Nursing students led simulations to improve healthcare workers' hand hygiene compliance

BACKGROUND

Hand hygiene compliance (HHC) is recognised as a major factor in the prevention of healthcare-associated infections. Healthcare workers (HCWs) compliance is still suboptimal. Simulation as an educational strategy may contribute to improved performance.

OBJECTIVE

This study aimed to assess the effect of simulation interventions led by nursing students on HCWs' HHC.

METHOD

A prospective quasi-experimental design with before and after intervention measurements was implemented in an 1150-bed tertiary hospital. Four consecutive periods, measuring before and after HHC, were examined in four hospital divisions. For each division, unique simulation activities were developed and led by nursing students, educators, and hospital leaders. Sixty seven students and 286 healthcare workers, along with two nurse educators, participated in the simulation sessions. HHC of all HCWs in the divisions was assessed by hospital infection control personnel.

RESULTS

Hospital HHC rose across the four periods in all four divisions during this study. In three out of four periods and divisions, HHC increased significantly more in the simulation intervention groups compared to the overall hospital improvement.

CONCLUSION

Student-led simulation for HCWs is an additional effective method to improve HHC. Nursing managers should consider joining forces with nursing educators to enable students to become agents of change in healthcare settings and encourage further collaboration.

Nursing students' experiences of unprofessional behaviours and associations with guideline compliance: A multicenter survey

AIMS

To assess the reported prevalence of unprofessional behaviours, including incivility and bullying, experienced by nursing students during their clinical practice. To assess the prevalence of students' abilities to speak up about unprofessional behaviours encountered and infection control concerns; their compliance with standard precautions and COVID-19 guidelines; and their perceived responsibility for infection prevention. Lastly, to describe the potential impact of unprofessional behaviour on compliance with these guidelines.

BACKGROUND

Unprofessional behaviours in healthcare settings are associated with a wide range of individual and organisational negative outcomes for nurses and nursing students, which may affect patient safety. The COVID-19 pandemic created new challenges for clinical education and for infection control.

DESIGN

A descriptive cross-sectional design.

METHODS

A multi-centre survey was carried out in six academic universities and colleges in Israel. The research study involved 369 undergraduate nursing students during 2022. Their clinical experiences were assessed using an online questionnaire. The STROBE guideline was used for accurate reporting.

RESULTS

301 (81.6%) students reported experience of unprofessional behaviour while undertaking clinical practice. Students with reported skills to speak up about unprofessional behaviour were less likely to report having experienced these behaviours (p = 0.003). Students who did not experience unprofessional behaviours were more likely to report higher compliance with standard and COVID-19 precaution guidelines (OR 3.624, 95% CI 1.790-7.335, p < 0.001). These students also had a higher perception of personal responsibility toward patient safety (OR 1.757, 95% CI 1.215-2.541, p = 0.003).

CONCLUSIONS

Nursing students experiencing unprofessional behaviours in the clinical setting reported lower compliance with standard and COVID-19 precautions. In addition, cultivating personal responsibility towards patients' safety may have a positive impact on guidelines compliance. Nursing educators and leaders should develop strategies to enable students to better cope with unprofessional behaviours. Closer cooperation between all stakeholders may promote civility among nurses and nursing students in the clinical setting.

Comparing the impact of two contact isolation modes for hospitalised patients with Clostridioides difficile infection on the quality of care

BACKGROUND

Clostridioides difficile causes healthcare-associated infections. Environmental spore acquisition is a major mode of transmission. Patient cohorting to prevent cross-transmission in healthcare-institutions is a reasonable component of an enhanced infection control strategy.

OBJECTIVE

The purpose of the study was to assess the effect of two different contact isolation modes on the quality of care of hospitalised patients with Clostridioides difficile infection (CDI).

METHODS

A retrospective cohort-study of patients with CDI hospitalised under one of two contact isolation modes: contact isolation in a multi-patient room without a dedicated nursing team vs. contact isolation in a permanent cohort isolation unit with a dedicated nursing team. Patients' files were reviewed for demographics, clinical characteristics, risk-assessment scores, clinical quality measures including the number of blood tests collected per day, the number of radiological tests applied per day and the time at which a radiological test was conducted, as process measurements, along with the length of stay and mortality, as outcome measures. The STROBE checklist for reporting observational studies was followed.

