Improved hand hygiene technique and compliance in healthcare workers using gaming technology

Enhancing Infection Control in ICUS Through AI: A Literature Review

Introduction

Infection control in intensive care units (ICUs) is crucial due to the high risk of healthcare-associated infections (HAIs), which can increase patient morbidity, mortality, and costs. Effective measures such as hand hygiene, use of personal protective equipment (PPE), patient isolation, and environmental cleaning are vital to minimize these risks. The integration of artificial intelligence (AI) offers new opportunities to enhance infection control, from predicting outbreaks to optimizing antimicrobial use, ultimately improving patient safety and care in ICUs.

Objectives

The primary objectives are to explore AI's impact on predicting HAIs, real-time monitoring, automated sterilization, resource optimization, and personalized infection control plans.

Methodology

A comprehensive search of PubMed and Scopus was conducted for relevant articles up to January 2024, including case series, reports, and cohort studies. Animal studies and irrelevant articles were excluded, with a focus on those considered to have significant clinical relevance.

Discussion

The review highlights AI's prowess in predicting HAIs, surpassing conventional methods. Existing evidence demonstrates AI's efficacy in accurately predicting and mitigating HAIs. Real-time patient monitoring and alert systems powered by AI are shown to enhance infection detection and patient outcomes. The paper also addresses AI's role in automating sterilization and disinfection, with studies affirming its effectiveness in reducing infections. AI's resource optimization capabilities are exemplified in ICU settings, showcasing its potential to improve resource allocation efficiency. Furthermore, the review emphasizes AI's personalized approach to infection control post-procedures, elucidating its ability to analyze patient data and create tailored control plans.

Effectiveness of sensing gloves-applied virtual reality education system on hand hygiene practice: A randomized controlled trial

BACKGROUND

We developed a virtual reality (VR) education system and evaluated its clinical utility for promoting hand hygiene practices.

METHODS

This prospective, 2-week, randomized controlled study conducted at Okayama University Hospital, Japan, from November 2023 to January 2024, involved 22 participants (18 medical students and 4 residents). A fully immersive 360° VR system (VIVE Pro Eye) using a head-mounted display and sensing gloves was used to develop 3 health care tasks in a virtual patient room-Environmental Cleaning, Gauze Exchange, and Urine Collection. After monitoring all participants' baseline usage data of portable hand-rubbing alcohol in the first week, we randomly assigned them into 1:1 groups (VR training and video lecture groups). The primary outcome was differences in hand-rubbed alcohol use before and after intervention.

RESULTS

Before the intervention, alcohol use did not significantly differ between both groups. After the intervention, a significant increase in alcohol use was observed in the VR training group (median: 8.2 g vs 16.2 g; P = .019) but not in the video lecture group.

CONCLUSIONS

Our immersive 360° VR education system enhanced hand hygiene practices. Infection prevention and control practitioners and digital technology experts must collaborate to advance the development of superior educational devices and content.

Game-based training to improve the compliance of hospital pharmacy operators with handwashing guidelines

INTRODUCTION

Good hand hygiene techniques (HHTs), like those of the World Health Organization (WHO), prevent microbial contamination of aseptic preparations. The objective of this study was to assess the efficacy of a game-based training (GBT) tool (the Handtastic Box) to improve the compliance of hospital pharmacy operators (HPOs) with handwashing guidelines.

METHODS

A camera recorded handwashing by HPOs for 1 month before the training day, for 1 month after the training day (M1), and between month 1 and month 3 (M2&3). Movements were scored as fully executed, partially executed or not executed. Compliance rates of each HPO with HHTs were compared between observation periods. During 1-h training sessions, pairs of HPO trainees watched handwashing videos and noted which of five guideline steps was missing. They examined wooden hands with areas stained with fluorescein under ultraviolet light to find the hand showing the matching contamination.

RESULTS

The mean compliance score for nine HPOs increased from 44.6% (before training, N=32 videos) to 86.7% (M1, N=40) to 82.5% (M2&3, N=45). Compliance with every step improved from before training to M1 and generally stabilized in M2&3, except for the fingertip washing step which dropped significantly in M2&3.

DISCUSSION

To the authors' knowledge, this is the first study to assess the efficacy of a GBT tool to improve HPO compliance with the WHO HHTs. The tool improved handwashing scores significantly, and maintained them at the same level for 3 months after training. The separate results for each step highlight the need to train every movement.

CONCLUSION

This GBT tool successfully improved compliance with the WHO HHTs for 3 months. This training could be used for other healthcare professionals.

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.

Virtual reality and augmented reality smartphone applications for upskilling care home workers in hand hygiene: a realist multi-site feasibility, usability, acceptability, and efficacy study

OBJECTIVES

To assess the feasibility and implementation, usability, acceptability and efficacy of virtual reality (VR), and augmented reality (AR) smartphone applications for upskilling care home workers in hand hygiene and to explore underlying learning mechanisms.

MATERIALS AND METHODS

Care homes in Northwest England were recruited. We took a mixed-methods and pre-test and post-test approach by analyzing uptake and completion rates of AR, immersive VR or non-immersive VR training, validated and bespoke questionnaires, observations, videos, and interviews. Quantitative data were analyzed descriptively. Qualitative data were analyzed using a combined inductive and deductive approach.

RESULTS

Forty-eight care staff completed AR training (n = 19), immersive VR training (n = 21), or non-immersive VR training (n = 8). The immersive VR and AR training had good usability with System Usability Scale scores of 84.40 and 77.89 (of 100), respectively. They had high acceptability, with 95% of staff supporting further use. The non-immersive VR training had borderline poor usability, scoring 67.19 and only 63% would support further use. There was minimal improved knowledge, with an average of 6% increase to the knowledge questionnaire. Average hand hygiene technique scores increased from 4.77 (of 11) to 7.23 after the training. Repeated practice, task realism, feedback and reminding, and interactivity were important learning mechanisms triggered by AR/VR. Feasibility and implementation considerations included managerial support, physical space, providing support, screen size, lagging Internet, and fitting the headset.

