Role of hand hygiene in healthcare-associated infection prevention

Reduction in diarrhea cases following implementation of COVID-19 hand hygiene interventions in Ghana: A causal impact analysis

BACKGROUND

The human hand has constant contact with the environment, hence requires regular hand hygiene. Hand hygiene has gained recognition because of the COVID-19 pandemic and is a largely effective, affordable preventive measure against infectious diseases. This study used both national and sub-national analyses to evaluate the effect of COVID-19 handwashing guidelines on instances of diarrhea in Ghana.

METHODS

Data on diarrhea cases spanning February 2018 and March 2022 were retrieved from the District Health Information Management System (DHIMS 2) using a data extraction guide. The data were summarized using descriptive statistics. The difference in diarrhea cases between the pre-COVID-19 and COVID-19 periods was measured using a two-sample t-test across Ghana's 16 administrative areas. Causal Impact package in R statistical software was employed to determine the impact of the introduction of COVID-19 hand hygiene protocols on diarrheal disease.

RESULTS

A total of 5,645,533 diarrheal cases reported between February 2018 and March 2022 through the routine MIS (DHIMS2) were examined. Fifty-three percent of the cases occurred before the introduction of the hand hygiene protocol. Descriptive statistics indicated a statistically significant decrease in average diarrheal cases during the hand hygiene implementation era (13,463 cases reduction, p<0.001). Sub-national analyses revealed significant reductions in various regions: Greater Accra, Ashanti, Ahafo, Central, Eastern, Northern, Upper East, Upper West, and Volta (p<0.05). Causal impact analysis confirmed 11.0% nationwide reduction in diarrheal cases attributed to the COVID-19 hand hygiene protocols (p<0.001).

CONCLUSION

This study underscores the effectiveness of COVID-19 hand hygiene protocols in reducing diarrheal morbidity in Ghana, with varying regional impacts. These findings advocate for the sustenance of investments and commitments made at the COVID hand hygiene protocols, particularly in this era where the pandemic appears controlled.

Evaluating the tolerability and acceptability of a locally produced alcohol-based handrub and hand hygiene behaviour among health workers in Sierra Leone: a longitudinal hospital-based intervention study

BACKGROUND

Alcohol-based handrub (ABHR) is the gold standard for hand hygiene (HH) and is a cornerstone of infection prevention and control (IPC) strategies. However, several factors influence the efficient use of ABHR by health workers. This study evaluated the tolerability and acceptability of a locally produced ABHR product and HH behaviour among health workers.

METHODS

A longitudinal hospital-based intervention study was conducted in accordance with the WHO's standardized protocol for evaluating ABHR tolerability and acceptability (Method 1). Sixty health workers across 4 hospitals in Sierra Leone were observed over a 30-day period at three separate visits (days 1, 3-5, and 30) by trained observers. The outcomes of interest included skin tolerability and product acceptabilityevaluated using subjective and objective measures.

RESULTS

Objective and subjective evaluations demonstrated strong skin tolerability and high acceptability with the product. At all three visits, the skin tolerability score assessed by trained observers was < 2 in ≥ 97% of participants, exceeding the WHO benchmark score (BMS = < 2 in ≥ 75%). Participants' self-evaluations of overall skin integrity were 97% (visit 2) and 98% (visit 3) for scores > 4 (BMS = > 4 in ≥ 75%). The primary acceptability criteria increased up to 95% (colour) and 88% (smell) at visit 3 (BMS = > 4 in ≥ 50%). Despite high acceptability, the product's drying effect remained low at 52% and 58% during visits 2 and 3, respectively (BMS = > 4 in ≥ 75%). There were positive HH behaviours (n = 53, 88%), with more than half (n = 38, 63%) of them exhibiting HH at almost every HH moment. The mean ABHR was notably high (76.1 ml, SD ± 35), especially among nurses (mean = 80.1 ml) and doctors (mean = 74.0 ml).

CONCLUSION

The WHO-formulated, locally produced ABHR was well tolerated and accepted by health workers. These findings support the continuous utilization of evidence-based, cost-effective hand hygiene interventions in resource-limited settings. High handrub consumption and frequent HH practices were noticeable HH behaviours. Further research is recommended to optimize product formulations for skin dryness and investigate the association between ABHR consumption and hand hygiene compliance.

Organizational and infrastructural risk factors for health care-associated Clostridioides difficile infections or methicillin-resistant Staphylococcus aureus in hospitals

BACKGROUND

This study explores the infrastructural and organizational risk factors for health care-associated (HCA) Clostridioides difficile infections (CDIs) and methicillin-resistant Staphylococcus aureus (MRSA) in hospitals.

METHODS

This is a retrospective observational study involving all eligible inpatient units from 12 hospitals in British Columbia, Canada, from April 1, 2020 to September 16, 2021. The outcomes were the average HCA CDI or MRSA rates. Covariates included, but were not limited to, infection control factors (eg, hand hygiene rate), infrastructural factors (eg, unit age), and organizational factors (eg, hallway bed utilization). Multivariable regression was performed to identify statistically significant risk factors.

RESULTS

Older units were associated with higher HCA CDI rates (adjusted relative risk [aRR]: 0.012; 95% confidence interval (CI) [0.004, 0.020]). Higher HCA MRSA rates were associated with decreased hand hygiene rate (aRR: -0.035; 95% CI [-0.063, -0.008]), higher MRSA bioburden (aRR: 9.008; 95% CI [5.586, 12.429]), increased utilization of hallway beds (aRR: 0.680; 95% CI [0.094, 1.267]), increased nursing overtime rate (aRR: 5.018; 95% CI [1.210, 8.826]), and not keeping the clean supply room door closed (aRR: -0.283; 95% CI [-0.536, -0.03]).

CONCLUSIONS

The study confirmed the multifaceted nature of infection prevention and emphasized the importance of interdepartmental collaboration to improve patient safety.

Transfer of micro-organisms from dry surface biofilms and the influence of long survival under conditions of poor nutrition and moisture on the virulence of Staphylococcusaureus

BACKGROUND

Biofilms on dry hospital surfaces can enhance the persistence of micro-organisms on dry harsh clinical surfaces and can potentially act as reservoirs of infectious agents on contaminated surfaces.

AIM

This study was conducted to quantify the transfer of viable Staphylococcus aureus cells from dry biofilms through touching and to investigate the impact of nutrient and moisture deprivation on virulence levels in S. aureus.

METHODS

Dry biofilms of S. aureus ATCC 25923 and a defective biofilm-forming ability mutant, S. aureus 1132, were formed in 24-well plates under optimized conditions mimicking dry biofilm formation on clinical surfaces. Microbial cell transfer was induced through the touching of the dry biofilms, which were quantified on nutrient agar. To investigate the impact of nutrient and moisture deprivation on virulence levels, dry and standard biofilms as well as planktonic cells of S. aureus ATCC 25923 were inoculated into Galleria mellonella and their kill rates compared.

FINDINGS

Results of this study showed that viable cells from dry biofilms of S. aureus ATCC 25923 were significantly more virulent and readily transferrable from dry biofilms through a touch test, therefore representing a greater risk of infection. The biofilm-forming capability of S. aureus strains had no significant impact on their transferability with more cells transferring when biofilm surfaces were wet.

CONCLUSIONS

These findings indicate that dry biofilms on hospital surfaces may serve as a reservoir for the dissemination of pathogenic micro-organisms in hospitals, thus highlighting the importance of regular cleaning and adequate disinfection of hospital surfaces.

Process Evaluation of an Acute-Care Nurse-Centred Hand Hygiene Intervention in US Hospitals

This paper describes a process evaluation of a 'wise' intervention that took place in six acute care units in two medical-surgical teaching hospitals in the United States during 2016-2017. 'Wise' interventions are short, inexpensive interventions that depend on triggering specific psychological mechanisms to achieve behaviour change. This study sought to increase the hand hygiene compliance (HHC) rates before entering a patient's room among nurses. The intervention centred on the use of threat to professional identity to prompt improved HHC. Through questionnaires administered to intervention participants and the implementation facilitator, together with independent observation of intervention delivery, we examined whether the steps in the Theory of Change occurred as expected. We found that aspects of the implementation-including mode of delivery, use of incentives, and how nurses were recruited and complied with the intervention-affected reach and likely effectiveness. While components of the intervention's mechanisms of impact-such as the element of surprise-were successful, they ultimately did not translate into performance of the target behaviour. Performance was also not affected by use of an implementation intention as repeated performance of HHC over years of being a nurse has likely already established well-ingrained practices. Context did have an effect; the safety culture of the units, the involvement of the Nurse Managers, the level of accountability for HHC in each unit, and the hospitals themselves all influenced levels of engagement. These conclusions should have implications for those interested in the applicability of 'wise' interventions and those seeking to improve HHC in hospitals.

Implementation and long-term efficacy of a multifaceted intervention to reduce central line-associated bloodstream infections in intensive care units of a low-middle-income country

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) pose a significant risk to critically ill patients, particularly in intensive care units (ICU), and are a significant cause of hospital-acquired infections. We investigated whether implementation of a multifaceted intervention was associated with reduced incidence of CLABSIs.

METHODS

This was a prospective cohort study over nine years. We implemented a bundled intervention approach to prevent CLABSIs, consisting of a comprehensive unit-based safety program (CUSP). The program was implemented in the Neonatal ICU, Medical ICU, and Surgical ICU departments at the Aga Khan University Hospital in Pakistan.

