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

The state of hand rub dispensers in healthcare settings - a multicenter assessment in 19 German healthcare facilities

BACKGROUND

Hand hygiene is one of the most important hygiene measures to prevent healthcare-associated infections. Well-functioning hand rub dispensers are the foundation of hand hygiene but are often overlooked in research. As the point of origin for hand hygiene, dispensers not only promote compliance through ease of use, but also strongly influence the amount of hand rub used per disinfection. This work investigates how dispenser types and conditions affect dispensed volumes and usability.

METHODS

Data from 5,014 wall-mounted or point-of-care dispensers was collected from 19 German healthcare facilities during installation of an electronic hand hygiene monitoring system, including dispenser type and dispensed hand rub volumes. Of these dispensers, 56.2% were metal dispensers, and the majority (89.5%) were wall-mounted. For one hospital, 946 wall-mounted dispensers were analyzed in detail regarding pump material, damages, functionality, cleanliness, and filling levels.

RESULTS

Dispensed volumes varied across and within dispenser types, ranging from 0.4 mL to 4.4 mL per full actuation, with the largest volumes generally dispensed by plastic dispensers with a preset of 1.0 to 3.0 mL per actuation. In general, most dispensers dispense more hand rub per full actuation than specified by the manufacturer. When different types of dispensers are used within a healthcare facility, vastly different volumes can be dispensed, making reliable and reproducible disinfection difficult for healthcare workers. In the detailed analysis of 946 dispensers, 27.1% had cosmetic defects, reduced performance, or were unusable, with empty disinfectant being the most common reason. Only 19.7% of working dispensers delivered their maximum volume on the first full actuation.

CONCLUSION

Even though several studies addressed the variability in dispensed volumes of hand hygiene dispensers, studies dealing with dispenser types and functionality are lacking, promoting the common but false assumption that different dispensers may be equivalent and interchangeable. Variability in dispensed volumes, coupled with frequent dispenser defects and maintenance issues, can be a major barrier to hand hygiene compliance. To support healthcare workers, more attention should be paid to 'dispenser compliance', selecting dispensers with similar volume ranges and proper maintenance.

Is there a relationship between nurses' hand hygiene beliefs, practices and ethical sensitivity?

BACKGROUND

Hand hygiene is the most important way to prevent health care-associated infections. It is important for all nurses that come in physical contact with patients the most to follow hand hygiene rules.

AIM

This study aimed to determine the relationship between nurses' hand hygiene beliefs and practices and their ethical sensitivity.

METHOD

This descriptive and cross-sectional study was conducted with nurses working in internal medicine, surgery and intensive care clinics of a university hospital between June and August 2022. A total of 350 nurses participated in the study. A Personal Information Form, the Ethical Sensitivity Questionnaire (ESQ), the Hand Hygiene Practice Inventory (HHPI), and the Hand Hygiene Beliefs Scale (HHBS) were used for data collection.

RESULTS

Findings support that nurses have moderate ethical sensitivity (88.36 ± 26.33), good hand hygiene beliefs (85.60 ± 9.21) and practice (66.14 ± 5.90). Despite there being no statistical significance in evaluating the relationship between hand hygiene practice and ethical sensitivity (p = 0.253, r = -0.061), there was a statically significant inverse relationship between hand hygiene beliefs and ethical sensitivity (p = 0.001, r = -0.172). The hand hygiene compliance score of the nurses who received only ethics training after nursing school (p = 0.000); the hand hygiene belief (p = 0.011) and hand hygiene practice (p = 0.007) scores of those who received both ethics and hand hygiene training were higher.

CONCLUSIONS

It can be said that the ethical sensitivity of nurses does not affect their hand hygiene practices, and the hand hygiene and ethics education they receive after school education increases their hand hygiene beliefs and practices.

Rinse, gel, and foam - is there any evidence for a difference in their effectiveness in preventing infections?

BACKGROUND

Following publication of the 2009 World Health Organizations Guidelines for Hand Hygiene in Health Care, a debate has emerged regarding the relative antimicrobial efficacy of the different formats (rinse, gel, foam) of ABHRs and their ability to contribute to reduction of healthcare-associated infections (HAIs).

