Performance feedback of hand hygiene, using alcohol gel as the skin decontaminant, reduces the number of inpatients newly affected by MRSA and antibiotic costs

Rinse, gel, and foam - is there any evidence for a difference in their effectiveness in preventing infections?

BACKGROUND

Following publication of the 2009 World Health Organizations Guidelines for Hand Hygiene in Health Care, a debate has emerged regarding the relative antimicrobial efficacy of the different formats (rinse, gel, foam) of ABHRs and their ability to contribute to reduction of healthcare-associated infections (HAIs).

METHODS

Data regarding the in-vivo antimicrobial efficacy of ABHRs and other factors that likely affect their effectiveness in reducing HAIs were reviewed, and a comprehensive review of studies that reported the effectiveness of each of the three ABHR formats to improve hand hygiene compliance and reduce HAIs was conducted.

RESULTS

The amount of rubbing time it takes for hands to feel dry (dry time) is the major driver of ABHR antimicrobial efficacy. ABHR format is not a major factor, and several studies found that rinse, gel, and foam ABHRs have comparable in-vivo antimicrobial efficacy. Other factors that likely impact the ability of ABHRs to reduce transmission of healthcare-associated pathogens and HAIs include ABHR formulation, the volume applied to hands, aesthetic characteristics, skin tolerance, acceptance by healthcare personnel, and hand hygiene compliance rates. When accompanied by complementary strategies, promoting the use of each of the three ABHR formats has been associated with improvements in hand hygiene compliance rates. A review of 67 studies failed to identify an ABHR format that was significantly more effective in yielding statistically significant reductions in transmission of healthcare-associated pathogens or HAIs.

CONCLUSIONS

Current evidence is insufficient to definitively determine if one ABHR format is more effective in reducing transmission of healthcare-associated pathogens and HAIs. More rigorous studies such as multicenter randomized controlled trials comparing the different formats are needed to establish if one format is significantly more effective in reducing HAIs.

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.

Increased Frequency of Hand Hygiene and Other Infection Prevention Practices Correlates with Reduced Surgical Wound Infection Rates in Spinal Surgery during the COVID-19 Pandemic

BACKGROUND

Due to the COVID-19 pandemic outbreak, many changes were done in the hospital practice, and new guidelines were issued in order to contain the infection spread. One of the most common measures is represented by a correct and frequent hand washing. Recently, an association between increased adherence to hand hygiene (HH) protocols and reduction in hospital infections was documented however no studies about the surgical wound infection rate were reported in the Literature.

METHODS

The present study represents a multicentric retrospective epidemiological study. The HH compliance rate was recorded through direct observations by trained nurses, 24 h a day. The primary outcome was HH compliance rate. The association of HH with spinal surgical wound infections was the secondary outcome.

RESULTS

We reported a compliance to HH practices during the pandemic period of 85.2% compared with 57% observed during 2019. Our analysis showed an overall surgical wound infection reduction of 66.6% during the hospital stay in the pandemic period.

CONCLUSION

Hand hygiene has always been considered one of the most effective, reproducible and low-cost weapons to deal with hospital infections. The good health habits acquired during the COVID-19 pandemic should be maintained even after the virus is eradicated.

Effect of the COVID-19 Pandemic on Rates of Ninety-Day Peri-Prosthetic Joint and Surgical Site Infections after Primary Total Joint Arthroplasty: A Multicenter, Retrospective Study

Background: The impact of the coronavirus 2019 (COVID-19) pandemic on the rate of primary total joint arthroplasty (TJA) peri-prosthetic joint infection (PJI) and superficial surgical site infections (SSI) is currently unknown. The purpose of this multicenter study was to evaluate any changes in the rates of 90-day PJI or 30-day SSI, including trends in microbiology of the infections, during the COVID-19 pandemic compared to the three years prior. Patients and Methods: An Institutional Review Board-approved, multicenter, retrospective study was conducted with five participating academic institutions across two healthcare systems in the northeastern United States. Primary TJA patients from the years 2017-2019 were grouped as a pre-COVID-19 pandemic cohort and patients from the year 2020 were grouped as a COVID-19 pandemic cohort. Differences in patient demographics, PJI, SSI, and microbiology between the two cohorts were assessed. Results: A total of 14,844 TJAs in the pre-COVID-19 pandemic cohort and 5,453 TJAs in the COVID-19 pandemic cohort were evaluated. There were no substantial differences of the combined 90-day PJI and 30-day superficial SSI rates between the pre-COVID-19 pandemic cohort (0.35%) compared with the COVID-19 pandemic cohort (0.26%; p = 0.303). Conclusions: This study did not find any change in the rates of 90-day PJI or 30-day superficial SSI in patients undergoing primary TJA between a pre-COVID-19 pandemic and COVID-19 pandemic cohort. Larger national database studies may identify small but substantial differences in 90-day PJI and 30-day superficial SSI rates between these two time periods. Our data may support continued efforts to maintain high compliance with hand hygiene, use of personal protective equipment, and limited hospital visitation whenever possible.

Hand Hygiene Compliance in Pediatric Emergency of a Lower-Middle Income Country: A Quality Improvement Study

BACKGROUND

Prospective data on hand hygiene compliance in pediatric emergency department (PED) settings is limited. We studied the impact of quality improvement measures on the overall and health care personnel wise hand hygiene compliance rates in a busy PED.

METHODS

The baseline hand hygiene compliance rates were audited from May-July 2018. The quality improvement interventions included various structural changes to the environment, administrative changes, education and training. During the interventions, auditing was continued for 2 months (August - September 2018). Statistical Process control charts were created.

RESULTS

We observed a significant increase in overall compliance rates from 31.8 to 53.9% (p < 0.001). These improvements were observed in the children (29.6 to 46.4%, p < 0.001) as well as neonatal area (35.7% to 59.7, p < 0.001) of PED as well as amongst various health care personnel and in four out of the five moments of hand hygiene.

CONCLUSION

Hand hygiene compliance improved significantly in a busy PED of a lower middle-income country following quality improvement interventions. Such improvement was observed amongst all categories of health care personnel and different types of hand hygiene opportunities. This study demonstrates the feasibility and efficacy of simple quality improvement interventions in a challenging hospital environment.

Impact of coronavirus disease 2019 on infectious disease treatment and infection control at a tertiary hospital in Japan

Introduction

Coronavirus disease 2019 (COVID-19) has greatly impacted medical care practices. Although the effects on infectious disease treatment and infection control, such as antimicrobial resistance, have been specified, very few reports exist on the specific effects of COVID-19.