RESULTS

One hundred and seventy-eight patients with CDI were included; 100 in a permanent cohort isolation unit and 78 under contact isolation in a multi-patient room. No difference was found in all clinical quality process measures and in all outcome measures. Multivariable logistic regression showed that nursing home residence was associated with in-hospital mortality (OR, 2.51; CI, 1.29-4.97; p = .007), whereas the mode of hospitalisation was not.

CONCLUSIONS

The different contact isolation modes of hospitalisation did not compromise the quality of care of patients with CDI.

RELEVANCE TO CLINICAL PRACTICE

Cohorting of patients with CDI is used to prevent cross-transmission, though it raises a major concern regarding quality of care. In this study we show there was no compromise in patient care, therefore it is a reasonable component of an enhanced infection control strategy in a hospital setting.

The long-term impact of immediate verbal feedback of hand hygiene compliance after overt observation sessions, as assessed by continuous closed-circuit television monitoring in an intensive care setting

Background

Hand hygiene compliance by health care workers (HCWs) is pivotal in controlling and preventing health care associated infections. The aim of this interventional study is to assess the long-term impact of personal verbal feedback on hand hygiene compliance of HCWs in an intensive care unit (ICU) immediately after overt observation by an infection control nurse.

Methods

An infection control nurse overtly observed HCWs’ hand hygiene compliance and immediately gave personal verbal feedback with emphasis on aseptic technique. Overt non-interventional sessions were also performed. We measured compliance rates using covert continuous closed-circuit television (CCTV) monitoring. We compared these rates to previously-published hand hygiene compliance data.

Results

Overall compliance rates in the first (41.5%) and third phases (42%) of the study, before and after the intervention were similar. The two moments that were lowest in the first phase, “before aseptic contact” and “after exposure to body fluids”, showed significant improvement, but two moments showed a significant decline in compliance: “before patient contact” and “after contact with patient surrounding”. The compliance rates during the intervention phase were 64.8% and 63.8% during the sessions with and without immediate verbal personal feedback, respectively.

Conclusion

The overall hand hygiene compliance rate of HCWs did not show an improvement after immediate verbal personal feedback. Covert CCTV observational sessions yielded much lower hand hygiene compliance rates then overt interventional and non-interventional observations. We suggest that a single intervention of personal feedback immediately after an observational session is an ineffective strategy to change habitual practices.

Nurse-performed ultrasound assessment of gastric residual volume and enteral nasogastric tube placement in the general intensive care unit

OBJECTIVE

Ultrasonography is an essential imaging modality in the critical care population and has been increasingly utilized to check gastric residual volume . Various studies have shown that intensive care unit nurses untrained in ultrasound can easily be trained in its accurate interpretation. We prospectively analyzed nurse-performed repeated measurements of gastric residual volume and nasogastric tube positioning via an ultrasound technique in the intensive care unit.

DESIGN

This was a single-center, cross-sectional prospective study. Four intensive care unit nurses, evenly divided into two groups (teams A and B), underwent four hours of formal ultrasound training by three critical care staff physicians. The trained nurses provided bedside ultrasound assessments of gastric residual volume and nasogastric tube positioning which were compared to a standard protocol of syringe aspiration.

RESULTS

Ninety patients were recruited to the study. Four measurements per patient were performed, for a total of 360 assessments. The ultrasound gastric residual volume assessments were correlated with the syringe aspiration protocol and demonstrated high Intraclass Correlation Coefficient rates of 0.814 (0.61-0.92) for team A and 0.85 (0.58-0.91) for team B. Nasogastric tube placement was successfully and independently verified by ultrasound in most of the critically ill patients (78% of team A and 70% of team B). The comparative ultrasound assessments of tube positioning demonstrated good correlation of 0.733 (0.51-0.88) between each team's two independent observers.

CONCLUSION

Our study demonstrated a strong correlation between US utilization for assessment of gastric residual volume and nasogastric tube positioning and standard protocol methods, suggesting it is a safe, simple and effective practice for intensive care unit nurses.