CONCLUSIONS

AR and immersive VR apps are feasible, usable, and acceptable for delivering training. Future work should explore whether they are more effective than previous training and ensure equity in training opportunities.

The Effect of Video-Assisted Training and Visual Feedback With UV Germ Technology on Nursing Students' Hand Hygiene Beliefs, Practices, and Compliance: A Randomized Controlled Study

BACKGROUND

Hand hygiene (HH) is the most effective way to prevent health care-associated infections; however, HH compliance rates continue to be suboptimal.

PURPOSE

To determine the effectiveness of video-assisted training and visual feedback with ultraviolet (UV) germ technology on nursing students' HH beliefs, practices, and compliance.

METHODS

This study used a double-blind, posttest randomized controlled design. The experimental group received training, visual feedback with UV germ technology, and instructional videos.

RESULTS

A total of 46 students were included in the study (experimental 21 and control 25). The mean score of the HH skills checklist of the experimental group was significantly higher than that of the control group ( P = .0001). The HH compliance rate was also higher in the experimental group (52.62%) compared with the control group (39.1%).

CONCLUSIONS

The training, visual feedback with UV germ technology, and instructional videos increased HH compliance rates in nursing students.

Quality Improvement Project to Improve Hand Hygiene Compliance in a Level III Neonatal Intensive Care Unit

This quality improvement project aimed to improve hand hygiene (HH) compliance in a Level III Neonatal Intensive Care Unit. The project was conducted over three Plan-Do-Study-Act (PDSA) cycles, with each cycle lasting two months. The interventions included healthcare worker (HCW) education on HH, repetition of education, and immediate feedback to HCWs. Compliance data were collected through covert observations of HCWs in the NICU. The overall compliance rate increased from 31.56% at baseline to 46.64% after the third PDSA cycle. The HH compliance was noted to be relatively low after touching patient care surroundings, at entry and exit from the NICU main unit, before wearing gloves and after removing gloves, at baseline and throughout the three PDSA cycles. HCW education alone did not result in significant improvements, highlighting the need for additional interventions. The study underscores the importance of involving NICU leadership and providing immediate feedback to promote HH compliance. Further efforts should focus on addressing the false sense of security associated with glove usage among HCWs, individual rewards and involving the healthcare staff in the shared goal of increasing HH compliance. Consideration of workload metrics and their impact on compliance could steer future interventions.

Respiratory infection prevention: perceptions, barriers and facilitators after SARS-CoV-2

BACKGROUND

Respiratory hygiene, especially in context of COVID-19, is of upmost importance. Healthcare professionals (HCPs) play an important role in the prevention of infections. Their perceptions of the subject are needed to tailor effective communication and training on prevention.

METHODS

20 French HCPs were questioned about their perceptions on respiratory hygiene and infections, by the means of recorded semi-structured interviews and a focus group. The interviews and focus group were transcribed then analysed through lexicometric and thematic content analyses.

RESULTS

HCP discourse revolved around the use of face masks, the prevention and the characteristics of respiratory infections and the means to prevent them.COVID-19 excepted, HCPs considered respiratory infections as benign. They associated respiratory hygiene to the observance of cough etiquette, the preservation of lung health, the act of protecting oneself and others, and the adherence to safety protocols. Main barriers to good practices were organizational ones, such as the lack of consultation and mobilization of HCPs in the development of preventive measures, suboptimal information sharing and the physical and relational constraints of face masks. They advised means of improving communication and information promotion.

CONCLUSION

Since the pandemic crisis, HCPs have developed a better awareness about the prevention of respiratory infections. Except for COVID-19, respiratory infections are mostly considered as benign. Barriers and facilitators evoked by HCPs will help to build national communication and tools.

A nudge intervention to improve hand hygiene compliance in the hospital

Hand hygiene among professionals plays a crucial role in preventing healthcare-associated infections, yet poor compliance in hospital settings remains a lasting reason for concern. Nudge theory is an innovative approach to behavioral change first developed in economics and cognitive psychology, and recently spread and discussed in clinical medicine. To assess a combined nudge intervention (localized dispensers, visual reminders, and gain-framed posters) to promote hand hygiene compliance among hospital personnel. A quasi-experimental study including a pre-intervention phase and a post-intervention phase (9 + 9 consecutive months) with 117 professionals overall from three wards in a 350-bed general city hospital. Hand hygiene compliance was measured using direct observations by trained personnel and measurement of alcohol-based hand-rub consumption. Levels of hand hygiene compliance were low in the pre-intervention phase: 11.44% of hand hygiene opportunities prescribed were fulfilled overall. We observed a statistically significant effect of the nudge intervention with an increase to 18.71% (p < 0.001) in the post-intervention phase. Improvement was observed in all experimental settings (the three hospital wards). A statistical comparison across three subsequent periods of the post-intervention phase revealed no significant decay of the effect. An assessment of the collected data on alcohol-based hand-rub consumption indirectly confirms the main result in all experimental settings. Behavioral outcomes concerning hand hygiene in the hospital are indeed affected by contextual, nudging factors to a significant extent. If properly devised, nudging measures can provide a sustainable contribution to increase hand hygiene compliance in a hospital setting.

Teaching health care students hand hygiene theory and skills: a systematic review

Hand hygiene is the cornerstone of infection prevention but is poorly undertaken and under-appreciated by medical, nursing, and other health care students. This systematic review aimed to identify and describe strategies used to teach the theory and practice of hand hygiene, determine impact on knowledge and practice, and identify need for future education and research. Ten studies met the criteria for review. Health care students' theoretical knowledge of hand hygiene and their ability to practise are suboptimal and should be improved before they have contact with vulnerable patients. Educational input can increase knowledge and practice but the methodological heterogeneity of the studies and lack of rigour make it impossible to determine which interventions are most likely to be successful. The literature provides little evidence upon which to base educational practice in this area. There is a need for multi-centred longitudinal studies to measure effectiveness of teaching methods over time.