RESULTS

The three intervention ICUs combined were associated with an overall 36% reduction in CLABSI rates and a sustained reduction in CLABSI rates for > a year (5 quarters). The Neonatal ICU experienced a decrease of 77% in CLABSI rates lasting ∼1 year (4 quarters). An attendance rate above 88% across all stakeholder groups in each CUSP meeting correlated with a better and more sustained infection reduction.

CONCLUSIONS

Our multifaceted approach using the CUSP model was associated with reduced CLABSI-associated morbidity and mortality in resource-limited settings. Our findings suggest that a higher attendance rate (>85%) at meetings may be necessary to achieve sustained effects post-intervention.

Hand hygiene in a clinical setting: Evaluation of an electronic monitoring system in relation to direct observations

BACKGROUND

This study evaluated the accuracy of an electronic monitoring system for assessing hand hygiene in a clinical setting in relation to direct observations.

METHODS

An electronic monitoring system was installed in a surgical ward at a tertiary hospital in Sweden. Hand hygiene events registered by the system were compared with direct observations conducted simultaneously by a trained observer following the World Health Organization's "My five moments for hand hygiene". A 4-step protocol was developed to evaluate the system's ability to accurately monitor hand hygiene in a clinical setting.

RESULTS

A total of 947 opportunities for hand hygiene were observed during June to December 2019. Of these, 484 opportunities were correctly captured by the electronic monitoring system and included in the calculations for accuracy. Sensitivity was 90.2% with a positive predictive value of 95.7%, while specificity was 50.0% with a negative predictive value of 29.0%. Overall accuracy was 87.1%.

CONCLUSIONS

Evaluating technical systems assessing hand hygiene in clinical settings is hampered by several challenges. The 4-step protocol helped to identify the limitations and strengths of the evaluated electronic monitoring system, revealing high accuracy while also detecting system errors.

Appropriate Hand Drying - The Missed Step of Hand Hygiene: A Qualitative Evaluation of Hand Drying Practices among Indian Health Care Workers

Hand hygiene remains one of the most effective methods of preventing healthcare-associated infections. Hand drying is the end point of hand hygiene. Hand drying after hand hygiene is less explored, and the practice varies in different facilities. This explorative study was done to know the various hand-drying methods and practices of healthcare workers in Indian settings. This was a descriptive cross-sectional questionnaire-based observational study initiated from a tertiary care setup in Uttarakhand. Healthcare workers over 18 years of age directly involved in patient care were enrolled. A semi-structured questionnaire with both open-ended and close-ended questions was used with snowballing sampling technique. Statistical analysis was done using Statistical Package for Social Sciences (SPSS). Out of the eligible 395 respondents, 62.8% were female. The mean age of the respondents was 31.34 ± 8.44 years and average working hours were 8.87 ± 2.97 (range 4-24) hours. Only 72.7% did hand hygiene always before touching a patient. Nurses were more compliant about hand hygiene than doctors (P < 0.0001). A total of 82.8% were aware of appropriate hand-drying methods. Staff in the Intensive care unit Intensive care unit (ICU) setup were more aware of hand drying practices (P = 0.033). A total of 21.8% wiped their hands on their clothing to dry their hands. This was more in staff from paraclinical departments (P = 0.001). A total of 35.7% used handkerchiefs to dry hands. Resident doctors used handkerchiefs more than senior doctors or nursing staff (P = 0.01). A total of 49.9% of respondents spent less than 10 seconds in hand drying. Hand-hygiene knowledge is high among healthcare workers in India, but the knowledge of appropriate hand-drying practices is lacking. There is wide variation in the practice of hand drying. Better hand drying guidelines and incorporating hand drying as the essential endpoint of the hand hygiene ritual are warranted.

Video-based automatic hand hygiene detection for operating rooms using 3D convolutional neural networks

Hand hygiene among anesthesia personnel is important to prevent hospital-acquired infections in operating rooms; however, an efficient monitoring system remains elusive. In this study, we leverage a deep learning approach based on operating room videos to detect alcohol-based hand hygiene actions of anesthesia providers. Videos were collected over a period of four months from November, 2018 to February, 2019, at a single operating room. Additional data was simulated and added to it. The proposed algorithm utilized a two-dimensional (2D) and three-dimensional (3D) convolutional neural networks (CNNs), sequentially. First, multi-person of the anesthesia personnel appearing in the target OR video were detected per image frame using the pre-trained 2D CNNs. Following this, each image frame detection of multi-person was linked and transmitted to a 3D CNNs to classify hand hygiene action. Optical flow was calculated and utilized as an additional input modality. Accuracy, sensitivity and specificity were evaluated hand hygiene detection. Evaluations of the binary classification of hand-hygiene actions revealed an accuracy of 0.88, a sensitivity of 0.78, a specificity of 0.93, and an area under the operating curve (AUC) of 0.91. A 3D CNN-based algorithm was developed for the detection of hand hygiene action. The deep learning approach has the potential to be applied in practical clinical scenarios providing continuous surveillance in a cost-effective way.

Connecting pathogen transmission and healthcare worker cognition: a cognitive task analysis of infection prevention and control practices during simulated patient care

BACKGROUND

Relatively little is known about the cognitive processes of healthcare workers that mediate between performance-shaping factors (eg, workload, time pressure) and adherence to infection prevention and control (IPC) practices. We taxonomised the cognitive work involved in IPC practices and assessed its role in how pathogens spread.

METHODS

Forty-two registered nurses performed patient care tasks in a standardised high-fidelity simulation. Afterwards, participants watched a video of their simulation and described what they were thinking, which we analysed to obtain frequencies of macrocognitive functions (MCFs) in the context of different IPC practices. Performance in the simulation was the frequency at which participants spread harmless surrogates for pathogens (bacteriophages). Using a tertiary split, participants were categorised into a performance group: high, medium or low. To identify associations between the three variables-performance groups, MCFs and IPC practices-we used multiblock discriminant correspondence analysis (MUDICA).

RESULTS

MUDICA extracted two factors discriminating between performance groups. Factor 1 captured differences between high and medium performers. High performers monitored the situation for contamination events and mitigated risks by applying formal and informal rules or managing their uncertainty, particularly for sterile technique and cleaning. Medium performers engaged more in future-oriented cognition, anticipating contamination events and planning their workflow, across many IPC practices. Factor 2 distinguished the low performers from the medium and high performers who mitigated risks with informal rules and sacrificed IPC practices when managing tradeoffs, all in the context of minimising cross-contamination from physical touch.

CONCLUSIONS

To reduce pathogen transmission, new approaches to training IPC (eg, cognitive skills training) and system design are needed. Interventions should help nurses apply their knowledge of IPC fluidly during patient care, prioritising and monitoring situations for risks and deciding how to mitigate risks. Planning IPC into one's workflow is beneficial but may not account for the unpredictability of patient care.

Italian National Surveillance of Alcohol-Based Hand Rub Consumption in a Healthcare Setting-A Three-Year Analysis: 2020-2022

Background/Objectives: Hand hygiene (HH) is pivotal in mitigating infectious disease transmission and enhancing public health outcomes. This study focuses on detailing the national surveillance system for alcohol-based hand rub (ABHR) consumption in healthcare facilities across Italy, presenting results from a comprehensive three-year evaluation period, from 2020 to 2022. It aims to delineate this surveillance system and report on ABHR consumption trends in various Regions/Autonomous Provinces (Rs/APs). Methods: ABHR consumption data, collected through the ABHR Italian national surveillance system, coordinated by the Istituto Superiore di Sanità (ISS), were analyzed. Statistical methods, e.g., the Mann-Whitney test, were used to assess trends in ABHR consumption, expressed in liters per 1000 patient days (L/1000PD). Results: The results show significant variation in ABHR consumption across Rs/APs and over the years studied. National median ABHR consumption decreased from 2020 to 2022, with a significant reduction from a median of 24.5 L/1000PD in 2020 to 20.4 L/1000PD in 2021 and 15.6 L/1000PD in 2022. Conclusions: The decline in ABHR consumption raises concerns about the ongoing adherence to HH practices in Italian healthcare settings. This underscores the essential role that systematic ABHR monitoring and improved surveillance play in enhancing HH compliance, suggesting that sustained and strategic efforts are fundamental to uphold high standards of hygiene and to effectively respond to fluctuating ABHR usage trends over time. Further research is needed to explore barriers to effective ABHR use and to develop targeted strategies to improve HH practices.

Hand Hygiene Education Components Among First-Year Nursing Students: A Cluster Randomized Clinical Trial

Importance

Few studies have directly and objectively measured the individual and combined effects of multifaceted hand hygiene education programs.

Objective

To evaluate the individual and combined immediate effects of an instructional video and hand scan images on handwashing quality, decontamination, and knowledge improvement.

Design, Setting, and Participants

This cluster randomized clinical trial was conducted in June to July 2023 among first-year nursing students at a university in Hong Kong. The study used an intention-to-treat analysis.

Intervention

Hand hygiene education sessions featuring an instructional video, hand scan images, or both.

Main Outcomes and Measures

The primary outcome was the change in residue from fluorescent lotion remaining on participants' hands after handwashing before and after the intervention. The secondary outcomes included handwashing quality and knowledge of hand hygiene.

