Cluster randomized trial to evaluate the effect of a multimodal hand hygiene improvement strategy in primary care

Effectiveness of a hand hygiene training intervention in improving knowledge and compliance rate among healthcare workers in a respiratory disease hospital

Background

Practicing hand hygiene (HH) is a crucial element of infection control, with healthcare workers (HCWs) playing a vital role in preventing the spread of infection. However, inadequate knowledge and non-compliance to HH protocols pose significant challenges in healthcare settings. This study aimed to evaluate the effectiveness of an HH training intervention in enhancing knowledge and staff compliance within a respiratory disease hospital.

Method

A pre-and post-training study was conducted among the healthcare workers in a respiratory disease treatment facility. The intervention comprised a series of 3-hour training sessions conducted over five days, focusing on the World Health Organization's (WHO) recommended guideline "Your Five Moments For Hand Hygiene." These sessions covered proper HH techniques and underscored the repercussions of inadequate compliance. Educational materials related to HH were displayed in prominent locations throughout the facility. The knowledge levels and compliance rate were assessed before and after the intervention.

Result

The intervention significantly improved HH knowledge levels and compliance rates among the participants. Marking a significant improvement, the compliance rate of HH protocols increased from 66.0% to 88.3% during the pre-to post-training period, with a concurrent increase in the mean knowledge score from 68.6% to 78.9%.

Conclusion

This study underscores the potential of training and education in elevating HH compliance and knowledge among healthcare workers. The findings advocate that healthcare facilities routinely incorporate such interventions into their infection control programs, ultimately improving patient and healthcare worker safety.

Sustainability of healthcare professionals' adherence to clinical practice guidelines in primary care

BACKGROUND

Sustainability of adherence to clinical practice guidelines (CPGs) represents an important indicator of the successful implementation in the primary care setting.

AIM

To explore the sustainability of primary care providers' adherence to CPGs after receiving planned guideline implementation strategies, activities, or programmes.

METHODS

Cochrane Central Register of Controlled Trials (CENTRAL); Cumulative Index to Nursing and Allied Health Literature (CINAHL); EMBase; Joanna Briggs Institute; Journals@Ovid; Medline; PsycoINFO; PubMed, and Web of Science were searched from January 2000 through May 2021 to identify relevant studies. Studies evaluating the sustainability of primary care providers' (PCPs') adherence to CPGs in primary care after any planned guideline implementation strategies, activities, or programmes were included. Two reviewers extracted data from the included studies and assessed methodological quality independently. Narrative synthesis of the findings was conducted.

RESULTS

Eleven studies were included. These studies evaluated the sustainability of adherence to CPGs related to drug prescribing, disease management, cancer screening, and hand hygiene in primary care. Educational outreach visits, teaching sessions, reminders, audit and feedback, and printed materials were utilized in the included studies as guideline implementation strategies. None of the included studies utilized purpose-designed measurements to evaluate the extent of sustainability. Three studies showed positive sustainability results, three studies showed mixed sustainability results, and four studies reported no significant changes in the sustainability of adherence to CPGs. Overall, it was difficult to quantify the extent to which CPG-based healthcare behaviours were fully sustained based on the variety of results reported in the included studies.

CONCLUSION

Current guideline implementation strategies may potentially improve the sustainability of PCPs' adherence to CPGs. However, the literature reveals a limited body of evidence for any given guideline implementation strategy. Further research, including the development of a validated purpose-designed sustainability tool, is required to address this important clinical issue.

TRIAL REGISTRATION

The study protocol has been registered at PROSPERO (No. CRD42021259748 ).

Dissemination interventions to improve healthcare workers' adherence with infection prevention and control guidelines: a systematic review and meta-analysis

Background

The COVID-19 pandemic has challenged health systems worldwide since 2020. At the frontline of the pandemic, healthcare workers are at high risk of exposure. Compliance with infection prevention and control (IPC) should be encouraged at the frontline. This systematic review aimed to assess the effects of dissemination interventions to improve healthcare workers’ adherence with IPC guidelines for respiratory infectious diseases in the workplace.

Methods

We searched CENTRAL, MEDLINE, Embase, and the Cochrane COVID-19 Study Register. We included randomized controlled trials (RCTs) and cluster RCTs that assessed the effect of any dissemination strategy in any healthcare settings. Certainty of evidence was assessed using the GRADE approach. We synthesized data using random-effects model meta-analysis in Stata 14.2.

