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Cohen R, Gesser-Edelsburg A. Advanced theoretical-applied model based on the PD approach in the light of healthcare-associated infections: what have we achieved so far? Front Public Health 2024; 12:1291551. [PMID: 38410666 PMCID: PMC10894930 DOI: 10.3389/fpubh.2024.1291551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 02/02/2024] [Indexed: 02/28/2024] Open
Abstract
Healthcare-associated infections remain a persistent concern despite decades of research and intervention efforts. Adherence to infection prevention and control guidelines by health professionals remains a challenge, necessitating innovative strategies. The Positive Deviance (PD) approach, rooted in harnessing localized solutions, holds promise but lacks comprehensive frameworks and empirical validation to bolster its theoretical underpinnings. This perspective article serves a dual purpose: first, to examine the unique challenges of applying the PD approach in the context of HAIs; and second, to introduce a robust theoretical-applied model developed in response to these challenges. This article addresses these gaps through a multi-faceted model developed in a mixed-methods study across three Israeli governmental hospitals and comprises four essential components that address the identified gaps in existing research. This article enriches the dialog on PD's applicability in HAIs by providing a robust model that not only offers solutions but reshapes the approach to healthcare hygiene and safety. It responds to critical gaps highlighted in the literature, offering tailored interventions by practical, context-specific solutions to improve adherence to IPC guidelines in the long term. Methodological clarity is also a key focus, offering a toolkit for practical implementation. This bottom-up approach empowers HPs to drive change, fostering a culture of innovation and improvement in healthcare settings.
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Affiliation(s)
- Ricky Cohen
- Cheryl Spencer Department of Nursing and the Health and Risk Communication Research Lab, University of Haifa, Haifa, Israel
| | - Anat Gesser-Edelsburg
- Head of the Health Promotion Program and Head of the Health and Risk Communication Lab, School of Public Health, University of Haifa, Haifa, Israel
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CHAUDHARY PREETI, GUPTA VARSHA. Hand hygiene with interventions: an observational study from a tertiary care institute over 2 years. JOURNAL OF PREVENTIVE MEDICINE AND HYGIENE 2023; 64:E488-E492. [PMID: 38379742 PMCID: PMC10876021 DOI: 10.15167/2421-4248/jpmh2023.64.4.3087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 01/03/2024] [Indexed: 02/22/2024]
Abstract
Background Appropriate adherence to hand hygiene (HH) practices by health care workers (HCWs) reduces the transmission of pathogens and subsequently the incidence of hospital acquired infections (HAIs), in health care settings. Strict monitoring and auditing of this simple and cost-effective intervention is very important, as it significantly contributes in reducing the HAIs. Material and methods A retrospective observational study, evaluating the HH audits from June 2021 till May 2023 in a tertiary health care facility in North India. HH audits were conducted in the ICUs and wards daily, by the trained infection control nurses (ICNs), using direct observation method based on World health organization (WHO) hand hygiene observational forms. HH total adherence (HHTAR), partial adherence (HHPAR) and complete adherence rate (HHCAR) were analyzed in Microsoft Excel sheet. HHTAR rates were compared among different profession, moments and the month wise trend was also observed over the period. Results A total of 24,740 HH opportunities were observed. The compliance rate for HHCAR, HHPAR and HHTAR were 20.3%, 41.5% and 61.4% respectively. Overall better compliance was reported from the ICUs, profession-specific compliance was highest among nurses (62.8%) and doctors (61.5%). Significant increase in adherence rate was appreciated post intervention 46.1% to 67.3%, (p value < 0.01). Conclusions Continuous monitoring and reinforcement with timely feedback for intervention and regular auditing is a necessity to improve and maintain the appropriate HH practices among the HCWs. Low- and middle-income countries need to focus more on this simple and promising measure to combat the increasing HAI rates.
