Interactive Interventions Can Improve Hand Hygiene and Aseptic Techniques During Perioperative Care-Experience From the "Safe Hands" Project

PURPOSE

This paper evaluates a theory-driven, interactive hand hygiene (HH) intervention, the Safe Hands project, based on theories of organizational learning and culture including leadership support, dialogue and co-creation.

DESIGN

This prospective quasi-experimental study used unobtrusive overt observations to evaluate adherence to HH recommendations after implementing an infection-prevention intervention.

METHODS

The primary outcome was differences in HH practices "Before aseptic/clean procedure" (WHO moment 2), "After body fluid exposure risk" (WHO moment 3) and performance of aseptic techniques. One operating room (OR) department served as the study hospital and the other as the control hospital, both at Swedish university hospitals. Adherence to HH guidelines was measured 4 times during 2015 to 2017.

FINDINGS

The intervention site displayed a significant improvement in adherence to HH guidelines and aseptic techniques. WHO 2; from 23.8% to 36.2%, (P = .014), WHO 3; from 22.2% to 42.3%, (P = .002), and aseptic techniques; from 17.5% to 31.6%, (P = .003). No changes in adherence were identified at the control site. The use of contaminated gloves decreased post intervention at the study operating department.

CONCLUSIONS

This study shows that implementing tailored interventions that are underpinned by theories from organizational learning and culture can improve adherence to hand hygiene in a complex setting as the OR up to 6 months post-intervention. The interprofessional co-creation of standards operating procedures addressing specific care procedures and emphasizing the importance of aseptic techniques can be an acceptable and feasible way to reduce the risks of contaminating medical devices and patients during perioperative care.

Compliance with a novel hand hygiene protocol tailored to non-sterile healthcare workers in the operating theatre

BACKGROUND

Observing hand hygiene compliance (HHC) among non-sterile healthcare workers (HCWs) in the operating theatre (OT) is challenging as there are no tailored protocols or observation tools.

AIM

To develop and test a hand hygiene protocol tailored to non-sterile HCWs in the OT.

METHODS

In this prospective observational study, nine hospitals in the Rotterdam-Rijnmond region provided input on a draft protocol on hand hygiene in the OT, resulting in a new consensus protocol for the region. An observation tool based on the protocol was developed and tested. HHC rates with 95% confidence intervals (CI) were calculated by type of hospital and type of HCW.

FINDINGS

The protocol has three sections: (1) written general hand hygiene rules; (2) written hand hygiene rules specific for anaesthesia and surgery; and (3) visual representation of the OT, divided into four hand hygiene areas. Hand hygiene should be applied when changing area. Average HHC of 48.0% (95% CI 45.2-61.2%) was observed in OTs across all hospitals. HHC was highest in the two specialized hospitals (64.0%, 95% CI 30.6-89.8%; 76.7%, 95% CI 62.8-84.5%) and lowest in the academic teaching hospital (23.1%, 95% CI 0.0-45.8%). In terms of type of HCW, HHC was lowest among anaesthesiologists (31.6%, 95% CI 19.2-62.4%) and highest among OT assistants (57.4%, 95% CI 50.1-78.2%).

CONCLUSION

This uniform way of observing HHC in the OT enables evaluation of the effectiveness of interventions in the OT and facilitates friendly competition. In the Rotterdam-Rijnmond region, HHC in the OT was below 50%; this needs to be addressed, particularly in teaching hospitals and among physicians.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Outbreak of Sepsis Following Surgery: Utilizing 16S RNA Sequencing To Detect the Source of Infection

Background

Nosocomial infections are a significant health concern. Following surgery, infections are most commonly associated with the surgical site, yet there are other potential sources for infections after surgical interventions. Identification of the source of infections can be very challenging.

Methodology

An outbreak of postoperative infections following surgery led to intensive care unit (ICU) admission of patients immediately after the surgical procedure. The blood cultures of two patients were positive for Citrobacter freundii. The only connection between all cases was the anesthesiologist. An epidemiological inquiry could not definitively identify the source of the outbreak. Therefore, we utilized an RNA sequencing technique to evaluate the microbiome of the anesthesiologist and compared the results to bacteria cultured from the bloodstream of the two patients.

Results

The anesthesiologist’s microbiome contained amplicons that were identical to those of the bacteria in the patient’s bloodstream. Because Citrobacter freundii is an uncommon source of bloodstream infections, and in the normal human microbiome, the results establish the source of a cluster of infections to the anesthesiologist.

Conclusions

In cases of nosocomial infections, when conventional microbiological techniques do not clearly establish the source of the infection, using 16S RNA sequencing should be considered.

Moving beyond hand hygiene monitoring as a marker of infection prevention performance: Development of a tailored infection control continuous quality improvement tool

BACKGROUND

Infection control practice compliance is commonly monitored by measuring hand hygiene compliance. The limitations of this approach were recognized in 1 acute health care organization that led to the development of an Infection Control Continuous Quality Improvement tool.

METHODS

The Pronovost cycle, Barriers and Mitigation tool, and Hexagon framework were used to review the existing monitoring system and develop a quality improvement data collection tool that considered the context of care delivery.

RESULTS

Barriers and opportunities for improvement including ambiguity, consistency and feasibility of expectations, the environment, knowledge, and education were combined in a monitoring tool that was piloted and modified in response to feedback. Local adaptations enabled staff to prioritize and monitor issues important in their own workplace. The tool replaced the previous system and was positively evaluated by auditors. Challenges included ensuring staff had time to train in use of the tool, time to collect the audit, and the reporting of low scores that conflicted with a target-based performance system.

CONCLUSIONS

Hand hygiene compliance monitoring alone misses other important aspects of infection control compliance. A continuous quality improvement tool was developed reflecting specific organizational needs that could be transferred or adapted to other organizations.