Impact of a multimodal intervention on compliance with hand hygiene among health care workers of a tertiary hospital

BACKGROUND AND OBJECTIVE

Hand hygiene (HH) is the simplest and most effective measure for the prevention of infection related to healthcare. Despite this, compliance in healthcare professionals continues to be suboptimal. The aim of this study is to assess the impact of an expanded World Health Organization (WHO) multimodal strategy on HH compliance in healthcare personnel.

MATERIAL AND METHODS

A quasi-experimental before-after study was designed, carrying out the expanded WHO multimodal strategy in 2018, aimed at professionals in a tertiary hospital. In this strategy, apart from applying the 5 pillars of the WHO, a video was made, the administration of the WHO perceptions questionnaire and an incentive to the service/unit with better compliance, adding to the training a modality of practical workshops. The compliance percentages for 2017 and 2018 were compared.

RESULTS

In 2017, 1056 opportunities were observed, registering 631 HH actions, with global compliance of 60% (95% CI 56.7-62.7). In 2018, with 1481 opportunities observed and 1111 HH actions, compliance was 75% (95% CI 72.7-77.2) (P<.001). This compliance increased in all professional categories and in all indications.

CONCLUSIONS

The application of an expanded multimodal strategy has a positive impact on HH compliance. Strategies should be directed to the categories with the worst compliance and continuously over time.

Brazilian Mobile Phone Applications Related to Hand Hygiene and Their Applicability for Healthcare Professionals

The objective of this study was to identify available mobile applications regarding education for hand hygiene and their applicability as a resource for nurses and other healthcare professionals. The aim was to assess the quality of the mobile apps for education on hand hygiene for health professionals. A review of mobile apps available from Apple App Store and Google Play Store in Brazil was conducted. The World Health Organization recommendations and the Mobile Application Rating Scale for evaluating quality were used. Six applications were selected, only three presented gamification elements incorporated into the learning method and only two of them-SureWash Pocket and Give Me 5-used the international recommendations to improve hand hygiene compliance in a more substantial and interactive way. The mean quality total score for the five rated apps was 3.41, indicating poor to acceptable quality. SureWash Pocket was the only application that reached Mobile Application Rating Scale ≥4 in all dimensions. These mobile applications can be used as complementary alternatives in addition to other available education strategies to improve the standards of hand hygiene and change the behavior of health professionals.

How Gameful Experience Affects Public Knowledge, Attitudes, and Practices Regarding COVID-19 Among the Taiwanese Public: Cross-sectional Study

Background

In 2019, with the COVID-19 pandemic sweeping across the globe, public health systems worldwide faced severe challenges. Amid the pandemic, one simulation game, Plague Inc., has received substantial attention. This game has indirectly drawn greater public attention to public health issues by simulating pathogen transmission and disease symptoms.

Objective

Against this backdrop, this research investigates whether the gameful experience of Plague Inc. has indirectly affected public knowledge, attitudes, and practices (KAP) regarding COVID-19.

Methods

An online survey was conducted through social networking services in Taiwan from May 6-28, 2020.

Results

A total of 486 subjects participated in this study, of which 276 (56.8%) had played Plague Inc. This study had several findings. First, participants who had played Plague Inc. demonstrated higher levels of knowledge (P=.03, median 7, IQR 7-8) and attitudes (P=.007, median 8, IQR 7-8) than participants who had not played Plague Inc. (knowledge: median 7, IQR 6-8; attitude: median 7, IQR 6-8). Second, there was a significant correlation between creative thinking (ρ=.127, P=.04) and dominance (ρ=.122, P=.04) in attitude. Finally, there was a significant correlation between creative thinking (ρ=.126, P<.001) and dominance (ρ=.119, P=.049) in practice.

Conclusions

Serious games highlighting the theme of pathogen transmission may enhance public knowledge and attitudes regarding COVID-19. Furthermore, the creative thinking and dominance involved in gameful experiences may act as critical factors in public attitudes and practices regarding COVID-19. These findings should be further verified through experimental research in the future.

Information technology on hand hygiene compliance among health care professionals: A systematic review and meta-analysis

AIM

To determine the effectiveness of information technology interventions on hand hygiene compliance among health care professionals.

BACKGROUND

Performing hand hygiene is the optimal approach to prevent the transmission of health care-associated infections. However, results regarding the effectiveness of information technology interventions on hand hygiene compliance were inconsistent to date.

EVALUATION

A search for studies published up to May 2020 was undertaken. A meta-analysis was conducted using RevMan 5.3 software.

KEY ISSUES

The most commonly used information technology systems were as follows: automated training, electronic counting devices and remote monitoring, real-time hand hygiene reminders and feedback, and automated monitoring. These four types of technology systems can significantly improve hand hygiene compliance among health care professionals (odds ratio = 3.06, p < .001).

CONCLUSION

The four types of information technology can be effectively used to change the hand hygiene behaviour. Because the information systems can monitor personnel and conduct statistical analyses automatically, they save labour costs of human monitors, are more time efficient and eliminate accompanying human error.

IMPLICATIONS FOR NURSING MANAGEMENT

The use of the four types of information technology is convenient and could reduce health care-associated infections; thus, they could be widely used in the future as the key to increase hand hygiene compliance rate.

Powdered Activated Charcoal Tracing in Hand Hygiene Training and Compliance Assessment During the COVID-19 Pandemic

Objective

Because of the COVID-19 pandemic there has been a significant increase in the prevalence of nosocomial infections. As a result, we sought to find an effective, efficient and safe way to train healthcare workers on proper hand washing techniques. We used powdered activated carbon (PAC) as a tracer to visually display hand washing defects after the hand washing process. The real-time visual assessment of the efficacy of the hand washing technique aided in the immediate correction of errors, and this definitively improved hand hygiene techniques of the interns.

Methods

Clinical interns at the emergency department of Shengjing Hospital were included in this study and received training in relation to the six-step hand-washing technique developed by the World Health Organization (WHO). The subjects’ hand-washing defects or faults were traced using PAC and corrected accordingly. Acceptance of the PAC tracing method by the interns, and its safety, were both assessed using a questionnaire survey.