Results

We identified 14 RCTs conducted from 2004 to 2020 with over 65,370 healthcare workers. Adherence to IPC guidelines was assessed by influenza vaccination uptake, hand hygiene compliance, and knowledge on IPC. The most assessed intervention was educational material in combined strategies (plus educational meetings, local opinion leaders, audit and feedback, reminders, tailored interventions, monitoring the performance of the delivery of health care, educational games, and/or patient-mediated interventions). Combined dissemination strategies compared to usual routine improve vaccination uptake (risk ratio [RR] 1.59, 95% confidence interval [CI] 1.54 to 1.81, moderate-certainty evidence), and may improve hand hygiene compliance (RR 1.70; 95% CI 1.03 to 2.83, moderate-certainty). When compared to single strategies, combined dissemination strategies probably had no effect on vaccination uptake (RR 1.01, 95% CI 0.95 to 1.07, low-certainty), and hand hygiene compliance (RR 1.16, 95% CI 0.99 to 1.36, low-certainty). Knowledge of healthcare workers on IPC improved when combined dissemination strategies were compared with usual activities, and the effect was uncertain in comparison to single strategy (very low-certainty evidence).

Conclusions

Combined dissemination strategies increased workers’ vaccination uptake, hand hygiene compliance, and knowledge on IPC in comparison to usual activities. The effect was negligible when compared to single dissemination strategies. The adoption of dissemination strategies in a planned and targeted way for healthcare workers may increase adherence to IPC guidelines and thus prevent dissemination of infectious disease in the workplace.

Trial registration

Protocol available at http://osf.io/aqxnp.

Continuing education meetings and workshops: effects on professional practice and healthcare outcomes

BACKGROUND

Educational meetings are used widely by health personnel to provide continuing medical education and to promote implementation of innovations or translate new knowledge to change practice within healthcare systems. Previous reviews have concluded that educational meetings can result in small changes in behaviour, but that effects vary considerably. Investigations into which characteristics of educational meetings might lead to greater impact have yielded varying results, and factors that might explain heterogeneity in effects remain unclear. This is the second update of this Cochrane Review.

OBJECTIVES

• To assess the effects of educational meetings on professional practice and healthcare outcomes • To investigate factors that might explain the heterogeneity of these effects SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, ERIC, Science Citation Index Expanded (ISI Web of Knowledge), and Social Sciences Citation Index (last search in November 2016).

SELECTION CRITERIA

We sought randomised trials examining the effects of educational meetings on professional practice and patient outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. One review author assessed the certainty of evidence (GRADE) and discussed with a second review author. We included studies in the primary analysis that reported baseline data and that we judged to be at low or unclear risk of bias. For each comparison of dichotomous outcomes, we measured treatment effect as risk difference adjusted for baseline compliance. We expressed adjusted risk difference values as percentages, and we noted that values greater than zero favour educational meetings. For continuous outcomes, we measured treatment effect as per cent change relative to the control group mean post test, adjusted for baseline performance; we expressed values as percentages and noted that values greater than zero favour educational meetings. We report means and 95% confidence intervals (CIs) and, when appropriate, medians and interquartile ranges to facilitate comparisons to previous versions of this review. We analysed professional and patient outcomes separately and analysed 22 variables that were hypothesised a priori to explain heterogeneity. We explored heterogeneity by using univariate meta-regression and by inspecting violin plots.

MAIN RESULTS

We included 215 studies involving more than 28,167 health professionals, including 142 new studies for this update. Educational meetings as the single intervention or the main component of a multi-faceted intervention compared with no intervention • Probably slightly improve compliance with desired practice when compared with no intervention (65 comparisons, 7868 health professionals for dichotomous outcomes (adjusted risk difference 6.79%, 95% CI 6.62% to 6.97%; median 4.00%; interquartile range 0.29% to 13.00%); 28 comparisons, 2577 health professionals for continuous outcomes (adjusted relative percentage change 44.36%, 95% CI 41.98% to 46.75%; median 20.00%; interquartile range 6.00% to 65.00%)) • Probably slightly improve patient outcomes compared with no intervention (15 comparisons, 2530 health professionals for dichotomous outcomes (adjusted risk difference 3.30%, 95% CI 3.10% to 3.51%; median 0.10%; interquartile range 0.00% to 4.00%); 28 comparisons, 2294 health professionals for continuous outcomes (adjusted relative percentage change 8.35%, 95% CI 7.46% to 9.24%; median 2.00%; interquartile range -1.00% to 21.00%)) The certainty of evidence for this comparison is moderate. Educational meetings alone compared with other interventions • May improve compliance with desired practice when compared with other interventions (6 studies, 1402 health professionals for dichotomous outcomes (adjusted risk difference 9.99%, 95% CI 9.47% to 10.52%; median 16.5%; interquartile range 0.80% to 16.50%); 2 studies, 72 health professionals for continuous outcomes (adjusted relative percentage change 12.00%, 95% CI 9.16% to 14.84%; median 12.00%; interquartile range 0.00% to 24.00%)) No studies met the inclusion criteria for patient outcome measurements. The certainty of evidence for this comparison is low. Interactive educational meetings compared with didactic (lecture-based) educational meetings • We are uncertain of effects on compliance with desired practice (3 studies, 370 health professionals for dichotomous outcomes; 1 study, 192 health professionals for continuous outcomes) or on patient outcomes (1 study, 54 health professionals for continuous outcomes), as the certainty of evidence is very low Any other comparison of different formats and durations of educational meetings • We are uncertain of effects on compliance with desired practice (1 study, 19 health professionals for dichotomous outcomes; 1 study, 20 health professionals for continuous outcomes) or on patient outcomes (1 study, 113 health professionals for continuous outcomes), as the certainty of evidence is very low. Factors that might explain heterogeneity of effects Meta-regression suggests that larger estimates of effect are associated with studies judged to be at high risk of bias, with studies that had unit of analysis errors, and with studies in which the unit of analysis was the provider rather than the patient. Improved compliance with desired practice may be associated with: shorter meetings; poor baseline compliance; better attendance; shorter follow-up; professionals provided with additional take-home material; explicit building of educational meetings on theory; targeting of low- versus high-complexity behaviours; targeting of outcomes with high versus low importance; goal of increasing rather than decreasing behaviour; teaching by opinion leaders; and use of didactic versus interactive teaching methods. Pre-specified exploratory analyses of behaviour change techniques suggest that improved compliance with desired practice may be associated with use of a greater number of behaviour change techniques; goal-setting; provision of feedback; provision for social comparison; and provision for social support. Compliance may be decreased by the use of follow-up prompts, skills training, and barrier identification techniques.