Perceptions of patients' and healthcare workers' experiences in cohort isolation units: a qualitative study

BACKGROUND

Given the scarce therapeutic options for carbapenemase-producing Enterobacterales (CPE), aggressive interventions are implemented to limit its spread among hospitalized patients. One such option is contact isolation by cohorting patients in designated units.

AIM

To describe the experiences in a cohort isolation unit (CIU) due to CPE from the perspectives of patients admitted to this unit and their families, and those of healthcare workers (HCWs) who served in the same unit.

METHODS

Qualitative study. Face-to-face, semi-structured interviews were conducted in a large tertiary hospital. Twenty-four participants were interviewed, including 15 HCWs, three patients and six family members. Data were coded using thematic analysis.

FINDINGS

The CIU provoked negative feelings such as fear, risk, loneliness, distrust and unfairness. They also created a sense of conflict with the curative assumptions of hospital care. The poor CIU infrastructure was echoed in perceptions of crowdedness in the site. Moreover, family members described HCWs' inconsistent protective behaviours that led them to a state of vigilance. The hospital infection control unit imparted and refreshed HCWs' knowledge and expected behaviours regarding the CIU. However, patients and families expressed dissatisfaction with the information, guidance and education regarding the 'why and how' of the CIU. They were not guided consistently about recommended behaviours after discharge. In retrospect, HCWs found that the CIU took a psychological, physical and professional toll.

CONCLUSION

The CIU was planned as a temporary containment mechanism. It needs to develop into a permanent system, capable of addressing the various needs of all involved.

Efficacy of covert closed-circuit television monitoring of the hand hygiene compliance of health care workers caring for patients infected with multidrug-resistant organisms in an intensive care unit

BACKGROUND

To compare covert closed-circuit television (CCTV) monitoring to standard overt observation in assessing the hand hygiene (HH) conduct of health care workers (HCWs) caring for patients infected with multidrug-resistant organisms (MDROs). This was a cross-sectional study in a general intensive care unit of a 1,000-bed university hospital.

METHODS

Forty-six general intensive care unit HCWs (staff physicians, registered nurses, and auxiliary workers) caring for contact isolation MDRO-infected patients. The study incorporated the following 3 phases: phase 1, establishment of interrater reliability between 2 simultaneous observers using the overt observation method; phase 2, establishment of interrater reliability between 2 simultaneous observers using the CCTV method; and phase 3, simultaneous monitoring of HH by both methods to evaluate the suitability of CCTV as an alternative to direct observation of the HH conduct of HCWs caring for MDRO-infected patients.

RESULTS

Overall, 1,104 opportunities to perform HH were documented during 49 observation sessions. The compliance rate observed by the overt method (37.3%) was significantly higher than that observed when only the covert method was used (26.5%). However, simultaneous overt-covert observations were found to have intraclass correlation coefficients of >0.85.

CONCLUSIONS

Covert CCTV observation of HCW HH compliance appears to provide a truer and more realistic picture than overt observation, probably because of its ability to neutralize the Hawthorne effect of overt observation. The high intraclass correlation coefficients between covert observation and overt observation supports this conclusion.

Monitoring the hand hygiene compliance of health care workers in a general intensive care unit: Use of continuous closed circle television versus overt observation

INTRODUCTION

A variety of hand hygiene monitoring programs (HHMPs) have come into use in hospitals throughout the world. In the present study, we compare continuous closed circle television (CCTV) with overt observation for monitoring the hand hygiene compliance of health care workers (HCWs) in a general intensive care unit (GICU).

METHODS

This is a cross-sectional and comparative study. In this study, we use a novel hand hygiene CCTV monitoring system for hand hygiene performance monitoring. The study population incorporated all the GICU HCWs, including registered nurses, staff physicians, and auxiliary workers.

RESULTS

All HCWs of our GICU were observed, including ICU registered nurses, ICU staff physicians, and auxiliary workers participated in the present study. Overall, each observer team did 50 sessions in each arm of the study. Total number of hand hygiene opportunities was approaching 500 opportunities. The compliance rates when only overt observations were performed was higher than when only covert observations were performed with a delta of approximately 10% (209 out of 590 [35.43%] vs 130 out of 533 [24.39%]; P < .001). Both methods of observations (overt and covert [CCTV]) demonstrated excellent reliability (intraclass correlation coefficient [ICC], 0.96 [0.93-0.98] of overt and ICC, 0.81 [0.69-0.89] for covert, respectively). However, the correlation between both methods was found weak in simultaneous sessions (ICC, 0.40 [0.62-0.107]).

