An observational study of the hand hygiene initiative: a comparison of preintervention and postintervention outcomes

The power of feedback: Implementing a comprehensive hand hygiene observer program

BACKGROUND

Hand hygiene (HH) is a fundamental component of infection prevention within all healthcare settings. We implemented a hospital-wide program built on overt HH observation, real-time feedback, and thematic analysis of HH misses.

METHODS

A robust observer training program was established to include foundational training in the WHO's My Five Moments of HH. Observational data from 2011 to 2019 were analyzed by unit, provider type, and thematic analyses of misses.

RESULTS

During the study period, we conducted 160,917 hospital-wide observations on 29 units (monthly average of 1,490 observations). Institutional compliance remained above 95% from 2013 to 2019. Thematic analysis revealed "touching self" and "touching phone" as common, institution-wide reasons for HH misses.

DISCUSSION

Overt observations facilitated communication between HH program and healthcare staff to better understand workflow and educate staff on HH opportunities. This program is an integral part of the Infection Prevention team and has been deployed to collect supplemental data during clusters and outbreaks investigations.

CONCLUSIONS

In addition to having rich HH data, successes of this program, include increased awareness of IPC practices, enhanced communication about patient safety, enriched dialog and feedback around HH misses, and relationship building among program observers, unit staff and leaders.

Developing a design-based concept to improve hand hygiene in the neonatal intensive care unit

BACKGROUND

Hand hygiene (HH) is the most critical measure in the prevention of nosocomial infections in the neonatal intensive care unit (NICU). Improving and sustaining adequate HH compliance rates, however, remains a significant challenge. Using a behavioral change framework and nudge theory, we developed a design-based concept aimed at facilitating and stimulating HH behavior.

METHODS

Concept development was initiated by selecting a theoretical framework after which contextual field studies aimed at discovering causes for poor compliance were conducted. Potential solutions were brainstormed upon during focus group sessions. Low-fidelity prototypes were tested regarding feasibility, usability, and acceptability. A final concept was crafted drawing from findings from each design phase.

RESULTS

Complying with recommended HH guidelines is unrealistic and infeasible due to frequent competing (clinical) priorities requiring HH. The concept "Island-based nursing," where a patient room is divided into two geographical areas, namely, the island and general zone, was created. HH must be performed upon entering and exiting the island zone, and after exposure to any surface within the general zone. Reminding of HH is prompted by illuminated demarcation of the island zone, serving as the concept's nudge.

CONCLUSIONS

Island zone demarcation facilitates and economizes HH indications in an innovative and intuitive manner.

IMPACT

Although hand hygiene (HH) is the single most important element in the prevention of nosocomial infections in neonates, improving and sustaining adequate HH compliance rates remains a significant challenge. Complying with recommended HH guidelines was found to be unrealistic and infeasible due to the significant amount of time required for HH in a setting with a high workload and many competing (clinical) priorities. The concept of "Island-based nursing," under which the primary HH indication is upon entering and exiting the island zone, facilitates and economizes HH indications in an innovative and user-friendly manner.

Discordance among Belief, Practice, and the Literature in Infection Prevention in the NICU

This study evaluates practices of infection control in the NICU as compared with the available literature. We aimed to assess providers’ awareness of their institutional policies, how strongly they believed in those policies, the correlation between institution size and policies adopted, years of experience and belief in a policy’s efficacy, and methods employed in the existing literature. An IRB-approved survey was distributed to members of the AAP Neonatal Section. A systematic review of the literature provided the domains of the survey questions. Data was analyzed as appropriate. A total of 364 providers responded. While larger NICUs were more likely to have policies, their providers are less likely to know them. When a policy is in place and it is known, providers believe in the effectiveness of that policy suggesting consensus or, at its worst, groupthink. Ultimately, practice across the US is non-uniform and policies are not always consistent with best available literature. The strength of available literature is adequate enough to provide grade B recommendations in many aspects of infection prevention. A more standardized approach to infection prevention in the NICU would be beneficial and is needed.

Hand Hygiene Compliance in Pediatric Emergency of a Lower-Middle Income Country: A Quality Improvement Study

BACKGROUND

Prospective data on hand hygiene compliance in pediatric emergency department (PED) settings is limited. We studied the impact of quality improvement measures on the overall and health care personnel wise hand hygiene compliance rates in a busy PED.

METHODS

The baseline hand hygiene compliance rates were audited from May-July 2018. The quality improvement interventions included various structural changes to the environment, administrative changes, education and training. During the interventions, auditing was continued for 2 months (August - September 2018). Statistical Process control charts were created.

