Handwashing practices in an intensive care unit: the effects of an educational program and its relationship to infection rates

Body positioning of intensive care patients: clinical practice versus standards

OBJECTIVE

The routine turning of immobilized critically ill patients at a minimum of every 2 hrs has become the accepted standard of care. There has never been an objective assessment of whether this standard is achieved routinely. To determine if immobilized patients in the intensive care unit (ICU) receive the prevailing standard of change in body position every 2 hrs. To determine prevailing attitudes about patient positioning among ICU physicians.

DESIGN

Prospective longitudinal observational study. E-mail survey of ICU physicians.

SETTING AND PARTICIPANTS

Convenience sample of mixed medical/surgical ICU patients at three tertiary care hospitals in two different cities in the United States. Random sampling of ICU professionals from a directory.

MAIN OUTCOME MEASURES

Changes in body position recorded at 15-min intervals. RESULTS Seventy-four patients were observed for a total of 566 total patient hours of observation, with a mean observation time per patient of 7.7 hrs (range, 5-12). On average, 49.3% of the observed time, patients remained without a change in body position for >2 hrs. Only two of 74 patients (2.7%) had a demonstrable change in body position every 2 hrs. A total of 80-90% of respondents to the survey agreed that turning every 2 hrs was the accepted standard and that it prevented complications, but only 57% believed it was being achieved in their ICUs.

CONCLUSIONS

The majority of critically ill patients may not be receiving the prevailing standard of changes in body position every 2 hrs. This warrants a reappraisal of our care of critically ill patients.

Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial

OBJECTIVE

To compare the efficacy of handrubbing with an alcohol based solution versus conventional handwashing with antiseptic soap in reducing hand contamination during routine patient care.

DESIGN

Randomised controlled trial during daily nursing sessions of 2 to 3 hours.

SETTING

Three intensive care units in a French university hospital.

PARTICIPANTS

23 healthcare workers.

INTERVENTIONS

Handrubbing with alcohol based solution (n=12) or handwashing with antiseptic soap (n=11) when hand hygiene was indicated before and after patient care. Imprints taken of fingertips and palm of dominant hand before and after hand hygiene procedure. Bacterial counts quantified blindly.

MAIN OUTCOME MEASURES

Bacterial reduction of hand contamination.

RESULTS

With handrubbing the median percentage reduction in bacterial contamination was significantly higher than with handwashing (83% v 58%, P=0.012), with a median difference in the percentage reduction of 26% (95% confidence interval 8% to 44%). The median duration of hand hygiene was 30 seconds in each group.

CONCLUSIONS

During routine patient care handrubbing with an alcohol based solution is significantly more efficient in reducing hand contamination than handwashing with antiseptic soap.

Effect of an evidence-based hand washing policy on hand washing rates and false-positive coagulase negative staphylococcus blood and cerebrospinal fluid culture rates in a level III NICU

OBJECTIVE

To determine the effect of implementing an evidence-based hand washing policy on between-patient hand washing compliance and on blood and cerebrospinal fluid (CSF) culture rates in a level III neonatal intensive care unit (NICU).

METHODS

An evidence-based hand washing policy, supported by an intensive education program, was introduced in a regional NICU. A total of 2009 preintervention neonates (16,168 patient days) over 17 months were compared to 676 postintervention neonates (5779 patient days) over 6 months. Hand washing compliance and rates of blood and CSF cultures yielding coagulase negative staphylococci (CONS) were compared before and after intervention.

RESULTS

Compliance with appropriate between-patient hand washing improved (from 47.4% to 85.4%, p=0.001) after the hand washing policy was introduced. The rate of cultures positive for CONS declined from 6.1+/-2.3 to 3.2+/-1.6 per 1000 patient days (p=0.005). Most of this reduction was attributable to a reduction in false-positive cultures, from 4.2+/-2.4 to 1.9+/-1.8 per 1000 patient days (p=0.042), but there was a trend toward decreased true-positive cultures (from 2.1+/-1.2 to 1.2+/-1.0 per 1000 patient days, p=0.074) as well. Potential confounders and demographics factors were similar between the control and intervention subjects.