CONCLUSION

We demonstrated that CCTV is an appropriate, reliable, and neutral method for observation of hand hygiene. However, there is no clear basis for incorporating a CCTV observation modality into a health care system that already operates an overt observation program. We have shown that CCTV methodology records a different distribution of opportunities for performing hand hygiene and of actual performances of hand hygiene compared with overt observation.

Computerized test versus personal interview as admission methods for graduate nursing studies: A retrospective cohort study

The purpose of this study was to compare the predictive validity, economic efficiency, and faculty staff satisfaction of a computerized test versus a personal interview as admission methods for graduate nursing studies. A mixed method study was designed, including cross-sectional and retrospective cohorts, interviews, and cost analysis. One hundred and thirty-four students in the Master of Nursing program participated. The success of students in required core courses was similar in both admission method groups. The personal interview method was found to be a significant predictor of success, with cognitive variables the only significant contributors to the model. Higher satisfaction levels were reported with the computerized test compared with the personal interview method. The cost of the personal interview method, in annual hourly work, was 2.28 times higher than the computerized test. These findings may promote discussion regarding the cost benefit of the personal interview as an admission method for advanced academic studies in healthcare professions.

Nursing students' intentions to comply with standard precautions: an exploratory prospective cohort study

BACKGROUND

Partial compliance of health care workers with standard precaution (SP) guidelines has been extensively documented. The aim of this study was to describe the development of nursing students' intentions to comply with SPs.

METHODS

Prospective cohort study. Two consecutive classes of a 4-year bachelor of nursing program completed questionnaires 3 times. The transtheoretical model of change was used to describe the change in intentions to comply with SPs. Factor analysis displayed 2 behavioral categories: commonly used standard precautions (CUSPs) and less commonly used standard precautions (LUSPs). Knowledge, risk perception, sense of coherence (SOC), safety climate (SC), and emphasis given by educators were evaluated as associated factors.

RESULTS

Of the 91 students, 85 (93%) completed the questionnaire during their second year, 57 of 88 students (65%) completed it during the third year, and 70 of 82 students (85%) completed it at the end of the fourth year. Of the 82 students, 45 (55%) completed 3 measurements. CUSPs exhibited a rise from the second to the third year, with a moderate decline from the third to the fourth year, whereas LUSPs continued ascending. CUSPs were positively associated with SC and SOC; LUSPs were commonly associated with risk perception.

CONCLUSION

The different evolution of CUSPs and LUSPs and dissimilar associations may suggest that different strategies might encourage diverse SP behaviors. Improving the SC might be appropriate when aiming to encourage CUSPs, and highlighting risks may be appropriate to encourage LUSPs.

Relationship between shared patient care items and healthcare-associated infections: a systematic review

BACKGROUND

Environmental surfaces may contribute to transmission of nosocomial pathogens. Noninvasive portable clinical items potentially shared among patients (NPIs) are part of the patient's immediate surroundings and may pose a threat of pathogen transmission.

OBJECTIVE

To assess the body of literature describing the range of microorganisms found on NPIs and evaluate the evidence regarding the potential for cross-transmission of microorganisms between NPIs and hospitalized patients in non-outbreak conditions.

DESIGN

A comprehensive list of NPIs was developed, and a systematic review of these items combined with healthcare-associated infection related keywords was performed.

DATA SOURCES

PubMed, Scopus, and Cochrane Library.

REVIEW METHODS

A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist to identify and synthesize research reports published between January 1990 and July 2013 on studies regarding contamination of NPIs and association to infections in non-outbreak circumstances.

RESULTS

1498 records were scanned for eligibility. Thirteen studies met inclusion criteria. Overall, rates of NPI contamination ranged from 23% to 100%. Normal skin or environmental flora were found on almost all positive cultures. Potential pathogens, e.g., Staphylococcus aureus, were present on up to 86%, and Pseudomonas spp. and/or Enterobacteriaceae in 38% of positive cultures. Multi-drug resistant organisms were isolated from up to 25% of items. Three studies explored association between NPIs contamination and patient colonization and infection. One study reported 5 patients with healthcare-associated infections with pathogens found concurrently on NPIs, one found cross-transmission between patient skin bacteria and NPI contamination, and a third did not find any cross-transmission.

