Social cohesion: The missing factor required for a successful hand hygiene program

Determinants of hand hygiene compliance among healthcare workers in intensive care units: a qualitative study

BACKGROUND

Practicing hand hygiene is a cost-effective method to decrease the occurrence of Healthcare-Associated Infections (HAIs). However, despite their simplicity, adhering to hand hygiene methods among healthcare workers (HCWs) can be highly challenging. We aim to examine the factors influencing hand hygiene compliance as perceived by HCWs working in the intensive care units (ICUs) at several major hospitals in Riyadh, Saudi Arabia.

METHOD

This qualitative study was conducted by adopting a content analysis to examine the interviews of HCWs who are currently working in the ICUs of various major hospitals located in the capital city of Riyadh, Saudi Arabia.

RESULTS

We interviewed 49 HCWs working in ICUs, with an average age of 38 and 8 years of experience. The HCWs comprised doctors (n = 12), anesthesiologists (n = 6), and nurses (n = 31). There were 34 females and 15 males among the participants. Our analysis revealed several factors that impact hand hygiene compliance, including individual, work/environment, team, task, patient, organizational, and management concerns. Several obstacles and possibilities for enhancement have been identified.

CONCLUSION

The results of this study would enhance our comprehension of hand hygiene practices and serve as a foundation for creating future strategies and assessment methods to enhance compliance with hand hygiene protocols in ICUs.

The effect of a prospective intervention program with automated monitoring of hand hygiene performance in long-term and acute-care units at a Veterans Affairs medical center

OBJECTIVE

To measure the impact of an automated hand hygiene monitoring system (AHHMS) and an intervention program of complementary strategies on hand hygiene (HH) performance in both acute-care and long-term care (LTC) units.

DESIGN

Prospective, nonrandomized, before-and-after intervention study.

SETTING

Single Veterans Affairs Medical Center (VAMC), with 2 acute-care units and 6 LTC units.

METHODS

An AHHMS that provides group HH performance rates was implemented on 8 units at a VAMC from March 2021 through April 2022. After a 4-week baseline period and 2.5-week washout period, the 52-week intervention period included multiple evidence-based components designed to improve HH compliance. Unit HH performance rates were expressed as the number of dispenses (events) divided by the number of patient room entries and exits (opportunities) × 100. Statistical analysis was performed with a Poisson general additive mixed model.

RESULTS

During the 4-week baseline period, the median HH performance rate was 18.6 (95% CI, 16.5-21.0) for all 8 units. During the intervention period, the median HH rate increased to 21.6 (95% CI, 19.1-24.4; P < .0001), and during the last 4 weeks of the intervention period (exactly 1 year after baseline), the 8 units exhibited a median HH rate of 25.1 (95% CI, 22.2-28.4; P < .0001). The median HH rate increased from 17.5 to 20.0 (P < .0001) in LTC units and from 22.9 to 27.2 (P < .0001) in acute-care units.

CONCLUSIONS

The intervention was associated with increased HH performance rates for all units. The performance of acute-care units was consistently higher than LTC units, which have more visitors and more mobile veterans.

Current issues in hand hygiene

BACKGROUND

Multiple aspects of hand hygiene have changed in recent years.

METHODS

A PubMed search was conducted to identify recent articles about hand hygiene.

RESULTS

The COVID-19 pandemic caused temporary changes in hand hygiene compliance rates and shortages of alcohol-based hand sanitizers (ABHSs), and in marketing of some products that were ineffective or unsafe. Fortunately, ABHSs are effective against SARS-CoV-2 and other emerging pathogens including Candida auris and mpox. Proper placement, maintenance, and design of ABHS dispensers have gained additional attention. Current evidence suggests that if an adequate volume of ABHS has been applied to hands, personnel must rub their hands together for at least 15 seconds before hands feel dry (dry time), which is the primary driver of antimicrobial efficacy. Accordingly, practical methods of monitoring hand hygiene technique are needed. Direct observation of hand hygiene compliance remains a challenge in many healthcare facilities, generating increased interest in automated hand hygiene monitoring systems (AHHMSs). However, several barriers have hindered widespread adoption of AHHMSs. AHHMSs must be implemented as part of a multimodal improvement program to successfully improve hand hygiene performance rates.

CONCLUSIONS

Remaining gaps in our understanding of hand hygiene warrant continued research into factors impacting hand hygiene practices.