CONCLUSION

Implementation of an evidence-based hand washing policy resulted in a significant increase in hand washing compliance and a significant decrease in false-positive coagulase negative staphylococcal blood and CSF culture rates. Exploratory data analysis revealed a possible effect on true-positive coagulase negative staphylococcal blood and CSF culture rates, but these results need to be confirmed in future studies.

Gender influences handwashing rates in the critical care unit

BACKGROUND

Nurses tend to wash their hands more often than physicians, and among nonhealth care workers, women tend to wash their hands more often than men. This study examined the influence of gender on the handwashing rates of health care workers (HCWs). The null hypotheses were that there would be no intergender difference in (a) handwashing rates in HCWs across professions and (b) within professional groups.

METHODS

Handwashing by nurses, physicians, wardspersons, x-ray technicians, and physiotherapists after patient contact in a critical care unit (CCU) was determined through covert observation. The gender and profession of the subjects were recorded, but their identity was not.

RESULTS

Female CCU staff washed their hands significantly more often than did their male counterparts after patient contact (P =.0001). When the results were examined for the influence of profession on handwashing, significant intergender differences remained for physicians (P =.0468) and wardspersons (P =.0001). There was also a nonsignificant trend (P =.07) toward higher rates of handwashing among female x-ray technicians. There were no statistically significant intergender differences in handwashing rates among nurses (P =.7588) and physiotherapists.

CONCLUSIONS

It appears that gender may influence handwashing rates in HCWs in the CCU, although this difference appears to be modified in particular professional groups. Further research should examine factors that modify handwashing rates within professional groups and in settings other than the CCU.

Understanding adherence to hand hygiene recommendations: the theory of planned behavior

BACKGROUND

Most health care workers (HCWs) are aware of the rationale for hand hygiene procedures, yet failure to adhere to guidelines is common. Little is known about factors that motivate HCWs to practice hand hygiene.

PURPOSE

The purposes of this study were to (1) estimate adherence to hand hygiene recommendations; (2) describe relationships among motivational factors, adherence, and intensity of nursing unit activity; and (3) test an explanatory model for adherence to hand hygiene guidelines based on the theory of planned behavior (TPB).

METHOD

A longitudinal, observational design was used to collect data from 120 registered nurses employed in critical care and postcritical care units. Nurses provided information about motivational factors and intentions and a self-report of the proportion of time they followed guidelines. At least 2 weeks later, the nurses' hand hygiene performance was observed while they provided patient care. Structural equation modeling was used to test the TPB-based model.

RESULTS

Rate of adherence to recommendations for 1248 hand hygiene indications was 70%. The correlation between self-reported and observed adherence to handwashing recommendations was low (r = 0.21). TPB variables predicted intention to handwash, and intention was related to self-reported hand hygiene. Intensity of activity in the nursing unit, rather than TPB variables, predicted observed adherence to hand hygiene recommendations.

CONCLUSIONS

The limited association between self-reported and observed hand hygiene scores remains an enigma to be explained. Actual hand hygiene behavior may be more sensitive to the intensity of work activity in the clinical setting than to internal motivational factors.

Compliance with hand disinfection and its impact on hospital-acquired infections

Hand hygiene prevents cross-infection in hospitals, but adherence to guidelines is poor among healthcare workers. Although some interventions to improve compliance have been successful, none had achieved lasting improvement until very recently. Reasons for non-compliance with recommendations occur at individual, group and institutional levels. The complexity of the process of behavioural change would suggest that the application of multimodal, multidisciplinary strategies are necessary. Both easy access to hand hygiene in a timely fashion and skin protection appear necessary prerequisites for satisfactory hand hygiene behaviour. Alcohol-based hand-rub may be superior to traditional handwashing as it requires less time, acts faster, irritates hands less often, and recently proved significantly to contribute to sustained improvement in compliance associated with decreased infection rates. This paper reviews barriers to appropriate hand hygiene and describes the results of the first successful experience of sustained hand hygiene promotion and its effectiveness on hospital-acquired infection.