Results

The results indicated that the back of the hands, fingers, and the wrists were prone to hand-washing defects. The hand-washing defects were significantly reduced after targeted corrections by the trainers. Subjects reported satisfactory acceptance toward the PAC tracing method and the method was relatively safe for subjects.

Conclusion

The PAC tracing method can visually display hand-washing defects and significantly improve the effectiveness of hand-washing training.

Using an ultraviolet cabinet improves compliance with the World Health Organization's hand hygiene recommendations by undergraduate medical students: a randomized controlled trial

BACKGROUND

Appropriate hand hygiene (HH) is key to reducing healthcare-acquired infections. The World Health Organization (WHO) recommends education and training to improve HH knowledge and compliance. Physicians are ranked among the worst of all healthcare workers for compliant handrubbing with its origin probably being the failure to learn this essential behavior during undergraduate medical studies. This study evaluated if the use of Ultraviolet-cabinets (UVc) for fluorescent-alcohol-based handrubs (AHR) during an undergraduate medical student training improved the compliance rate to the WHO hand hygiene recommendations (completeness of AHR application and HH opportunities).

METHODS

This randomized trial compared a HH training with personal feedback (using UVc) to a control group. The first year, the students (2nd degree) were convened by groups (clusters) of 6-9 for a demonstration of the correct execution of WHO procedure. Randomization by cluster was done prior HH training. In the control group, the students hand rubbed under visual supervision of a tutor. In the intervention group after the same visual supervision, completeness of fluorescent-AHR hand application was recorded under UVc and was shown to the student. The intervention group had free access to the UVc until complete application. HH practices were included in simulation sessions for the both groups. One year after (3rd degree), all the students were asked to hand rub with fluorescent-AHR. A tutor (blinded to the study group) assessed the completeness of hand application under UVc and the compliance with the WHO opportunities. Complete application of AHR was defined as fluorescence for all the surfaces of hands and wrists.

RESULTS

242 students participated (140 in the intervention group and 102 in the control group). One year after the initial training, the rate of complete application of AHR was doubled in the intervention group (60.0% vs. 30.4%, p < 0.001). In a multivariate analysis which included gender, additional HH or UVc training, surgical traineeship and regular use of AHR, the hazard ratio for the intervention was 3.84 (95%CI: 2.09-7.06). The compliance with the HH WHO's opportunities was increased in the intervention group (58.1% vs. 42.4%, p < 0.018).

CONCLUSION

Using UVc for undergraduate medical students education to hand hygiene improves their technique and compliance with WHO recommendations.

Using Artificial Intelligence in Infection Prevention

Purpose of Review

Artificial intelligence (AI) offers huge potential in infection prevention and control (IPC). We explore its potential IPC benefits in epidemiology, laboratory infection diagnosis, and hand hygiene.

Recent Findings

AI has the potential to detect transmission events during outbreaks or predict high-risk patients, enabling development of tailored IPC interventions. AI offers opportunities to enhance diagnostics with objective pattern recognition, standardize the diagnosis of infections with IPC implications, and facilitate the dissemination of IPC expertise. AI hand hygiene applications can deliver behavior change, though it requires further evaluation in different clinical settings. However, staff can become dependent on automatic reminders, and performance returns to baseline if feedback is removed.

Summary

Advantages for IPC include speed, consistency, and capability of handling infinitely large datasets. However, many challenges remain; improving the availability of high-quality representative datasets and consideration of biases within preexisting databases are important challenges for future developments. AI in itself will not improve IPC; this requires culture and behavior change. Most studies to date assess performance retrospectively so there is a need for prospective evaluation in the real-life, often chaotic, clinical setting. Close collaboration with IPC experts to interpret outputs and ensure clinical relevance is essential.

A new approach to infection prevention: A pilot study to evaluate a hand hygiene ambassador program in hospitals and clinics

BACKGROUND

A pilot study was conducted to assess the perceptions of visitors, patients, and staff to the presence of a hand hygiene ambassador (HHA).

METHODS

Two hundred and twenty-five entrants to various health care settings were surveyed. Only entrants who failed to clean their hands at the alcohol-based handrub (ABHR) station on entry to the lobby were offered application of ABHR by an HHA. Several questions were also asked to assess their attitudes about the presence of an HHA.

RESULTS

When asked whether they think it is a good idea to have an HHA place ABHR on an entrant's hands, the majority of staff, visitors, and patients agreed. No one refused administration of handrub by the HHA.

DISCUSSION

HHA programs have direct and indirect benefits. Although the cost of such an initiative should be considered prior to implementation, it should be weighed against the annual spending for health care-associated infections.

CONCLUSIONS

Considering that hand hygiene compliance and health care-associated infection are clearly linked, a new approach using an HHA may help reduce infection, acting as a source of hand hygiene on entry to the hospital and possibly as a reminder to perform hand hygiene elsewhere in the hospital and clinics.

Applying thematic synthesis to interpretation and commentary in epidemiological studies: identifying what contributes to successful interventions to promote hand hygiene in patient care

OBJECTIVES

Hand hygiene is considered the most important preventive measure for healthcare-associated infections, but adherence is suboptimal. We previously undertook a Cochrane Review that demonstrated that interventions to improve adherence are moderately effective. Impact varied between organisations and sites with the same intervention and implementation approaches. This study seeks to explore these differences.

METHODS

A thematic synthesis was applied to the original authors' interpretation and commentary that offered explanations of how hand hygiene interventions exerted their effects and suggested reasons why success varied. The synthesis used a published Cochrane Review followed by three-stage synthesis.

RESULTS

Twenty-one papers were reviewed: 11 randomised, 1 non-randomised and 9 interrupted time series studies. Thirteen descriptive themes were identified. They reflected a range of factors perceived to influence effectiveness. Descriptive themes were synthesised into three analytical themes: methodological explanations for failure or success (eg, Hawthorne effect) and two related themes that address issues with implementing hand hygiene interventions: successful implementation needs leadership and cooperation throughout the organisation (eg, visible managerial support) and understanding the context and aligning the intervention with it drives implementation (eg, embedding the intervention into wider patient safety initiatives).