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Affiliation(s)
- PREETI CHAUDHARY
- Department of Microbiology, Government Medical College and Hospital, Sector 32, Chandigarh. India
| | - VARSHA GUPTA
- Department of Microbiology, Government Medical College and Hospital, Sector 32, Chandigarh. India
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Jansen SJ, Müller BJ, Cramer SJE, Te Pas AB, Lopriore E, Bekker V. Developing a design-based concept to improve hand hygiene in the neonatal intensive care unit. Pediatr Res 2023:10.1038/s41390-023-02482-9. [PMID: 36694024 PMCID: PMC10382316 DOI: 10.1038/s41390-023-02482-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/26/2023]
Abstract
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.
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Affiliation(s)
- Sophie J Jansen
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center (LUMC), Leiden, The Netherlands.
| | - Britt J Müller
- Department of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
| | - Sophie J E Cramer
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Vincent Bekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center (LUMC), Leiden, The Netherlands
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Al-Anazi S, Al-Dhefeery N, Al-Hjaili R, Al-Duwaihees A, Al-Mutairi A, Al-Saeedi R, Al-Dhaen R, Al-Rabiah S, Sharaf-Alddin R. Compliance with hand hygiene practices among nursing staff in secondary healthcare hospitals in Kuwait. BMC Health Serv Res 2022; 22:1325. [PMID: 36348401 PMCID: PMC9640802 DOI: 10.1186/s12913-022-08706-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background Hand hygiene (HH) among healthcare workers, especially nurses, is the main preventive measure to control healthcare associated infections but compliance with hand hygiene (CwHH) remains low in various settings including Kuwait. This study aimed to assess the knowledge of, attitudes towards, and CwHH among nursing staff in secondary care hospitals in Kuwait. Methods A cross-sectional study was conducted on nursing staff in all six secondary care hospitals in Kuwait. Data on knowledge of, attitudes towards, and self-reported CwHH were collected through a self-administered questionnaire that was developed based on WHO’s questionnaire, while the data on actual compliance were objectively collected through direct observation of nurses during routine care by two independent observers using WHO’s observation form. Results Of 829 nurses approached, 765 (92.2%) responded and participated. Of all participants, 524 (68.5%) were able to list “My Five Moments for Hand Hygiene” fully and appropriately. However, several misconceptions (e.g. air circulation in hospital is the main route of infection) about HH were found among the nurses. CwHH was (25.0%) by direct observation while self-reported compliance was (69.5%) each varied significantly (p < 0.001) between different hospitals. Female nurses compared to male nurses and non-Arab compared to Arab nationalities were more likely to report CwHH in multivariable analysis. Several items on knowledge of and attitudes towards HH were also associated with self-reported CwHH. Conclusion Observed CwHH among nursing staff in secondary care hospitals in Kuwait was low, which highlights the need to make more efforts to improve HH practices. Interventions that have been used elsewhere and found to be effective may be tested in Kuwait. Despite the good overall knowledge on HH among nurses, there are several misconceptions that need to be corrected.
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Richter SM, Barnard TG. Knowledge, Attitudes, and Perceptions Towards Hand Hygiene of Optometry Students Pre- and Peri-COVID-19 at a Tertiary Institution in Johannesburg, South Africa. CLINICAL OPTOMETRY 2022; 14:195-205. [PMID: 36325521 PMCID: PMC9621026 DOI: 10.2147/opto.s379659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/13/2022] [Indexed: 06/16/2023]
Abstract
PURPOSE Limited research has been completed relating to the knowledge, attitudes and practices (KAP) towards hand hygiene in optometry. The necessity of identifying possible gaps in the cycle of the optometric examination that may have an impact on standard hygiene practices is essential, especially seen in the context of the COVID-19 pandemic. The purpose of the study was to determine if optometry students' KAP towards hand hygiene changed pre- and peri-COVID-19 to minimize the risk of possible infection it may have for their patients, family, and themselves. PATIENTS AND METHODS A cross-sectional purposeful sample study was completed among optometry students at a training institution in Johannesburg, South Africa, pre- (2019) and peri-COVID-19 (2022). The WHO hand hygiene knowledge and perception questionnaires for health care workers were adapted and used in the current study. Statistical analyses were performed to test for significant changes between the two groups. RESULTS There was a significant change (p < 0.01) in the use of alcohol-based hand rub (ABHR) in 2022 (87.2%) compared to 2019 (46.5%), although only 41% of students peri-COVID-19 (2022), were aware that a minimum of 20 seconds is required to effectively clean hands. Students, both pre-COVID-19 (63.8%) and peri-COVID-19 (81.8%) perceived performing a hand hygiene regime during an optometric examination to be problematic. A significant peri-COVID-19 (2022) change in perception (p < 0.01) regarding the importance of completing required hand hygiene practices in front of a patient during examination was seen. CONCLUSION The COVID-19 pandemic provided a unique opportunity to research a possible change in KAP towards hand hygiene practices in optometry students that have not been investigated before. Students were more aware of the impact of hand hygiene practices and the perception thereof, especially by patients and fellow students during the peri-COVID-19 (2022) period. An important finding was the difficulty that students experienced to perform a hand hygiene regime during an optometric examination.