Infection control measures to limit antimicrobial resistance

Increasing antimicrobial resistance has resulted in a rapidly decreasing array of therapeutic options for infections in the critical care setting. Reports of reduced susceptibility to vancomycin in Staphylococcus aureus raise the possibility of patients being infected with a virulent pathogen for which most antibiotics are ineffective. Infection control methods to contain resistance, exclusive of antimicrobial restrictions, focus on surveillance to identify carriers of resistant organisms, prevention of nosocomial infections, adequate hand hygiene, isolation of patients who harbor resistant organisms, and the use of barrier techniques such as gowns and gloves. Surveillance using clinical isolates alone is inadequate for the identification of the majority of patients who carry resistant organisms. However, it is unclear what intensity of surveillance is needed to control the spread of these organisms in the intensive care unit in nonoutbreak situations. Attempts at eradicating carriage are often unsuccessful when there is extranasal colonization with methicillin-resistant S. aureus. Transmission of resistant organisms is primarily the result of transient contamination of healthcare workers' hands. Adequate handwashing, isolation of carriers, and barrier techniques are all necessary for containing resistance within the intensive care unit, however, compliance with these measures can be compromised by high staff turnover and heavy workload.

The effectiveness of interventions aimed at increasing handwashing in healthcare workers - a systematic review

Handwashing is widely accepted as being key to the prevention of hospital-acquired infection but the frequency of handwashing by healthcare workers has been found to be low. A systematic critical literature review was conducted to establish the effectiveness of interventions aimed at increasing compliance with handwashing in healthcare workers. The results showed that one-off educational interventions have a very short-term influence on handwashing behaviour. Use of strategically placed reminders, or asking patients to remind staff of the need to conduct handwashing can have a modest but more sustained effect. Feedback of performance can increase levels of handwashing but if feedback is not repeated regularly, then this effect is not maintained over long periods. Automated sinks increase the quality of handwashing but healthcare workers can be discouraged from using these because of the additional time involved. Provision of moisturized soaps appears to make little difference to handwashing behaviour but providing 'dry' hand rubs near patient beds may lead to a minimal increase in the frequency with which staff decontaminate their hands. Multifaceted approaches which combine education with written material, reminders and continued feedback of performance can have an important effect on handwashing compliance and rates of hospital-acquired infection.

An organizational climate intervention associated with increased handwashing and decreased nosocomial infections

Handwashing practices are persistently suboptimal among healthcare professionals and are also stubbornly resistant to change. The purpose of this quasi-experimental intervention trial was to assess the impact of an intervention to change organizational culture on frequency of staff handwashing (as measured by counting devices inserted into soap dispensers on four critical care units) and nosocomial infections associated with methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). All staff in one of two hospitals in the mid-Atlantic region received an intervention with multiple components designed to change organizational culture; the second hospital served as a comparison. Over a period of 8 months, 860,567 soap dispensings were recorded, with significant improvements in the study hospital after 6 months of follow-up. Rates of MRSA were not significantly different between the two hospitals, but rates of VRE were significantly reduced in the intervention hospital during implementation.

The role of gown and glove isolation and strict handwashing in the reduction of nosocomial infection in children with solid organ transplantation

OBJECTIVE

Nosocomial infection is an important contributor to morbidity and mortality in pediatric solid organ transplantation. The relative effect of protective gown and glove isolation was compared with strict handwashing in pediatric intensive care unit (PICU) patients with solid organ transplantation.

DESIGN/SETTING

A prospective, randomized design was used; children in a 23-bed PICU with solid organ transplantation were enrolled into a gown and glove protective isolation protocol or a strict handwashing protocol.

PATIENTS

All children admitted to the PICU immediately after solid organ transplantation, excluding renal transplantation, and at subsequent readmissions to the PICU were eligible for the study. Children with current infection or known exposure to varicella were excluded from the study initially or at readmission.

INTERVENTIONS

By using a block randomization design based on organ transplanted, age, and initial admission vs. readmission, each patient was randomized to either strict handwashing or protective gown and glove isolation intervention groups.