CONCLUSIONS

The analytical themes help to explain the original authors' perceptions of the degree to which interventions were effective and suggested new directions for research: exploring ways to avoid the Hawthorne effect; exploring the impact of components of multimodal interventions; the use of theoretical frameworks for behaviour change; potential to embed interventions into wider patient safety initiatives; adaptations to demonstrate sustainability; and the development of systematic approaches to implementation. Our findings corroborate studies exploring the success or failure of other clinical interventions: context and leadership are important.

The effect of training and awareness of subtle control on the frequency of hand hygiene among intensive care unit nurses

Objective

This study aimed to determine the effect of awareness of subtle control after training on the hand hygiene compliance among nurses in intensive care units (ICUs). The study was conducted in two ICUs of a trauma center in Shiraz, Iran on 48 nurses. The nurses of one ICU were randomly allocated to the intervention and the nurses of the other ICU were allocated to the control group. All nurses were trained on hand hygiene. Then a fake closed camera television (CCTV) was visibly installed in the intervention group’s ICU, while the nurses were aware of it. The degree of compliance with hand hygiene was observed in both groups before and after the intervention. Data were gathered using a checklist based on the World Health Organization hand hygiene protocol and analyzed using SPSS 16 and the Chi square, Wilcoxon, Mann–Whitney U, and Independent T-tests, were performed.

Results

The mean percentage of hand hygiene compliance in the intervention group after the intervention was significantly higher than before the intervention (p < 0.001). Additionally, the changes in the mean percentage of the intervention group was significantly higher than that for the control group (p = 0.001). The findings showed that a fake CCTV after training, installed in ICUs, can improve hand hygiene compliance.

Teaching best practice in hand hygiene: student use and performance with a gamified gesture recognition system

The use of an automated gesture recognition system to teach the commonly adopted, seven-stage hand hygiene technique to veterinary undergraduate students was evaluated. The system features moderate gamification, intended to motivate the student to use the machine repeatedly. The system records each handwash stage, and those found to be difficult are identified and reported back. The gamification element alone was not sufficient to encourage repeated use of the machine, with only 13.6 per cent of 611 eligible students interacting with the machine on one or more occasion. Overall engagement remained low (mean sessions per user: 3.5, ±0.60 confidence interval), even following recruitment of infection control ambassadors who were given a specific remit to encourage engagement with the system. Compliance monitoring was introduced to explore how students used the system. Hand hygiene performance did not improve with repeated use. There was evidence that the stages-fingers interlaced, rotation of the thumb, rotation of the fingertips and rotation of the wrists-were more challenging for students to master (p=0.0197 to p<0.0001) than the back of the hand and of the fingers. Veterinary schools wishing to use such a system should consider adopting approaches that encourage peer buy-in, and highlight the ability to practise difficult stages of the technique.

Evaluating the effectiveness of the "Germ-Free Hands" intervention for improving the hand hygiene practices of public health students

PURPOSE

This quasi-experimental study sought to assess the effectiveness of a multidisciplinary intervention called "Germ-Free Hands" to improve the hand hygiene practices of students attending Thailand's Sirindhorn College of Public Health (SCPH).

METHODS

The intervention was developed and implemented at SCPH and incorporated education, training, a workshop, and performance feedback. The intervention targeted behavioral antecedents specified by the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB). Handwashing determinants (knowledge, beliefs, attitudes, subjective norms, perceived behavioral control, and intentions) and hand hygiene behaviors were assessed at baseline, immediately post-intervention, and 3 months post-intervention for the intervention group at (n=60) at the Suphanburi campus of SCPH and a matched control group (n=60) of students at the Ubonratchathani campus. Data analysis included descriptive statistics, independent samples t-tests, two-way measures of analysis of variance, and a generalized estimating equation to compare handwashing practices by self-reports between two groups.

RESULTS

The "Germ-Free Hands" intervention produced significant improvements in the intervention group's handwashing knowledge, behavioral and control beliefs, subjective norm scores, intentions, and behaviors, as compared to the control group. However, the intervention had no significant impact on normative beliefs, attitudes, or perceived behavioral control. Reported improvements also decreased 3 months post-intervention, and the number of bacterial colonies on students' hands increased over the course of the study.

CONCLUSION

This study adds to the evidence that multidisciplinary interventions can be effective at improving handwashing rates. However, education and training must be continuous, rather than delivered as a one-time program, in order to have sustained results. Participants may also require more in-depth instruction in correct handwashing and drying techniques to remove bacteria effectively and prevent recolonization.

The use of privacy-protected computer vision to measure the quality of healthcare worker hand hygiene

OBJECTIVES

(i) To demonstrate the feasibility of automated, direct observation and collection of hand hygiene data, (ii) to develop computer visual methods capable of reporting compliance with moment 1 (the performance of hand hygiene before touching a patient) and (iii) to report the diagnostic accuracy of automated, direct observation of moment 1.

DESIGN

Observation of simulated hand hygiene encounters between a healthcare worker and a patient.

SETTING

Computer laboratory in a university.

PARTICIPANTS

Healthy volunteers.

MAIN OUTCOME MEASURES

Sensitivity and specificity of automatic detection of the first moment of hand hygiene.

METHODS

We captured video and depth images using a Kinect camera and developed computer visual methods to automatically detect the use of alcohol-based hand rub (ABHR), rubbing together of hands and subsequent contact of the patient by the healthcare worker using depth imagery.

RESULTS

We acquired images from 18 different simulated hand hygiene encounters where the healthcare worker complied with the first moment of hand hygiene, and 8 encounters where they did not. The diagnostic accuracy of determining that ABHR was dispensed and that the patient was touched was excellent (sensitivity 100%, specificity 100%). The diagnostic accuracy of determining that the hands were rubbed together after dispensing ABHR was good (sensitivity 83%, specificity 88%).