Methods

We investigated the effects of COVID-19 on daily medical practices at a tertiary hospital in Japan by comparing the use of hand sanitizers, the detection of bacteria from blood cultures, and the amount dose of antibacterial drugs used for one year before (April 2019 to March 2020, fiscal year 2019.) and after COVID-19 admissions began (April 2020 to March 2021, fiscal year 2020).

Results

The use of hand sanitizers increased by 1.4–3 times during the year after COVID-19 admissions began; the incidence of methicillin-susceptible Staphylococcus aureus and all S. aureus detected in blood cultures reduced in all departments. No decrease was observed in the usage of all antibacterial drugs; rather, the usage of all antibacterial drugs tended to increase in all departments. Therefore, no significant change was observed in the detection of drug-resistant bacteria and the trends of antibacterial drug use based on the acceptance of COVID-19 patients.

Conclusions

The prevalence of drug-resistant bacteria and trends of antibacterial drug use remained unchanged despite the increased use of hand sanitizers due to the admission of patients with COVID-19.

A Strategy for Hospital Pharmacists to Control Antimicrobial Resistance (AMR) in Japan

In Japan, there is concern regarding the relation between the inappropriate use of antibiotics and antibiotic resistance (AMR). Increased bacterial resistance is due in part to the inappropriate use of antimicrobial agents. The support of the pharmacist becomes important, and there is growing interest in antimicrobial stewardship to promote the appropriate and safe use of antimicrobials needed for the optimal selection of drugs, doses, durations of therapy, therapeutic drug monitoring (TDM), and implementations of cost containment strategies in Japan. Pharmacists should strive to disseminate the concept of "choosing wisely" in relation to all medicines, implement further interventions, and put them into practice. In this article, we present data for antimicrobial stewardship and Japan's AMR action plan, focusing on how pharmacists should be involved in enabling physicians to choose antimicrobials wisely.

Hand Washing Before and After Applying Different Hand Hygiene Techniques in Places of Public Concern in Tripoli-Libya

Background:

Hand hygiene has being considered as one of the primary measures to improve standards and practice for hospital care and to minimize the transmission of nosocomial pathogens. There is substantial evidence that incidence of hospital acquired infections is reduced by applying hand antisepsis. Regarding hand hygiene and public concern, hand washing has revealed that 85% of the observed adults wash their hands after using public toilets.

Objective:

To compare the efficacy of hand rubbing with an alcohol based solution versus conventional hand washing with antiseptic and non-antiseptic soaps in reducing bacterial counts using different hand hygiene techniques.

Methods:

Ninety-three volunteers took part in this study; 57 from Tripoli Medical Center (TMC); 16 from school; 11 from bank; and 9 from office. All volunteers performed six hand hygiene techniques, immediately before and after a volunteer practice activity: hand washing with non-antiseptic soap for 10 and 30 second (s); hand washing with antiseptic soap for 10, 30 or 60 s; and alcohol-based hand rub. A total of 864 specimens were taken: 432 before and 432 after volunteer's hand hygiene. The fingertips of the dominant hand for each volunteer were pressed on to agar for culture before and after each hand hygiene technique. Plates were incubated at 37oC, and colony-forming units were counted after 48 hours and pathogenic bacteria were identified.

Results:

Results showed that 617 specimens (71.41%) were positive for bacterial growth. 301 (48.78%) were from TMC, 118 (19.12%) were from office; 107 (14.34%) were from school and 91 (14.75%) were from bank.

Conclusion:

Both antiseptic and non–antiseptic soaps did not work properly in reducing bacterial counts of worker’s hands at all places of study, but significantly improved by an application of alcohol based gel.

Methicillin-resistant Staphylococcus aureus bacteremia among liver transplant recipients: epidemiology and associated risk factors for morbidity and mortality

Bacteremia due to Staphylococcus aureus, especially methicillin-resistant S. aureus (MRSA), complicates the clinical course of liver transplantation and is associated with high morbidity and mortality. Intravascular catheters had been reported to be the most frequent source of MRSA bacteremia. Among bacteremic liver recipients, 26.3%-100% of S. aureus were MRSA. Previous studies identified pre-transplant and post-transplant acquired S. aureus carriage, greater severity of liver disease, hepatocellular carcinoma and infection with immuno-modulatory viruses as predictors of S. aureus bacteremia in liver recipients. MRSA bacteremia accompanied by pneumonia and abdominal infections was related to mortality. Vancomycin, as well as daptomycin, is a first-line antibiotic for MRSA bacteremia. The purpose of this review is to better understand the characteristics of MRSA bacteremia by summarizing the epidemiology and antimicrobial resistance of S. aureus, the primary source, and related risk factors for morbidity and mortality of MRSA bacteremia. We have also explored the diagnostic, therapeutic and preventive measures for MRSA bacteremia to improve the outcomes of liver recipients.

Review: Antimicrobial efficacy validation using in vitro and in vivo testing methods

Pre-clinical antimicrobial validation testing for single and combination products, and parameters that should be considered when testing the antimicrobial performance of a medical device, are discussed. Guidance is provided on key elements required for in vitro and in vivo antimicrobial validation, including validation of microbial growth, microbial recovery, neutralization, and antimicrobial activity. An important consideration, both in terms of practicality and economics, is designing in vitro studies that bridge to in vivo testing: A representative in vitro model is used to generate data on many clinically relevant microorganisms, and then one microorganism is selected for use in in vivo testing. If the in vivo results correlate to the in vitro results, it can reasonably be extrapolated that the same would be true for the remaining microorganisms tested in vitro. Thus, the selection of relevant in vitro models for testing is critical for successful antimicrobial validation testing.

A quasi-experimental study to determine the effects of a multifaceted educational intervention on hand hygiene compliance in a radiography unit

Background

Whilst numerous studies have investigated nurses’ compliance with hand hygiene and use of alcohol-based hand rub (ABHR), limited attention has been paid to these issues in allied health staff. Reports have linked infections to breaches in infection control in the radiography unit (RU). With advances in medical imaging, a higher proportion of patients come into contact with RU staff increasing the need for good hand hygiene compliance. This study aimed to evaluate effectiveness on compliance of an intervention to improve awareness of hand hygiene in the RU of a district hospital.

Methods

A quasi-experimental study design including questionnaires assessing knowledge and attitudes of hand hygiene and direct observation of participants was used to evaluate an educational programme on hand hygiene of the RU of a large district hospital. All healthcare workers (HCW), comprising 76 radiographers, 17 nurses, and nine healthcare assistants (HCA), agreed to participate in the study. Of these, 85 completed the initial and 76 the post-test anonymous questionnaire. The hand hygiene compliance of all 102 HCW was observed over a 3-week period prior to and after the intervention. The 2-month intervention consisted of talks on hand hygiene and benefits of ABHR, provision of visual aids, wall-mounted ABHR dispensers, and personal bottles of ABHR.