AUTHORS' CONCLUSIONS

Compared with no intervention, educational meetings as the main component of an intervention probably slightly improve professional practice and, to a lesser extent, patient outcomes. Educational meetings may improve compliance with desired practice to a greater extent than other kinds of behaviour change interventions, such as text messages, fees, or office systems. Our findings suggest that multi-strategy approaches might positively influence the effects of educational meetings. Additional trials of educational meetings compared with no intervention are unlikely to change the review findings; therefore we will not further update this review comparison in the future. However, we note that randomised trials comparing different types of education are needed.

The Effectiveness of Interventions in Improving Hand Hygiene Compliance: A Meta-Analysis and Logic Model

Background

Despite the availability of various guidelines, rules, and strategies, hand hygiene adherence rates among healthcare workers are reported significantly lower than expected. The aim of this meta-analysis is to determine the most effective interventions to improve hand hygiene and to develop a logic model based on the characteristics of the most effective interventions.

Methods

A literature search was conducted on PubMed, ProQuest, Web of Knowledge, Scopus, Cochrane Library, and ScienceDirect databases up to December 21, 2019, with no time limit. Randomized clinical trials which had designed interventions to improve hand hygiene were reviewed. Data were extracted independently by two authors. All statistical analyses were performed using Comprehensive Meta-Analysis (CMA) software (version 2.0). A random-effects model was used to estimate odds ratios.

Results

Although 14 studies were initially reviewed, only 12 studies entered the meta-analysis, since they had identified percentage rates of hand hygiene compliance. The most effective intervention (odds ratio 18.4, 95% CI (13.6–24.8)) was a multilevel strategy that influenced the determinants of hand hygiene behavior at individual, interpersonal, and organizational levels. Following this, a theory-driven logic model was mapped out to promote hand hygiene, based on situational analysis.

Conclusion

This study suggests that designing integrated interventions based on a multilevel socioecological approach has the greatest potential to improve hand hygiene compliance in healthcare workers. The logical model proposed in this study can thus provide a useful guide for designing and conducting future experimental research.

Is a nudge all we need to promote deliberate clinical inertia and thoughtful clinical decision making?

Deliberate clinical inertia is the art of doing nothing as a positive response. Individual clinicians can promote deliberate clinical inertia through teaching, re-framing the act of 'doing nothing' as 'doing something' and engaging in shared decision making. Behaviour change on a larger scale requires a systematic approach. Nudging is a subtle change to the decision-making context to prompt specific choices. A nudge unit is a team of relevant professionals who engage with various multidisciplinary teams within a health service who help test and implement nudge interventions in a clinical environment. A nudge unit could be used to design environments to prompt clinicians to re-think before ordering unnecessary tests or treatments. Nudge units could improve knowledge translation, support continuous quality improvement and help build a learning health system. They could also boost collaboration and empower staff to evaluate their workplace decision-making frameworks.

Hand-hygiene-related clinical trials reported between 2014 and 2020: a comprehensive systematic review

Background

There is general consensus that hand hygiene is the most effective way to prevent healthcare-associated infections. However, low rates of compliance amongst healthcare workers have been reported globally. The coronavirus disease 2019 pandemic has further emphasized the need for global improvement in hand hygiene compliance by healthcare workers.