METHODS

Data regarding the in-vivo antimicrobial efficacy of ABHRs and other factors that likely affect their effectiveness in reducing HAIs were reviewed, and a comprehensive review of studies that reported the effectiveness of each of the three ABHR formats to improve hand hygiene compliance and reduce HAIs was conducted.

RESULTS

The amount of rubbing time it takes for hands to feel dry (dry time) is the major driver of ABHR antimicrobial efficacy. ABHR format is not a major factor, and several studies found that rinse, gel, and foam ABHRs have comparable in-vivo antimicrobial efficacy. Other factors that likely impact the ability of ABHRs to reduce transmission of healthcare-associated pathogens and HAIs include ABHR formulation, the volume applied to hands, aesthetic characteristics, skin tolerance, acceptance by healthcare personnel, and hand hygiene compliance rates. When accompanied by complementary strategies, promoting the use of each of the three ABHR formats has been associated with improvements in hand hygiene compliance rates. A review of 67 studies failed to identify an ABHR format that was significantly more effective in yielding statistically significant reductions in transmission of healthcare-associated pathogens or HAIs.

CONCLUSIONS

Current evidence is insufficient to definitively determine if one ABHR format is more effective in reducing transmission of healthcare-associated pathogens and HAIs. More rigorous studies such as multicenter randomized controlled trials comparing the different formats are needed to establish if one format is significantly more effective in reducing HAIs.

Health Science Students' Perceptions of Hand Hygiene Education and Practice in a South African University: Introducing the University Hand Hygiene Improvement Model

Hand hygiene serves as a critical preventative measure against the spread of acquired infections in healthcare facilities and is an integral component of patient safety programs. While healthcare students in training are typically introduced to the principles underlying hand hygiene, the translation of this understanding into practice is often lacking, and compliance has remained low. This study aimed to evaluate health science students' in biomedical sciences, chiropractic and emergency medical care, environmental health, complementary medicine, medical imaging and radiation sciences, nursing, optometry, podiatry, and sports and movement studies perceptions regarding hand hygiene education (knowledge and attitude) and practice at a university in South Africa. Consenting students were asked to complete an online questionnaire that tested their knowledge, practices, and skills in handwashing. The ANOVA analysis results suggested significant differences in hand hygiene scores across departments and years of study. The multiple regression analyses confirmed these findings, suggesting that the department of study significantly influenced all aspects of hand hygiene, while the year of study affected hand hygiene skills, and age group influenced hand hygiene practices. Based on these findings, a conceptual model, the University Hand Hygiene Improvement Model (UHHIM), was proposed to enhance the teaching and learning of hand hygiene at the university level. The model underscores the necessity of targeted education, continuous monitoring, and feedback, and the pivotal roles of hand hygiene facilitators and student participation in enhancing hand hygiene behaviors.

Effectiveness of educational and training intervention for improving hand hygiene compliance amongst nurses: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND AND AIMS

Developing and implementing an educational and training programmes for improving hand hygiene compliance of the nursing personnel might help in increasing their knowledge, promoting positive attitude and follow adequate practice measures.

MATERIAL AND METHODS

Systematic search was done in PubMed, SCOPUS, CENTRAL, EMBASE, ScienceDirect, Clinicaltrials.gov and Google Scholar databases for articles published between 1964 and December 2022. Meta-analysis was carried out using a random-effects model, and the results were reported as pooled risk ratio (RR) with 95% confidence intervals (CIs), pooled standardised mean differences (SMD) or risk ratios (RR).

RESULTS

Eight studies were included in the analysis. Most studies had higher risk of bias. Nurses receiving educational and training programmes had significantly higher compliance to hand hygiene practices (pooled RR of 1.69 [95% CI: 1.23-2.31; I2  =  99.1%], p  =  0.001). The pooled analysis based on studies reporting the compliance to hand hygiene as continuous outcome has reported the pooled SMD as 1.28 with 95% CI: 0.62 to 1.95 and I2  =  74.5%. There were no single-study effects with respect to this outcome, since the sensitivity analysis showed no difference in either direction or strength of effect estimate.

CONCLUSION

Educational and training programmes are effective in improving the hand hygiene compliance amongst the nursing professionals.