RESULTS

We observed a significant increase in overall compliance rates from 31.8 to 53.9% (p < 0.001). These improvements were observed in the children (29.6 to 46.4%, p < 0.001) as well as neonatal area (35.7% to 59.7, p < 0.001) of PED as well as amongst various health care personnel and in four out of the five moments of hand hygiene.

CONCLUSION

Hand hygiene compliance improved significantly in a busy PED of a lower middle-income country following quality improvement interventions. Such improvement was observed amongst all categories of health care personnel and different types of hand hygiene opportunities. This study demonstrates the feasibility and efficacy of simple quality improvement interventions in a challenging hospital environment.

Quality Improvement Initiative to Improve Hand Hygiene Compliance in Indian Special Newborn Care Unit

Supplemental Digital Content is available in the text.

Pilot data on Hand hygiene (HH) compliance using a standard World Health Organisation checklist for 1-week suggested only 20% compliance. So, we planned a Quality Improvement study to improve HH compliance among health care providers in our Special Newborn Care Unit from 20% to 60% over 12 months.

Stepwise interventions for improving hand hygiene compliance in a level 3 academic neonatal intensive care unit in north India

OBJECTIVE

We evaluated effect of sequentially introducing four WHO-recommended interventions to promote hand-hygiene compliance in tertiary-care NICU.

STUDY DESIGN

Four dedicated research nurses directly observed doctors and nurses to record success in hand-hygiene opportunities at randomly selected NICU beds and randomly sampled time-slots in four phases (of 4-weeks each): I-Baseline, II-Self-directed learning; III-Participatory learning; IV-Closed-Circuit Television (CCTV); and V-CCTV-plus (with feedback).

FINDINGS

Hand-hygiene compliance changed from 61.8% (baseline) to 77% (end) with overall relative change: 24.6% (95% CI 18, 32; p value= 0.003); compared with preceding phase, relative changes of 21% (15, 28; <0.001), 4% (0, 8; 0.008), -10% (-13, -6; <0.001), and 10% (5, 15; <0.001) during phases II, III, IV, and V, respectively were observed. Rise in hand-hygiene compliance was higher for after-WHO-moments (12.7%; upto 2.5-folds for moment 5, <0.001) compared to before-WHO-moments (5.2%). Educational interventions, feedback and monitoring WHO moments can improve hand-hygiene compliance significantly among health-care providers in NICU.

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

BACKGROUND

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

AIM

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

A Quality Improvement Initiative to Increase Hand Hygiene Awareness and Compliance in a Neonatal Intensive Care Unit in Haiti

INTRODUCTION

Healthcare-associated infections (HCAI) are major causes of morbidity, mortality, increased lengths of stay and are an economic burden on healthcare systems in resources-limited settings. This is especially true for neonates, who are more susceptible with underdeveloped immune systems. Hand hygiene (HH) is a key weapon against HCAI, yet globally, HH compliance remains substandard. This study sought to determine the compliance with HH among healthcare workers (HCWs) in a children's hospital neonatal intensive care unit (NICU) in Haiti.

METHODS

A HH educational intervention was performed in the NICU, including lectures and posters. Pre- and post-intervention HH data were collected on HCWs and parents using the World Health Organization '5 Moments for HH'. Data were analyzed using standard statistical analysis.

RESULTS

HH increased in all HCW roles but not in parents. Correct HH increased in all groups, including parents. HH was more likely to occur prior to patient contact than after patient contact. Correct HH was more likely to occur with alcohol-based hand rub than with soap and water.

CONCLUSION

This study demonstrates that an inexpensive and simple intervention can significantly increase HH compliance in a resource-limited NICU, which may lead to decreased rates of hospital-acquired sepsis. Parents, however, due to cultural norms as well as literacy and language barriers, need targeted educational interventions distinct from those that HCW benefit from.

Profiles of microorganisms isolated from neonates' blood cultures, incubators, cradles, ventilators, washbasins, and health-workers of Libreville University Hospital Neonatal Service: focus on infection prevention and control measures

Background

Nosocomial infection outbreaks in neonatal services are a serious healthcare concern in both developed and developing countries, but few studies have been conducted in sub-Saharan Africa.

Objective

This study explored the etiology of septicemia in neonates and associated patterns of antimicrobial susceptibility in Gabon.

Methods

We analyzed cultures from neonates’ blood and swabs from medical personnel and equipment located in the neonatology service.

Results

Sixty-eight microorganisms were isolated from the medical personnel and equipment; 46 microorganisms were isolated from neonates’ blood culture. Klebsiella pneumoniae spp pneumoniae was the most common bacteria found in both (30.6% and 26.9%, respectively). All Klebsiella pneumoniae spp pneumonia isolates were resistant to amoxicillin with clavulanic acid, gentamycin resistance ranged from 93% to 100%, and cephalosporin resistance ranged from 33.3% to 47%.