Aim

This comprehensive systematic review provides an up-to-date compilation of clinical trials, reported between 2014 and 2020, assessing hand hygiene interventions in order to inform healthcare leaders and practitioners regarding approaches to reduce healthcare-associated infections using hand hygiene.

Methods

CINAHL, Cochrane, EMbase, Medline, PubMed and Web of Science databases were searched for clinical trials published between March 2014 and December 2020 on the topic of hand hygiene compliance among healthcare workers. In total, 332 papers were identified from these searches, of which 57 studies met the inclusion criteria.

Findings

Forty-five of the 57 studies (79%) included in this review were conducted in Asia, Europe and the USA. The large majority of these clinical trials were conducted in acute care facilities, including hospital wards and intensive care facilities. Nurses represented the largest group of healthcare workers studied (44 studies, 77%), followed by physicians (41 studies, 72%). Thirty-six studies (63%) adopted the World Health Organization's multi-modal framework or a variation of this framework, and many of them recorded hand hygiene opportunities at each of the ‘Five Moments’. However, recording of hand hygiene technique was not common.

Conclusion

Both single intervention and multi-modal hand hygiene strategies can achieve modest-to-moderate improvements in hand hygiene compliance among healthcare workers.

Hand hygiene compliance in Dutch general practice offices

BACKGROUND

Hand hygiene (HH) is considered one of the most important measures to prevent healthcare-associated infections (HAI). Most studies focus on HH compliance within the hospital setting, whereas little is known for the outpatient setting. The aim of this study was to evaluate compliance with HH recommendations in general practitioners (GPs) office, based on World Health Organization (WHO) guideline.

METHODS

An observational study was conducted at five Dutch GPs-practices in September 2017. We measured HH compliance through direct observation using WHO's 'five moments of hand hygiene' observation tool. All observations were done by one trained professional.

RESULTS

We monitored a total of 285 HH opportunities for 30 health care workers (HCWs). The overall compliance was 37%. Hand hygiene compliance was 34, 51 and 16% for general practitioners, practice assistants, and nurses, respectively. It varies between 63% after body fluid exposure and no HH performance before-, during and after home visit of a patient (defined as moment 5). The preferred method of HH was soap and water (63%) versus 37% for alcohol-based hand rub (ABHR). The median time of disinfecting hands was 8 s (range 6-11 s) for HCWs in our study.

CONCLUSIONS

HH compliance among HCWs in Dutch GPs was found to be low, especially with regard to home visits. The WHO recommended switch from hand wash to ABHR was not implemented by the majority of HCWs in 5 observed GPs offices.

A multimodal intervention to improve hand hygiene compliance in peripheral wards of a tertiary care university centre: a cluster randomised controlled trial

Background

Interventions to improve hand hygiene (HH) compliance are a key element in the practice infection prevention and control. It was our objective to assess the effect of a multimodal intervention on HH compliance at a tertiary care university hospital. As a secondary objective, we investigated the effect of the intervention on the occurrence of device-associated bloodstream infections.

Methods

We performed a single centre cluster randomised controlled trial at a university hospital in Germany. Twenty peripheral wards were invited to participate and randomly assigned to either the intervention (n = 10) or control group (n = 10). Quarterly, specifically trained student employees conducted direct compliance observations in all twenty wards. The intervention entailed dissemination of teaching materials on aseptic procedures, equipment with flexibly mountable alcoholic hand rub dispensers, and quarterly feedback on HH compliance.

Results

In total, 21,424 HH opportunities were observed. Overall, compliance did not change significantly in either group (intervention group: 59% vs. 61% (1482 HH actions for 2494 HH opportunities vs. 5033 HH actions for 8215 HH opportunities), odds ratio (OR) 1.08 (95% confidence interval (CI95) 0.88, 1.33)); control group: 59% vs. 60% (1457 HH actions for 2484 HH opportunities vs. 4948 HH actions for 8231 HH opportunities), OR 1.06 (CI95 0.84, 1.35)). Compliance prior to aseptic procedures improved significantly in the intervention group from 44% (168 HH actions for 380 HH opportunities) to 53% (764 HH actions for 1452 HH opportunities) (OR 1.40 (CI95 1.04, 1.89), p = 0.03), while no significant increase was noted in the control group. In the intervention group, significantly fewer device-associated bloodstream infections per 1000 patient-days occurred than in the control group (84 vs. 123, incidence rate ratio 0.61 (CI95 0.46, 0.81), p < 0.01).

Conclusions

The lack of a significant overall improvement of HH compliance demonstrated that comprehensive implementation of HH interventions in multiple wards simultaneously is difficult. However, through targeted intervention measures, we were able to significantly increase HH compliance before aseptic procedures.