Are there reasons behind high Handrub consumption? A French National in-depth qualitative assessment

Background

Hand hygiene (HH) is the most important measure for preventing healthcare-associated infections. A significant correlation between alcohol-based handrub consumption (AHRC) and observed HH compliance rates has been established. In France, publicly reported AHRC displayed a large heterogeneity across healthcare facilities (HCFs). We aimed to describe programmes for promoting HH in the top and medium AHRC scorers and to assess factors and drivers leading to a high AHRC score in a panel of French HCFs.

Methods

We performed a nationwide qualitative comparative case study based on in-depth semi-structured interviews in 16 HCFs with high, 4-year AHRC scores, and a sample of seven university hospitals (UHs) with medium AHRC scores. Infection Prevention and Control Team (IPC) members (n = 62), quality managers/chief executive officers (n = 23) and frontline workers (n = 6) were interviewed, using a grounded theory approach and an iterative thematic approach.

Results

Ninety-one interviews were performed. There was a large heterogeneity in IPC structures and objectives, with specific patterns associated with high AHRC that were more organisational than technical. Four areas emerged: (1) strong cohesive team structure with supportive and outcome-oriented work attitude, (2) IPC structure within the organization, (3) active support from the institution, (4) leadership and role model. Among high AHRC scorers, a good core IPC organisation, a proactive and flexible management, a frequent presence in the clinical wards, and working in a constructive safety climate were prominent.

Conclusion

We highlighted that IPC structure and activity is heterogeneous, with organisational and behavioural characteristics associated with high AHRC score. Beyond technical challenge, our work underlines the importance of strong structure of the IPC and behavioural approaches in implementing key IPC programmes.

Using nudges to promote clinical decision making of healthcare professionals: A scoping review

Nudging has been discussed in the context of policy and public health, but not so much within healthcare. This scoping review aimed to assess the empirical evidence on how nudging techniques can be used to affect the behavior of healthcare professionals (HCPs) in clinical settings. A systematic database search was conducted for the period January 2010-December 2020 using the PRISMA extension for Scoping Review checklist. Two reviewers independently screened each article for inclusion. Included articles were reviewed to extract key information about each intervention, including purpose, target behavior, measured outcomes, key findings, nudging strategies, intervention objectives and their theoretical underpinnings. Two independent dimensions, building on Kahneman's System 1 and System 2, were used to describe nudging strategies according to user action and timing of their implementation. Of the included 51 articles, 40 reported statistically significant results, six were not significant and two reported mixed results. Thirteen different nudging strategies were identified aimed at modifying four types of HPCs' behavior: prescriptions and orders, procedure, hand hygiene, and vaccination. The most common nudging strategy employed were defaults or pre-orders, followed by alerts or reminders, and active choice. Many interventions did not require any deliberate action from users, here termed passive interventions, such as automatically changing prescriptions to their generic equivalent unless indicated by the user. Passive nudges may be successful in changing the target outcome but may go unnoticed by the user. Future work should consider the broader ethical implications of passive nudges.

Electronic monitoring of doffing using video surveillance to minimise error rate and increase safety at Howard Springs International Quarantine Facility

Background

Safe donning and doffing of personal protective equipment (PPE) are critical to prevent transmission of infectious diseases. Novel strategies to improve infection prevention and control (IPC) adherence can optimise safety. We describe and quantify video surveillance of doffing at an outdoor hotel quarantine facility led by the Australian Medical Assistance Team in the Northern Territory, Australia.

Methods

Motion-activated video cameras were installed in seven areas where personnel doffed PPE upon exit from an area dedicated to quarantined residents. Video footage was reviewed daily and compliance issues were identified using a standardised checklist and risk graded to initiate feedback. We collated audit data from 1 February to 18 April 2021 to describe trends by month, staff group, doffing component and risk.

Results

In 235 h of video footage, 364 compliance issues were identified, of which none were considered high-risk compromising to PPE integrity. Compliance issues were low risk (55/364, 15%) or moderate risk (309/364, 85%) and the most common issue was missed or inadequate hand hygiene (156/364, 43%). Compliance issues per minute of video footage reviewed decreased following introduction of the activity, from 24 per 1000 in February to 7 per 1000 in March and April.