MEASUREMENTS

We analyzed demographics, infection outcomes (defined according to Centers for Disease Control criteria), and monitoring of patient contacts in compliance with protocols.

RESULTS

The infection rate in the overall PICU population did not change significantly from the year before the study compared with during the study (2.1 per 100 vs. 1.95 per 100 patient days; p =.4) The infection rate in the gown and glove group (2.3 per 100 patient days) was reduced significantly compared with the prestudy infection rate in the transplant population (4.9 per 100 patient days; p =.0008). Strict handwashing also significantly reduced the infection rate in the transplant population (3.0 per 100 patient days; p =.008). Compliance with gowning and gloving was 82% and compliance with handwashing was 76% (compared with 22% before study [p <.0001] and 52% after the study [p <.0001]). Despite an increased mean length of stay in the PICU in the gown and glove group (p =.014), there was a trend toward reduction in the incidence of infection (Fisher's exact test, p =.07; odds ratio,.76) in the gown and glove group.

CONCLUSIONS

Increased compliance with handwashing was associated with a reduction in nosocomial infections, and gown and glove isolation appeared to have an additional protective effect. Some nosocomial infections may be preventable in the pediatric solid organ transplantation population.

Improving adherence to hand hygiene practice: a multidisciplinary approach

Hand hygiene prevents cross-infection in hospitals, but health-care workers' adherence to guidelines is poor. Easy, timely access to both hand hygiene and skin protection is necessary for satisfactory hand hygiene behavior. Alcohol- based hand rubs may be better than traditional handwashing as they require less time, act faster, are less irritating, and contribute to sustained improvement in compliance associated with decreased infection rates. This article reviews barriers to appropriate hand hygiene and risk factors for noncompliance and proposes strategies for promoting hand hygiene.

The effectiveness of an educational intervention in changing nursing practice and preventing catheter-related infection for patients receiving total parenteral nutrition

Catheter-related infections are one of the most serious complications of TPN therapy. Nurses have important responsibilities in the care of patients who are receiving TPN. This quasi-experimental study was conducted for the purpose of investigating the effectiveness of an educational intervention on changing nursing practice and preventing catheter-related infections in patients receiving total parenteral nutrition. The nurses' practice and the colonisation rate of control and comparative group patients in the surgical clinics of Hacettepe University Hospital (Turkey), and related variables were examined before and after an educational intervention. The findings of the study indicate that the intervention was successful in improving appropriate nursing practice, mean scores of nurses' practices were 45.7 before and 66.5 after the intervention (p<0.05). The rate of microorganism colonisation was also decreased but statistical analysis demonstrated no association between nursing practices and microorganism colonisation of catheter cultures.

Maximising handwashing rates in the critical care unit through yearly performance feedback

Handwashing following patient contact reduces the incidence of nosocomial infections. Despite this, handwashing rates by health care workers (HCWs) are often poor. Feedback on handwashing has been shown to significantly improve its rates. This study determined the optimum time to repeat performance feedback on handwashing rates of hospital staff in order to maximise its incidence. The baseline incidence of handwashing by staff following patient contact was determined by covert observation. This was followed by a period of feedback on handwashing performance by means of histograms displayed in the unit. Handwashing incidence was reassessed 6 and 12 months after the feedback ended. Performance feedback induced significant increases in handwashing incidence amongst nurses (p = 0.0433), resident medical officers (p = 0.0134), specialists (p = 0.0021) and radiographers (p = 0.0001). Non-significant increases were noted in handwashing rates amongst wardsmen/women and physiotherapists. Overall, handwashing incidence declined significantly (p = 0.0001) 12 months post feedback. This study demonstrated that feedback should be repeated within 12 months in order to maximise handwashing rates with the minimum intervention.