Results

A total of 270 of 280 students (mean [SD] age, 19 [1] years; 182 [67.4%] female) participated in the trial (96.4% participation rate). Participants were randomized to a control group (66 participants), hand scan image group (68 participants), instructional video group (67 participants), and hand scan image with instructional video group (69 participants). All intervention groups had greater reductions in residue after the intervention compared with the control group, although none reached statistical significance (hand scan image group: 3.9 [95% CI, 2.0-5.8] percentage points; instructional video group: 4.8 [95% CI, 2.9-6.7] percentage points; hand scan image with instructional video: 3.5 [95% CI, 1.6-5.4] percentage points; control group: 3.2 [95% CI, 1.3-5.2] percentage points). The instructional video group showed a significant improvement in their handwashing performance, with a higher percentage of participants correctly performing all 7 steps compared with the control group (22.4% [95% CI, 13.1% to 31.6%] vs 1.5% [-7.9% to 10.9%]; P < .001). Hand scan images revealed that wrists, fingertips, and finger webs were the most commonly ignored areas in handwashing.

Conclusions and Relevance

In this cluster randomized clinical trial of an education program for hand hygiene, a handwashing instructional video and hand scan images did not enhance the level of decontamination. The intervention group had improved handwashing techniques compared with the control group, a secondary outcome.

Trial Registration

ClinicalTrials.gov Identifier: NCT05872581.

Hand hygiene in emergencies: Multiprofessional perceptions from a mixed methods based online survey in Germany

Introduction

Despite high vulnerability to infection, hand disinfection compliance in emergencies is low. This is regularly justified as the disinfection procedure delays life support, and instead, wearing disposable gloves is preferred. Simulation studies showed higher achievable compliance than detected in real-life situations. This study aimed to explore healthcare providers' attitudes toward hand disinfection and using gloves in emergencies.

Methods

We conducted an anonymous online survey in Germany on the attitude and subjective behavior in the five moments of hand hygiene in a closed environment and an open convenience sampling survey. Statistics included paired student's t-tests corrected for multiple testing. For qualitative analysis, we employed a single-coder approach.

Results

In 400 participants, we detected low priority of WHO-1 (before touching a patient) and WHO-2 (before clean/aseptic procedure) hand hygiene moments, despite knowing the risks of omission of hand disinfection. For all moments, self-assessment exceeded the assessment of colleagues (p < 0.001). For WHO-3, we detected a lower disinfection priority for wearing gloves compared to contaminated bare hands. Qualitative analyses revealed five themes: basic conditions, didactic implementations, cognitive load, and uncertainty about feasibility and efficacy.

Discussion

Considering bias, the study's subjective nature, the unknown role of emergency-related infections contributing to hospital-acquired infections, and different experiences of healthcare providers, we conclude that hand disinfection before emergencies is de-prioritized and justified by the emergency situation regardless of the objective feasibility.

Conclusion

This study reveals subjective and objective barriers to implementation of WHO-1 and WHO-2 moments of hand disinfection to be further evaluated and addressed in educational programs.

Hand hygiene knowledge among nurses and nursing students-a descriptive cross-sectional comparative survey using the WHO's "Hand Hygiene Knowledge Questionnaire"

Aim

To determine the level of knowledge and explore the difference of hand hygiene between nursing students and nurses.

Background

Annually, 3.8 million people in Europe acquire healthcare-associated infections, highlighting the importance of hand hygiene. Despite WHO's emphasis on the fact that greater hand hygiene knowledge correlates with improved hand hygiene compliance, several studies have shown knowledge gaps among nurses and nursing students regarding hand hygiene.

Design

Descriptive cross-sectional comparative survey.

Methods

A version of the WHO "Hand Hygiene Knowledge Questionnaire", translated into Swedish, was used for data collection among nursing students in the first and last semester, and registered nurses from a university and associated hospital. Data were analyzed by descriptive statistics, and comparison between groups with Fisher's exact test, one-way ANOVA, and post-hoc tests (Pairwise Z-Tests, Tukey HSD).

Results

The survey, conducted between December 2020 and January 2021, received responses from 201 participants, including 71 first semester students, 46 last semester students and 84 registered nurses, showing moderate (55.7% [50-74% correct answers]) to good (43.8% [75-100% correct answers]) knowledge levels. First-semester students scored lower (17.0 ± 2.1) than last-semester students (18.8 ± 1.8) and registered nurses (18.3 ± 2.1) out of 25 questions.

Discussion

It is necessary for all groups to receive proper education on hand hygiene knowledge and to have an educational program that does not separate the groups but combines them with continuing education, since the students will someday be influencing future hand hygiene knowledge as a peer, together with the nurse.

Implementing a multimodal intervention using local resources to improve hand hygiene compliance in a comprehensive specialized hospital in Mekelle, Northern Ethiopia

BACKGROUND

Hand hygiene (HH) is known to be the most effective practice to reduce Healthcare-associated infections (HAIs). The main barriers to HH practices among healthcare workers (HCWs) in Sub-Saharan Africa are heavy workload, infrastructural deficits, and poorly positioned facilities. There is limited data on HH compliance and particularly on the impact of the World Health Organization's (WHO) multimodal HH strategy in low- and middle-income countries. This study aimed to provide insights into a strategy to implement the WHO concept adapted to local conditions and obstacles encountered at a tertiary university hospital in Mekelle, Tigray, Ethiopia.

METHODS

We conducted a study aiming at increasing the quality of the HH practice of HCWs using the WHO HH improvement strategy. The study adopted a pre-and post-interventional design from April 2018 to May 2019. In the pre-intervention phase, a baseline infrastructural survey was made. The intervention consisted of in-house production of hand sanitizer and dispensers for every patient bed, staff education and motivation, and implementation of a multidisciplinary infection prevention committee. The intervention was followed by two one-week compliance observations of HH practice among HCWs within the six months post-intervention period and microbiological sample collection from HCWs' hands to assess the quality of HH.

RESULTS

We observed 269 (baseline), 737 (first follow-up) and 574 (second follow-up) indications for HH among HCWs. The overall baseline hand rub compliance was 4.8%, which significantly increased to 37.3% (first follow-up) and 56.1% (second follow-up) (p < 0.0001). Consistent and significant increases in hand rub compliance during the entire follow-up period were observed before touching a patient, after touching a patient, and after touching the patient's surroundings (all p < 0.01). Nurses and medical interns achieved consistent and significant increases in hand rub compliance during the entire follow-up period (all p < 0.01).

CONCLUSION

Implementing the WHO HH improvement strategy significantly increased HH compliance despite a shortage of water and other resources. Hand rub was accepted as the main HH method in the hospital. HH campaigns in developing settings profit from multimodal strategies, knowledge exchange and utilization of local resources.

Active surveillance of antimicrobial resistance in companion animals: A pilot study in a Spanish Veterinary Teaching Hospital

The role of small animal veterinary hospitals in the onset and dissemination of antimicrobial-resistant organisms (AMROs) is still not clear, and the implementation of an internal surveillance systems is a cost-effective tool to better understand their impact. The aim of this study was to describe a pilot program of active surveillance in a Spanish Veterinary Teaching Hospital, developed to estimate the detection frequency of AMROs in the commensal flora of patients and in the environment. Surveillance was focused on Methicillin-resistant Staphylococci (MRS), third generation cephalosporins resistant gram-negative bacteria (3GCR-GNB), and carbapenems-resistant gram-negative bacteria (CR-GNB). Oral and perirectal swabs were collected in the same dogs and cats hospitalized > 48 h, at their admission and before their discharge. Out of 50 patients sampled, 24% (12/50) were carriers at admission of at least one of the three investigated AMROs. Twenty-eight percent of patients (14/50) acquired at least one AMRO during the hospital stay. MRS detection frequency at admission was 12% (6/50), while acquisition was 6% (3/50). 3GCR-GNB detection frequency was 14% at admission (7/50) and acquisition 22% (11/50), while CR-GNB detection frequency was 2% at admission (1/50) and acquisition 2% (1/50). Environmental surveillance (98 samples) showed a total detection frequency of 22.4% for MRS (22/98), 2% for 3GCR-GNB and CR-GNB (2/98). Clinical staff' shoe soles showed high detection frequency for MRS (50%). 3GCR Escherichia coli was the most isolated species in patients (n = 17). The results show how active surveillance can be used as a tool to assess the impact of AMROs in veterinary hospitals to subsequently build up tailored control plans based on specific issues.

How reliable are test results from 17 laboratories on the basis of EN 1500 for a hand rub based on 80% (w/w)?

INTRODUCTION

A ring trial organized by the Association of Applied Hygiene (VAH) on the bactericidal efficacy of an ethanol-based hand rub was carried out in 17 laboratories according to EN 1500 with the aim of describing the variability of test results and fulfilment of the methodological acceptance criteria.

METHOD

As a test product, a hand rub based on 80% ethanol (w/w) was tested in comparison with the reference alcohol (60% iso-propanol, v/v) in a crossover design. After pre-washing and contamination following the norm, hands were treated either with the reference alcohol (2 × 3 mL for 2 × 30 s) or the test product (3 mL in 30 s). Post-decontamination values were determined immediately after the rub-in period. Validated neutralizers were used. The arithmetic means of all individual log10 pre-values, post-values and reduction values were calculated per laboratory. Non-inferiority was assumed when the Hodges-Lehmann 97.5% confidence limit was <0.6 in comparison with the reference. A z-score was calculated to determine the laboratory performance.