Results

Before the intervention, overall hand hygiene compliance was low (28.9 %). Post-intervention, compliance with hand hygiene increased to 51.4 %. This improvement was significant for radiographers and HCA. Additionally, knowledge and attitudes improved in particular, understanding that ABHR can largely replace handwashing and there is a need to perform hand hygiene after environmental contact. The increased use of ABHR allowed HCW to feel they had enough time to perform hand hygiene.

Conclusions

The educational intervention led to increased awareness of hand hygiene opportunities and better acceptance of ABHR use. The reduced time needed to perform hand rubbing and improved access to dispensers resulted in fewer missed opportunities. Although radiographers and other allied HCW make frequent contact with patients, these may be mistakenly construed as irrelevant with respect to healthcare associated infections. Stronger emphasis on hand hygiene compliance of these staff may help reduce infection risk.

The Cutaneous Microbiome and Aspects of Skin Antimicrobial Defense System Resist Acute Treatment with Topical Skin Cleansers

The human skin microbiome has been suggested to play an essential role in maintaining health by contributing to innate defense of the skin. These observations have inspired speculation that the use of common skin washing techniques may be detrimental to the epidermal antibacterial defense system by altering the microbiome. In this study, several common skin cleansers were used to wash human forearms and the short-term effect on the abundance of the antimicrobial peptide LL-37 and the abundance and diversity of bacterial DNA was measured. Despite small but significant decreases in the amount of LL-37 on the skin surface shortly after washing, no significant change in the bacterial community was detected. Furthermore, Group A Streptococcus did not survive better on the skin after washing. In contrast, the addition of antimicrobial compounds such as benzalkonium chloride or triclocarban to soap before washing decreased the growth of Group A Streptococcus applied after rinse. These results support prior studies that hand washing techniques in the health care setting are beneficial and should be continued. Additional research is necessary to better understand the effects of chronic washing and the potential impact of skin care products on the development of dysbiosis in some individuals.

Eliminating Infections in the ICU: CLABSI. Curr Infect Dis Rep. 2015;17:491. [PMID: 26031963 DOI: 10.1007/s11908-015-0491-8]

Central line-associated bloodstream infections (CLABSI) are one of the leading causes of death in the USA and around the world. As a preventable healthcare-associated infection, they are associated with significant morbidity and excess costs to the healthcare system. Effective and long-term CLABSI prevention requires a multifaceted approach, involving evidence-based best practices coupled with effective implementation strategies. Currently recommended practices are supported by evidence and are simple, such as appropriate hand hygiene, use of full barrier precautions, avoidance of femoral lines, skin antisepsis, and removal of unnecessary lines. The most successful and sustained improvements in CLABSI rates further utilize an adaptive component to align provider behaviors with consistent and reliable use of evidence-based practices. Great success has been achieved in reducing CLABSI rates in the USA and elsewhere over the past decade, but more is needed. This article aims to review the initiatives undertaken to reduce CLABSI and summarizes the sentinel and recent literature regarding CLABSI and its prevention.

Colloidal and antibacterial properties of novel triple-headed, double-tailed amphiphiles: exploring structure-activity relationships and synergistic mixtures

Two novel series of tris-cationic, tripled-headed, double-tailed amphiphiles were synthesized and the effects of tail length and head group composition on the critical aggregation concentration (CAC), thermodynamic parameters, and minimum inhibitory concentration (MIC) against six bacterial strains were investigated. Synergistic antibacterial combinations of these amphiphiles were also identified. Amphiphiles in this study are composed of a benzene core with three benzylic ammonium bromide groups, two of which have alkyl chains, each 8-16 carbons in length. The third head group is a trimethylammonium or pyridinium. Log of critical aggregation concentration (log[CAC]) and heat of aggregation (ΔHagg) were both inversely proportional to the length of the linear hydrocarbon chains. Antibacterial activity increases with tail length until an optimal tail length of 12 carbons per chain, above which, activity decreased. The derivatives with two 12 carbon chains had the best antibacterial activity, killing all tested strains at concentrations of 1-2μM for Gram-positive and 4-16μM for Gram-negative bacteria. The identity of the third head group (trimethylammonium or pyridinium) had minimal effect on colloidal and antibacterial activity. The antibacterial activity of several binary combinations of amphiphiles from this study was higher than activity of individual amphiphiles, indicating that these combinations are synergistic. These amphiphiles show promise as novel antibacterial agents that could be used in a variety of applications.

Multicenter Intervention Program to Increase Adherence to Hand Hygiene Recommendations and Glove Use and to Reduce the Incidence of Antimicrobial Resistance

Objective.

To determine whether a multimodal intervention could improve adherence to hand hygiene and glove use recommendations and decrease the incidence of antimicrobial resistance in different types of healthcare facilities.

Design.

Prospective, observational study performed from October 1, 1999, through December 31, 2002. We monitored adherence to hand hygiene and glove use recommendations and the incidence of antimicrobial-resistant bacteria among isolates from clinical cultures. We evaluated trends in and predictors for adherence and preferential use of alcohol-based hand rubs, using multivariable analyses.

Setting.

Three intervention hospitals (a 660-bed acute and long-term care hospital, a 120-bed community hospital, and a 600-bed public teaching hospital) and a control hospital (a 700-bed university teaching hospital).

Intervention.

At the intervention hospitals, we introduced or increased the availability of alcohol-based hand rub, initiated an interactive education program, and developed a poster campaign; at the control hospital, we only increased the availability of alcohol-based hand rub.

Results.

We observed 6,948 hand hygiene opportunities. The frequency of hand hygiene performance or glove use significantly increased during the study period at the intervention hospitals but not at the control hospital; the maximum quarterly frequency of hand hygiene performance or glove use at intervention hospitals (74%, 80%, and 77%) was higher than that at the control hospital (59%). By multivariable analysis, preferential use of alcohol-based hand rubs rather than soap and water for hand hygiene was more likely among workers at intervention hospitals compared with nonintervention hospitals (adjusted odds ratio, 4.6 [95% confidence interval, 3.3-6.4]) and more likely among physicians (adjusted odds ratio, 1.4 [95% confidence interval, 1.2-1.8]) than among nurses at intervention hospitals. A significantly reduced incidence of antimicrobial-resistant bacteria among isolates from clinical culture was found at a single intervention hospital, which had the greatest increase in the frequency of hand hygiene performance.

Conclusions.

During a 3-year period, a multimodal intervention program increased adherence to hand hygiene recommendations, especially to the use of alcohol-based hand rubs. In one hospital, a concomitant reduction was found in the incidence of antimicrobial-resistant bacteria among isolates from clinical cultures.

Systematic Review of Studies on Compliance with Hand Hygiene Guidelines in Hospital Care

Objectives.