A survey on handwashing practices and opinions of healthcare workers

Studies have consistently demonstrated rates of handwashing compliance are less than 50%. The objective of this study was to gain the following information about handwashing: self-reported compliance; attitudes towards handwashing in different patient settings; and attitudes towards interventions aimed at increasing compliance. A 74-question survey was administered to healthcare workers in two tertiary care hospitals. One hundred and ninety nine healthcare workers completed the survey and 89% reported that handwashing is an important means of preventing infection. Sixty-four percent believed that they washed their hands as often as their peers and 2% believed that they washed less often than their peers. Patients with diarrhoea, AIDS or patients on antibiotics led to increased handwashing. Relative to potential interventions, 76% reported that rewards for handwashing would have no effect, 73% reported that punishment would have no effect and 80% reported that easy access to sinks and availability of washing facilities would lead to increased compliance. This survey suggests that healthcare workers understand the importance of handwashing, but tend to overestimate their own compliance. Healthcare workers are not in favour of interventions involving rewards and punishments, but are more attracted to interventions that make handwashing easier.

Hand hygiene-beliefs or science?

Over a century has passed since Ignaz P. Semmelweis demonstrated the association between hand hygiene and nosocomial infections, but this simple procedure is still not recognized by many healthcare workers as one of the most important measures to prevent cross-transmission of microorganisms. A relatively large amount of research has been done, in particular to try to understand why compliance remains so low, in order to implement successful promotion campaigns. This research has generated a fair amount of strong scientific data which are sometimes misunderstood and misused because of myths or certain beliefs. Observational or intervention studies have consistently shown a number of risk factors associated with non-compliance, such as high workload, professional category, or type of ward. Others are thought to be barriers to adequate compliance but have not yet been properly assessed. These include skin irritation due to hand hygiene agents, lack of knowledge of hand hygiene recommendations, or lack of institutional policy. Future interventions to promote hand hygiene will need to address these risk factors, and target the individual healthcare worker, as well as the group or institution if a significant degree of success is to be achieved.

Replace hand washing with use of a waterless alcohol hand rub?

Hand hygiene is one of the basic components of any infection control program and is frequently considered synonymous with hand washing. However, health care workers frequently do not wash their hands, and compliance rarely exceeds 40%. Hand rubbing with a waterless, alcohol-based rub-in cleanser is commonly used in many European countries instead of hand washing. Scientific evidence and ease of use support employment of a hand rub for routine hand hygiene. It is microbiologically more effective in vitro and in vivo, it saves time, and preliminary data demonstrate better compliance than with hand washing. Therefore, a task force comprising experts from the Centers for Disease Control and Prevention and from professional societies is designing guidelines for the use of a hand rub in the United States. Today, most countries of Northern Europe recommend a hand rub for hand hygiene unless the hands are visibly soiled. Side effects are rare and are mainly related to dryness of the skin. This review evaluates the scientific and clinical evidence that support the use of alcohol-based hand rubs in health care facilities as a new option for hand hygiene.

Hand hygiene rates unaffected by installation of dispensers of a rapidly acting hand antiseptic

OBJECTIVE

The objective of the study was to improve health care workers' compliance with hand hygiene after patient contact by use of an alcohol-based hand antiseptic.

DESIGN AND METHODS

Six commercially available alcohol-based hand antiseptics were evaluated. The one most pleasing to the evaluators' hands was selected for the study. Baseline handwashing rates were assessed on 2 medical wards. Alcohol dispensers were mounted by every door on the 2 wards. An educational campaign was conducted with 4 weekly visits to these floors to remind and reinstruct staff about the use of the alcohol dispensers and to address questions. After 2 months handwashing rates were reassessed.

SETTING

The study was set in a university hospital.

RESULTS

The baseline handwashing rate was 60% (76/126). Physicians were most compliant (83%), followed by nurses (60%), technologists (56%), and housekeepers (36%). Two months later overall hand hygiene rates had decreased to 52% (P = .26). Nurses were most compliant (67%), followed by technologists (57%), physicians (29%), and housekeepers (25%). Physician compliance was associated with compliance by attending physicians whose example was usually followed by all other physicians on rounds.

