliance was 73%, ranging from 55% (10th percentile) to 89% (90th percentile). The results demonstrated only small differences between adult and non-adult intensive care units (ICUs) with neonatal ICUs and paediatric non-ICUs maintaining higher compliance than adult care units. Performance among nurses was better than physicians, and overall rates of hand hygiene performance were significantly higher after patient contact than before.

Impact of implementation of the World Health Organization multimodal hand hygiene improvement strategy in a teaching hospital in Taiwan

BACKGROUND

Hand hygiene (HH) is considered to be the most simple, rapid, and economic way to prevent health care-associated infection (HAI). However, poor HH compliance has been repeatedly reported. Our objective was to evaluate the impact of implementing the updated World Health Organization (WHO) multimodal HH guidelines on HH compliance and HAI in a tertiary hospital in Taiwan.

METHODS

We conducted a before-and-after interventional study during 2010-2011. A multimodal HH promotion campaign was initiated. Key strategies included providing alcohol-based handrub dispensers at points of care, designing educational programs tailored to the needs of different health care workers, placement of general and individual reminders in the workplace, and establishment of evaluation and feedback for HH compliance and infection rates.

RESULTS

Overall HH compliance increased from 62.3% to 73.3% after 1 year of intervention (P < .001). The rate of overall HAI decreased from 3.7% to 3.1% (P < .05), urinary tract infection rate decreased from 1.5% to 1.2% (P < .05), and respiratory tract infection rate decreased from 0.53% to 0.35% (P < .05). This campaign saved an estimated $940,000 and 3,564 admission patient days per year.

CONCLUSION

The WHO multimodal HH guidelines are feasible and effective for the promotion of HH compliance and are associated with the reduction of HAIs.

Implementation of an innovative hands-on training to improve adherence to hygiene rules: A feasibility Study

BACKGROUND

Hospital-acquired infections (HAI) still pose a major problem in inpatient care. The single most important measure for preventing HAIs is to improve adherence to hand hygiene among health care professionals.

OBJECTIVE

To assess the feasibility of an innovative hands-on training to improve adherence to hygiene rules under standardized and under real life conditions.

DESIGN

Before-after controlled cohort trial to assess the feasibility of implementing an innovative hands-on training to improve hand hygiene adherence.

SETTING

Large university hospital in Germany.

PARTICIPANTS

Fifty trained nurses from three wards with an average age of 32years (±10.22years) and an average vocational experience of 6.85years (±7.54years).

METHODS

The intervention consisted of a hands-on training in the skills lab of the University of Cologne complemented by a 12-week observation period before and after the training on participating wards. The training comprised important skills with respect to hand hygiene, venipuncture, dressing changes of central venous catheters, preparation of IV infusions, and donning of gloves using sterile technique. A communication training was included to enable nurses to enforce hygiene rules in their collaboration with peers and physicians. The intervention was taught in small groups with a wide array of interactive teaching methods. It was evaluated using the objective structured clinical examination (OSCE) format. Observations were conducted by a trained infection control nurse.

RESULTS

Before (after) the intervention 622 (612) occasions of hand hygiene were documented. A highly significant improvement in hygiene compliance was observed pre- and post-intervention (64.3% vs. 79.2%; p≤0.0001). The OSCE evaluation showed significant improvements in all subscales.

CONCLUSION

The developed and conducted hands-on training seems feasible and is successful in significantly improving adherence to hygiene rules under standardized and real life conditions. Whether the effect is stable over time is subject to further investigation.

Manual cleaning of hospital mattresses: an observational study comparing high- and low-resource settings

BACKGROUND

Hospital-associated infections (HAIs) are more frequently encountered in low- than in high-resource settings. There is a need to identify and implement feasible and sustainable approaches to strengthen HAI prevention in low-resource settings.

AIM

To evaluate the biological contamination of routinely cleaned mattresses in both high- and low-resource settings.

METHODS

In this two-stage observational study, routine manual bed cleaning was evaluated at two university hospitals using adenosine triphosphate (ATP). Standardized training of cleaning personnel was achieved in both high- and low-resource settings. Qualitative analysis of the cleaning process was performed to identify predictors of cleaning outcome in low-resource settings.

FINDINGS

Mattresses in low-resource settings were highly contaminated prior to cleaning. Cleaning significantly reduced biological contamination of mattresses in low-resource settings (P < 0.0001). After training, the contamination observed after cleaning in both the high- and low-resource settings seemed comparable. Cleaning with appropriate type of cleaning materials reduced the contamination of mattresses adequately. Predictors for mattresses that remained contaminated in a low-resource setting included: type of product used, type of ward, training, and the level of contamination prior to cleaning.

CONCLUSION

In low-resource settings mattresses were highly contaminated as noted by ATP levels. Routine manual cleaning by trained staff can be as effective in a low-resource setting as in a high-resource setting. We recommend a multi-modal cleaning strategy that consists of training of domestic services staff, availability of adequate time to clean beds between patients, and application of the correct type of cleaning products.

The application of epic3 guidelines: the complexity of practice

Healthcare-associated infection (HCAI) is a major patient safety concern and is associated with morbidity, mortality and increased healthcare costs. Prevention and control requires a multi-modal approach, but the individual's accountability and rigorous application of standard infection prevention and control behaviours is at its core. The third instalment of the epic3 guidance ( Loveday et al, 2014a ) provided the evidence and advanced the importance of hand-hygiene behaviour, the use of non-sterile gloves and environmental cleanliness. This discussion considers some of the recommendations made in these areas of practice and some of the underlying complexities. Producing guidelines based on the best available evidence and transforming them into policies can be a useful adjunct to communicating the necessary standards. However, policies often erase the complexity of implementation. To strive for the best possible standard is an understandable and laudable objective, but organisations need to be mindful of the difficulties and obstacles that stand in their way, particularly in an era where the philosophy of 'zero tolerance' is gaining popularity.