Conclusions:

Awareness of the etiology, prevalence, and outcome of nosocomial infection is the first and most important step to appropriate interventions.

Validity of hand hygiene compliance measurement by observation: A systematic review

BACKGROUND

Hand hygiene is monitored by direct observation to improve practice, but this approach can potentially cause information, selection, and confounding bias, threatening the validity of findings. The aim of this study was to identify and describe the potential biases in hand hygiene compliance monitoring by direct observation; develop a typology of biases and propose improvements to reduce bias; and increase the validity of compliance measurements.

METHODS

This systematic review of hospital-based intervention studies used direct observation to monitor health care workers' hand hygiene compliance.

RESULTS

Seventy-one publications were eligible for review. None was free of bias. Selection bias was present in all studies through lack of data collection on the weekends (n = 61, 86%) and at night (n = 46, 65%) and observations undertaken in single-specialty settings (n = 35, 49%). We observed inconsistency of terminology, definitions of hand hygiene opportunity, criteria, tools, and descriptions of the data collection. Frequency of observation, duration, or both were not described or were unclear in 58 (82%) publications. Observers were trained in 56 (79%) studies. Inter-rater reliability was measured in 26 (37%) studies.

CONCLUSIONS

Published research of hand hygiene compliance measured by direct observation lacks validity. Hand hygiene should be measured using methods that produce a valid indication of performance and quality. Standardization of methodology would expedite comparison of hand hygiene compliance between clinical settings and organizations.

Impact of Educational Intervention for Hand Hygiene on Dental Students' Knowledge, Attitude, and Bacterial Contamination Level on Hands

AIM

The present study aimed to investigate the impact of the educational intervention for hand hygiene (HH) on knowledge, attitude, and mean colony-forming bacterial counts and type of bacteria on hands of undergraduate dental students.

MATERIALS AND METHODS

A total of 86 dental students from different clinical grades were included in the study. They were divided into two groups, group I (55 students) received onetime educational session for HH at the start of the academic year and group II (31 students) received an extra reenforce-ment session 6 months later. After 2 weeks of reenforcement session, a self-administrated questionnaire was directed to all participants assessing their knowledge and attitude about HH. Fingertip prints of the five fingers of the dominant hand from every participant were pressed onto blood agar plates in triplets at the same clinical session, before and after HH. Bacterial colony-forming units (CFUs) on each plate were recorded and identified microbiologically.

RESULTS

The overall scores of knowledge and attitude showed higher levels in group II than in group I with nonsignificant differences between both groups as regards knowledge and significant differences (p < 0.05) as regards attitude. Mean CFUs showed extremely significant differences (p < 0.000) between 2nd and 3rd counts and between 1st and 2nd counts except for students of group I where the difference was only significant (p < 0.05). Normal bacterial flora was identified in 94.9% of the plates (92.2% coagulase-negative Staphylococci and 2.7% Micrococcus). Potentially pathogenic bacteria isolated from the other plates were Klebsiella pneumonia, Pseudomonas spp., and spore-forming aerobic nonhemolytic Bacilli.

CONCLUSION

Reenforcement session had a positive impact on HH knowledge, attitude, and reduction of bacterial CFUs.

CLINICAL SIGNIFICANCE

Continuous education with frequent training sessions is recommended to reinforce HH compliance and reduce cross-contamination.

Electronic monitoring in combination with direct observation as a means to significantly improve hand hygiene compliance

Monitoring hand hygiene compliance among health care personnel (HCP) is an essential element of hand hygiene promotion programs. Observation by trained auditors is considered the gold standard method for establishing hand hygiene compliance rates. Advantages of observational surveys include the unique ability to establish compliance with all of the World Health Organization "My 5 Moments for Hand Hygiene" initiative Moments and to provide just-in-time coaching. Disadvantages include the resources required for observational surveys, insufficient sample sizes, and nonstandardized methods of conducting observations. Electronic and camera-based systems can monitor hand hygiene performance on all work shifts without a Hawthorne effect and provide significantly more data regarding hand hygiene performance. Disadvantages include the cost of installation, variable accuracy in estimating compliance rates, issues related to acceptance by HCP, insufficient data regarding their cost-effectiveness and influence on health care-related infection rates, and the ability of most systems to monitor only surrogates for Moments 1, 4, and 5. Increasing evidence suggests that monitoring only Moments 1, 4, and 5 provides reasonable estimates of compliance with all 5 Moments. With continued improvement of electronic monitoring systems, combining electronic monitoring with observational methods may provide the best information as part of a multimodal strategy to improve and sustain hand hygiene compliance rates among HCP.

Characteristics of late-onset sepsis in the NICU: does occupancy impact risk of infection?