To assess the prevalence and correlates of compliance and noncompliance with hand hygiene guidelines in hospital care.

Design.

A systematic review of studies published before January 1, 2009, on observed or self-reported compliance rates.

Methods.

Articles on empirical studies written in English and conducted on general patient populations in industrialized countries were included. The results were grouped by type of healthcare worker before and after patient contact. Correlates contributing to compliance were grouped and listed.

Results.

We included 96 empirical studies, the majority (n= 65) in intensive care units. In general, the study methods were not very robust and often ill reported. We found an overall median compliance rate of 40%. Unadjusted compliance rates were lower in intensive care units (30%–40%) than in other settings (50%–60%), lower among physicians (32%) than among nurses (48%), and before (21%) rather than after (47%) patient contact. The majority of the time, the situations that were associated with a lower compliance rate were those with a high activity level and/or those in which a physician was involved. The majority of the time, the situations that were associated with a higher compliance rate were those having to do with dirty tasks, the introduction of alcohol-based hand rub or gel, performance feedback, and accessibility of materials. A minority of studies (n= 12) have investigated the behavioral determinants of hand hygiene, of which only 7 report the use of a theoretical framework with inconclusive results.

Conclusions.

Noncompliance with hand hygiene guidelines is a universal problem, which calls for standardized measures for research and monitoring. Theoretical models from the behavioral sciences should be used internationally and should be adapted to better explain the complexities of hand hygiene.

Social Marketing Analysis of 2 Years of Hand Hygiene Promotion

Objective.

To assess published hand hygiene behavioral interventions that employed a social marketing framework and to recommend improvements to future interventions.

Methods.

We performed a systematic literature review by searching the PubMed database and the Cumulative Index to Nursing and Allied Health Literature for published articles about hand hygiene behavioral interventions in healthcare facilities, schools, and community settings. Our analysis included articles that describe multifaceted interventions and evaluated them with predefined social marketing benchmark criteria.

Results.

Of 53 interventions analyzed in this review, 16 (30.2%) employed primary formative audience research, 5 (9.4%) incorporated social or behavioral theories, 27 (50.9%) employed segmentation and targeting of the audience, 44 (83.0%) used components of the “marketing mix,” 3 (5.7%) considered the influence of competing behaviors, 7 (13.2%) cultivated relationships with the target audience, and 15 (28.3%) provided simple behavioral messages. Thirty-five (66.0%) of the interventions demonstrated a significant improvement in performance, but only 21 (39.6%) were considered to have a strong evaluative design. The median duration of the interventions was 8.0 months.

Conclusions.

From a social marketing perspective, the promotion of hand hygiene could be improved in several ways. The effectiveness of social marketing in hand hygiene promotion should be tested in future interventions.

A Qualitative Exploration of Reasons for Poor Hand Hygiene Among Hospital Workers Lack of Positive Role Models and of Convincing Evidence That Hand Hygiene Prevents Cross-Infection

Objective.

To study potential determinants of hand hygiene compliance among healthcare workers in the hospital setting.

Design.

A qualitative study based on structured-interview guidelines, consisting of 9 focus group interviews involving 58 persons and 7 individual interviews. Interview transcripts were subjected to content analysis.

Setting.

Intensive care units and surgical departments of 5 hospitals of varying size in the Netherlands.

Participants.

A total of 65 nurses, attending physicians, medical residents, and medical students.

Results.

Nurses and medical students expressed the importance of hand hygiene for preventing of cross-infection among patients and themselves. Physicians expressed the importance of hand hygiene for self-protection, but they perceived that there is a lack of evidence that handwashing is effective in preventing cross-infection. All participants stated that personal beliefs about the efficacy of hand hygiene and examples and norms provided by senior hospital staff are of major importance for hand hygiene compliance. They further reported that hand hygiene is most often performed after tasks that they perceive to be dirty, and personal protection appeared to be more important for compliance that patient safety. Medical students explicitly mentioned that they copy the behavior of their superiors, which often leads to noncompliance during clinical practice. Physicians mentioned that their noncompliance arises from their belief that the evidence supporting the effectiveness of hand hygiene for prevention of hospital-acquired infections is not strong.

Conclusion.

The results indicate that beliefs about the importance of self-protection are the main reasons for performing hand hygiene. A lack of positive role models and social norms may hinder compliance.

Effect of a Multifaceted Intervention on Adherence to Hand Hygiene among Healthcare Workers: A Cluster-Randomized Trial

Objectives.

Adherence to hand hygiene among healthcare workers (HCWs) is widely believed to be a key factor in reducing the spread of healthcare-associated infection. The objective of this study was to evaluate the impact of a multifaceted intervention to increase rates of adherence to hand hygiene among HCWs and to assess the effect on the incidence of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) colonization.

Design.

Cluster-randomized controlled trial.

Setting.

Thirty hospital units in 3 tertiary care hospitals in Hamilton, Ontario, Canada.

Intervention.

After a 3-month baseline period of data collection, 15 units were randomly assigned to the intervention arm (with performance feedback, small-group teaching seminars, and posters) and 15 units to usual practice. Hand hygiene was observed during randomly selected 15-minute periods on each unit, and the incidence of MRSA colonization was measured using weekly surveillance specimens from June 2007 through May 2008.

Results.

We found that 3,812 (48.2%) of 7,901 opportunities for hand hygiene in the intervention group resulted in adherence, compared with 3,205 (42.6%) of 7,526 opportunities in the control group (P < .001; independent t test). There was no reduction in the incidence of hospital-acquired MRSA colonization in the intervention group.

Conclusion.

Among HCWs in Ontario tertiary care hospitals, the rate of adherence to hand hygiene had a statistically significant increase of 6% with a multifaceted intervention, but the incidence of MRSA colonization was not reduced.

Hospital hand hygiene compliance improves with increased monitoring and immediate feedback

BACKGROUND

Health care-associated infections are serious complications impacting 2 million patients and accounting for approximately 100,000 deaths per year. In the present study, we evaluated the effectiveness of a new hand hygiene monitoring program (HHMP) and measured the sustainability of this effectiveness over a 1-year period.

METHODS

The HHMP consisted of 4 key components: extensive education, conspicuous and visible monitors, immediate feedback concerning compliance to health care workers, and real-time data dissemination to leadership. The HHMP was implemented in 2 hospital care units. Two different, but similar, departments served as controls, and hand hygiene compliance was monitored via the "secret shopper" technique. All 4 departments were followed for 12 months.

RESULTS

Both experimental departments showed statistically significant increases in hand hygiene compliance. Experimental department 1 increased compliance from 49% to an average of 90%, and experimental department 2 increased compliance from 60% to an average of 96%. Both experimental departments were able to sustain these results for at least 6 months. Compliance rates were significantly higher in the experimental departments compared with the control departments. No significant changes were seen in the control departments.