RESULTS

Two laboratories did not meet the acceptance criteria and were excluded from the analysis. The bactericidal efficacy of the test product was non-inferior to the reference product in four laboratories and not non-inferior in 11 laboratories. The z-score for the Hodges-Lehmann 97.5% confidence limit indicated a satisfactory performance in all laboratories.

CONCLUSION

We consider the EN 1500 test method to be robust in terms of the variability of test results. For products of borderline efficacy, the evaluation should be based on more than one test.

Central aspects when implementing an electronic monitoring system for assessing hand hygiene in clinical settings: A grounded theory study

Background

New technologies, such as electronic monitoring systems, have been developed to promote increased adherence to hand hygiene among healthcare workers. However, challenges when implementing these technologies in clinical settings have been identified.

Aim

The aim of this study was to explore healthcare workers' experiences when implementing an electronic monitoring system to assess hand hygiene in a clinical setting.

Method

Interviews with healthcare workers (registered nurses, nurse assistants and leaders) involved in the implementation process of an electronic monitoring system (n = 17) were conducted and data were analyzed according to the grounded theory methodology formulated by Strauss and Corbin.

Results

Healthcare workers' experiences were expressed in terms of leading and facilitating, participating and contributing, and knowing and confirming. These three aspects were merged together to form the core category of collaborating for progress. Leaders were positive and committed to the implementation of the electronic monitoring system, endeavouring to enable facilitation and support for their co-workers (registered nurses and nurse assistants). At the same time, co-workers were positive about the support they received and contributed by raising questions and demands for the product to be used in clinical settings. Moreover, leaders and co-workers were aware of the objective of implementing the electronic monitoring system.

Conclusion

We identified dynamic collective work between leaders and co-workers during the implementation of the electronic monitoring system. Leadership, participation and knowledge were central aspects of enhancing a collaborative process. We strongly recommend involving both ward leaders and users of new technologies to promote successful implementation.

An outbreak of multi-drug-resistant Acinetobacter baumannii on a burns ICU and its control with multi-faceted containment measures

BACKGROUND

Patients in burns centres are at high risk of acquiring multi-drug-resistant organisms (MDROs) due to the reduced skin barrier and long hospital stay.

METHODS

This study reports the investigation and control of an outbreak of MDR Acinetobacter baumannii in a burns centre. The 27 patients hospitalized in the centre during the outbreak were screened regularly, and a total of 132 environmental samples were analysed to identify a potential source. Fourier-transform infra-red (FT-IR) spectroscopy and multi-locus sequence typing were applied to characterize the outbreak strain.

RESULTS

Between August and November 2022, the outbreak affected eight patients, with 11 infections and three potentially related fatal outcomes. An interdisciplinary and multi-professional outbreak team implemented a bundle strategy with repetitive admission stops, isolation precaution measures, patient screenings, enhanced cleaning and disinfection, and staff education. FT-IR spectroscopy suggested that the outbreak started from a patient who had been repatriated 1 month previously from a country with high prevalence of MDR A. baumannii. Environmental sampling did not identify a common source. Acquisition of the outbreak strain was associated with a higher percentage of body surface area with burn lesions ≥2a [per percent increase: odds ratio (OR) 1.05, 95% confidence interval (CI) 0.99-1.12; P=0.09], and inversely associated with a higher nurse-to-patient ratio (per 0.1 increase: OR 0.34, 95% CI 0.10-1.12; P=0.06).

CONCLUSIONS

Burn patients with a higher percentage of body surface area with burn lesions ≥2a are at high risk of colonization and infection due to MDROs, particularly during periods of high workload. A multi-faceted containment strategy can successfully control outbreaks due to MDR A. baumannii in a burns centre.

Impact of the COVID-19 pandemic on the incidence of surgical site infection after orthopaedic surgery: an interrupted time series analysis of the nationwide surveillance database in Japan

BACKGROUND

During the COVID-19 pandemic, hygiene awareness was increased in communities and hospitals. However, there is controversy regarding whether such circumstances affected the incidence of surgical site infections (SSIs) in the orthopaedic surgical field.

AIM

To examine the impact of the COVID-19 pandemic on the incidence of SSIs after orthopaedic surgery.

METHODS

The medical records of patients having undergone orthopaedic surgery were extracted from the nationwide surveillance database in Japan. The primary outcomes were the monthly incidences of total SSIs, deep or organ/space SSIs, and SSIs due to meticillin-resistant Staphylococcus aureus (MRSA). Interrupted time series analysis was conducted between pre-pandemic (January 2017 to March 2020) and pandemic (April 2020 to June 2021) periods.

RESULTS

A total of 309,341 operations were included. Interrupted time series analysis adjusted for seasonality showed no significant changes in the incidence of total SSIs (rate ratio 0.94 and 95% confidence interval 0.98-1.02), deep or organ/space SSIs (0.91, 0.72-1.15), or SSIs due to MRSA (1.07, 0.68-1.68) along with no remarkable slope changes in any parameter (1.00, 0.98-1.02; 1.00, 0.97-1.02; and 0.98, 0.93-1.03, respectively).

CONCLUSIONS

Awareness and measures against the COVID-19 pandemic did not markedly influence the incidence of total SSIs, deep or organ/space SSIs, or SSIs due to MRSA following orthopaedic surgery in Japan.

Knowledge, Practices, and Nasal Carriage Rate of MRSA Amongst Dental Professionals

OBJECTIVE

Resistance of Staphylococcus aureus (S. aureus) against common antibiotics has been increasing given the rampant use of antibiotics. Methicillin-resistant S. aureus (MRSA) is particularly important because it has been reported to present in hospital-acquired as well as community-acquired infections. Our aim was to study the types and subtypes of MRSA isolated from nasal swabs taken from volunteering dental school students and to assess and analyse the knowledge of dental health care workers (DHCWs) on MRSA and prevention of its infection.

METHODS

A total of 100 participants, which included staff, students, and dental auxiliaries, from the School of Dental Sciences, Krishna Institute of Medical Sciences, Deemed to Be University, Karad, India, were included in the study which was conducted from June 2020 to 1 June 2021. All the participants completed a survey and underwent collection of nasal swabs. The samples were cultured and underwent microbiological and molecular analysis for MRSA. The questionnaire was sent out electronically via SurveyMonkey.

RESULTS

Sixty-three percent of the participants were female. The majority were undergraduate students (66%) and younger than 25 years (77%). The prevalence of MRSA in the sample was the MRSA type SCCmec type V (54.8%). The survey reports a lack of knowledge amongst dental students on MRSA and prevention of its infection. The majority (69%) of participants had not heard of MRSA infection and had inadequate knowledge of MRSA infection. Only 29% of the participants think that a healthy person may have MRSA without feeling ill. Eighty-five percent of the participants reported that they have written polices and guidelines to control MRSA. Eighty-five percent of the participants indicated that they are less confident in their knowledge on MRSA infection control protocols, and 94% mentioned that the dental clinics have written guidelines for hand hygiene.

CONCLUSIONS

DHCWs have limited knowledge of MRSA infection, emphasising the need for appropriate clinical training. Academic institutions should promote effective infection control training to protect students, faculty, and other employees.

Building capacity for point of care alcohol-based handrub (ABHR) and hand hygiene compliance among health care workers in the rural maternity and surgical units of a hospital in Cameroon

BACKGROUND

Hand hygiene (HH) is challenging in health care, but particularly in resource-limited settings due to a lack of training, resources, and infrastructure. This study aimed to evaluate the implementation of wall-mounted alcohol-based handrub (ABHR) at the point of care (POC) on HH compliance among health care workers in a Cameroon hospital.

METHODS

It was a three-stage before and after study. The first stage involved baseline collection of ABHR utilization and HH compliance data. The second stage included the implementation of ABHR at the POC, supported by an implementation strategy involving HH training, monitoring and feedback, and HH champions. The third stage involved postimplementation data collection on ABHR use and HH compliance.

RESULTS

5,214 HH opportunities were evaluated. HH compliance significantly increased from 33.3% (baseline) to 83.1% (implementation stage) (P < .001) and to 87.2% (postimplementation stage) (P < .001). Weekly ABHR usage increased significantly during implementation (5,670 ml), compared to baseline, (1242.5 ml, P = .001), and remained high in postimplementation (7,740 ml).

CONCLUSIONS

Continuous availability of ABHR at POC, supported by implementation strategy, significantly increased HH compliance and ABHR use. Learning from this study could be used to implement ABHR at POC in other facilities.

Consensus on the treatment of second-degree burn wounds (2024 edition)

Second-degree burns are the most common type of burn in clinical practice and hard to manage. Their treatment requires not only a consideration of the different outcomes that may arise from the dressing changes or surgical therapies themselves but also an evaluation of factors such as the burn site, patient age and burn area. Meanwhile, special attention should be given to the fact that there is no unified standard or specification for the diagnosis, classification, surgical procedure, and infection diagnosis and grading of second-degree burn wounds. This not only poses great challenges to the formulation of clinical treatment plans but also significantly affects the consistency of clinical studies. Moreover, currently, there are relatively few guidelines or expert consensus for the management of second-degree burn wounds, and no comprehensive and systematic guidelines or specifications for the treatment of second-degree burns have been formed. Therefore, we developed the Consensus on the Treatment of Second-Degree Burn Wounds (2024 edition), based on evidence-based medicine and expert opinion. This consensus provides specific recommendations on prehospital first aid, nonsurgical treatment, surgical treatment and infection treatment for second-degree burns. The current consensus generated a total of 58 recommendations, aiming to form a standardized clinical treatment plan.