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Affiliation(s)
| | - Tobias George Barnard
- Water and Health Research Centre, University of Johannesburg, Johannesburg, South Africa
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Impact of conducting hand hygiene audit in COVID-19 care locations of India-A large scale national multicentric study - HHAC study. Indian J Med Microbiol 2022; 43:39-48. [PMID: 36192255 PMCID: PMC9525202 DOI: 10.1016/j.ijmmb.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/07/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022]
Abstract
Purpose Hand hygiene (HH), the core element in infection prevention in healthcare, especially for multidrug resistant organism's transmission. The role of HH audits and HH adherence rates in the COVID-19 pandemic, especially in resource limited settings, are yet to be established. Methods A nationwide multicenter study was conducted in India, involving public, private, teaching and non-teaching COVID healthcare facilities (COVID-HCFs) using the IBhar mobile application based on WHO's hand hygiene audit tool. The HH adherence rates (HHAR) such as complete HHAR (HHCAR), total HHAR (HHTAR), profession specific HHAR, WHO's 5 HH moment specific HHAR and associated variables were measured over 6 month duration (June–December 2021). Results A total of 2,01,829 HH opportunities were available and the HHCAR and HHTAR were 27.3% and 59.7%. The HHTAR was significantly higher in the west zone (72.2%), private institutes (65.6%), non-teaching institutes (67.7%), nurses (61.6%), HH moments 2 (71.8%) and 3 (72.1%), and morning shift (61.4%). The HHTAR was better in non-COVID HCFs (65.4%) than COVID-HCFs (57.8%) as well as non-COVID ICUs (68.1%) than COVID ICUs (58.7%). The HHTAR was increased from month 1 to month 6 except a small decrease in the month of December. Conclusions The hand hygiene adherence is comparable with adherence rate during COVID-19 pandemic in western countries as well as the resource limited settings. The use of gloves during the pandemic and simplified HH techniques and their influence over the HH adherence to be studied further. The sustainable adherence rate over long duration needs to be ensured by continuing the HH audit using multimodal interventions.
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Casaroto E, Generoso JR, Serpa Neto A, Prado M, Gagliardi GM, de Menezes FG, Gonçalves P, Hohmann FB, Olivato GB, Gonçalves GP, Xavier N, Fernandes Miguel M, Edmond MB, Marra AR. Comparing human to electronic observers to monitor hand hygiene compliance in an intensive care unit. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e161. [PMID: 36483392 PMCID: PMC9726540 DOI: 10.1017/ash.2022.303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE We sought to determine whether an electronic hand hygiene (HH) system could monitor HH compliance at similar rates to direct human observation. METHODS This 4-year proof-of-concept study was conducted in an intensive care unit (ICU) of a private tertiary-care hospital in São Paulo, Brazil, where electronic HH systems were installed in 2 rooms. HH compliance was reported respectively using direct observation and electronic counter devices with an infrared system for detecting HH opportunities. RESULTS In phase 1, HH compliance by human observers was 56.3% (564 of 1,001 opportunities), while HH compliance detected by the electronic observer was 51.0% (515 of 1,010 opportunities). In phase 2, human observers registered 484 HH opportunities with a HH compliance rate of 64.7% (313 of 484) versus 70.6% (346 of 490) simultaneously detected by the electronic system. In addition, an enhanced HH electronic system monitored activity 24 hours per day and HH compliance without the presence of a human observer was 40.3% (10,642 of 26,421 opportunities), providing evidence for the Hawthorne effect. CONCLUSIONS The electronic HH monitoring system had good correlation with human HH observation, but compliance was remarkably lower when human observers were not present due to the Hawthorne effect (25%-30% absolute difference). Electronic monitoring systems can replace direct observation and can markedly reduce the Hawthorne effect.