CONCLUSIONS

These finding suggest that continuous monitoring by salient observers and immediate feedback are critical to the success of hand hygiene programs.

epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

Infection control strategies for preventing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in nursing homes for older people

BACKGROUND

Nursing homes for older people provide an environment likely to promote the acquisition and spread of meticillin-resistant Staphylococcus aureus (MRSA), putting residents at increased risk of colonisation and infection. It is recognised that infection prevention and control strategies are important in preventing and controlling MRSA transmission.

OBJECTIVES

To determine the effects of infection prevention and control strategies for preventing the transmission of MRSA in nursing homes for older people.

SEARCH METHODS

In August 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Database of Abstracts of Reviews of Effects (DARE, The Cochrane Library), Ovid MEDLINE, OVID MEDLINE (In-process and Other Non-Indexed Citations), Ovid EMBASE, EBSCO CINAHL, Web of Science and the Health Technology Assessment (HTA) website. Research in progress was sought through Current Clinical Trials, Gateway to Reseach, and HSRProj (Health Services Research Projects in Progress).

SELECTION CRITERIA

All randomised and controlled clinical trials, controlled before and after studies and interrupted time series studies of infection prevention and control interventions in nursing homes for older people were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed the results of the searches. Another review author appraised identified papers and undertook data extraction which was checked by a second review author.

MAIN RESULTS

For this third update only one study was identified, therefore it was not possible to undertake a meta-analysis. A cluster randomised controlled trial in 32 nursing homes evaluated the effect of an infection control education and training programme on MRSA prevalence. The primary outcome was MRSA prevalence in residents and staff, and a change in infection control audit scores which measured adherence to infection control standards. At the end of the 12 month study, there was no change in MRSA prevalence between intervention and control sites, while mean infection control audit scores were significantly higher in the intervention homes compared with control homes.

AUTHORS' CONCLUSIONS

There is a lack of research evaluating the effects on MRSA transmission of infection prevention and control strategies in nursing homes. Rigorous studies should be conducted in nursing homes, involving residents and staff to test interventions that have been specifically designed for this unique environment.

Changes in hand hygiene compliance after a multimodal intervention and seasonality variation

BACKGROUND

Hand hygiene is the most important measure to reduce health care-related infections and colonization with multiresistant micro-organisms. We sought to determine the rate and seasonality of handwashing compliance in a university-affiliated hospital.

METHODS

In January 2006 (baseline period), handwashing observation was first made in an intensive care unit. From March to May 2006, there was an intervention period; and, from June 2006 to August 2009, we followed hand hygiene compliance. Seasonality curves for handwashing compliance were made during follow-up period.

RESULTS

During baseline period, a total of 166 observations was made. During follow-up, 17,664 opportunities for hand hygiene were observed. Compliance improved from 30.0% to a mean of 56.7% after the intervention (P < .001). The highest mean rate of compliance was 77.9% for nurses, compared with 52.6% for technicians (P < .001) and 44.6% for physicians (P < .001). Compliance was lower during summer days (first trimester of the year) and increased after March and April and slowly decreased through the end of the year.

CONCLUSION

One of the reasons for the lower handwashing compliance in the first 3 months of the year is that, in Brazil, this is the summer vacation time; and, because of that, the staff's workload and the number of less well-trained personnel are higher. We emphasize the importance of continuously monitoring hand hygiene to determine the seasonal aspects of compliance.

Patients' potential role in the transmission of health care-associated infections: prevalence of contamination with bacterial pathogens and patient attitudes toward hand hygiene

BACKGROUND

Transmission of health care-associated infections (HAIs) has been primarily attributed to health care workers, and hand hygiene is considered the most important means to reduce transmission. Whereas hand hygiene research has focused on reducing health care worker hand contamination and improving hand hygiene compliance, contamination of patients' hands and their role in the transmission of HAIs remains unknown.

METHODS

Patients' hands were sampled by a "glove juice" recovery method and enumerated for the presence of common health care-associated pathogens. Patient demographics and other covariates were collected to determine their association with patient hand contamination. Patient attitudes and practices toward hand hygiene were also surveyed and analyzed.

RESULTS

Of the 100 patients in the study, 39% of hands were contaminated with at least 1 pathogenic organism, and 8% were contaminated with 2 or more pathogens 48 hours after admission. Patient admission from or discharge to an outside institution and self-reported functional limitations were the only covariates that were significantly associated with hand contamination.

CONCLUSION

Pathogenic organisms can be frequently detected on hands of acute care patients. Future studies are needed to better understand the relationship between patient hand contamination and the acquisition of HAIs in addition to the role patient hand hygiene can play in reducing HAIs.

An effective active surveillance method for controlling nosocomial MRSA transmission in a Japanese hospital

Hospital-wide active surveillance for methicillin-resistant Staphylococcus aureus (MRSA) targeted to adult patients with a history of MRSA carriage within the past 5 years was performed in Juntendo University Hospital (JUH) over a 2-year period. In the first year, MRSA screening culture was ordered by physicians in charge. In the second year, infection-control practitioners (ICPs) took samples for active surveillance culture. The average monthly transmission rate of MRSA in JUH was 0.35 per 1,000 bed-days in the first year and decreased significantly to 0.26 per 1,000 bed-days in the second year (P < 0.05). In the second year, more active commitment of ICPs to MRSA screening was effective in improving the performance rate of screening, shortening turn-around time of screening results, and decreasing transmission rate. Increasing compliance with active MRSA surveillance by involvement of ICPs, targeting patients with a previous history of MRSA carriage in the previous 5 years, was effective to control nosocomial MRSA transmission.

Hand hygiene perception among health care workers in Hungarian hospitals: prior to a nationwide microbiological survey

Transmission of pathogens via healthcare workers' (HCWs) hands is one of the most frequent means of spreading multi-resistant organisms and occurring healthcare-associated infections (HAIs) in hospitals. The role of contaminated hands in pathogen transmission was recognized by Hungarian physician, Ignác Semmelweis. Hand hygiene prevents cross-infections in hospitals, but numerous epidemiological and microbiology-based studies have documented low compliance of HCWs with this simple procedure. Furthermore, hand hygiene perception of HCWs plays an important role in determining hand hygiene compliance. Our aim was to describe the opinion of HCWs about their perception regarding hand hygiene practice. Our further goal was to strengthen a laboratory basis for bacterial backup control of nosocomial pathogens. A cross-sectional descriptive study was conducted between December 2010 and February 2011 in 13 participating hospitals in Hungary. HCWs know that there is correlation between contaminated hands and HAIs (83%), but neither the frequency (62%) nor the implementation (73%) of their hand hygiene performance are satisfying.We recommend that multimodal interventions - highlighted active microbiological surveillance of HCWs' hands - are the most suitable strategies to reduce the occurrence of HAIs and to determine their impact on cross-transmission of microorganisms and to overcome barriers of HCWs.