Unpacking nudge sensu lato: insights from a scoping review

Nudges may play an important role in improving infection prevention and control (IPC) in hospitals. However, despite the novelty of the framework, their objectives, strategies and implementation approaches are not new. This review aims to provide an overview of the methods typically used by nudge interventions in IPC in hospitals targeting healthcare workers (HCWs). The initial search in PubMed yielded nine hits. Consequently, the search criteria were broadened and a second search was conducted, introducing 'nudge sensu lato' which incorporates insights from sources beyond the traditional nudge framework while maintaining the same objectives, strategies and approaches. During the second search, PubMed, Epistemonikos, Web of Science and PsycInfo were searched in accordance with the PRISMA guidelines. Abstracts were screened, and reviewers from an interdisciplinary team read the full text of selected papers. In total, 5706 unique primary studies were identified. Of these, 67 were included in the review, and only four were listed as nudge sensu stricto, focusing on changing HCWs' hand hygiene. All articles reported positive intervention outcomes. Of the 56 articles focused on improving hand hygiene compliance, 71.4% had positive outcomes. For healthcare equipment disinfection, 50% of studies showed significant results. Guideline adherence interventions had a 66.7% significant outcome rate. The concept of nudge sensu lato was introduced, encompassing interventions that employ strategies, methods and implementation approaches found in the nudge framework. The findings demonstrate that this concept can enhance the scientific development of more impactful nudges. This may help clinicians, researchers and policy makers to develop and implement effective nudging interventions.

Effects of environmental conditions on healthcare worker wellbeing and quality of care: A qualitative study in Niger

Environmental conditions (water, sanitation, hygiene, waste management, cleaning, energy, building design) are important for a safe and functional healthcare environment. Yet their full range of impacts are not well understood. In this study, we assessed the impact of environmental conditions on healthcare workers' wellbeing and quality of care, using qualitative interviews with 81 healthcare workers at 26 small healthcare facilities in rural Niger. We asked participants to report successes and challenges with environmental conditions and their impacts on wellbeing (physical, social, mental, and economic) and quality of care. We found that all environmental conditions contributed to healthcare workers' wellbeing and quality of care. The norm in facilities of our sample was poor environmental conditions, and thus participants primarily reported detrimental effects. We identified previously documented effects on physical health and safety from pathogen exposure, but also several novel effects on healthcare workers' mental and economic wellbeing and on efficiency, timeliness, and patient centeredness of care. Key wellbeing impacts included pathogen exposure for healthcare workers, stress from unsafe and chaotic working environments, staff dissatisfaction and retention challenges, out-of-pocket spending to avoid stockouts, and uncompensated labor. Key quality of care impacts included pathogen exposure for patients, healthcare worker time dedicated to non-medical tasks like water fetching (i.e., reduced efficiency), breakdowns and spoilage of equipment and supplies, and patient satisfaction with cleanliness and privacy. Inefficiency due to time lost and damaged supplies and equipment likely have substantial economic value and warrant greater consideration in research and policy making. Impacts on staff retention and care efficiency also have implications for health systems. We recommend that future research and decision making for policy and practice incorporate more holistic impact measures beyond just healthcare acquired infections and reconsider the substantial contribution that environmental conditions make to the safety of healthcare facilities and strength of health systems.

Patterns and outcomes of health-care associated infections in the medical wards at Bugando medical centre: a longitudinal cohort study

BACKGROUND

The burden of healthcare associated infections (HCAIs) in low- and middle-income countries (LMICs) remains underestimated due to diagnostic complexity and lack of quality surveillance systems. We designed this study to determine clinical diagnosis, laboratory-confirmed, associated factors and risks of HCAIs.

METHODS

This hospital-based longitudinal cohort study was conducted between March and June 2022 among adults (≥ 18 years) admitted in medical wards at BMC in Mwanza, Tanzania. Patients who were negative for HCAIs by clinical evaluations and laboratory investigations during admission were enrolled and followed-up until discharge or death. Clinical samples were collected from patients with clinical diagnosis of HCAIs for conventional culture and antimicrobial sensitivity testing.

RESULTS

A total of 350 adult patients with a median [IQR] age of 54 [38-68] years were enrolled in the study. Males accounted for 54.6% (n = 191). The prevalence of clinically diagnosed HCAIs was 8.6% (30/350) of which 26.7% (8/30) had laboratory-confirmed HCAIs by a positive culture. Central-line-associated bloodstream infection (43.3%; 13/30) and catheter-associated urinary tract infection (36.7%; 11/30) were the most common HCAIs. Older age was the only factor associated with development of HCAIs [mean (± SD); [95%CI]: 58.9(± 12.5); [54.2-63.5] vs. 51.5(± 19.1); [49.4-53.6] years; p = 0.0391) and HCAIs increased the length of hospital stay [mean (± SD); [95%CI]: 13.8 (± 3.4); [12.5-15.1] vs. 4.5 (± 1.7); [4.3-4.7] days; p < 0.0001].

CONCLUSION

We observed a low prevalence of HCAIs among adult patients admitted to medical wards in our setting. Central-line-associated bloodstream infections and catheter-associated urinary tract infections are common HCAIs. Significantly, older patients are at higher risk of acquiring HCAIs as well as patients with HCAIs had long duration of hospital stays.

Surveillance of bacterial carriage in the nose and hands of healthcare workers and patients attending maternity and children's hospital

Introduction

Nosocomial infections have been acknowledged as a significant pathogen responsible for human illness due to the rise in the incidence of these infections that are mainly caused by resistant strains. As a result, it is important to prevent nosocomial infections. Therefore, in the epidemiology and pathogenesis of infection bacterial carriage appears to be of great importance and in healthy persons, three patterns of carriage are observed over time. The common ecological niches of microorganisms are the anterior nares and hands; hence, the present study aims to evaluate the surveillance of bacterial carriage from the hands and noses of healthcare workers that involve doctors, nurses, and housekeeping staffs and patients involving pregnant women or mothers.

Materials and Methods

An observational prospective study was conducted for 1.5 years in which collection of swabs from both the hands and nose were taken and inoculated on mannitol salt agar, blood agar, and MacConkey agar and incubated at 37°C for 24 h following which biochemical reactions were performed from isolates and 160 nasal swabs and hand swabs were studied for bacterial growth.

Results

The percentages of bacterial growth in the hands of mothers, doctors, housekeeping staff, and nurses were 17.5, 12.5, 52.5, and 25%, respectively, and in the nose were 7.5, 5, 32.5, and 12.5%, respectively. Total bacterial carriage in hand and nose swabs were 26.87 and 14.37%, respectively.

Conclusion

Methicillin-resistant Staphylococcus aureus was the most common microorganism isolated and as a result to prevent its spread along with other nosocomial microorganisms, appropriate precautions should be taken as the spreading of these organisms can lead to drug resistance strains.

Impact of the COVID-19 pandemic on Clostridioides difficile infection in a tertiary healthcare institution in Belgium

OBJECTIVES

Clostridioides difficile infection (CDI) causes the greatest number of healthcare-associated infectious diarrhoea. CDIs are transmitted by direct and indirect patient-to-patient contact and risk increases with the use of antibiotics. Since early 2020, the COVID-19 pandemic has affected healthcare systems in many ways including substantial changes in hygiene behaviour. The aim of this study was to assess whether CDI incidence differed during the COVID-19 pandemic compared to a year before.

METHODS

All tests for suspected CDI cases were recorded for a hospital in Brussels, Belgium. The percentage of CDI-positive results and incidences (total and healthcare-associated (HA)-CDI)) for years 2019, 2020, 2021, and 2022 were calculated. Antibiotic consumption was analysed for years 2019 and 2020.

RESULTS

Since the COVID-19 pandemic struck, a significant reduction of up to 39% was observed in the number of Clostridioides difficile stool tests in our hospital. A significant decrease in the percentage of positive tests and a 50% decrease in the incidence of CDI (total and HA-CDI) was found for 2020 compared with 2019 and confirmed for years 2021 and 2022. The decrease in CDI incidence was mostly marked in haematology, nephrology, and gastroenterology units. No significant change in the use of antibiotics was found.

CONCLUSION

The global decrease in CDI incidence observed in our hospital was not associated with a change in the use of antibiotics. The control measures implemented to prevent COVID-19 transmission may explain a reduction in CDI incidence. An underdiagnosis of CDI cannot be excluded.