CONCLUSIONS

We have demonstrated that it is possible to automate the direct observation of hand hygiene performance in a simulated clinical setting. We used cheap, widely available consumer technology and depth imagery which potentially increases clinical application and decreases privacy concerns.

Guiding hand hygiene interventions among future healthcare workers: implications of knowledge, attitudes, and social influences

BACKGROUND

Medical students in their clinical years play an important role in healthcare delivery, yet poor levels of hand hygiene (HH) compliance in this population raise the risk for propagating nosocomial infections. To date, there has been a lack of dedicated interventions showing sustainable improvements in HH in this population.

METHODS

A multicenter, cross-sectional study was conducted among 450 medical students in their clinical years (third to fifth years). A self-administered, pre-validated questionnaire based on the World Health Organization's "Knowledge" and "Perception" questionnaires was used to explore HH knowledge, attitudes, practices, and desired interventions.

RESULTS

Self-reported HH compliance was found to be low (56.8%), and moderate HH knowledge (61.8%) was observed among all study respondents. Public university students expressed greater knowledge than students in private and semi-private universities. Superior HH practices were associated with better individual HH attitudes, positive perceived HH attitudes in other healthcare workers (HCWs), and higher HH knowledge scores. The highest-rated interventions for improving HH compliance included role-modeling by HCWs, display of "clear HH instructions," and "ensuring availability of hand sanitizers."

CONCLUSION

Our results call for a multifaceted approach to improve HH compliance among medical students, by ensuring adequate HH supplies/hand sanitizers, providing HH training in curricula, and effecting a cultural change mediated by professional modeling and open communication.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Interventions to improve hand hygiene compliance in patient care: Reflections on three systematic reviews for the Cochrane Collaboration 2007-2017

This article presents highlights from a recently updated systematic Cochrane review evaluating the effectiveness of interventions to improve hand hygiene compliance in patient care. It is an advance on the two earlier reviews we undertook on the same topic as it has, for the first time, provided very rigorous synthesis of evidence that such interventions can improve practice. In this article, we provide highlights from a recently updated Cochrane systematic review. We identify omissions in the information reported and point out important aspects of hand hygiene intervention studies that were beyond the scope of the review. A full report of the review is available free of charge on the Cochrane website.

Interventions to improve hand hygiene compliance in patient care

BACKGROUND

Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure. This is an update of a previously published review.

OBJECTIVES

To assess the short- and long-term success of strategies to improve compliance to recommendations for hand hygiene, and to determine whether an increase in hand hygiene compliance can reduce rates of health care-associated infection.

SEARCH METHODS

We conducted electronic searches of the Cochrane Register of Controlled Trials, PubMed, Embase, and CINAHL. We conducted the searches from November 2009 to October 2016.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series analyses (ITS) that evaluated any intervention to improve compliance with hand hygiene using soap and water or alcohol-based hand rub (ABHR), or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened citations for inclusion, extracted data, and assessed risks of bias for each included study. Meta-analysis was not possible, as there was substantial heterogeneity across studies. We assessed the certainty of evidence using the GRADE approach and present the results narratively in a 'Summary of findings' table.

MAIN RESULTS

This review includes 26 studies: 14 randomised trials, two non-randomised trials and 10 ITS studies. Most studies were conducted in hospitals or long-term care facilities in different countries, and collected data from a variety of healthcare workers. Fourteen studies assessed the success of different combinations of strategies recommended by the World Health Organization (WHO) to improve hand hygiene compliance. Strategies consisted of the following: increasing the availability of ABHR, different types of education for staff, reminders (written and verbal), different types of performance feedback, administrative support, and staff involvement. Six studies assessed different types of performance feedback, two studies evaluated education, three studies evaluated cues such as signs or scent, and one study assessed placement of ABHR. Observed hand hygiene compliance was measured in all but three studies which reported product usage. Eight studies also reported either infection or colonisation rates. All studies had two or more sources of high or unclear risks of bias, most often associated with blinding or independence of the intervention.Multimodal interventions that include some but not all strategies recommended in the WHO guidelines may slightly improve hand hygiene compliance (five studies; 56 centres) and may slightly reduce infection rates (three studies; 34 centres), low certainty of evidence for both outcomes.Multimodal interventions that include all strategies recommended in the WHO guidelines may slightly reduce colonisation rates (one study; 167 centres; low certainty of evidence). It is unclear whether the intervention improves hand hygiene compliance (five studies; 184 centres) or reduces infection (two studies; 16 centres) because the certainty of this evidence is very low.Multimodal interventions that contain all strategies recommended in the WHO guidelines plus additional strategies may slightly improve hand hygiene compliance (six studies; 15 centres; low certainty of evidence). It is unclear whether this intervention reduces infection rates (one study; one centre; very low certainty of evidence).Performance feedback may improve hand hygiene compliance (six studies; 21 centres; low certainty of evidence). This intervention probably slightly reduces infection (one study; one centre) and colonisation rates (one study; one centre) based on moderate certainty of evidence.Education may improve hand hygiene compliance (two studies; two centres), low certainty of evidence.Cues such as signs or scent may slightly improve hand hygiene compliance (three studies; three centres), low certainty of evidence.Placement of ABHR close to point of use probably slightly improves hand hygiene compliance (one study; one centre), moderate certainty of evidence.

AUTHORS' CONCLUSIONS

With the identified variability in certainty of evidence, interventions, and methods, there remains an urgent need to undertake methodologically robust research to explore the effectiveness of multimodal versus simpler interventions to increase hand hygiene compliance, and to identify which components of multimodal interventions or combinations of strategies are most effective in a particular context.