Conclusion

Video surveillance with feedback supported rapid response to improve IPC adherence in a challenging ambient environment. The activity focused on perfection to identify compliance issues that would go unreported in most healthcare settings and contributed to a suit of activities that prevented any high-risk PPE breaches or compromises to safety.

The impact of automated hand hygiene monitoring with and without complementary improvement strategies on performance rates

Objective:

To determine how engagement of the hospital and/or vendor with performance improvement strategies combined with an automated hand hygiene monitoring system (AHHMS) influence hand hygiene (HH) performance rates.

Design:

Prospective, before-and-after, controlled observational study.

Setting:

The study was conducted in 58 adult and pediatric inpatient units located in 10 hospitals.

Methods:

HH performance rates were estimated using an AHHMS. Rates were expressed as the number of soap and alcohol-based hand rub portions dispensed divided by the number of room entries and exits. Each hospital self-assigned to one of the following intervention groups: AHHMS alone (control group), AHHMS plus clinician-based vendor support (vendor-only group), AHHMS plus hospital-led unit-based initiatives (hospital-only group), or AHHMS plus clinician-based vendor support and hospital-led unit-based initiatives (vendor-plus-hospital group). Each hospital unit produced 1–2 months of baseline HH performance data immediately after AHHMS installation before implementing initiatives.

Results:

Hospital units in the vendor-plus-hospital group had a statistically significant increase of at least 46% in HH performance compared with units in the other 3 groups (P ≤ .006). Units in the hospital only group achieved a 1.3% increase in HH performance compared with units that had AHHMS alone (P = .950). Units with AHHMS plus other initiatives each had a larger change in HH performance rates over their baseline than those in the AHHMS-alone group (P < 0.001).

Conclusions:

AHHMS combined with clinician-based vendor support and hospital-led unit-based initiatives resulted in the greatest improvements in HH performance. These results illustrate the value of a collaborative partnership between the hospital and the AHHMS vendor.

[Hand hygiene and pandemic. Controversies]

Durante la pandemia de COVID-19 los sistemas sanitarios mundiales han estado tensionados de forma extrema. Las unidades de cuidados intensivos se situaron al límite de su capacidad y los centros sanitarios se vieron obligados a habilitar espacios para atender a pacientes críticos. Los profesionales requirieron trabajar en condiciones extenuantes alterando completamente sus rutinas de trabajo.

En este escenario, la higiene de las manos y el uso de guantes de los profesionales asistenciales se convirtieron en puntos críticos del riesgo de transmisión de infecciones relacionadas con la asistencia sanitaria.

Los resultados del estudio ENVIN de los años 2020 y 2021, correspondientes al momento pandémico, arrojaron datos preocupantes de crecimiento de las tasas de infección asociadas a dispositivos invasivos, llegando a constatar aumentos del 250% de las tasas en los peores momentos de la pandemia. Esto hizo pensar que se estaban produciendo excesivas situaciones de riesgo para el paciente. Cualquier estrategia preventiva debe situar la correcta higiene de manos y el uso adecuado de los guantes dentro de sus objetivos prioritarios. Por este motivo, el Consejo Asesor de los Proyectos Zero realizó una serie de adaptaciones y recomendaciones basadas en la evidencia disponible y en la opinión de expertos relacionadas con ambas medidas durante la situación de pandemia, y así favorecer las mejores prácticas en situaciones extremas. El objetivo de este artículo es revisar los aspectos clave relacionados con la higiene de manos, siempre enmarcada en la estrategia de seguridad de la OMS, las principales barreras para su cumplimiento, y la formulación de las principales adaptaciones propuestas por el Consejo Asesor de los proyectos Zero.

Nudging healthcare professionals in clinical settings: a scoping review of the literature

BACKGROUND

Healthcare organisations are in constant need of improvement and change. Nudging has been proposed as a strategy to affect people's choices and has been used to affect patients' behaviour in healthcare settings. However, little is known about how nudging is being interpreted and applied to change the behaviour of healthcare professionals (HCPs). The objective of this review is to identify interventions using nudge theory to affect the behaviour of HCPs in clinical settings.

METHODS

A scoping review. We searched PubMed and PsycINFO for articles published from 2010 to September 2019, including terms related to "nudging" in the title or abstract. Two reviewers screened articles for inclusion based on whether the articles described an intervention to change the behaviour of HCPs. Two reviewers extracted key information and categorized included articles. Descriptive analyses were performed on the data.