Nudge strategies to improve healthcare providers' implementation of evidence-based guidelines, policies and practices: a systematic review of trials included within Cochrane systematic reviews

BACKGROUND

Nudge interventions are those that seek to modify the social and physical environment to enhance capacity for subconscious behaviours that align with the intrinsic values of an individual, without actively restricting options. This study sought to describe the application and effects of nudge strategies on clinician implementation of health-related guidelines, policies and practices within studies included in relevant Cochrane systematic reviews.

METHODS

As there is varied terminology used to describe nudge, this study examined studies within relevant systematic reviews. A two-stage screening process was undertaken where, firstly, all systematic reviews published in the Cochrane Library between 2016 and 2018 were screened to identify reviews that included quantitative studies to improve implementation of guidelines among healthcare providers. Secondly, individual studies within relevant systematic reviews were included if they were (i) randomised controlled trials (RCTs), (ii) included a nudge strategy in at least one intervention arm, and (iii) explicitly aimed to improve clinician implementation behaviour. We categorised nudge strategies into priming, salience and affect, default, incentives, commitment and ego, and norms and messenger based on the Mindspace framework.

SYNTHESIS

The number and percentage of trials using each nudge strategy was calculated. Due to substantial heterogeneity, we did not undertake a meta-analysis. Instead, we calculated within-study point estimates and 95% confidence intervals, and used a vote-counting approach to explore effects.

RESULTS

Seven reviews including 42 trials reporting on 57 outcomes were included. The most common nudge strategy was priming (69%), then norms and messenger (40%). Of the 57 outcomes, 86% had an effect on clinician behaviour in the hypothesised direction, and 53% of those were statistically significant. For continuous outcomes, the median effect size was 0.39 (0.22, 0.45), while for dichotomous outcomes the median Odds Ratio was 1.62 (1.13, 2.76).

CONCLUSIONS

This review of 42 RCTs included in Cochrane systematic reviews found that the impact of nudge strategies on clinician behaviour was at least comparable to other interventions targeting implementation of evidence-based guidelines. While uncertainty remains, the review provides justification for ongoing investigation of the evaluation and application of nudge interventions to support provider behaviour change.

TRIAL REGISTRATION

This review was not prospectively registered.

Hand Hygiene Teaching Strategies among Nursing Staff: A Systematic Review

Background: Patient safety is a priority of any healthcare system, and one of the most effective measures is hand hygiene. For this, it is important that health staff have correct adherence and perform the technique properly. Otherwise, the incidence of nosocomial infections can increase, with consequent complications. The aim here was to analyze hand hygiene training and the effectiveness of different methods and educational strategies among nurses and whether they maintained correct adherence over time. Methods: A systematic review was conducted in the sources CINAHL (Cumulative Index to Nursing and Allied Health Literature), Dialnet, Lilacs (Latin American and Caribbean Health Sciences Literature), ProQuest (Proquest Health and Medical Complete), Medline, SciELO (Scientific Electronic Library Online), and Scopus. The search equation with Medical Subject Headings (MeSH) descriptors was “Nurs* AND (handwashing OR hand hygiene) AND clinical trial”. The review was performed following the recommendations of the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: n = 17 clinical trials were included, with a total of 5747 nurses and nursing students. Strategies such as reminder sounds, practical simulations, videos, and audiovisual media improved handwashing compliance. Adherence overtime increased by up to 60%. The greatest effectiveness was related to the use of povidone–iodine, which reduced colony formation compared Hand hygiene teaching strategies among nursing staff: a systematic review to soap. Conclusions: The strategies that go beyond teaching techniques such as lectures may be more effective at increasing hand hygiene compliance. Combined approaches to learning/instruction improve user satisfaction by enabling self-management, flexibility, and repetition.

Evaluating the effectiveness of the "Germ-Free Hands" intervention for improving the hand hygiene practices of public health students

PURPOSE

This quasi-experimental study sought to assess the effectiveness of a multidisciplinary intervention called "Germ-Free Hands" to improve the hand hygiene practices of students attending Thailand's Sirindhorn College of Public Health (SCPH).

METHODS

The intervention was developed and implemented at SCPH and incorporated education, training, a workshop, and performance feedback. The intervention targeted behavioral antecedents specified by the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB). Handwashing determinants (knowledge, beliefs, attitudes, subjective norms, perceived behavioral control, and intentions) and hand hygiene behaviors were assessed at baseline, immediately post-intervention, and 3 months post-intervention for the intervention group at (n=60) at the Suphanburi campus of SCPH and a matched control group (n=60) of students at the Ubonratchathani campus. Data analysis included descriptive statistics, independent samples t-tests, two-way measures of analysis of variance, and a generalized estimating equation to compare handwashing practices by self-reports between two groups.