Construct validity-Current issues and recommendations for future hand hygiene research

Health care-associated infection is a leading cause of morbidity and mortality. Hand hygiene is widely regarded as an effective prevention strategy. Often, hand hygiene research is designed and conducted by health care practitioners who may lack formal training in research methods, particularly in the area of social science. In a research context, a construct is a concept that can be measured or observed in some way. A construct can be directly or indirectly measured. For example, height can be directly measured by centimeters, whereas depression can be indirectly measured by a scale of 20 items. Every construct needs to be operationalized by measure(s) to make it a variable. Hence, construct validity refers to the degree of fit between the construct of interest and its operational measure. However, issues with construct validity often weaken the translation from construct to measure(s). This article will (1) describe the common threats to construct validity pertaining to hand hygiene research, (2) identify practical limitations in current research design, and (3) provide recommendations to improve construct validity in future hand hygiene research. By understanding how construct validity may affect hand hygiene research design, there is great potential to improve the validity of future hand hygiene research findings.

Persuasive technology in teaching acute pain assessment in nursing: Results in learning based on pre and post-testing

BACKGROUND

Thousands of patients seek health services every day with complaints of pain. However, adequate pain assessment is still flawed, a fact that is partly related to gaps in professional learning on this topic. Innovative strategies such as the use of a virtual learning object mediated by persuasive technology in the learning of undergraduate nursing students can help to fill these gaps and to provide different ways of learning to learn.

OBJECTIVE

To evaluate the results in learning among undergraduate nursing students about assessment of acute pain in adults and newborns, before and after an online educational intervention.

DESIGN

This is a quasi-experimental, non-equivalent study using pre-and post-testing.

SETTING

Federal University of Santa Catarina, Brazil.

PARTICIPANTS

75 undergraduate nursing students.

METHODS

Our study was conducted in three steps (pre-test, education intervention, post-test). Data were collected from November 2013 to February 2014. The educational intervention was performed using online access to virtual learning object about acute pain assessment, which students accessed on their mobile devices.

CONCLUSION

A significant difference was seen in student learning (p<0.001) in the post-test compared with the pre-test results. The students understood the importance of the topic, and were satisfied and motivated by the technology and method applied. The use of persuasive technology such as small mobile devices as mediators of online educational interventions broadens learning spaces in an innovative, flexible, motivational, and promising manner.

Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations

Health care-associated infections (HAI) are a major public health problem with a significant impact on morbidity, mortality and quality of life. They represent also an important economic burden to health systems worldwide. However, a large proportion of HAI are preventable through effective infection prevention and control (IPC) measures. Improvements in IPC at the national and facility level are critical for the successful containment of antimicrobial resistance and the prevention of HAI, including outbreaks of highly transmissible diseases through high quality care within the context of universal health coverage. Given the limited availability of IPC evidence-based guidance and standards, the World Health Organization (WHO) decided to prioritize the development of global recommendations on the core components of effective IPC programmes both at the national and acute health care facility level, based on systematic literature reviews and expert consensus. The aim of the guideline development process was to identify the evidence and evaluate its quality, consider patient values and preferences, resource implications, and the feasibility and acceptability of the recommendations. As a result, 11 recommendations and three good practice statements are presented here, including a summary of the supporting evidence, and form the substance of a new WHO IPC guideline.

Evidence-based practices to increase hand hygiene compliance in health care facilities: An integrated review

BACKGROUND

Hand hygiene (HH) in health care facilities is a key component to reduce pathogen transmission and nosocomial infections. However, most HH interventions (HHI) have not been sustainable.

AIMS

This review aims to provide a comprehensive summary of recently published evidence-based HHI designed to improve HH compliance (HHC) that will enable health care providers to make informed choices when allocating limited resources to improve HHC and patient safety.

METHODS

The Medline electronic database (using PubMed) was used to identify relevant studies. English language articles that included hand hygiene interventions and related terms combined with health care environments or related terms were included.

RESULTS

Seventy-three studies that met the inclusion criteria were summarized. Interventions were categorized as improving awareness with education, facility design, and planning, unit-level protocols and procedures, hospital-wide programs, and multimodal interventions. Past successful HHIs may not be as effective when applied to other health care environments. HH education should be interactive and engaging. Electronic monitoring and reminders should be implemented in phases to ensure cost-effectiveness. To create hospitalwide programs that engage end users, policy makers should draw expertise from interdisciplinary fields. Before implementing the various components of multimodal interventions, health care practitioners should identify and examine HH difficulties unique to their organizations.

CONCLUSIONS

Future research should seek to achieve the following: replicate successful HHI in other health care environments, develop reliable HHC monitoring tools, understand caregiver-patient-family interactions, examine ways (eg, hospital leadership, financial support, and strategies from public health and infection prevention initiatives) to sustain HHC, and use simulated lab environments to refine study designs.

Assessment of hand hygiene techniques using the World Health Organization's six steps

The quality of hand hygiene was evaluated via direct observation for compliance with the six recommended World Health Organization steps. A total of 2497 HH opportunities, of which 1573 (63.0%) were hand rubs, were monitored over a five month period. Compliance was higher in nurses compared with physicians and auxiliaries and in steps 1 and 2 for hand rubs as well as the first three steps of hand washing, with lower rates after these steps. Rubbing of the thumbs and fingertips achieved the lowest rates of compliance in both HH types. A combination of the five recommended moments and six steps and staff education is recommended to improve the quality of hand hygiene.

An automated hand hygiene training system improves hand hygiene technique but not compliance

INTRODUCTION

The hand hygiene technique that the World Health Organization recommends for cleansing hands with soap and water or alcohol-based handrub consists of 7 poses. We used an automated training system to improve clinicians' hand hygiene technique and test whether this affected hospitalwide hand hygiene compliance.

METHODS

Seven hundred eighty-nine medical and nursing staff volunteered to participate in a self-directed training session using the automated training system. The proportion of successful first attempts was reported for each of the 7 poses. Hand hygiene compliance was collected according to the national requirement and rates for 2011-2014 were used to determine the effect of the training system on compliance.

RESULTS

The highest pass rate was for pose 1 (palm to palm) at 77% (606 out of 789), whereas pose 6 (clean thumbs) had the lowest pass rate at 27% (216 out of 789). One hundred volunteers provided feedback to 8 items related to satisfaction with the automated training system and most (86%) expressed a high degree of satisfaction and all reported that this method was time-efficient. There was no significant change in compliance rates after the introduction of the automated training system. Observed compliance during the posttraining period declined but increased to 82% in response to other strategies.