Efficacy of a New Alcohol-Free Organic Acid-Based Hand Sanitizer against Foodborne Pathogens

In light of the global health crisis triggered by the COVID-19 pandemic, numerous experts have deemed the utilization of hand sanitizers imperative as a precautionary measure against the virus. Consequently, the demand for hand sanitizers has experienced a substantial surge. Since the beginning of 2020, the utilization of alcohol-free hand sanitizers has been increasingly favored due to the potential risks associated with alcohol poisoning, flammability, as well as the adverse effects on skin lipid dissolution, dehydration, and sebum reduction, which can lead to severe cases of eczema and norovirus infections. In this study, we developed an aqueous hand sanitizer that does not contain alcohol. The sanitizer consists of naturally occurring, food-grade organic acids, including lactic, citric, and azelaic acids. Additionally, food-grade ammonium sulfate and a small amount of povidone-iodine (PVPI) were included in the formulation to create a synergistic and potent antibacterial effect. The effectiveness of the hand sanitizer was evaluated against four common foodborne pathogens, namely Clostridium botulinum, Escherichia coli, Listeria monocytogenes, and Staphylococcus aureus, via in vitro testing. The organic acids exhibited a synergistic inhibitory function, resulting in a 3-log reduction in CFU/mL. Furthermore, the presence of povidone-iodine and ammonium sulfate enhanced their antibacterial effect, leading to a 4-log reduction in CFU/mL. The hand sanitizer solution remained stable even after 60 days of storage. During this period, the detection of additional triiodide (I3-) ions occurred, which have the ability to release broad-spectrum molecular iodine upon penetrating the cell walls. This alcohol-free hand sanitizer may offer extended protection and is anticipated to be gentle on the skin. This is attributed to the presence of citric and lactic acids, which possess cosmetic properties that soften and smoothen the skin, along with antioxidant properties.

Ultrasound guidance practices used for the placement of vascular accesses in intensive care units: an observational multicentre study

BACKGROUND

Central catheters expose ICU patients at risk of catheter-related bloodstream infections. A mechanism by which these infections occur is the contamination of the catheter during its insertion if aseptic techniques are not strictly applied. Recent studies suggest that the use of ultrasound guidance (USG) may increase the risk of catheter contamination during insertion. We assessed current practices regarding the use of USG during catheter insertion, with a focus on identifying breaches of the surgical asepsis required for this invasive procedure.

METHODS

In 26 intensive care units, we evaluated the use of USG during catheter insertion, using a questionnaire addressed to intensivists and direct observation of their practices.

RESULTS

We analyzed 111 questionnaires and 36 observations of intensivists placing catheters. The questionnaires revealed that 88% of intensivists used USG for catheter insertion. Among those using USG, 56% had received specific training, 17% benefited from specific recommendations, 76% marked the insertion site before skin antisepsis, and during catheter insertion, 96% used sterile gel and 100% used a sterile sheath and sterile gloves. We identified potential deviations from strict aseptic technique, including contact between the sheath and the needle (19.4%), handling of the US system during catheter insertion (2.8%), and use of sterile devices, where they were not yet necessary (during the marking site or skin antisepsis), resulting in their contamination at the time of catheter insertion.

CONCLUSIONS

Interventions aimed at ensuring compliance with measures to prevent CRBs should be organized to prevent an increase in infections associated with US-guided catheter insertion.

Efficacy of Violet-Blue (405 nm) LED Lamps for Disinfection of High-Environmental-Contact Surfaces in Healthcare Facilities: Leading to the Inactivation of Microorganisms and Reduction of MRSA Contamination

Effective disinfection procedures in healthcare facilities are essential to prevent transmission. Chemical disinfectants, hydrogen peroxide vapour (HPV) systems and ultraviolet (UV) light are commonly used methods. An emerging method, violet-blue light at 405 nm, has shown promise for surface disinfection. Its antimicrobial properties are based on producing reactive oxygen species (ROS) that lead to the inactivation of pathogens. Studies have shown significant efficacy in reducing bacterial levels on surfaces and in the air, reducing nosocomial infections. The aim of this study was to evaluate the antimicrobial effectiveness of violet-blue (405 nm) LED lamps on high-contact surfaces in a hospital infection-control laboratory. High-contact surfaces were sampled before and after 7 days of exposure to violet-blue light. In addition, the effect of violet-blue light on MRSA-contaminated surfaces was investigated. Exposure to violet-blue light significantly reduced the number of bacteria, yeasts and moulds on the sampled surfaces. The incubator handle showed a low microbial load and no growth after irradiation. The worktable and sink showed an inconsistent reduction due to shaded areas. In the second experiment, violet-blue light significantly reduced the microbial load of MRSA on surfaces, with a greater reduction on steel surfaces than on plastic surfaces. Violet-blue light at 405 nm has proven to be an effective tool for pathogen inactivation in healthcare settings Violet-blue light shows promise as an additional and integrated tool to reduce microbial contamination in hospital environments but must be used in combination with standard cleaning practices and infection control protocols. Further research is needed to optimise the violet-blue, 405 nm disinfection method.

Factors associated with better alcohol hand rub in 2020. Results from the French national audit "Pulpe'friction"

Background

The application of alcohol-based hand rub on hands (ABHR) can prevent the transmission of microorganisms. But, in some situations the practices remain perfectible.

Aim

The aim of this study was to assess the self-reported ABHR practices of healthcare workers (HCWs) and to identify the factors associated with better ABHR compliance.

Methods

A cross-sectional study was conducted using the French national "Pulpe'friction" audit, from 1st January 2020 to 31st December 2020, in healthcare facilities and social welfare facilities in France. Data were analyzed using descriptive statistics and multivariate logistic regression models.

Results

Of the 6769 HCWs, the average ABHR compliance was 75% "before patient contact," 95% "before an invasive technique," 86% "after patient contact," and 79% "after contact with patient surroundings." The main reported barriers were the availability, the discomfort and the harmfulness of the product. The factors significantly associated with a better compliance were the individual importance given to hand hygiene (HH); working in a healthcare facility, except in the situation "before an invasive technique"; medical profession "after patient contact"; paramedical profession "after contact with patient surroundings."

Discussion

These results call for national actions to fight the most reported barriers and raise awareness on the importance of HH, especially before touching the patient.

Examining outpatients' hand hygiene behaviour and its relation to COVID-19 infection prevention measures

BACKGROUND

The increasing demand for outpatient care is associated with a higher risk of infection transmission in these settings. However, there is limited research on infection prevention and control practices in ambulatory clinics, and none focuses on patients.

AIM

To examine outpatients' hand hygiene behaviours, their determinants, and their associations with other infection prevention measures during the COVID-19 pandemic.

METHODS

We observed the hand hygiene behaviour of one cohort of patients in one outpatient clinic and surveyed a separate sample in five clinics about their hand hygiene practice in outpatient facilities. A questionnaire based on the Theoretical Domains Framework (TDF) was used to examine predictors of the behaviour. Moreover, patients indicated their compliance with COVID-19 infection prevention measures, vaccination status, disease risk perception, and vaccine hesitancy.

FINDINGS

Observed hand hygiene rates among 618 patients were low (12.8%), while 67.3% of the 300 surveyed patients indicated sanitizing their hands upon entering the clinic. The TDF domains 'memory, attention, and decision processes' and 'emotions' significantly predicted both current (today's) and general hand hygiene behaviour in outpatient clinics. Hand hygiene behaviour and compliance with COVID-19 infection prevention showed a positive association; however, no significant connection was found with patients' vaccination status, suggesting different behavioural motivators.

CONCLUSION

Hand hygiene among outpatients should be improved through interventions focusing on helping patients remember to clean their hands. More research on infection prevention in outpatient facilities is needed to ensure patient safety.

The impact of COVID-19 prevention measures on surgical wound infection rates post-cardiac surgery

The COVID-19 pandemic had a huge impact on medical services. Several measures have been implemented to reduce the risk of viral transmission. In this paper, we assessed the impact of these measures on surgical wound infection rates in post-cardiac surgery patients. Hypothesis testing was used to compare post-cardiac operation infection rates between the year prior to the COVID-19 pandemic being declared and the first 13 months of the pandemic. The infection rates in 969 patients with operations between 01/03/2019 and 29/02/2020 were compared to those of 925 patients with cardiac surgery between 01/03/2020 and 31/03/2021. Infection rates for various operative urgencies and infection types were analyzed. To compare infection rates, a two-tailed pooled z-test using the difference in infection proportions was performed. A 5% significance level was used, and only categories with at least 10 patients in both the pre-COVID and COVID populations were tested. For leg infections, only operations involving coronary artery bypass grafting were included. To ensure that any differences in outcomes were not due to differences in patient demographics resulting in unequal operative risks, Euroscore II values, a measure of cardiac operative risk, were compared between the pre-COVID and post-COVID cohorts. The Mann-Whitney U-test was used to determine whether the distributions of Euroscore II values were likely to be drawn from the same population. A significance level of 5% was used. A total of 1901 patients (932 during the COVID-19 pandemic) were included in this study. There was a significant reduction in post-operative infections for all patients undergoing cardiac surgery, from 4.3% of patients before COVID-19 to 1.5% during the pandemic. During the pandemic, fewer elective and more urgent operations were performed. This study suggests a significant role for iatrogenic causes in wound infections before the pandemic. The implementation of COVID-19 prevention measures by healthcare providers can reduce surgical infection rates. As COVID-19-related restrictions have been eased, we suggest maintaining them for healthcare providers to reduce the incidence of surgical wound infections.

Impact of a training strategy on improving compliance of hand hygiene and gloving during the placement of a short peripheral venous catheter: the multicentre study CleanHand4

BACKGROUND

Patients who have short peripheral venous catheters (PVC) face an elevated risk of developing bloodstream infections. Preventing catheter-related infections relies on implementing multiple measures, including practicing proper hand hygiene (HH) during catheter placement.

METHODS

We conducted a four-part study: (1) an evaluation of HH practices through direct observation of PVC placements, coupled with the study of the microbial flora of the HCWs fingers just before the placement; (2) the development of an educational tool based on the collected observational and microbiological data; (3) the training to the HCWs observed during the first part, using this tool; and (4) the subsequent observation of the trained HCWs to measure the impact of the training on practice improvement.