Report of a Multimodal Strategy for Improvement of Hand Hygiene Compliance in a Latin American Hospital. How Far From Excellence?

OBJECTIVE

The aim of the study was to report the results of a multimodal strategy for improvement of hand hygiene (HH) compliance in a third-level hospital in Mexico.

METHODS

This is an epidemiological study in a public, acute care, academic, tertiary referral center from 2009 to 2019. Healthcare worker (HCW) compliance with HH was assessed after implementation of the World Health Organization multimodal strategy that included permanent and widespread access to alcohol-based hand rubs; educational activities for staff, students, patients, and relatives; reminders in healthcare areas; patient empowerment; water quality surveillance; frequent evaluation of compliance; and feedback. The primary outcome was HH compliance rate (measured by direct observation). The association of HH with healthcare-associated infections was the secondary outcome.

RESULTS

A total of 60,685 HH opportunities were evaluated. The HH compliance rate increased significantly from 39.83% (95% confidence interval [CI] = 38.83%-40.84%) to 64.81% (95% CI = 64.08%-65.54%), mostly due to HH compliance in World Health Organization moments 3 to 5 (r = 0.86, P = 0.001). A statistically significant inverse association was found between HH compliance rates and surgical site infection rates (incidence rate ratio = 0.9977, 95% CI = 0.9957-0.9997, P = 0.029).

CONCLUSIONS

A multimodal strategy in a Latin American setting showed an increase in HH compliance over 10 years of follow-up that should nonetheless be improved. An association between HH compliance and surgical site infection rates was noticed, but this did not occur with other healthcare-associated infections; this underscores the need for a comprehensive bundled approach in their prevention.

Hand hygiene compliance by direct observation in physicians and nurses: a systematic review and meta-analysis

BACKGROUND

Direct observation of hand hygiene compliance is the "gold standard" despite limitations and potential for bias. Previous literature highlights poorer hand hygiene compliance amongst physicians than nurses and suggests that covert monitoring may give better compliance estimates than overt monitoring.

AIM

This review aimed to explore differences in compliance between physicians and nurses further, and to analyse if compliance estimates differed when observations were covert rather than overt.

METHODS

A systematic search of databases PubMed, EMBASE, CENTRAL and CINAHL was performed. Experimental or observational studies in hospital settings in high-income countries published in English from 2010 onwards were included if estimates for both physicians and nurses using direct observation were reported. The search yielded 4814 studies, of which 105 were included.

FINDINGS

The weighted pooled compliance rate for nurses was 52% (95% CI 47% to 57%) and for doctors was 45% (95% CI 40% to 49%). Heterogeneity was considerable (I²=99%). The majority of studies were at moderate or high risk of bias. Random-effects meta-analysis of low risk of bias studies suggests higher compliance for nurses than physicians for both overt (difference of 7%, 95% CI for the difference 0.8% to 13.5%, p=0.027) and covert (difference of 7%, 95% CI 3% to 11%, p=0.0002) observation. Considerable heterogeneity was found in all analyses.

CONCLUSION

Wide variability in compliance estimates and differences in the methodological quality of hand hygiene studies were identified. Further research with meta-regression should explore sources of heterogeneity and improve the conduct and reporting of hand hygiene studies.

Supporting the Delivery of Infection Prevention and Control Training to Healthcare Workers: Insights from the Sector

Infection prevention and control (IPC) cannot be implemented without healthcare workers (HCWs) being properly trained and competent. The provision of training is essential, yet there is a gap in our understanding of the factors impacting the implementation of IPC training. This paper reports the results from in-depth interviews that explored the current landscape around IPC training delivered across low-, middle-, and high-income countries. Semi-structured interviews were conducted with the key stakeholders involved in policymaking or IPC implementation in Saudi Arabia, Pakistan, India, Indonesia, the Philippines, and Australia. Although the training was mandated for many HCWs, participants indicated that only some training elements were mandatory. Participants spoke about covering various topics, but those in low-resource settings spoke about the challenges of delivering training. Classroom-based training dominated, but online delivery modes were also used in some locations. Whilst HCW’s training was postulated to have improved during the COVID-19 pandemic, the capacity to deliver training did not improve in some settings. More research is needed to establish the essential elements that could underpin the development of training packages.