RESULTS

The "Germ-Free Hands" intervention produced significant improvements in the intervention group's handwashing knowledge, behavioral and control beliefs, subjective norm scores, intentions, and behaviors, as compared to the control group. However, the intervention had no significant impact on normative beliefs, attitudes, or perceived behavioral control. Reported improvements also decreased 3 months post-intervention, and the number of bacterial colonies on students' hands increased over the course of the study.

CONCLUSION

This study adds to the evidence that multidisciplinary interventions can be effective at improving handwashing rates. However, education and training must be continuous, rather than delivered as a one-time program, in order to have sustained results. Participants may also require more in-depth instruction in correct handwashing and drying techniques to remove bacteria effectively and prevent recolonization.

Visibility and transmission: complexities around promoting hand hygiene in young children - a qualitative study

Background

Effective hand hygiene practice can reduce transmission of diseases such as respiratory tract infections (RTIs) and gastrointestinal infections, especially in young children. While hand hygiene has been widely promoted within Australia, primary care providers’ (PCPs) and parents’ understanding of hand hygiene importance, and their views on hand hygiene in reducing transmission of diseases in the community are unclear. Therefore, the aim of this study was to explore the views of PCPs and parents of young children on their knowledge and practice of hand hygiene in disease transmission.

Methods

Using a cross-sectional qualitative research design, we conducted 30 in-depth interviews with PCPs and five focus groups with parents (n = 50) between June 2014 and July 2015 in Melbourne, Australia. Data were thematically analysed.

Results

Participants agreed that hand hygiene practice was important in reducing disease transmissions. However, barriers such as variations of hand hygiene habits, relating visibility to transmission; concerns around young children being obsessed with washing hands; children already being ‘too clean’ and the need to build their immunity through exposure to dirt; and scepticism that hand hygiene practice was achievable in young children, all hindered participants’ motivation to develop good hand hygiene behaviour in young children.

Conclusion

Despite the established benefits of hand hygiene, sustained efforts are needed to ensure its uptake in routine care. To overcome the barriers identified in this study a multifaceted intervention is needed that includes teaching young children good hand hygiene habits, PCPs prompting parents and young children to practice hand hygiene when coming for an RTI consultation, reassuring parents that effective hand hygiene practice will not lead to abnormal psychological behaviour in their children, and community health promotion education campaigns.

Impact of a simulation-based training in hand hygiene with alcohol-based hand rub in emergency departments

BACKGROUND

Hand hygiene is the primary measure for reducing nosocomial infections based on 7 steps recommended by the WHO. The aim of this study was to assess the duration and the quality of hand hygiene before and after simulation-based training (SBT).

METHODS

The study took place in a University Hospital Pediatric Department among its residents and nurses. In assessment A, 10 hand-rubbing procedures per participant during a work day were scored by observers using a validated, anatomically based assessment scale. Two weeks later, all participants received a didactic course and SBT, followed 1 month later by assessment B, observation of 10 hand-rubbing procedures. Assessments were performed by 2 independent observers. Before-and-after testing was used to evaluate the demonstration of theoretical knowledge.

RESULTS

In total, 22 participants were included, for whom 438 hand hygiene procedures were assessed: 218 for assessment A and 220 for assessment B. The duration of hand rubbing increased from 31.16 seconds in assessment A to 35.75 seconds in assessment B (P=.04). In assessment A, participants averaged 6.33 steps, and in assessment B, participants averaged 6.03 steps (difference not significant). Significant improvement in scores was observed between assessments A and B, except for the dorsal side of the right hand. The wrist and interdigital areas were the least-cleaned zones. A difference between assessments A and B was observed for nail varnish (P=.003) but not for long nails or jewelry. Theoretical scores increased from 2.83 to 4.29 (scale of 0-5; P<.001).

CONCLUSION

This study revealed that an optimal number of steps were performed during hand-rubbing procedures and that SBT improved the duration and quality of hand hygiene, except for the dorsal right side. Emphasis should be placed on the specific hand areas that remained unclean after regular hand-rubbing procedures.

Knowledge about precautions in Primary Health Care: tool validation

OBJECTIVE

To elaborate and validate a tool to assess knowledge and behavior of nursing professionals about standards and specific precautions in the Primary Health Care.

METHOD

Methodological study of the elaboration and validation of the tool by thirteen experts judges, using a Likert scale of 4 points, with Content Validity Index ≥ 0.80, on clarity, relevance and pertinence.

RESULTS

A tool composed of 47 dichotomous questions to assess knowledge and 12 questions, with five options of answers, for the referred behavior. In the validation, only one item was deleted, related to the "Hands Hygiene" axis and one item was reformulated, regarding "Use of Common Gloves" and another 11 changed writing. The tool as a whole was assessed for relevance, comprehensiveness and representativeness within the scope of the topic investigated.