Effectiveness of a comprehensive hand hygiene program for reduction of infection rates in a long-term care facility

BACKGROUND

Alcohol-based hand rubs play a key role in reducing the transmission of pathogens in acute care settings, especially as part of a comprehensive hand hygiene program. However, their use in long-term care facilities (LTCFs) has been virtually unstudied.

METHODS

Infection data, including those meeting McGeer et al and the Pennsylvania Patient Safety Authority's surveillance definitions, for lower respiratory tract infections (LRTIs) and skin and soft-tissue infections (SSTIs), as well as hospitalization data were collected in a 174-bed LTCF for 22 months (May 2009 to February 2011). In March 2010, a comprehensive hand hygiene program including increased product availability, education for health care personnel (HCP) and residents, and an observation tool to monitor compliance, was implemented.

RESULTS

Infection rates for LRTIs were reduced from 0.97 to 0.53 infections per 1,000 resident-days (P = .01) following the intervention, a statistically significant decline. Infection rates for SSTIs were reduced from 0.30 to 0.25 infections per 1,000 resident-days (P = .65). A 54% compliance rate was observed among HCP.

CONCLUSION

This study demonstrates that the use of alcohol-based hand rubs, as part of a comprehensive hand hygiene program for HCP and residents, can decrease infection rates in LTCFs.

Cost-effectiveness of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial

BACKGROUND

Many strategies have been designed and evaluated to address poor hand hygiene compliance. Unfortunately, well-designed economic evaluations of hand hygiene improvement strategies are lacking.

OBJECTIVE

To compare the cost-effectiveness of two successful implementation strategies for improving nurses' hand hygiene compliance and reducing hospital acquired infections (HAI's).

DESIGN AND SETTING

A cost-effectiveness analysis alongside a cluster randomised controlled trial was conducted in 67 nursing wards of three hospitals in the Netherlands. The evaluation used a hospital perspective.

PARTICIPANTS

All affiliated nurses of the nursing wards. Wards were randomly assigned to either the control group (n=30) or the experimental group (n=37).

METHODS

The control group received a state-of-the-art strategy including education, reminders feedback and optimising materials and facilities. The experimental group received a team and leaders-directed strategy which included all elements of the state-of-the-art strategy supplemented with interventions aimed at the social context of teams and enhancing leadership. The most efficient implementation strategy was determined by the incremental cost-effectiveness ratio per extra percentage of hand hygiene compliance gained and the incremental cost-effectiveness ratio per additional percentage reduction in the HAI rate. Bootstrap methods were used to determine confidence intervals for these incremental cost-effectiveness ratio's. Two scenarios of 15 and 30% were used to express the association between increased hand hygiene compliance and the reduction in HAIs.

RESULTS

The team and leaders-directed strategy was significantly more effective in improving hand hygiene compliance. The mean difference effect was 8.91% (95% CI, 0.75-17.06). This extra increase was achieved at an average cost of €5497 per ward. The incremental cost per extra percentage of hand hygiene gained on ward level was €622. The incremental cost per additional percentage reduction in the HAI rate on ward level was €2074 (30% scenario) and €4125 (15% scenario). Within the 30% scenario, there is a probability of 90% that the team and leaders-directed strategy is cost-effective and within the 15% scenario, there is a probability of 70% that the team and leaders-directed strategy is cost-effective.

CONCLUSIONS

Optimising hand hygiene compliance through a team and leaders-directed strategy is cost-effective as compared to a state-of-the-art strategy.

"The 3/3 strategy": a successful multifaceted hospital wide hand hygiene intervention based on WHO and continuous quality improvement methodology

Background

Only multifaceted hospital wide interventions have been successful in achieving sustained improvements in hand hygiene (HH) compliance.

Methodology/Principal Findings

Pre-post intervention study of HH performance at baseline (October 2007– December 2009) and during intervention, which included two phases. Phase 1 (2010) included multimodal WHO approach. Phase 2 (2011) added Continuous Quality Improvement (CQI) tools and was based on: a) Increase of alcohol hand rub (AHR) solution placement (from 0.57 dispensers/bed to 1.56); b) Increase in frequency of audits (three days every three weeks: “3/3 strategy”); c) Implementation of a standardized register form of HH corrective actions; d) Statistical Process Control (SPC) as time series analysis methodology through appropriate control charts. During the intervention period we performed 819 scheduled direct observation audits which provided data from 11,714 HH opportunities. The most remarkable findings were: a) significant improvements in HH compliance with respect to baseline (25% mean increase); b) sustained high level (82%) of HH compliance during intervention; c) significant increase in AHRs consumption over time; c) significant decrease in the rate of healthcare-acquired MRSA; d) small but significant improvements in HH compliance when comparing phase 2 to phase 1 [79.5% (95% CI: 78.2–80.7) vs 84.6% (95% CI:83.8–85.4), p<0.05]; e) successful use of control charts to identify significant negative and positive deviations (special causes) related to the HH compliance process over time (“positive”: 90.1% as highest HH compliance coinciding with the “World hygiene day”; and “negative”:73.7% as lowest HH compliance coinciding with a statutory lay-off proceeding).

Conclusions/Significance

CQI tools may be a key addition to WHO strategy to maintain a good HH performance over time. In addition, SPC has shown to be a powerful methodology to detect special causes in HH performance (positive and negative) and to help establishing adequate feedback to healthcare workers.

The World Health Organization '5 moments of hand hygiene': the scientific foundation

The World Health Organization (WHO) launched the first Global Patient Safety Challenge in 2005 and introduced the '5 moments of hand hygiene' in 2009 in an attempt to reduce the burden of health care associated infections. Many NHS trusts in England adopted this model of hand hygiene, which prompts health care workers to clean their hands at five distinct stages of caring for the patient. Our review analyses the scientific foundation for the five moments of hand hygiene and explores the evidence, as referenced by WHO, to support these recommendations. We found no strong scientific support for this regime of hand hygiene as a means of reducing health care associated infections. Consensus-based guidelines based on weak scientific foundations should be assessed carefully to prevent shifting the clinical focus from more important issues and to direct limited resources more effectively. We recommend caution in the universal adoption of the WHO '5 moments of hand hygiene' by orthopaedic surgeons and other health care workers and emphasise the need for evidence-based principles when adopting hospital guidelines aimed at promoting excellence in clinical practice.