CONCLUSIONS

Technology for training clinicians in the 7 poses played an important education role but did not affect compliance rates.

Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis

OBJECTIVE

To evaluate the relative efficacy of the World Health Organization 2005 campaign (WHO-5) and other interventions to promote hand hygiene among healthcare workers in hospital settings and to summarize associated information on use of resources.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, Embase, CINAHL, NHS Economic Evaluation Database, NHS Centre for Reviews and Dissemination, Cochrane Library, and the EPOC register (December 2009 to February 2014); studies selected by the same search terms in previous systematic reviews (1980-2009).

REVIEW METHODS

Included studies were randomised controlled trials, non-randomised trials, controlled before-after trials, and interrupted time series studies implementing an intervention to improve compliance with hand hygiene among healthcare workers in hospital settings and measuring compliance or appropriate proxies that met predefined quality inclusion criteria. When studies had not used appropriate analytical methods, primary data were re-analysed. Random effects and network meta-analyses were performed on studies reporting directly observed compliance with hand hygiene when they were considered sufficiently homogeneous with regard to interventions and participants. Information on resources required for interventions was extracted and graded into three levels.

RESULTS

Of 3639 studies retrieved, 41 met the inclusion criteria (six randomised controlled trials, 32 interrupted time series, one non-randomised trial, and two controlled before-after studies). Meta-analysis of two randomised controlled trials showed the addition of goal setting to WHO-5 was associated with improved compliance (pooled odds ratio 1.35, 95% confidence interval 1.04 to 1.76; I(2)=81%). Of 22 pairwise comparisons from interrupted time series, 18 showed stepwise increases in compliance with hand hygiene, and all but four showed a trend for increasing compliance after the intervention. Network meta-analysis indicated considerable uncertainty in the relative effectiveness of interventions, but nonetheless provided evidence that WHO-5 is effective and that compliance can be further improved by adding interventions including goal setting, reward incentives, and accountability. Nineteen studies reported clinical outcomes; data from these were consistent with clinically important reductions in rates of infection resulting from improved hand hygiene for some but not all important hospital pathogens. Reported costs of interventions ranged from $225 to $4669 (£146-£3035; €204-€4229) per 1000 bed days.

CONCLUSION

Promotion of hand hygiene with WHO-5 is effective at increasing compliance in healthcare workers. Addition of goal setting, reward incentives, and accountability strategies can lead to further improvements. Reporting of resources required for such interventions remains inadequate.

Efficacy of a new educational tool to improve Handrubbing technique amongst healthcare workers: a controlled, before-after study

Introduction

Hand hygiene is a key component of infection control in healthcare. WHO recommends that healthcare workers perform six specific poses during each hand hygiene action. SureWash (Glanta Ltd, Dublin, Ireland) is a novel device that uses video-measurement technology and immediate feedback to teach this technique. We assessed the impact of self-directed SureWash use on healthcare worker hand hygiene technique and evaluated the device's diagnostic capacity.

Methods

A controlled before-after study: subjects in Group A were exposed to the SureWash for four weeks followed by Group B for 12 weeks. Each subject's hand hygiene technique was assessed by blinded observers at baseline (T₀) and following intervention periods (T₁ and T₂). Primary outcome was performance of a complete hand hygiene action, requiring all six poses during an action lasting ≥20 seconds. The number of poses per hand hygiene action (maximum 6) was assessed in a post-hoc analysis. SureWash's diagnostic capacity compared to human observers was assessed using ROC curve analysis.

Results

Thirty-four and 29 healthcare workers were recruited to groups A and B, respectively. No participants performed a complete action at baseline. At T₁, one Group A participant and no Group B participants performed a complete action. At baseline, the median number of poses performed per action was 2.0 and 1.0 in Groups A and B, respectively (p = 0.12). At T₁, the number of poses per action was greater in Group A (post-intervention) than Group B (control): median 3.8 and 2.0, respectively (p<0.001). In Group A, the number of poses performed twelve weeks post-intervention (median 3.0) remained higher than baseline (p<0.001). The area under the ROC curves for the 6 poses ranged from 0.59 to 0.88.

Discussion

While no impact on complete actions was demonstrated, SureWash significantly increased the number of poses per hand hygiene action and demonstrated good diagnostic capacity.

Influence of signal colored hand disinfectant dispensers on hand hygiene compliance at a medical intensive care unit

To assess the influence of signal colors on hand disinfectant dispenser activities, health care workers (HCWs) at a medical intensive care unit were analyzed for a total of 20 weeks with 8 weeks before and 12 weeks after exchange to signal color. No significant increase in hand rubs (HRs) per patient day (PD) was observed (about 40 HRs/PD); however, HCW-adjusted compliance showed a 6% increase with signal colored devices. Therefore, colored devices may help to improve hand hygiene compliance.

An observational study of hand hygiene adherence following the introduction of an education intervention

Hand hygiene adherence needs to be increased and sustained in order to prevent and reduce healthcare associated infections. We implemented an educational intervention and observed the adherence of healthcare workers, patients and visitors over 24 hour periods at four observation points. For healthcare workers a total of 2,294 opportunities were observed and for patients and visitors, a total of 597 opportunities were observed. Healthcare worker adherence increased following the introduction of the educational intervention, with 53.0% (282/532) adherence at baseline (observation point 1), and was sustained varying between 67.7% and 70.8% in the post-intervention points (p=0.0007). The greatest increase in adherence was observed between baseline and the observation point 2. Adherence varied according to type of opportunity (p<0.0001) with the lowest level of adherence observed after contact with patient surroundings, however there was no obvious trend across the observation points. There was an interaction between point of study and ward (p=0.0001). For patients and visitors, adherence did differ according to the point of study (p=0.0074) with adherence prior to the intervention being 49.1% and then ranging from 43.5-61.8%. We suggest that future educational interventions should be implemented as this study implies that there is potential for increased and sustained adherence to hand hygiene protocols.