RESULTS

Search results yielded 997 unique articles, of which 25 articles satisfied the inclusion criteria. Five additional articles were selected from the reference lists of the included articles. We identified 11 nudging strategies: accountable justification, goal setting, suggested alternatives, feedback, information transparency, peer comparison, active choice, alerts and reminders, environmental cueing/priming, defaults/pre-orders, and education. These strategies were employed to affect the following 4 target behaviours: vaccination of staff, hand hygiene, clinical procedures, prescriptions and orders. To compare approaches across so many areas, we introduced two independent dimensions to describe nudging strategies: synchronous/asynchronous, and active/passive.

CONCLUSION

There are relatively few studies published referring to nudge theory aimed at changing HCP behaviour in clinical settings. These studies reflect a diverse set of objectives and implement nudging strategies in a variety of ways. We suggest distinguishing active from passive nudging strategies. Passive nudging strategies may achieve the desired outcome but go unnoticed by the clinician thereby not really changing a behaviour and raising ethical concerns. Our review indicates that there are successful active strategies that engage with clinicians in a more deliberate way. However, more research is needed on how different nudging strategies impact HCP behaviour in the short and long term to improve clinical decision making.

Examining Australian's beliefs, misconceptions and sources of information for COVID-19: a national online survey

OBJECTIVE

Public cooperation to practise preventive health behaviours is essential to manage the transmission of infectious diseases such as COVID-19. We aimed to investigate beliefs about COVID-19 diagnosis, transmission and prevention that have the potential to impact the uptake of recommended public health strategies.

DESIGN

An online cross-sectional survey.

PARTICIPANTS

A national sample of 1500 Australian adults with representative quotas for age and gender provided by an online panel provider.

MAIN OUTCOME MEASURE

Proportion of participants with correct/incorrect knowledge of COVID-19 preventive behaviours and reasons for misconceptions.

RESULTS

Of the 1802 potential participants contacted, 289 did not qualify, 13 declined and 1500 participated in the survey (response rate 83%). Most participants correctly identified 'washing your hands regularly with soap and water' (92%) and 'staying at least 1.5 m away from others' (90%) could help prevent COVID-19. Over 40% (incorrectly) considered wearing gloves outside of the home would prevent them from contracting COVID-19. Views about face masks were divided. Only 66% of participants correctly identified that 'regular use of antibiotics' would not prevent COVID-19.Most participants (90%) identified 'fever, fatigue and cough' as indicators of COVID-19. However, 42% of participants thought that being unable to 'hold your breath for 10 s without coughing' was an indicator of having the virus. The most frequently reported sources of COVID-19 information were commercial television channels (56%), the Australian Broadcasting Corporation (43%) and the Australian Government COVID-19 information app (31%).

CONCLUSIONS

Public messaging about hand hygiene and physical distancing to prevent transmission appears to have been effective. However, there are clear, identified barriers for many individuals that have the potential to impede uptake or maintenance of these behaviours in the long term. We need to develop public health messages that harness these barriers to improve future cooperation. Ensuring adherence to these interventions is critical.

Nudging clinicians: A systematic scoping review of the literature

BACKGROUND

While the quality of medical care delivered by physicians can be very good, it can also be inconsistent and feature behaviours that are entrenched despite updated information and evidence. The "nudge" paradigm for behaviour change is being used to bring clinical practice in line with desired standards. The premise is that behaviour can be voluntarily shifted by making particular choices instinctively appealing. We reviewed studies that are explicit about their use of nudge theory in influencing clinician behaviour.

METHODS

Databases were searched from April 2008 (the publication date of the book that introduced nudge theory to a wider audience) to November 2018, inclusive. The search strategy and narrative review of results addressed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

RESULTS

22 studies were identified. Randomized trials or pre-post comparisons were generally used in community-based settings; single-site pre-post studies were favoured in hospitals. The studies employed eight intervention types: active choice; patient chart redesign; default and default alerts; partitioning of prescription menus; audit and feedback; commitment messages; peer comparisons; and redirection of workflow. Three core cognitive factors underpinned the eight interventions: bias towards prominent choices (salience); predisposition to social norms; and bias towards time or cost savings.