Effectiveness of an audible reminder on hand hygiene adherence

BACKGROUND

Multimodal interventions aim to improve health care workers' adherence to hand hygiene guidelines. Visitors are not primarily targeted, but may spread epidemic infections. Effective interventions that improve the adherence of visitors to hand hygiene guidelines are needed to prevent the transmission of epidemic infections to or from health care environments.

METHODS

An electronic motion sensor-triggered audible hand hygiene reminder was installed at hospital ward entrances. An 8-month preinterventional and postinterventional study was carried out to measure the adherence of hospital visitors and staff to hand hygiene guidelines.

RESULTS

Overall hand hygiene adherence increased from 7.6% to 49.9% (P < .001). The adherence of visitors and nonclinical staff increased immediately from 10.6% to 63.7% and from 5.3% to 34.8%, respectively (P < .001). Adherence of doctors, nurses, and physiotherapists increased gradually from 4.5% to 38.3%, from 5.4% to 43.4%, and from 8.7% to 49.5%, respectively (P < .001). Improved adherence was sustained among visitors and clinical staff (P < .001), but not among nonclinical staff (P = .341).

CONCLUSIONS

The electronic motion sensor-triggered audible reminder immediately and significantly improved and sustained greater adherence of hospital visitors and clinical staff to hand hygiene guidelines. This is an effective addition to multimodal hand hygiene interventions and may help control epidemic infections.

Back to the future: rising to the Semmelweis challenge in hand hygiene

Hand hygiene is the single most important intervention for reducing healthcare associated infections and preventing the spread of antimicrobial resistance. This sentence begins most publications regarding hand hygiene in the medical literature. But why - as we mark 150 years since the publication of Ignaz Semmelweis' landmark monograph on the subject - do we continue to repeat it? One might be tempted to regard it as a truism. However, while tremendous progress has certainly been made in this field, a significant amount of work is yet to be done in both strengthening the evidence regarding the impact of hand hygiene and maximizing its implementation. Hand hygiene cannot yet be taken for granted. This article summarizes historical perspectives, dynamics of microbial colonization and efficacy of hand cleansing methods and agents, elements and impacts of successful hand hygiene promotion, as well as scale-up and sustainability. We also explore hand hygiene myths and current challenges such as monitoring, behavior change, patient participation and research priorities.

Infection control strategies for preventing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in nursing homes for older people

BACKGROUND

Nursing homes for older people provide an environment likely to promote the acquisition and spread of meticillin-resistant Staphylococcus aureus (MRSA), putting residents at increased risk of colonisation and infection. It is recognised that infection prevention and control strategies are important in preventing and controlling MRSA transmission.

OBJECTIVES

To determine the effects of infection prevention and control strategies for preventing the transmission of MRSA in nursing homes for older people.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2011, Issue 2), the Cochrane Wounds Group Specialised Register (searched May 27th, 2011). We also searched Ovid MEDLINE (from 1950 to April Week 2 2011), OVID MEDLINE (In-process and Other Non-Indexed Citations, April 26th 2011) Ovid EMBASE (1980 to 2011 Week 16), EBSCO CINAHL (1982 to April 21st 2011), DARE (1992 to 2011, week 16), Web of Science (1981 to May 2011), and the Health Technology Assessment (HTA) website (1988 to May 2011). Research in progress was sought through Current Clinical Trials (www.controlled-trials.com), Medical Research Council Research portfolio, and HSRPRoj (current USA projects).

SELECTION CRITERIA

All randomised and controlled clinical trials, controlled before and after studies and interrupted time series studies of infection prevention and control interventions in nursing homes for older people were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed the results of the searches. Another review author appraised identified papers and undertook data extraction which was checked by a second review author.

MAIN RESULTS

For this second update only one study was identified, therefore it was not possible to undertake a meta-analysis. A cluster randomised controlled trial in 32 nursing homes evaluated the effect of an infection control education and training programme on MRSA prevalence. The primary outcome was MRSA prevalence in residents and staff, and a change in infection control audit scores which measured adherence to infection control standards. At the end of the 12 month study, there was no change in MRSA prevalence between intervention and control sites, while mean infection control audit scores were significantly higher in the intervention homes compared with control homes.

AUTHORS' CONCLUSIONS

There is a lack of research evaluating the effects on MRSA transmission of infection prevention and control strategies in nursing homes. Rigorous studies should be conducted in nursing homes, to test interventions that have been specifically designed for this unique environment.

Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare

BACKGROUND

Hand hygiene is a key measure in preventing infections. We evaluated healthcare worker (HCW) hand hygiene with the use of remote video auditing with and without feedback.

METHODS

The study was conducted in an 17-bed intensive care unit from June 2008 through June 2010. We placed cameras with views of every sink and hand sanitizer dispenser to record hand hygiene of HCWs. Sensors in doorways identified when an individual(s) entered/exited. When video auditors observed a HCW performing hand hygiene upon entering/exiting, they assigned a pass; if not, a fail was assigned. Hand hygiene was measured during a 16-week period of remote video auditing without feedback and a 91-week period with feedback of data. Performance feedback was continuously displayed on electronic boards mounted within the hallways, and summary reports were delivered to supervisors by electronic mail.

RESULTS

During the 16-week prefeedback period, hand hygiene rates were less than 10% (3933/60 542) and in the 16-week postfeedback period it was 81.6% (59 627/73 080). The increase was maintained through 75 weeks at 87.9% (262 826/298 860).

CONCLUSIONS

The data suggest that remote video auditing combined with feedback produced a significant and sustained improvement in hand hygiene.

[Epidemiology of healthcare-associated infections due to MRSA in Brest University Hospital from 2004 to 2007. Impact of hydroalcoholic gel and antibiotics consumptions]

The fight against healthcare-associated infections is based on preventive measures of multidrug resistant bacteria diffusion. Hand hygiene is the simplest and the most effective preventive measure to reduce cross-transmission of infectious agents. Hydroalcoholic solutions for hand hygiene was recently introduced in the University Hospital of Brest (France). The aims of the study were: to describe the epidemiology of healthcare-associated infections due to methicillin-resistant Staphylococcus aureus (MRSA); to determine the annual consumptions of antistaphylococcal antibiotics; and to discuss the relation between consumption of antiseptic products or antibiotics and the epidemiology of MRSA.

METHODS

A retrospective epidemiological and pharmaco-epidemiological study was realized from January 2004 to December 2007 in the University Hospital of Brest (France). It allowed to bring to light the cases of healthcare-associated infections due to MRSA and to quantify the consumptions of hang hygiene products and antistaphylococcal antibiotics.

RESULTS

this retrospective study showed a decrease of healthcare-associated infections due to MRSA and an increase of the consumption of hydroalcoholic solutions. Antistaphylococcal resistance rates also decreased in a context of fall of the global antibiotics consumption in the hospital.