CONCLUSIONS

Potential pathogens and multiply resistant organisms present on NPIs in routine, non-outbreak conditions and in a variety of settings confirms the need to improve NPIs decontamination practices.

A prospective study of the patterns and dynamics of colonization with Candida spp. in very low birth weight neonates

BACKGROUND

Knowledge of fungal colonization patterns in very low birth weight infants (VLBWI) admitted to the neonatal intensive care unit (NICU) is essential in understanding the process of fungal infections in neonates. We analyzed prospectively, during 2009-2010, the patterns and dynamics of fungal colonization in VLBWI, including timing, colonization sites, and species involved.

METHODS

Weekly skin, oropharynx, and rectum/stool surveillance fungal cultures were collected from admission until discharge in VLBWI in the NICU. None received antifungal prophylaxis.

RESULTS

Overall, 118 VLBWI provided 1723 samples; 34 (29%) had 104 positive samples at least once during the first 10 hospitalization weeks. Thirty-nine (33%) weighed < 1000 g; 68 were delivered by cesarean section. Candida albicans (57/104, 55%) and Candida parapsilosis (26/104, 25%) were the main fungi isolated. Eight (24%) VLBWI were colonized during the first week and 23 (68%) during the second week. No differences in colonization were recorded between cesarean section and vaginally delivered VLBWI. The colonization risk at least once during the first 10 weeks was 23% for skin, 14% for oropharynx, 27% for rectum/stool, and 38% for any anatomic site sampled. Persistent colonization was recorded in 5/34 (15%), while transient colonization was found in 14/34 (41%) VLBWI; 16/34 (47%) were discharged or died colonized with Candida spp. Candidemia was diagnosed in 4 (3%) VLBWI and previous/simultaneous colonization was found in 3/4.

CONCLUSIONS

The cumulative risk of colonization, at any sampled site and at least once during follow-up, was high. Initial colonization occurred most often during the first 2 weeks of life. Colonization dynamics were characterized by various persistence, disappearance, and recolonization patterns. Candidemia was rare.

Risk factors for developing clinical infection with carbapenem-resistant Klebsiella pneumoniae in hospital patients initially only colonized with carbapenem-resistant K pneumoniae

BACKGROUND

This study examined predictors of carbapenem-resistant Klebsiella pneumoniae (CRKP) colonization and risk factors for the development of CRKP infection in patients initially only colonized with CRKP.

METHODS

A total of 464 patients with CRKP rectal colonization (CRKP-RC) were identified. Two case-control studies were performed, one comparing risk factors for CRKP-RC in patients who did not develop CRKP infection (CRKP-IN) versus patients without CRKP-RC and CRKP-IN, and the other comparing CRKP-RC patients who did not develop CRKP-IN with those who did.

RESULTS

Forty-two of the 464 colonized patients developed CRKP-IN. Multivariate analysis identified the following predictors for CRKP-RC: antibiotic therapy (odds ratio [OR], 5.76; P ≤ .0001), aminopenicillin therapy (OR, 7.753; P = .004), bedridden (OR, 3.09; P = .021), and nursing home residency (OR, 3.09; P = .013). Risk factors for CRKP-IN in initially CRKP-RC-positive patients were previous invasive procedure (OR, 5.737; P = .021), diabetes mellitus (OR, 4.362; P = .017), solid tumor (OR, 3.422; P = .025), tracheostomy (OR, 4.978; P = .042), urinary catheter insertion (OR, 4.696; P = .037), and antipseudomonal penicillin (OR, 23.09; P ≤ .0001).

CONCLUSIONS

We suggest that in patients with CRKP-RC, a strategy for preventing CRKP-IN might include limiting antipseudomonal penicillin and carbapenem use and preventing infections by closely following compliance with infection control bundles.

A multifaceted intervention strategy for eradication of a hospital-wide outbreak caused by carbapenem-resistant Klebsiella pneumoniae in Southern Israel

OBJECTIVE

To devise a local strategy for eradication of a hospital-wide outbreak caused by carbapenem-resistant Klebsiella pneumoniae (CRKP).