CONCLUSION

The developed tool has been validated and is now available for use in Primary Health Care.

Hand Hygiene Improvement and Sustainability: Assessing a Breakthrough Collaborative in Western Switzerland

OBJECTIVE

To assess hand hygiene improvement and sustainability associated with a Breakthrough Collaborative.

DESIGN

Multicenter analysis of hand hygiene compliance through direct observation by trained observers.

SETTING

A total of 5 publicly funded hospitals in 14 locations, with a total of 1,152 beds, in the County of Vaud, Switzerland.

PARTICIPANTS

Clinical staff.

INTERVENTIONS

In total, 59,272 opportunities for hand hygiene were monitored for the duration of the study, for an average of 5,921 per audit (range, 5,449–6,852). An 18-month Hand Hygiene Breakthrough Collaborative was conducted to implement the WHO multimodal promotional strategy including improved access to alcohol-based hand rub, education, performance measurement and feedback, reminders and communication, leadership engagement, and safety culture.

RESULTS

Overall hand hygiene compliance improved from 61.9% to 88.3% (P<.001) over 18 months and was sustained at 88.9% (P=.248) 12 months after the intervention. Hand hygiene compliance among physicians increased from 62% to 85% (P<.001) and finally 86% at follow-up (P=.492); for nursing staff, compliance improved from 64% to 90% (P<.001) and finally 90% at follow-up (P=.464); for physiotherapists compliance improved from 50% to 90% (P<.001) and finally 91% at follow-up (P=.619); for X-ray technicians compliance improved from 45% to 80% (P<.001) and finally 81% at follow-up (P=.686). Hand hygiene compliance also significantly increased with sustained improvement across all hand hygiene indications and all hospitals.

CONCLUSIONS

A rigorously conducted multicenter project combining the Breakthrough Collaborative method for its structure and the WHO multimodal strategy for content and measurement was associated with significant and substantial improvement in compliance across all professions, all hand hygiene indications, and all participating hospitals.

Infect Control Hosp Epidemiol 2017;38:1420–1427

Adherence to precautions for preventing the transmission of microorganisms in primary health care: a qualitative study

Background

Health care associated infections (HAIs) are a source of concern worldwide. No health service in any country can be considered HAI risk-free. However, there is scarcity of data on the risks to which both patients and health workers are subject in non-hospital settings. The aim of this study was to identify issues that determine the adherence of professionals to precautions for preventing transmission of microorganisms in primary health care.

Method

This was a qualitative study, using focus groups of primary health care staff, in two Brazilian municipalities. The data were analysed using content analysis.

Results

Four focus groups were conducted with 20 professionals (11 community health workers, 5 nursing assistants and 4 nurses), and the analysed content was organized into four thematic categories. These categories are: low risk perception, weaknesses in knowledge, insufficient in-service training and infrastructure limitations.

Participants expressed their weaknesses in knowledge of standard and transmission based precautions, mainly for hand hygiene and tuberculosis. A lack of appropriate resources and standardization in sharps disposal management was also highlighted by the participants.

Conclusion

The study points out the need to provide in-service training for professionals on the transmission of microorganisms in primary health care to ensure adequate level of risk perception and knowledge. Further recommendations include investment to improve infrastructure to facilitate adherence to precautions and to minimize the risk of disease transmission for both patients and health care workers.

Interventions to improve hand hygiene compliance in patient care

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessment of Fidelity in Interventions to Improve Hand Hygiene of Healthcare Workers: A Systematic Review

OBJECTIVE

Compliance with hand hygiene in healthcare workers is fundamental to infection prevention yet remains a challenge to sustain. We examined fidelity reporting in interventions to improve hand hygiene compliance, and we assessed 5 measures of intervention fidelity: (1) adherence, (2) exposure or dose, (3) quality of intervention delivery, (4) participant responsiveness, and (5) program differentiation.

DESIGN

Systematic review

METHODS

A librarian performed searches of the literature in PubMed, Cumulative Index to Nursing and Allied Health (CINAHL), Cochrane Library, and Web of Science of material published prior to June 19, 2015. The review protocol was registered in PROSPERO International Prospective Register of Systematic Reviews, and assessment of study quality was conducted for each study reviewed.

RESULTS

A total of 100 studies met the inclusion criteria. Only 8 of these 100 studies reported all 5 measures of intervention fidelity. In addition, 39 of 100 (39%) failed to include at least 3 fidelity measures; 20 of 100 (20%) failed to include 4 measures; 17 of 100 (17%) failed to include 2 measures, while 16 of 100 (16%) of the studies failed to include at least 1 measure of fidelity. Participant responsiveness and adherence to the intervention were the most frequently unreported fidelity measures, while quality of the delivery was the most frequently reported measure.