Male Sex, Cartilage Surgery, Tobacco Use, and Opioid Disorders are Associated with an Increased Risk of Infection After Anterior Cruciate Ligament Reconstruction

PURPOSE

To identify patient-related risk factors for infection following anterior cruciate ligament reconstruction (ACLR).

METHODS

The Mariner database within PearlDiver was queried for patients from 2010 to 2019 undergoing primary arthroscopic ACLR. Patients undergoing ACLR with concomitant open surgery or additional ligament reconstructions were excluded. Postoperative diagnoses or procedures for superficial or deep infection within 6 months were assessed. A multivariable logistic regression analysis was then used to evaluate patient-related risk factors for postoperative infection. Adjusted odds ratios (OR) and 95% confidence intervals (CIs) were calculated for each risk factor, with P < .05 considered statistically significant.

RESULTS

In total, 217,541 patients underwent ACLR and 1779 (0.8%) patients had a postoperative infection within 6 months. Significant independent risk factors included male sex (OR 1.58, 95% CI 1.43-1.75, P < .001), obesity (OR 1.22, 95% CI 1.05-1.43, P = .020), morbid obesity (OR 2.54, 95% CI 2.11-3.06, P = .002), tobacco use (OR 1.36, 95% CI 1.19-1.55, P < .001), age younger than 40 years (OR 1.21, 95% CI 1.07-1.37, P = .033), depression (OR 1.18, 95% CI 1.04-1.34, P = .012), opioid disorder (OR 1.50, 95% CI 1.22-1.85, P < .001), concomitant simple cartilage surgery (OR 1.63, 95% CI 1.43-1.86, P < .001), and complex cartilage surgery (OR 1.67, 95% CI 1.20-2.32, P = .002). Partial meniscectomy and meniscal repair at the time of ACLR were not associated with an increased risk of infection.

CONCLUSIONS

In a large national sample, male sex, obesity, tobacco use, older age, depression, opioid disorders and concomitant cartilage surgery were significant risk factors for infection following ACLR.

LEVEL OF EVIDENCE

Therapeutic Level IV, retrospective case series.

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 Areas Which Are Commonly Missed during Hand Disinfection by Nursing Students Who Completed a Basic Educational Course in Hand Hygiene

BACKGROUND

Teaching nursing students how to correctly perform hand hygiene procedures may guarantee a reduction in transmitting pathogens through direct contact and, thus, it may lead to a decrease in the number of hospital infections. The aim of the study, which was conducted in low fidelity simulation conditions, was to assess the performance and the efficiency of a hand-rubbing disinfection technique among nursing students on the last day of their course.

MATERIALS AND METHODS

The study was conducted in a group of 190 nursing students studying at the Jagiellonian University and it focused on the performed hand-rubbing disinfection procedure. The accuracy of the task performance was assessed by measuring the percentage of the amount of Fluo-Rub (B. Braun) fluorescent alcohol-based gel remaining on students' hands after disinfection. The gel was rubbed into particular hand parts including four surfaces (left palm, right palm, left back and right back) divided into thirteen areas (I-XIII) and each surface was examined separately. The results were then dichotomized based on the cut-off point of 10% and two categories: "clean" and "dirty" were established. Additionally, the range of negligence in the disinfection procedure was assessed by counting the total number of the areas classified as "dirty". The comparison of continuous and categorical variables was conducted by means of Friedman's and Cochrane's tests, respectively.

RESULTS

It was found out that the palm surfaces that were commonly missed during hand disinfection included the whole thumb (I and VI), the fingertip of the little finger (V) and the midpalm (XIII), whereas in the case of back surfaces (on both right and left hand) the most commonly missed areas were the fingertips and the whole thumb I-VI. Only 30 students (13%) had all 52 areas of both hands completely clean, whereas more than one third-66 students (33%)-failed to disinfect properly more than 10 areas out of all assessed ones on the surfaces of both hands.

CONCLUSIONS

In the examined group of nursing students, a significant lack of compliance with hand disinfection procedures was observed and it was related mainly to thumbs and back parts of both hands. Therefore, it is essential to conduct systematic training sessions and assessment of hand hygiene procedures for nursing students at the end of every educational stage as it can lead to their developing these skills properly.