CONCLUSIONS

A brief educational campaign and installation of dispensers containing a rapidly acting hand hygiene product near hospital rooms did not affect hand hygiene compliance. The behavior of attending physicians was predictive of handwashing rates for all others in the attending's retinue. Compliance with handwashing after half of all patient contacts was a result of perfect compliance by some and total noncompliance by others being observed.

Improving compliance with hand hygiene in hospitals

Hand hygiene prevents cross-infection in hospitals, but compliance with recommended instructions often is poor among healthcare workers. Although some previous interventions to improve compliance have been successful, none has achieved lasting improvement. This article reviews reported barriers to appropriate hand hygiene and factors associated with poor compliance. Easy access to hand hygiene in a timely fashion and the availability of skin-care lotion both appear to be necessary prerequisites for appropriate hand-hygiene behavior. In particular, in high-demand situations, hand rub with an alcohol-based solution appears to be the only alternative that allows a decent compliance. The hand-hygiene compliance level does not rely on individual factors alone, and the same can be said for its promotion. Because of the complexity of the process of change, it is not surprising that solo interventions often fail, and multimodal, multidisciplinary strategies are necessary. A framework that includes parameters to be considered for hand-hygiene promotion is proposed, based on epidemiologically driven evidence and review of the current knowledge. Strategies for promotion in hospitals should include reasons for noncompliance with recommendations at individual, group, and institutional levels. Potential tools for change should address each of these elements and consider their interactivity.

Handwashing before entering the intensive care unit: what we learned from continuous video-camera surveillance

Handwashing is one of the most important factors in controlling the spread of bacteria and in preventing the development of infections. This simple procedure does not have a high compliance rate. The Association for Professionals in Infection Control and Epidemiology, Inc, guideline recommends that hands must be washed before and after patient contact. In our intensive care unit (ICU), we have made it a rule that everyone should wash their hands before entering the ICU. The purpose of this study was to ascertain the handwashing compliance of all personnel and visitors to the ICU. A ceiling-mounted video camera connected to a time-lapse video cassette recorder recorded each person's actions when they entered the ICU during a 7-day period. Handwashing compliance was assessed for 3 different categories: ICU personnel, non-ICU personnel, and visitors to patients. There were 1030 entries to the ICU during the observation period. ICU personnel complied with handwashing in 71% of entries, non-ICU personnel in 74% of entries, and visitors to patients in 94% of entries. Handwashing compliance by visitors to patients was significantly higher than among personnel (P <.001). Handwashing compliance among personnel before entering the ICU was low. Continuous effort is needed to raise awareness of the handwashing issue, not only to ensure compliance with APIC recommendations but also in our facility, to ensure that health care personnel wash their hands on entry to the ICU.

A simple hand hygiene exercise

In an illustrative sequence of exercises, we teach our students how to don, use, and take off sterile gloves correctly and how to wash hands properly. During this sequence, the effect of a good handwashing technique as well as the effect of failures in aseptic technique with gloves is made directly visible by the use of finger paints. This technique helps medical staff to visualize microbial contamination of the hands and to increase the awareness of breaks in aseptic technique.

Patient education model for increasing handwashing compliance

BACKGROUND

A review of the literature on handwashing has documented the absence of research on the education of the patient as an intervention model for changing staff behavior regarding handwashing compliance. The primary objective of this project was to conduct a prospective control study of the effect of patient handwashing education on staff compliance with handwashing.

METHOD

A prospective, controlled, 6-week intervention/control study was performed in 4 community hospitals in South Jersey. Each hospital served as its own control. Patients were educated within 24 hours of admission about the importance of asking their health care workers to wash their hands. Soap usage and handwashing was calculated by bed-days. Patient follow-up was conducted through telephone interviews 2 weeks after discharge.

RESULTS

The patient handwashing education model increased soap usage by health care workers an average of 34% (P =.021); this increase was consistent across hospitals regardless of the initial soap usage rates. Of the patients interviewed, 81% read the materials provided, 57% asked health care workers whether they had washed their hands, and 81% of this 57% said they received positive responses.

CONCLUSIONS

For the first time, our findings document that education of patients regarding their role in monitoring handwashing compliance among health care workers can increase soap usage and handwashing and provide sustainable reinforcement of handwashing principles for health care workers.