DESIGN

Quasi-experimental, before-and-after, interrupted time-series study.

SETTING

A 1,000-bed tertiary-care university teaching hospital.

METHODS

Retrospectively, all relevant data were collected from the medical records of patients with CRKP infections from May 2006 through April 2007, the preintervention period. From May 1, 2007, through May 1, 2010, the postintervention period, the intervention was applied and prospectively followed. The 5 key elements of this strategy were an emergency department flagging system, the building of a cohort ward, the eradication of clusters, environmental and personnel hand cultures, and a carbapenem-restriction policy. The demographic and clinical parameters of patients colonized by and/or infected with CRKP were collected from medical records.

RESULTS

A total of 10,680 rectal cultures were performed for 8,376 patients; 433 (5.16%) and 370 (4.4%) were CRKP-colonized and CRKP-infected patients, respectively, and 789 (98%) of 803 patients were admitted to the CRKP cohort ward. The CRKP infection density was reduced from 5.26 to 0.18 per 10,000 patient-days (P ≤ .001), and no nosocomial CRKP infections were diagnosed. Twenty-three percent of environmental cultures were found to be positive. Meropenem use was reduced from 283 ± 70.92 to 118 ± 74.32 defined daily doses per 1,000 patient-days (P ≤ .001).

CONCLUSION

This intervention produced an enormous impact on patient location, surveillance cultures, and antibiotic policies and a massive investment in infection control resources.

Risk factors for community-acquired pneumonia with influenza A/H1N1 in southern Israel

OBJECTIVES

To determine the risk factors for community-acquired pneumonia (CAP) with influenza A/H1N1 flu in our region.

METHODS

Adult patients with CAP from July 2009 to February 2010 who were screened for influenza A/H1N1 were identified retrospectively. This was a retrospective case-control study. Cases had CAP with influenza A/H1N1 and controls had CAP without influenza A/H1N1. Patient files were reviewed for demographics, clinical characteristics, treatment, and outcome.

RESULTS

Three hundred and eight patients with CAP were identified: 107 cases and 201 controls. For cases vs. controls there were significant differences in the following: median age (40 (range 18-82) vs. 56 (range 18-89) years; p<0.001), female gender (63.6% vs. 44.3%; p<0.05), Bedouin Arab origin (41.1% vs. 26.4%; p<0.05), pyrexia (97.6% vs. 88.5%; p<0.01), cough (96.3% vs. 75%; p<0.05), admission to the intensive care unit (18.7% vs. 10.6%; p<0.05), and CURB-65 score ≥ 3 (2.8% vs. 11.4%; p<0.05). Laboratory values including white blood cell (WBC) and platelet counts were lower in cases than in controls, whereas creatine phosphokinase and lactate dehydrogenase levels were higher (p<0.01). By logistic regression models, young age, Bedouin origin, and lower WBC and platelet counts were independent risk factors for the acquisition of CAP with influenza A/H1N1.

CONCLUSIONS

In our region CAP with influenza A/H1N1 occurred in younger females of Bedouin Arab origin with less co-morbidity. No difference in mortality was found. We believe that inequalities in socioeconomic conditions could explain our findings.

Hospital-acquired conjunctivitis in a neonatal intensive care unit: Bacterial etiology and susceptibility patterns

Our study investigates the causative pathogens of hospital-acquired conjunctivitis in our neonatal intensive care unit and their susceptibility patterns. Coagulase-negative Staphylococcus was the most common bacterium, 22.1% of all isolates. The frequency of the pathogens changed during neonates' stay; Klebsiella pneumoniae (from 18% to 6.9%) and Escherichia coli (from 16% to 4.8%) decreased, whereas methicillin-susceptible Staphylococcus aureus (from 4% to 12.7%) and Enterococcus spp (from 1% to 5.3%) increased. Gram-positive cocci showed high resistant patterns. Our study indicates that the distribution of bacteria causing hospital-acquired conjunctivitis in our neonates shifted from gram-negative to gram-positive microorganisms during their neonatal intensive care unit stay. The resistance patterns are worrisome among gram-positive cocci.