OBJECTIVE

Infants in neonatal intensive care units (NICUs) are vulnerable to a variety of infections, and occupancy in the unit may correlate with risk of infection.

STUDY DESIGN

A retrospective cohort of infants admitted to the NICUs between 1997 and 2014. Survival analysis was used to model the relative hazard of sepsis infection in relation to two measures of occupancy: 1) the average census and 2) proportion of infants <32 weeks gestation in the unit.

RESULT

There were 446 (2.3%) lab-confirmed cases of bacterial or fungal sepsis, which steadily declined over time. For each additional percentage of infants <32 weeks gestation, there was an increased hazard of 2% (hazard ratio 1.02, 95% confidence interval: 1.00, 1.03) over their NICU hospitalization. Census was not associated with risk for infection.

CONCLUSION

During times of a greater proportion of infants <32 weeks gestation in the NICU, enhanced infection-control interventions may be beneficial to further reduce the incidence of infections.

Optimizing the Use of Antibacterial Agents in the Neonatal Period

Antibiotics are invaluable in the management of neonatal infections. However, overuse or misuse of antibiotics in neonates has been associated with adverse outcomes, including increased risk for future infection, necrotizing enterocolitis, and mortality. Strategies to optimize the use of antibiotics in the neonatal intensive care unit include practicing effective infection prevention, improving the diagnostic evaluation and empiric therapy for suspected infections, timely adjustment of therapy as additional information becomes available, and treating proven infections with an effective, narrow-spectrum agent for the minimum effective duration. Antibiotic stewardship programs provide support for these strategies but require the participation and input of neonatologists as stakeholders to be most effective.

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.

Measuring readiness for and satisfaction with a hand hygiene e-learning course among healthcare workers in a paediatric oncology centre in Guatemala City

E-learning has been widely used in the infection control field and has been recommended for use in hand hygiene (HH) programs by the World Health Organization. Such strategies are effective and efficient for infection control, but factors such as learner readiness for this method should be determined to assure feasibility and suitability in low- to middle-income countries. We developed a tailored, e-learning, Spanish-language HH course based on the WHO guidelines for HH in healthcare settings for the pediatric cancer center in Guatemala City. We aimed to identify e-readiness factors that influenced HH course completion and evaluate HCWs' satisfaction. Pearson's chi-square test of independence was used to retrospectively compare e-readiness factors and course-completion status (completed, non-completed, and never-started). We surveyed 194 HCWs for e-readiness; 116 HCWs self-enrolled in the HH course, and 55 responded to the satisfaction survey. Most e-readiness factors were statistically significant between course-completion groups. Moreover, students were significantly more likely to complete the course if they had a computer with an Internet connection (P=0.001) and self-reported comfort with using a computer several times a week (p=0.001) and communicating through online technologies (p=0.001). Previous online course experience was not a significant factor (p=0.819). E-readiness score averages varied among HCWs, and mean scores for all e-readiness factors were significantly higher among medical doctors than among nurses. Nearly all respondents to the satisfaction survey agreed that e-learning was as effective as the traditional teaching method. Evaluating HCWs' e-readiness is essential while integrating technologies into educational programs in low- to middle-income countries.

Blood culture contamination rate in an intensive care setting: Effectiveness of an education-based intervention

BACKGROUND

Blood culture (BC) contamination rate is an indicator of quality of care scarcely explored in intensive care units (ICUs). We analyzed the BC contamination rate in our ICU to assess the effectiveness of an education-based intervention.

METHODS

We conducted an interventional study with concurrent controls. Consecutive BCs drawn during a 6-month period were included. An education-based intervention was presented to case nurses (optimal technique). The remaining nurses comprised the control group (standard technique). Two independent observers assessed clinical significance of saprophytic skin bacteria isolated in BCs.

RESULTS

Six hundred fifty-six BCs were obtained: 308 (47%) via optimal technique and 348 (53%) via standard technique (47%). One hundred eighty-seven BCs were positive for saprophytic microorganisms; 127 (89%) were considered unrelated to infection. Coagulase-negative staphylococci isolation was lower in the optimal technique group (14% vs 26%; P < .001), as well as contamination due to coagulase-negative staphylococci (12% vs 21%; P = .002) or Acinetobacter baumannii (0.3% vs 2%; P = .013). BC contamination rate was 13% in the optimal technique group versus 23% in the standard group (P < .005). In the optimal technique group, BC contamination rate was higher in BCs drawn through the catheter (17% vs 7%; P = .028).

CONCLUSIONS

An education-based intervention significantly reduced the BC contamination rate in our ICU. It seems necessary to design a tool to extract BCs through the catheter to minimize the risk of contamination.