Importance of handwashing in the prevention of cross-infection

Although the importance of handwashing is routinely acknowledged, a religious application of this practice still does not exist. Discussion in modern medicine on the subject of handwashing always states that it is the single most important factor in preventing hospital-acquired infection. This article continues the series on infection control and practical procedures by looking at the evidence that supports the above statement and discusses various handwashing methods and how to increase compliance to handwashing in the healthcare setting.

Behavioral interventions to improve infection control practices

No single intervention has been successful in improving and sustaining such infection control practices as universal precautions and handwashing by health care professionals. This paper examines several behavioral theories (Health Belief Model, Theory of Reasoned Action and Theory of Planned Behavior, self-efficacy, and the Transtheoretic Model) and relates them to individual factors, also considering interpersonal and organizational factors. Further, this article includes recommendations of individual and organizational components to be addressed when planning a theoretically based intervention for improving infection control practices. A hypothetic framework to enhance handwashing practice is proposed.

Infection control concepts in critical care

Patients with critical illnesses requiring aggressive medical intervention are at risk of acquiring serious nosocomial infection that may lead to increases in medical expenditures, morbidity, and mortality. Infection control in this population entails continuous surveillance for hospital-acquired infection, with investigation of outbreaks. Policies for effective antibiotic utilization, disinfection of medical devices and hospital environment, and patient isolation may limit nosocomial infection in this population. Finally, an effective infection control program should protect the health care worker from hospital-acquired infections through educational programs, routine health surveillance, vaccinations, and post-exposure care.

A multifaceted approach to changing handwashing behavior

BACKGROUND

Few interventions to influence handwashing have had measurable effects. This prospective quasi-experimental study was designed to address predisposing, enabling, and reinforcing factors to improve frequency of handwashing.

METHODS

Over a 12-month time period, a multifaceted intervention including focus group sessions, installation of automated sinks, and feedback to staff on handwashing frequency was implemented in one intensive care unit; a second unit served as a control. Dependent variables observed were handwashing frequency and self-reported practices and opinions about handwashing. Study phases included baseline, three phases of about 2 months each in duration in which sink automation was incrementally increased, and follow-up 2 months after intervention.

RESULTS

During 301 hours of observation, 2624 handwashings were recorded. Proportion of times hands were washed varied by indication, ranging from 38% before invasive procedures to 86% for dirty-to-clean procedures (p < 0.00001). Although there were some significant differences between experimental and control units in handwashing during the study, these differences had returned to baseline by the 2-month follow-up. There were no significant differences in self-reported practices and opinions from before to after intervention nor between units.

CONCLUSIONS

Intensive intervention, including feedback, education, and increased sink automation, had minimal long-term effect on handwashing frequency.

The use of a ward-based educational teaching package to enhance nurses' compliance with infection control procedures

Obtaining study leave is becoming difficult for clinical nurses in the current economic climate, but the need to develop new clinical skills and to maintain existing good practice remains of prime importance to patient care and will become mandatory with the advent of post-registration education and practice (PREP) in the UK. The ward is widely acknowledged as the best venue for learning clinical skills by nurse educationalists and for many nurses is the preferred learning environment. The feasibility of using a ward-based teaching package to enhance nurses' compliance with key infection control precautions (hand decontamination, the use of gloves and the safe handling and disposal of sharp instruments) was tested in a quasi-experimental research study conducted on matched surgical wards in a teaching hospital, controlling for variables likely to influence performance (knowledge, availability of resources to perform infection control, previous opportunity to develop infection control expertise and nursing workload). Nurses on two wards received the intervention (experimental group). The remaining wards, which received no intervention, operated as controls. The ward-based sessions consisted of a carefully planned sequence of theory and practical demonstration delivered to qualified nurses in the clinical environment at convenient times selected by the ward managers. Performance of infection control precautions was audited before the intervention and 3 months afterwards. The sessions were well evaluated and the clinical environment was considered suitable for teaching by the nurses, but heavy and unpredictable workload prevented the teaching programme from being implemented as planned. The analysis of covariance failed to detect any changes in performance between nurses in the control and experimental groups. The implications of the study findings are discussed to help develop creative new ways of strengthening ward-based educational programmes.