CONCLUSIONS

Published studies that are explicit about their use of nudge theory are few in number and diverse in their settings, targets, and results. Default and chart re-design interventions reported the most substantial improvements in adherence to evidence and guideline-based practice. Studies that are explicit in their use of nudge theory address the widespread failure of clinical practice studies to identify theoretical frameworks for interventions. However, few studies identified in our review engaged in research to understand the contextual and site-specific barriers to a desired behaviour before designing a nudge intervention.

"Prevention is the biggest success": Barriers and enablers to personal biosecurity in the thoroughbred breeding industry

Employees in the equine industry are at occupational risk of zoonoses such as Hendra virus and equine chlamydiosis through exposure to infected materials. This study aimed to gain a deeper understanding of the views and experiences of employees, and the key drivers of infection control and personal biosecurity (PB) practices in the Thoroughbred breeding industry. Methods: An exploratory qualitative study was conducted in 2018 in New South Wales, Australia using interviews (9) and small group discussions (7). The 29 participants included veterinarians, veterinary nurses, foaling staff, stud managers and laboratory personnel working in a range of equine medicine settings. Interviews and focus groups were recorded, transcribed and analysed manually by at least two members of the research team. An iterative approach was used to derive themes. Results: Five main themes emerged: (i) greater awareness of current and emerging infectious risks promotes use of Personal Protective Equipment (PPE); (ii) currently available PPE is not comfortable, practical or well-suited to equine reproductive work in Australia's hot climate; (iii) creating supportive environments for PB reduces risk of exposure to infectious materials; (iv) strong leadership is required to implement sustainable change in workplace culture and practices; and (v) policy and economic factors play an important role in adopting biosecurity (BS) and PB measures in the workplace. Personnel working in the Australian Thoroughbred breeding industry face unique zoonotic risks in a challenging physical environment. A qualitative approach provided rich insights into social and physical factors motivating BS and PB in this occupational group. There is an opportunity for collaboration between Public Health services and industry partners to develop and implement strategies most likely to be effective in ensuring consistent uptake of PB measures in the workplace.

The impact of automatic video auditing with real-time feedback on the quality and quantity of handwash events in a hospital setting

BACKGROUND

Poor quality handwashing contributes to the spread of nosocomial infections. We investigate the impact of automatic video auditing (AVA) with feedback on the quality and quantity of handwashing in a hospital setting.

METHODS

AVA systems were mounted over all handwash sinks in a surgical unit. Phase 1 established baseline handwashing quality and quantity. Phase 2 examined the impact of real-time performance feedback, and phase 3 examined the incremental impact of weekly team performance reports. Phase 4 remeasured the baseline without feedback.

RESULTS

A total of 3,606 handwash events were audited. During phase 2 and 3, compliance with the World Health Organization technique improved from 15.7%-46% (P < .0001), and the average number of handwash events per patient per day increased from 0.91-2.25 (P < .0001). Performance returned to baseline in phase 4.

CONCLUSIONS

AVA with real-time feedback significantly improved the quality and quantity of handwashing. The combination of AVA with electronic monitoring will allow simultaneous auditing of hand hygiene quantity and quality. The impact of cognitive offloading onto the technology may have contributed to the return to baseline at the end of the study, and suggests further research is required in this area.

Hand hygiene promotion delivered by change agents-Two attitudes, similar outcome

OBJECTIVE

To assess the effect of peer-identified change agents (PICAs) compared to management-selected change agents (MSCAs) on hand hygiene behavior in acute care.

DESIGN

Randomized-controlled study.

SETTING

Two internal medicine wards of a public, university-affiliated, tertiary-care hospital in Malaysia.

METHODS

We randomly allocated 2 wards to hand hygiene promotion delivered either by PICAs (study arm 1) or by MSCAs (study arm 2). The primary outcome was hand hygiene compliance using direct observation by validated auditors. Secondary outcomes were hand hygiene knowledge and observations from ward tours.

RESULTS

Mean hand hygiene compliance in study arm 1 and study arm 2 improved from 48% (95% confidence interval [CI], 44%-53%) and 50% (95% CI, 44%-55%) in the preintervention period to 66% (63%-69%) and 65% (60%-69%) in the intervention period, respectively. We detected no statistically significant difference in hand hygiene improvement between the 2 study arms. Knowledge scores on hand hygiene in study arm 1 and study arm 2 improved from 60% and 63% to 98% and 93%, respectively. Staff in study arm 1 improved hand hygiene because they did not want to disappoint the efforts taken by the PICAs. Staff in study arm 2 felt pressured by the MSCAs to comply with hand hygiene to obtain good overall performance appraisals.