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Affiliation(s)
- Eduardo Casaroto
- Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Jose R. Generoso
- Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Ary Serpa Neto
- Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, ANZIC-RC, Melbourne, Victoria, Australia
| | - Marcelo Prado
- Universidade de São Paulo, São Carlos, São Paulo, Brazil
| | | | | | | | | | | | | | - Nathalia Xavier
- Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | | | - Michael B. Edmond
- West Virginia University School of Medicine, Morgantown, West Virginia, United States
| | - Alexandre R. Marra
- Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans’ Affairs Health Care System, Iowa City, Iowa, United States
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
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Cohen R, Gesser-Edelsburg A, Singhal A, Benenson S, Moses AE. Translating a theory-based positive deviance approach into an applied tool: Mitigating barriers among health professionals (HPs) regarding infection prevention and control (IPC) guidelines. PLoS One 2022; 17:e0269124. [PMID: 35657940 PMCID: PMC9165831 DOI: 10.1371/journal.pone.0269124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 05/13/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Although a wide range of intervention programs and methods have been implemented to increase health professionals’ (HPs) adherence with infection prevention and control (IPC) guidelines and decrease the incidence of healthcare associated infections (HAIs), a significant discrepancy remains between the guidelines and their implementation in practice.
Objectives
This study proposes an applied tool based on the integrated theoretical framework of the positive deviance (PD) approach for developing more effective interventions to mitigate this discrepancy.
Methods
A qualitative study guided by the PD approach based on data from two sources: (1) in-depth archival analysis of systematic review articles, and (2) integration and synthesis of findings based on an extensive empirical study we conducted, involving 250 HPs (nurses, physicians, support staff and cleaning staff) from three governmental hospitals in Israel, over 35 months (January 2017 to November 2020).
Results
The barriers faced by HPs were classified into four main categories: (1) individual-motivational, (2) social-cultural, (3) organizational, and (4) work environment and resource-centered. For each barrier, we constructed a set of questions based on the PD approach. For each question, we adapted and applied methodological tools (e.g., in-depth interviews, focus groups, social network maps, video clips and simulations) to help solve the problem.
Conclusion
Translating a theory-based approach into an applied tool that offers step-by-step actions can help researchers and practitioners adopt and implement the approach within intervention programs to mitigate barriers.
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Affiliation(s)
- Ricky Cohen
- School of Public Health, University of Haifa, Haifa, Israel
- The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
- * E-mail:
| | - Anat Gesser-Edelsburg
- School of Public Health, University of Haifa, Haifa, Israel
- The Health and Risk Communication Research Center, University of Haifa, Haifa, Israel
| | - Arvind Singhal
- Department of Communication, The University of Texas at El Paso, El Paso, Texas, United States of America
- School of Business and Social Sciences, Inland University of Applied Sciences, Hamar, Norway
| | - Shmuel Benenson
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Ein-Kerem, Jerusalem, Israel
| | - Allon E. Moses
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Ein-Kerem, Jerusalem, Israel
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Allegranzi B, Kilpatrick C, Sax H, Pittet D. 'My Five Moments': understanding a user-centred approach to hand hygiene improvement within a broader implementation strategy. BMJ Qual Saf 2022; 31:259-262. [PMID: 35131895 DOI: 10.1136/bmjqs-2021-013680] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Benedetta Allegranzi
- Infection Prevention and Control Technical and Clinical Hub, Department of Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - Claire Kilpatrick
- Infection Prevention and Control Technical and Clinical Hub, Department of Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - Hugo Sax
- Department of Infectious Diseases, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Didier Pittet
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
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