RESULTS

Compliant HH was observed in 23.5% of the 647 HCWs observed during PVC placement before training. The microbiological study revealed fewer pathogens on the fingertips of the HCWs practicing compliant HH compared other HCWs (2.6 vs 11,7%; p = 0.003). The comparison of practices before and after training, assessed among 180 HCWs, showed an increase in the proportion of HCWs performing compliant HH (25.0 vs 63.2%; p < 0.001).

CONCLUSIONS

Training HCWs using our educational tool, which combines reminders of best practices and risk factors associated with PVC-related infections, engaging HCWs (presentation of practice evaluation), identifying professionals deviating from best practices (simulation videos), and objectively assessing fingertip contamination (microbiological study), significantly improved compliance with HH gestures and glove usage. We encourage infection control teams to utilize this tool to raise awareness among HCWs responsible for PVC placement about the risk of infection associated inadequate hand hygiene.

Risk factors associated with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission, outbreak duration, and mortality in acute-care settings

BACKGROUND

Transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in acute-care settings affects patients, healthcare workers, and the healthcare system. We conducted an analysis of risk factors associated with outbreak severity to inform prevention strategies.

METHODS

This cross-sectional analysis of COVID-19 outbreaks was conducted at Fraser Health acute-care sites between March 2020 and March 2021. Outbreak severity measures included COVID-19 attack rate, outbreak duration, and 30-day case mortality. Generalized linear models with generalized estimating equations were used for all outcome measures. A P value of 0.05 indicated statistical significance. Analyses were performed using SAS version 3.8 software, R version 4.1.0 software, and Stata version 16.0 software.

RESULTS

Between March 2020 and March 2021, 54 COVID-19 outbreaks were declared in Fraser Health acute-care sites. Overall, a 10% increase in the hand hygiene rate during the outbreak resulted in an 18% decrease in the attack rate (P < .01), 1 fewer death (P = .03), and shorter outbreaks (P < .01). A 10-year increase in unit age was associated with 2.2 additional days of outbreak (P < 0.01) and increases in the attack rate (P < .05) and the number of deaths (P < .01).

DISCUSSION

We observed an inverse relationship between increased hand hygiene compliance during outbreaks and all 3 severity measures. Increased unit age was also associated with increases in each of the severity measures.

CONCLUSION

This study highlights the importance of hand hygiene practices during an outbreak and the difficulties faced by older facilities, many of which have infrastructural challenges. The latter reinforces the need to incorporate infection control standards into healthcare planning and construction.

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

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

Usefulness of dynamic regression time series models for studying the relationship between antimicrobial consumption and bacterial antimicrobial resistance in hospitals: a systematic review

BACKGROUNG

Antimicrobial resistance (AMR) is on the rise worldwide. Tools such as dynamic regression (DR) models can correlate antimicrobial consumption (AMC) with AMR and predict future trends to help implement antimicrobial stewardship programs (ASPs).

MAIN BODY

We carried out a systematic review of the literature up to 2023/05/31, searching in PubMed, ScienceDirect and Web of Science. We screened 641 articles and finally included 28 studies using a DR model to study the correlation between AMC and AMR at a hospital scale, published in English or French. Country, bacterial species, type of sampling, antimicrobials, study duration and correlations between AMC and AMR were collected. The use of β-lactams was correlated with cephalosporin resistance, especially in Pseudomonas aeruginosa and Enterobacterales. Carbapenem consumption was correlated with carbapenem resistance, particularly in Pseudomonas aeruginosa, Klebsiella pneumoniae and Acinetobacter baumannii. Fluoroquinolone use was correlated with fluoroquinolone resistance in Gram-negative bacilli and methicillin resistance in Staphylococcus aureus. Multivariate DR models highlited that AMC explained from 19 to 96% of AMR variation, with a lag time between AMC and AMR variation of 2 to 4 months. Few studies have investigated the predictive capacity of DR models, which appear to be limited.

CONCLUSION

Despite their statistical robustness, DR models are not widely used. They confirmed the important role of fluoroquinolones, cephalosporins and carbapenems in the emergence of AMR. However, further studies are needed to assess their predictive capacity and usefulness for ASPs.

Hand hygiene compliance and associated factors among healthcare workers in selected tertiary-care hospitals in Bangladesh

BACKGROUND

Hand hygiene (HH) is a fundamental element of patient safety. Adherence to HH among healthcare workers (HCWs) varies greatly depending on a range of factors, including risk perceptions, institutional culture, auditing mechanisms, and availability of HH supplies.

AIMS

This study aimed to evaluate HH compliance and associated factors among HCWs in selected tertiary-care hospitals in Bangladesh.

METHODS

During September 2020 to May 2021, we conducted non-participatory observations at 10 tertiary-care hospitals using the WHO's '5-moments for hand hygiene tool' to record HH compliance among physicians, nurses and cleaning staff. We also performed semi-structured interviews to determine the key barriers to complying with HH.

RESULTS

We observed 14,668 hand hygiene opportunities. The overall HH compliance was 25.3%, the highest among nurses (28.5%), and the lowest among cleaning staff (9.9%). HCWs in public hospitals had significantly higher odds of complying with HH practices than those in private hospitals (adjusted odds ratio: 1.73, 95% CI: 1.55-1.93). The odds of performing HH after touching a patient were 3.36 times higher compared with before touching a patient (95% CI: 2.90-3.90). The reported key barriers to performing HH were insufficient supplies (57.9%), skin reactions (26.3%), workload (26.3%) and lack of facilities (22.7%). Overall, observed HH supplies were available in 81.7% of wards for physicians and 95.1% of wards for nurses, however, no designated HH facilities were found for the cleaning staff.

CONCLUSIONS

HH compliance among HCWs fell significantly short of the standard for safe patient care. Inadequate HH supplies demonstrate a lack of prioritizing, promoting and investing in infection prevention and control.

Use of thermal imaging to measure the quality of hand hygiene

OBJECTIVES

Hand hygiene has long been promoted as the most effective way to prevent the transmission of infection. However, due to low compliance and low quality of hand hygiene reported in previous studies, constant monitoring of hand hygiene compliance and quality among healthcare workers is crucial. This study investigated the feasibility of using a thermal camera with an RGB camera to detect hand coverage of alcohol-based formulation, thereby monitoring the quality of hand rubbing.

METHODS

In total, 32 participants were recruited to participate in this study. Participants were required to perform four types of hand rubbing to achieve different coverage of the alcohol-based formulation. After each task, participants' hands were photographed under a thermal camera and an RGB camera, while an ultraviolet (UV) test was used to provide the ground truth of hand coverage of alcohol-based formulation. U-Net was used to segment areas exposed to alcohol-based formulation from thermal images, and system performance was evaluated by comparing differences in coverage between thermal images and UV images in terms of accuracy and Dice coefficient.

RESULTS

This system found promising results in terms of accuracy (93.5%) and Dice coefficient (87.1%) when observations took place 10 s after hand rubbing. At 60 s after hand rubbing, accuracy and Dice coefficient were 92.4% and 85.7%.

CONCLUSIONS

Thermal imaging has potential for accurate, constant and systematic monitoring of the quality of hand hygiene.

Have Hand Hygiene Practices in Two Tertiary Care Hospitals, Freetown, Sierra Leone, Improved in 2023 following Operational Research in 2021?

In 2021, an operational research study in two tertiary hospitals in Freetown showed poor hand hygiene compliance. Recommended actions were taken to improve the situation. Between February-April 2023, a cross-sectional study was conducted in the same two hospitals using the World Health Organization hand hygiene tool to assess and compare hand hygiene compliance with that observed between June-August 2021. In Connaught hospital, overall hand hygiene compliance improved from 51% to 60% (p < 0.001), and this applied to both handwash actions with soap and water and alcohol-based hand rub. Significant improvements were found in all hospital departments and amongst all healthcare worker cadres. In 34 Military Hospital (34MH), overall hand hygiene compliance decreased from 40% to 32% (p < 0.001), with significant decreases observed in all departments and amongst nurses and nursing students. The improvements in Connaught Hospital were probably because of more hand hygiene reminders, better handwash infrastructure and more frequent supervision assessments, compared with 34MH where interventions were less well applied, possibly due to the extensive hospital reconstruction at the time. In conclusion, recommendations from operational research in 2021 contributed towards the improved distribution of hand hygiene reminders, better handwash infrastructure and frequent supervision assessments, which possibly led to improved hand hygiene compliance in one of the two hospitals. These actions need to be strengthened, scaled-up and guided by ongoing operational research to promote good hand hygiene practices elsewhere in the country.

Multimodal environmental cleaning strategies to prevent healthcare-associated infections

Infection transmission in healthcare is multifaceted and by in large involves the complex interplay between a pathogen, a host and their environment. To prevent transmission, infection prevention strategies must also consider these complexities and incorporate targeted interventions aimed at all possible transmission pathways. One strategy to prevent and control infection is environmental cleaning. There are many aspects to an environmental cleaning strategy. We believe the key to successfully reducing the risk of healthcare-associated infections through the environment, is to design and implement a multimodal intervention. This paper aims to provide an overview of important considerations for designing a meaningful and sustainable environmental program for healthcare facilities.