CONCLUSION

Although the attitude of PICAs and MSCAs in terms of leadership, mode of action and perception of their task by staff were very different, or even opposed, both PICAs and MSCAs effectively changed behavior of staff toward improved hand hygiene to comparable levels.

Assessing sustainability of hand hygiene adherence 5 years after a contest-based intervention in 3 Japanese hospitals

BACKGROUND

Our goal was to evaluate the 5-year sustainability of a multimodal intervention that included a prize to the hospital with the highest overall hand hygiene adherence rates among health care workers.

METHODS

We conducted an observational study in 3 Japanese tertiary care hospitals using unobtrusive direct observation of physician and nurse hand hygiene adherence. Observations were performed by a trained observer on inpatient medical, surgical, intensive care, and emergency units. The primary outcome was hand hygiene adherence rates before patient contact. Secondary outcomes were health care worker survey responses to a World Health Organization (WHO) questionnaire on hand hygiene practices.

RESULTS

Hand hygiene adherence rates had improved significantly after the introduction of a multimodal intervention (based on principles recommend by the WHO) in 2012 and 2013 (from 18.0% pre-intervention to 32.7% 6 months post-intervention; P < .001). No significant changes were found in hand hygiene adherence in these hospitals 5 years after the original intervention (31.9% 5 years after intervention; P = .53); however, substantial variability in hand hygiene adherence by unit and health care worker type was noted.

CONCLUSIONS

A multimodal hand hygiene initiative achieved sustained improvement in hand hygiene adherence in 3 Japanese hospitals 5 years after the original intervention.

Assessing Hand Hygiene and Low-Level Disinfection of Equipment Compliance in an Acute Care Setting: Mixed Methods Approach

BACKGROUND

Hand hygiene and low-level disinfection of equipment behaviors among hospital staff are some of the leading cost-effective methods to reduce hospital-acquired infections (HAI) among patients.

OBJECTIVE

The aim of this study is to examine hand hygiene and low-level disinfection of equipment practices in a central Texas hospital and to explore pertaining gaps, perceptions, and challenges.

METHODS

Data were collected using a multipronged mixed methods approach that included the following: (1) observation of hand hygiene and low-level disinfection practices (12 and 8 units during morning and evening shifts, respectively); (2) observation of usability/placement of hand sanitizer dispensers; (3) semistructured interviews; and (4) a follow-up email survey.

RESULTS

In total, 222 (156 morning shift and 66 evening shift) staff members were observed. Of 526 hand hygiene and 33 low-level disinfection opportunities, compliance was observed 410 (78%) and 17 (51%) times, respectively. Overall, 6 units (50%) had ≥0.80 (favorable) hand hygiene compliance during the morning shift and 2 units (25%) had ≥0.80 hand hygiene compliance during the evening shift. Aggregated low-level disinfection compliance was 0.54 during the morning and 0.33 during the evening. Overall, the odds of noncompliant hand hygiene behavior were 1.4 times higher among staff who worked during night shifts compared to day shifts; however, this relationship was not statistically significant (95% CI 0.86-2.18; P=.18). Noncompliant behavior was most likely among unit B staff during the evening; however, this relationship was not statistically significant (OR 5.3, 95% CI 0.84-32.9; P=.07) All units, except one, had similar hand sanitizer dispenser usability characteristics. In the qualitative part of the study, the following challenges were identified: "shortage of time while seeing patients," "sometimes the staff forgets," "concern about drying hands," "behavior is difficult or requires reminders," and "there may be issues with resources or access to supplies to perform these behaviors." Staff also stated that "a process that is considered effective is the Stop the Line program," and that the "behavior is easy and automatic."

CONCLUSIONS

Hand hygiene and low-level disinfection compliance is dependent on several personal and nonpersonal factors. Issues such as time constraints, peer pressure, work culture, available resources, and understanding of guidelines could influence staff behavior. The information collected through this study can be used to re-examine similar or related issues at a larger scale.