Teaching hospital medical staff to handwash

OBJECTIVE

To increase the frequency of handwashing by medical staff.

DESIGN

a prospective study of handwashing before and after patient contact.

SETTING

A paediatric intensive care unit in a tertiary hospital.

PARTICIPANTS

61 intensive care unit medical staff and visiting medical staff.

INTERVENTIONS

A five-phase behaviour modification program:(i) unobtrusive observation for four weeks to obtain a baseline handwashing rate (ii) overt observation for five weeks (preceded by written advice); (iii) overt observation continued for four weeks with performance feedback; (iv) all observation and feedback discontinued for seven weeks; and (v) unobtrusive observation for five weeks to obtain a residual rate.

RESULTS

939 patient contacts were observed. The baseline handwashing rates before and after patient contact were 12.4% and 10.6%, respectively. During overt observation, the respective rates increased and plateaued at 32.7% and 33.3%, but increased further (to 68.3% and 64.8%) during the period of performance feedback. The residual handwashing rates, observed unobtrusively seven weeks after the cessation of performance feedback, were 54.6% before and 54.9% after patient contact.

Nurses' infection-control practice: hand decontamination, the use of gloves and sharp instruments

Infection is an acknowledged hospital problem. Micro-organisms are disseminated mainly via hands but there is evidence that hand decontamination, the most important means of prevention, is performed too seldom, and not always after activities likely to result in heavy contamination. Nurses themselves are exposed to risks of infection, chiefly through contact with blood and body fluids, yet it has also been reported that gloves are not always worn during contact with patients' secretions and that the handling and disposal of sharp instruments may be performed unsafely. The study reported in this paper documents nursing behaviour in relation to hand decontamination, the use of gloves and sharps, taking into consideration a number of variables which could influence practice: availability of the expertise afforded by an infection-control nurse, clinical setting, nursing workload, knowledge and the resources available to control infection. Hands were decontaminated after 28.78% of patient contacts. Hands were decontaminated after 49.85% of activities likely to result in heavy contamination. Performance was related to nursing workload and the availability of hand decontaminating agents, especially when the nurses became busy. Use of gloves when they were available also proved good, with little evidence of wasteful use. The handling and disposal of sharps were commendable for most subjects but a few grossly unsafe incidents were nevertheless witnessed, apparently not associated with any of the variables examined.

Infection control in GP surgeries: safe practices?

Any increase in the use of invasive procedures carries with it an increased risk of cross-infection. The spread of the human immunodeficiency virus, together with increasing awareness of hepatitis B virus, cytomegalovirus and human papillomavirus have focused attention on the nature and adequacy of procedures to prevent cross-infection in general practice.

Effect of intravascular surveillance and education program on rates of nosocomial bloodstream infections

BACKGROUND

Because of high proportions of central line-related bloodstream infections (BSIs), an intravascular surveillance and education program (IVSP) was instituted in the study institution in 1987.

METHODS

A 6 1/2-year historical prospective study was conducted to evaluate the effects of the IVSP on incidence of nosocomial BSIs. With use of Centers for Disease Control and Prevention criteria, concurrent data on nosocomial BSIs were collected by two infection control professionals before, during, and for 3 years after the IVSP.

RESULTS

Hospital-wide BSIs during the 3-year IVSP and for 3 years after were 0.9% and 0.9% (p = 0.58) or 1.4 and 1.2/1000 patient-days (p = 0.24). Central line-related BSIs represented 29%, 24%, and 29% of the total BSIs 6 months before, 3 years during, and 6 months after the intervention, respectively (p = 0.62).

CONCLUSIONS

The IVSP resulted neither in a reduction in the total intravascular catheter-related BSIs nor in a change in the proportion of potentially preventable central line-related BSIs. To be successful, an intervention must include the authority to mandate practice changes; education and feedback without such authority were inadequate.