CONCLUSIONS

Almost all hand hygiene intervention studies failed to report at least 1 fidelity measurement. To facilitate replication and effective implementation, reporting fidelity should be standard practice when describing results of complex behavioral interventions such as hand hygiene.

Hand hygiene-related clinical trials reported since 2010: a systematic review

Considerable emphasis is currently placed on reducing healthcare-associated infection through improving hand hygiene compliance among healthcare professionals. There is also increasing discussion in the lay media of perceived poor hand hygiene compliance among healthcare staff. Our aim was to report the outcomes of a systematic search for peer-reviewed, published studies - especially clinical trials - that focused on hand hygiene compliance among healthcare professionals. Literature published between December 2009, after publication of the World Health Organization (WHO) hand hygiene guidelines, and February 2014, which was indexed in PubMed and CINAHL on the topic of hand hygiene compliance, was searched. Following examination of relevance and methodology of the 57 publications initially retrieved, 16 clinical trials were finally included in the review. The majority of studies were conducted in the USA and Europe. The intensive care unit emerged as the predominant focus of studies followed by facilities for care of the elderly. The category of healthcare worker most often the focus of the research was the nurse, followed by the healthcare assistant and the doctor. The unit of analysis reported for hand hygiene compliance was 'hand hygiene opportunity'; four studies adopted the 'my five moments for hand hygiene' framework, as set out in the WHO guidelines, whereas other papers focused on unique multimodal strategies of varying design. We concluded that adopting a multimodal approach to hand hygiene improvement intervention strategies, whether guided by the WHO framework or by another tested multimodal framework, results in moderate improvements in hand hygiene compliance.

Effect of hand sanitizer location on hand hygiene compliance

BACKGROUND

Hand hygiene is the most important intervention to prevent infection in hospitals. Health care workers should clean their hands at least before and after contact with patients. Hand sanitizer dispensers are important to support hand hygiene because they can be made available throughout hospital units. The aim of this study was to determine whether the usability of sanitizer dispensers correlates with compliance of staff in using the sanitizer in a hospital. This study took place in a Midwest, 404-bed, private, nonprofit community hospital with 15 inpatient care units in addition to several ambulatory units.

METHODS

The usability and standardization of sanitizers in 12 participating inpatient units were evaluated. The hospital measured compliance of staff with hand hygiene as part of their quality improvement program. Data from 2010-2012 were analyzed to measure the relationship between compliance and usability using mixed-effects logistic regression models.

RESULTS

The total usability score (P = .0046), visibility (P = .003), and accessibility of the sanitizer on entrance to the patient room (P = .00055) were statistically associated with higher observed compliance rates. Standardization alone showed no significant impact on observed compliance (P = .37).

CONCLUSION

Hand hygiene compliance can be influenced by visibility and accessibility of dispensers. The sanitizer location should be part of multifaceted interventions to improve hand hygiene.

Integrative review of implementation strategies for translation of research-based evidence by nurses

OBJECTIVES

The purpose of this review was to synthesize and critique experimental and/or quasi-experimental research that has evaluated implementation strategies for translation of research-based evidence into nursing practice.

BACKGROUND

Successfully implementing evidence-based research can improve patient outcomes. Identifying successful implementation strategies is imperative to move research-based evidence into practice.

RATIONALE

As implementation science gains popularity, it is imperative to understand the strategies that most effectively translate research-based evidence into practice.

DESCRIPTION

The review used the CINAHL and MEDLINE (Ovid) databases. Articles were included if they were experimental and/or quasi-experimental research designs, were written in English, and measured nursing compliance to translation of research-based evidence. An independent review was performed to select and critique the included articles.

OUTCOME

A wide array of interventions were completed, including visual cues, audit and feedback, educational meetings and materials, reminders, outreach, and leadership involvement. Because of the complex multimodal nature of the interventions and the variety of research topics, comparison across interventions was difficult.

CONCLUSION

Many difficulties exist in determining what implementation strategies are most effective for translation of research-based evidence into practice by nurses.

IMPLICATIONS

With these limited findings, further research is warranted to determine which implementation strategies most successfully translate research-based evidence into practice.

Optimizing hospital infection control: the role of mathematical modeling

Multidrug-resistant bacteria are major causes of nosocomial infections and are associated with considerable morbidity, mortality, and healthcare costs. Preventive strategies have therefore become increasingly important. Mathematical modeling has been widely used to understand the transmission dynamics of nosocomial infections and the quantitative effects of infection control measures. This review will explore the principles of mathematical modeling used in nosocomial infections and discuss the effectiveness of infection control measures investigated using mathematical modeling.