Hand hygiene - social network analysis of peer-identified and management-selected change agents

Background

Hand hygiene compliance can be improved by strategies fostering collaborative efforts among healthcare workers (HCWs) through change agents. However, there is limited information about how change agents shape the social networks of work teams, and how this relates to organisational culture. The objectives of this study were to describe the influence of peer-identified change agents (PICAs) and management-selected change agents (MSCAs) on hand hygiene, perception of their leadership style by peers, and the role of the organisational culture in the process of hand hygiene promotion.

Methods

This study, stratified in pre-, during, and post-intervention periods, was conducted between February 2017 and March 2018 in two wards at a tertiary care hospital in Malaysia. Hand hygiene promotion was facilitated either by PICAs (study arm 1) or MSCAs (study arm 2), and the two wards were randomly allocated to one of the two interventions. Outcomes were: 1) perceived leadership styles of PICAs and MSCAs by staff, vocalised during question and answer sessions; 2) the social network connectedness and communication patterns between HCWs and change agents by applying social network analysis; and 3) hand hygiene leadership attributes obtained from HCWs in the post-intervention period by questionnaires.

Results

Hand hygiene compliance in study arm 1 and study arm 2 improved by from 48% (95% CI: 44–53%) to 66% (63–69%), and from 50% (44–55%) to 65% (60–69%), respectively. There was no significant difference between the two arms. Healthcare workers perceived that PICAs lead by example, while MSCAs applied an authoritarian top-down leadership style. The organisational culture of both wards was hierarchical, with little social interaction, but strong team cohesion. Position and networks of both PICAs and MSCAs were similar and generally weaker compared to the leaders who were nominated by HCWs in the post-intervention period. Healthcare workers on both wards perceived authoritative leadership to be the most desirable attribute for hand hygiene improvement.

Conclusion

Despite experiencing successful hand hygiene improvement from PICAs, HCWs expressed a preference for the existing top-down leadership structure. This highlights the limits of applying leadership models that are not supported by the local organisational culture.

Antimicrobial Stewardship in Veterinary Medicine

While antimicrobial resistance is already a public health crisis in human medicine, therapeutic failure in veterinary medicine due to antimicrobial resistance remains relatively uncommon. However, there are many pathways by which antimicrobial resistance determinants can travel between animals and humans: by close contact, through the food chain, or indirectly via the environment. Antimicrobial stewardship describes measures that can help mitigate the public health crisis and preserve the effectiveness of available antimicrobial agents. Antimicrobial stewardship programs have been principally developed, implemented, and studied in human hospitals but are beginning to be adapted for other applications in human medicine. Key learning from the experiences of antimicrobial stewardship programs in human medicine are summarized in this article-guiding the development of a stewardship framework suitable for adaptation and use in both companion animal and livestock practice. The antimicrobial stewardship program for veterinary use integrates infection prevention and control together with approaches emphasizing avoidance of antimicrobial agents. The 5R framework of continuous improvement that is described recognizes the importance of executive support; highly motivated organizations and teams (responsibility); the need to review the starting position, set objectives, and determine means of measuring progress and success; and a critical focus on reducing, replacing, and refining the use of antimicrobial agents. Significant issues that are currently the focus of intensive research include improved detection and diagnosis of infections, refined dosing regimens that are simultaneously effective while not selecting resistance, searches for alternatives to antimicrobial agents, and development of improved vaccines to enhance immunity and reduce disease.

Identifying heterogeneity in the Hawthorne effect on hand hygiene observation: a cohort study of overtly and covertly observed results

Background

Observation and feedback are core strategies of hand hygiene (HH) improvement. Direct overt observation is currently the gold standard method. Observation bias, also known as the Hawthorne effect, is a major disadvantage of this method. Our aim was to examine the variation of the Hawthorne effect on HH observation in different healthcare groups and settings.

Methods

A prospective cohort study was performed in a tertiary teaching hospital during a 15-month period. Up to 38 overt observers (82% nurses) and 93 covert observers (81% medical students) participated in HH observation. The HH events observed overtly were matched for occupation, department, observation time, and location with those observed covertly. The data of matched pairs were then analysed to detect possible Hawthorne effects on different variables.