Infection-free surgery: how to improve hand-hygiene compliance and eradicate methicillin-resistant Staphylococcus aureus from surgical wards

INTRODUCTION

Healthcare-associated infections cost the UK National Health Service 1 billion UK pounds per annum. Poor hand hygiene is the main route of transmission for methicillin-resistant Staphylococcus aureus (MRSA), leading to increased mortality and morbidity for infected patients. This study aims to quantify MRSA infection rates and compliance of alcohol gel application at the entrance to a surgical ward and assess how a simple intervention affects compliance.

SUBJECTS AND METHODS

Compliance was assessed via a discretely positioned close-surveillance camera at the ward entrance. Footage was reviewed to monitor compliance of all persons entering the ward over a 12-month period.

RESULTS

For the initial 6 months, mean alcohol gel compliance was 24% for all persons entering the ward. After this period, a conspicuous strip of bright red tape was positioned along the corridor approaching the ward entrance. The red line continued up the wall to an arrow head pointing to the two alcohol gel dispensers on the wall. Mean compliance over the subsequent 6 months significantly improved to 62% (P < 0.0001). Compliance improved for all persons entering the ward as follows (before - after, significance): doctors (0% - 54%, P < 0.01); nurses (24% - 75%, P < 0.05); porters (21% - 67%, P < 0.05); visitors (35% - 68%, P < 0.01); patients (23% - 44%, P > 0.05). There were two cases of MRSA bacteraemia in the initial 6 months and no cases in the following 6 months with the red line in situ.

CONCLUSIONS

This study demonstrates how a simple intervention significantly improves hand-hygiene compliance with associated eradication of MRSA.

Effect of the dried residues of two hand gels on the survival of meticillin-resistant Staphylococcus aureus and Acinetobacter calcoaceticus-baumannii

We assessed the ability of the residues of an alcohol-based hand gel (hand gel A) and an Aloe vera-based CuAL42 copper biocide-containing hand gel (hand gel B), to support the survival of meticillin-resistant Staphylococcus aureus (MRSA) and Acinetobacter calcoaceticus-baumannii (ACCB). One-millilitre samples of hand gels A and B were spread over marked 20 cm2 areas and dried overnight. MRSA or ACCB (1 × 104 CFU) were spread onto the dried residue and contact plated at various times. MRSA and ACCB survived for 8 hours on hand gel A residue, whilst MRSA did not survive on hand gel B residue and ACCB survived less than 30 min. Low concentrations of hand gel A facilitate the growth of ACCB, but this is not the case for hand gel B. Hand gel A is extensively used in UK hospitals and its residue left on high-touch surfaces may support the survival of bacteria that cause healthcare-acquired infections.

More than hand hygiene is needed to affect methicillin-resistant Staphylococcus aureus clinical indicator rates: clean hands save lives, part IV

OBJECTIVE

To examine whether improved hand hygiene compliance in health care workers after a statewide hand hygiene campaign in New South Wales hospitals was associated with a fall in rates of infection with multiresistant organisms.

DESIGN AND SETTING

Data on rates of new methicillin-resistant Staphylococcus aureus (MRSA) infections (expressed as four clinical indicators) are reported by some Australian hospitals to the Australian Council on Healthcare Standards (ACHS) for accreditation purposes and are mandatorily reported by all NSW hospitals to the NSW Department of Health. Infections are classified according to whether they are acquired in the intensive care unit (ICU) or other wards and whether they are from sterile sites (blood cultures) or non-sterile sites. The clinical indicators reflect four different site categories (ICU sterile site, ICU non-sterile site, non-ICU sterile site and non-ICU non-sterile site) and are expressed as the number of new health care-associated infections per 10,000 acute care bed-days. Clinical indicator rates were examined for any decline between the pre-campaign period (July-December 2005) and post-campaign period (January-July 2007), and were compared with trends over a similar period in states without a hand hygiene campaign.

MAIN OUTCOME MEASURES

Pre-campaign and post-campaign rates for four MRSA clinical indicators.

RESULTS

Between the pre- and post-campaign periods, there was a 25% fall in MRSA non-ICU sterile site infections, from 0.60/10,000 bed-days to 0.45/10,000 bed-days (P = 0.027), and a 16% fall in ICU non-sterile site infections, from 36.36/10,000 bed-days to 30.43/10,000 bed-days (P = 0.037). The pre- and post-campaign rates of MRSA infection from ICU sterile sites (5.28/10,000 bed-days v 4.80/10,000 bed-days; P = 0.664) and non-ICU non-sterile sites (5.92/10,000 bed-days v 5.66/10,000 bed-days; P = 0.207) remained stable. Australia-wide MRSA data reported to the ACHS showed a 45% decline in infections from ICU non-sterile sites, from 25.89/10,000 bed-days to 14.30/10,000 bed-days (P < 0.001), and a 46% decline in infections from non-ICU non-sterile sites, from 3.70/10,000 bed-days to 1.99/10,000 bed-days (P < 0.001) over the period 2005-2006.

CONCLUSION

Two out of four clinical indicators of MRSA infection remained unchanged despite significant improvements in hand hygiene compliance in NSW hospitals. The reduction in MRSA infections from ICU non-sterile sites in NSW hospitals was mirrored in ACHS data for other Australian states and cannot be assumed to be the result of improved hand hygiene compliance. Concurrent clinical and infection control practices possibly influence MRSA infection rates and may modify the effects of hand hygiene compliance. More sensitive measurements of hand hygiene compliance are needed.

Role of hand hygiene in healthcare-associated infection prevention

Healthcare workers' hands are the most common vehicle for the transmission of healthcare-associated pathogens from patient to patient and within the healthcare environment. Hand hygiene is the leading measure for preventing the spread of antimicrobial resistance and reducing healthcare-associated infections (HCAIs), but healthcare worker compliance with optimal practices remains low in most settings. This paper reviews factors influencing hand hygiene compliance, the impact of hand hygiene promotion on healthcare-associated pathogen cross-transmission and infection rates, and challenging issues related to the universal adoption of alcohol-based hand rub as a critical system change for successful promotion. Available evidence highlights the fact that multimodal intervention strategies lead to improved hand hygiene and a reduction in HCAI. However, further research is needed to evaluate the relative efficacy of each strategy component and to identify the most successful interventions, particularly in settings with limited resources. The main objective of the First Global Patient Safety Challenge, launched by the World Health Organization (WHO), is to achieve an improvement in hand hygiene practices worldwide with the ultimate goal of promoting a strong patient safety culture. We also report considerations and solutions resulting from the implementation of the multimodal strategy proposed in the WHO Guidelines on Hand Hygiene in Health Care.