Barriers to improving patient safety in India: focus groups with providers in the southern state of kerala

Objective:

To understand the perceptions of health care providers about barriers to improved patient safety in the Indian state of Kerala.

Materials and Methods:

Five focus group discussions were held with 16 doctors and 20 nurses across three institutions (primary, secondary and tertiary care centers) in Kerala, India. Transcripts were analyzed by thematic analysis.

Setting:

One rural primary care clinic, one secondary care hospital and one tertiary care center in Kerala, India.

Participants:

16 doctors and 20 nurses participated in five focus groups.

Results:

Overall, there were 129 unique mentions of barriers to patient safety; these barriers were categorized into five major themes. ‘Limited resources’ was the most prominent theme, followed by barriers related to health systems issues, the medical culture, provider training and patient education/awareness.

Conclusions:

Although inadequate resources are likely a substantial challenge to the improvement of patient safety in India, other patient safety barriers such as health systems changes, training, and education, could be addressed with fewer resources. While initial approaches to improving patient safety in India and other low- and middle-income countries have focused on implementing processes that represent best practices, this study suggests that multifaceted interventions to also address more structural problems (such as resource constraints, systems issues, and medical culture) may be important.

The relationship between hand hygiene and health care-associated infection: it's complicated

The reasoning that improved hand hygiene compliance contributes to the prevention of health care-associated infections is widely accepted. It is also accepted that high hand hygiene alone cannot impact formidable risk factors, such as older age, immunosuppression, admission to the intensive care unit, longer length of stay, and indwelling devices. When hand hygiene interventions are concurrently undertaken with other routine or special preventive strategies, there is a potential for these concurrent strategies to confound the effect of the hand hygiene program. The result may be an overestimation of the hand hygiene intervention unless the design of the intervention or analysis controls the effect of the potential confounders. Other epidemiologic principles that may also impact the result of a hand hygiene program include failure to consider measurement error of the content of the hand hygiene program and the measurement error of compliance. Some epidemiological errors in hand hygiene programs aimed at reducing health care-associated infections are inherent and not easily controlled. Nevertheless, the inadvertent omission by authors to report these common epidemiological errors, including concurrent infection prevention strategies, suggests to readers that the effect of hand hygiene is greater than the sum of all infection prevention strategies. Worse still, this omission does not assist evidence-based practice.

A qualitative study of senior hospital managers' views on current and innovative strategies to improve hand hygiene

BACKGROUND

Despite universal recognition of the importance of hand hygiene in reducing the incidence of healthcare associated infections, health care workers' compliance with best practice has been sub-optimal. Senior hospital managers have responsibilities for implementing patient safety initiatives and are therefore ideally placed to provide suggestions for improving strategies to increase hand hygiene compliance. This is an under-researched area, accordingly the aim of this study was to identify senior hospital managers' views on current and innovative strategies to improve hand hygiene compliance.

METHODS

Qualitative design comprising face-to-face interviews with thirteen purposively sampled senior managers at a major teaching and referral hospital in Sydney, Australia. Data were analysed thematically.

RESULTS

Seven themes emerged: culture change starts with leaders, refresh and renew the message, connect the five moments to the whole patient journey, actionable audit results, empower patients, reconceptualising non-compliance and start using the hammer.

CONCLUSIONS

To strengthen hand hygiene programmes, strategies based on the five moments of hand hygiene should be tailored to specific roles and settings and take into account the whole patient journey including patient interactions with clinical and non-clinical staff. Senior clinical and non-clinical leaders should visibly champion and mandate best practice initiatives and articulate that hand hygiene non-compliance is culturally and professionally unacceptable to the organization. Strategies that included a disciplinary component and which conceptualise hand hygiene non-compliance as a patient safety error may be worth evaluating in terms of staff acceptability and effectiveness.

Iranian healthcare workers' perspective on hand hygiene: a qualitative study

BACKGROUND

Hand hygiene (HH) has been identified as one of the simplest, but most important, methods to prevent cross-infection in healthcare facilities. In spite of this fact, the HH compliance rate remains low among healthcare workers (HCWs). Several factors may affect HH behavior. In this study, we aimed to assess various aspects of HH from the perspective of HCWs.

METHOD

This qualitative study was conducted in two hospital settings in Shiraz, Iran. Eight focus group discussions (FGDs) and six in-depth interview sessions were held with ICU and surgical ward nurses, attending physicians, medical and nursing students and supporting staff. Each FGD and interview was transcribed verbatim, open codes were extracted, and thematic analysis was conducted.

RESULTS

Three themes emerged from the thematic analysis including: "the relationship between personal factors and HH compliance," "the relationship between environmental factors and HH compliance" and "the impact of the health system on HH adherence, including the role of adequate health systems, administrative obligations and the effect of surveillance systems."

CONCLUSION

Several factors played a significant role in improving HCWs HH compliance, such as the regular adherence to health system tenets. HH compliance may be improved through application of realistic policies and better supervision. In addition, appropriate education may positively affect HH behavior and attitudes.

Infection control best practices in clinical research in resource-limited settings

Infection control activities in the international research setting include the development of meaningful and effective policies on specific topics such as hand and respiratory hygiene. Prevention of infection in health care workers and management of occupational exposure to transmissible agents are important aspects of the role of an infection control practitioner. Hand hygiene reduces health care associated infections and practices may be implemented in the research setting.