Nursing strategies for the mechanically ventilated patient

The goal of this manuscript is to provide a comprehensive and multi-disciplinary review of the best nursing practices of caring for mechanically ventilated patients. By reviewing human medicine literature, the authors will extrapolate procedures that have been found to be most effective in reducing the risk of mechanical ventilation (MV) complications. Paired with review of the current standards in veterinary medicine, the authors will compile the best practice information on mechanically ventilated patient care, which will serve as a detailed resource for the veterinary nursing staff. Written from a nursing standpoint, this manuscript aims to consolidate the nursing assessment of a mechanically ventilated patient, addressing both systemic and physical changes that may be encountered during hospitalization. The goal of this review article is to present information that encourages a proactive approach to nursing care by focusing on understanding the effects of polypharmacy, hemodynamic changes associated with MV, complications of recumbent patient care, and sources of hospital acquired infections. When applied in conjunction with the more technical aspects of MV, this manuscript will allow veterinary technicians involved in these cases to understand the dynamic challenges that mechanically ventilated patients present, provide guidance to mitigate risk, address issues quickly and effectively, and create an up-to date standard of practice that can be implemented.

Implications of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infected Hospitalised Patients with Co-Infections and Clinical Outcomes

The clinical severity of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection may rise because of acquiring a co-infection during the hospital stay of the patients. The rate of hospital co-infection alongside COVID-19 infection remains low. However, the mortality rates and intensive care unit (ICU) admission remains ambiguous. The present study investigates the implications of COVID-19 hospitalised infected patients with co-infection and the clinical outcomes. In this study, 142 patients were included. The eligible patients who tested positive for COVID-19 infection were hospitalised for more than two days. Each patient's characteristics and laboratory results were collected, such as who was admitted to the intensive care unit and who was discharged or expired. The results revealed that out of the 142 hospitalised patients, 25 (17.6%) were co-infection positive, and 12 identified types of co-infection: two Gram-positive bacterial infections, one fungal infection and nine Gram-negative bacterial infections. In addition, 33 (23.2%) were ICU admitted, 21 were co-infection negative and 12 were co-infection positive. Among the 12 ICU admitted with co-infection, 33.4% were discharged. The death rate and ICU admission had a p-value < 0.05, indicating statistical significance for co-infected patients compared to non-co-infected patients. It was concluded that co-infection remains very low within hospitalised COVID-19-infected patients but can have severe outcomes with increased ICU admission and increased mortality rates. Thus, implementing infection preventive measures to minimize the spread of hospital-acquired infections among COVID-19 hospitalised patients.

Multi-Model Strategies for Prevention of Infection Caused by Certain Multi-Drug Resistant Organisms in A Rehabilitation Unit: A Semi-Experimental Study

Objective: To assess the effectiveness of multi-model strategies on healthcare-associated infections (HAIs) caused by multi-drug resistant organisms (MDROs) in rehabilitation units. Methods: A semi-experimental study was conducted in a rehabilitation unit with 181 beds from January 2021 to December 2022 in a teaching hospital with 4300 beds in China. In 2021, many basic prevention and control measures were conducted routinely. Based on the basic measures, strengthening multi-model strategies for the prevention and control of MDROs was pursued year-round since 1 January 2022. Results: A total of 6206 patients were enrolled during the study period. The incidence density of HAIs caused by MDROs decreased from 1.22 (95% CI, 0.96~1.54) cases/1000 patient-days in the pre-intervention period to 0.70 (95% CI, 0.50~0.95) cases/1000 patient-days (p = 0.004). Similarly, the incidence of HAIs in the intervention period was 50.85% lower than that in the pre-intervention period (2.02 (95% CI, 1.50~2.72) vs. 4.11 (95% CI, 3.45-4.85) cases/100 patients, p < 0.001). The rate of MDROs isolated from the environment decreased by 30.00%, although the difference was not statistically significant (p = 0.259). Conclusion: Multi-model strategies can reduce the incidence of HAIs and HAIs caused by certain MDROs in the rehabilitation unit.

Healthcare Personnel Hand Hygiene Compliance: Are We There Yet?

Purpose of Review

Poor hand hygiene is well documented as a factor in healthcare-associated infections and excellent rates of hand hygiene remains elusive.

Recent Findings

There is increased use of universal or increased gloving to minimize hand contamination, but its use does not replace hand hygiene opportunities. There is significant interest in electronic hand hygiene monitoring systems, but they are not without their unique issues. Behavioral psychology remains a significant factor in motivating hand hygiene behaviors; even in COVID-19, hand hygiene rates initially improved but trended down back to baseline while still dealing with the pandemic.

Summary

More emphasis should be placed on the how to properly perform hand hygiene and why it is so important, as well as the role of gloves, is needed. Continued investment and awareness of their status as role models from both system leadership and senior healthcare providers are needed.

Nurse Staffing Level, Length of Work Experience, and Risk of Health Care-Associated Infections Among Hospital Patients: A Prospective Record Linkage Study

BACKGROUND

Nurse understaffing may have several adverse consequences for patients in hospitals, such as health care-associated infections (HAIs), but there is little longitudinal evidence available on staffing levels and HAIs with consideration of incubation times to confirm this. Using daily longitudinal data, we analyzed temporal associations between nurse understaffing and limited work experience, and the risk of HAIs.

METHODS

The study was based on administrative data of 40 units and 261,067 inpatient periods for a hospital district in Finland in 2013-2019. Survival analyses with moving time windows were used to examine the association of nurse understaffing and limited work experience with the risk of an HAI 2 days after exposure, adjusting for individual risk factors. We reported hazard ratios (HRs) with 95% CIs.

RESULTS

Neither nurse understaffing nor limited work experience were associated with the overall risk of HAIs. The results were inconsistent across staffing measures and types of HAIs, and many of the associations were weak. Regarding specific HAI types, 1-day exposure to low proportion of nurses with >3 years of in-hospital experience and low proportion of nurses more than 25 years old were associated with increased risk of bloodstream infections (HR=1.30; 95% CI: 1.04-1.62 and HR=1.40; 95% CI: 1.07-1.83). Two-day exposure to low nursing hours relative to target hours was associated with an increased risk of surgical-site infections (HR=2.64, 95% CI: 1.66-4.20).

CONCLUSIONS

Data from time-varying analyses suggest that nursing staff shortages and limited work experience do not always increase the risk of HAI among patients.

COMPLIANCE OF PATIENT COMPANIONS AND VISITORS WITH HAND HYGIENE: AN OBSERVATIONAL STUDY

BACKGROUND

Hand hygiene is a simple and low-cost practice to prevent the spread of many microorganisms that cause healthcare-associated infections (HCAIs). Compliance with hand hygiene, especially by patient companions and visitors, is very important in order to prevent the transmission of pathogenic microorganisms between the health institutions and the community.

AIM

This is a descriptive study designed to investigate the compliance of patient companions and visitors with hand hygiene.

METHODS

The sample of the study included 209 individuals who were the companions and visitors of the patients who were hospitalized in a University Hospital in the west of Turkey. A questionnaire containing Demographics and Hand Hygiene and the Observation Form to assess Hand Hygiene Practice were used to acquire data. In order to conduct the research, permission was obtained from the ethics committee and the institution, and consent was obtained from the patient companions and visitors. To evaluate the data, the numbers, percentage calculations, mean and independent inter-observer agreement coefficient were used.

FINDINGS

96.2% of the patient companions and visitors stated that they did not receive training on the importance of hand washing during their stay in the hospital, and 74.6% stated that hand washing was very important in the prevention of diseases. The patient families reported that they most often washed their hands after touching bodily fluids (91.7%), and that they rarely washed their hands before touching a patient (34.0%). The rates were decreased in the observations, and the lowest rate for handwashing was before touching a patient (22.4%) and the highest rate for handwashing was after the risk for contamination with body fluids of patient (68.6%).

CONCLUSION

The results of this study indicate that patient companions and visitors did not receive any training on the importance of hand hygiene during the hospital stay, and the observed rate of compliance with hand hygiene was lower than stated. Recommendations include delivering planned handwashing training to patient companions and visitors using different teaching methods, and to conduct longer observational studies.

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

PURPOSE

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

DESIGN

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Incidence of Healthcare-Associated Infections in a Neonatal Intensive Care Unit before and during the COVID-19 Pandemic: A Four-Year Retrospective Cohort Study

The COVID-19 pandemic may have had an impact on healthcare-associated infection (HAI) rates. In this study, we analyzed the occurrence of HAIs in a neonatal intensive care unit (NICU) of the Umberto I teaching hospital in Rome before and during the pandemic. All infants admitted from 1 March 2018 to 28 February 2022 were included and were divided into four groups according to their admission date: two groups before the pandemic (periods I and II) and two during the pandemic (periods III and IV). The association between risk factors and time-to-first event was analyzed using a multivariable Cox regression model. Over the four-year period, a total of 503 infants were included, and 36 infections were recorded. After adjusting for mechanical ventilation, birth weight, sex, type of delivery, respiratory distress syndrome, and previous use of netilmicin and fluconazole, the multivariable analysis confirmed that being hospitalized during the pandemic periods (III and IV) was the main risk factor for HAI acquisition. Furthermore, a change in the etiology of these infections was observed across the study periods. Together, these findings suggest that patient management during the pandemic was suboptimal and that HAI surveillance protocols should be implemented in the NICU setting promptly.