Results

A total of 31,522 HH opportunities were observed (4581 overtly, 26,941 covertly). There were 3047 matched pairs after 1:1 matching of overt and covert observations. The overall HH compliance was higher with overt observation than with covert observation (78% vs. 55%, p < 0.001). The Hawthorne effect was nearly three times larger in nurses (30 percentage points) than in physicians (11 percentage points) and was significantly greater in outpatient clinics (41 percentage points) than in intensive care units (11 percentage points). The magnitude of the Hawthorne effect varied among healthcare worker occupations and observation locations (p values both < 0.001) but not among departments, observation times, or HH indications.

Conclusions

Heterogeneity in the Hawthorne effect may influence the interpretation of overt observations and prevent the correct identification of target populations with poor HH compliance. Therefore, directly observed HH compliance may not be an adequate performance indicator for infection control.

Hand hygiene compliance rates: Fact or fiction?

BACKGROUND

The mandatory national hand hygiene program requires Australian public hospitals to use direct human auditing to establish compliance rates. To establish the magnitude of the Hawthorne effect, we compared direct human audit rates with concurrent automated surveillance rates.

METHODS

A large tertiary Australian teaching hospital previously trialed automated surveillance while simultaneously performing mandatory human audits for 20 minutes daily on a medical and a surgical ward. Subtracting automated surveillance rates from human audit rates provided differences in percentage points (PPs) for each of the 3 quarterly reporting periods for 2014 and 2015.

RESULTS

Direct human audit rates for the medical ward were inflated by an average of 55 PPs in 2014 and 64 PPs in 2015, 2.8-3.1 times higher than automated surveillance rates. The rates for the surgical ward were inflated by an average of 32 PPs in 2014 and 31 PPs in 2015, 1.6 times higher than automated surveillance rates. Over the 6 mandatory reporting quarters, human audits collected an average of 255 opportunities, whereas automation collected 578 times more data, averaging 147,308 opportunities per quarter. The magnitude of the Hawthorne effect on direct human auditing was not trivial and produced highly inflated compliance rates.

CONCLUSIONS

Mandatory compliance necessitates accuracy that only automated surveillance can achieve, whereas daily hand hygiene ambassadors or reminder technology could harness clinicians' ability to hyperrespond to produce habitual compliance.

Positive deviance and hand hygiene of nurses in a Quebec hospital: What can we learn from the best?

BACKGROUND

Although it is well known that hand hygiene is the most effective measure to prevent health care-associated infections, hand hygiene adherence is low in Quebec, as it is elsewhere. For this study, an innovative framework was used to explore the clinical practice of nurses regarding hand hygiene and the factors that influence it: positive deviance, or the idea that there are people who find better solutions to problems than their peers. This study investigated positive deviance at the level of the care team to shed light on group dynamics.

METHODS

We conducted focused ethnographies on 2 care units-a medical-surgery unit and a palliative care unit-at a Montreal university hospital. Data collection consisted mainly of systematic observations and individual interviews with nurses.

RESULTS

The results show that positive deviance related to hand hygiene is instigated by social cohesion within a care team, created, in this study, by the mobilizing leadership of the head nurse in the medical-surgery unit and the prevailing humanist philosophy in the palliative care unit.

CONCLUSIONS

In health care, it can be useful to apply the positive deviance approach to care teams instead of individuals to better understand the ideologic and structural differences linked to better hand hygiene performance by the nurses.

Pilot study of digital tools to support multimodal hand hygiene in a clinical setting

BACKGROUND

Digital tools for hand hygiene do not share data, limiting their potential to support multimodal programs. The Christie NHS Foundation Trust, United Kingdom, worked with GOJO (in the United States), MEG (in Ireland), and SureWash (in Ireland) to integrate their systems and pilot their combined use in a clinical setting.

METHODS

A 28-bed medical oncology unit piloted the system for 5 weeks. Live data from the tools were combined to create a novel combined risk status metric that was displayed publicly and via a management Web site.

RESULTS

The combined risk status reduced over the pilot period. However, larger and longer duration studies are required to reach statistical significance. Staff and especially patient reaction was positive in that 70% of the hand hygiene training events were by patients. The digital tools did not negatively impact clinical workflow and received positive engagement from staff and patients. The combined risk status did not change significantly over the short pilot period because there was also no specific hand hygiene improvement campaign underway at the time of the pilot study.

CONCLUSIONS

The results indicate that integrated digital tools can provide both rich data and novel tools that both measure impact and provide feedback to support the implementation of multimodal hand hygiene campaigns, reducing the need for significant additional personnel resources.