A multimodal regional intervention strategy framed as friendly competition to improve hand hygiene compliance

Validity of self-reported compliance and behavioural determinants of observed compliance: an application of the COM-B hand hygiene questionnaire in nine Dutch hospitals

BACKGROUND

Hand hygiene compliance (HHC) can be influenced by behavioural determinants, but knowledge on this is still scarce. The Capability, Opportunity, Motivation-Behaviour (COM-B) hand hygiene questionnaire was developed by Lydon et al. to gain insight in self-reported behavioural determinants and self-reported HHC.

AIM

To determine the validity of self-reported HHC, by using the COM-B questionnaire. To investigate the influence of self-reported behavioural determinants on observed HHC, while taking environmental determinants into account.

METHODS

Cross-sectional study, from September to November 2019, in nine hospitals in the Netherlands. Healthcare workers (HCW) filled in the COM-B questionnaire and direct hand hygiene observations were performed. In addition, information on environmental determinants (workload, ward category, type of hospital, infrastructure of a ward) was collected. Validity of self-reported HHC was determined by the intraclass correlation coefficient (ICC). Univariable and multivariable regression analyses were performed to investigate the relation between behavioural- and environmental determinants and observed HHC.

FINDINGS

The ICC showed no association between self-reported HHC and observed HHC (0.04 (-0.14, 0.21)). In the univariable regression analyses, ward category and the subscales opportunity and motivation were significantly associated with observed HHC. In the multivariable regression analysis, only ward category and motivation remained significant.

CONCLUSION

The self-reported HHC is not a valid substitute for direct hand hygiene observations. The behavioural determinant motivation was significantly associated with HCC, while almost none of the environmental determinants had an effect on observed HHC. In further development of hand hygiene interventions, increasing the intrinsic motivation of HCW should get extra attention.

Compliance with a novel hand hygiene protocol tailored to non-sterile healthcare workers in the operating theatre

BACKGROUND

Observing hand hygiene compliance (HHC) among non-sterile healthcare workers (HCWs) in the operating theatre (OT) is challenging as there are no tailored protocols or observation tools.

AIM

To develop and test a hand hygiene protocol tailored to non-sterile HCWs in the OT.

METHODS

In this prospective observational study, nine hospitals in the Rotterdam-Rijnmond region provided input on a draft protocol on hand hygiene in the OT, resulting in a new consensus protocol for the region. An observation tool based on the protocol was developed and tested. HHC rates with 95% confidence intervals (CI) were calculated by type of hospital and type of HCW.

FINDINGS

The protocol has three sections: (1) written general hand hygiene rules; (2) written hand hygiene rules specific for anaesthesia and surgery; and (3) visual representation of the OT, divided into four hand hygiene areas. Hand hygiene should be applied when changing area. Average HHC of 48.0% (95% CI 45.2-61.2%) was observed in OTs across all hospitals. HHC was highest in the two specialized hospitals (64.0%, 95% CI 30.6-89.8%; 76.7%, 95% CI 62.8-84.5%) and lowest in the academic teaching hospital (23.1%, 95% CI 0.0-45.8%). In terms of type of HCW, HHC was lowest among anaesthesiologists (31.6%, 95% CI 19.2-62.4%) and highest among OT assistants (57.4%, 95% CI 50.1-78.2%).

CONCLUSION

This uniform way of observing HHC in the OT enables evaluation of the effectiveness of interventions in the OT and facilitates friendly competition. In the Rotterdam-Rijnmond region, HHC in the OT was below 50%; this needs to be addressed, particularly in teaching hospitals and among physicians.

Incentivized self-vaccination for global measles eradication

Measles-we've become inured to its cruel, insidious impact as it kills over 100,000 children yearly because of suboptimal vaccination coverage. It does not have to be this way. A familiar, safe, exceptionally effective measles vaccine saves lives and permanent, global measles eradication is within reach. But now we need to be clever and courageously explore new strategies to save lives. Firstly, let us enable people to vaccinate themselves, not with a needle and syringe, but with a quick inhaled puff of dry powder vaccine. Secondly, let us provide micro-payments using digital currency to incentivize those who vaccinate themselves. Thirdly, let us leverage learnings from how our social networks guide our behaviors to further encourage self-vaccination. Fourthly, let us inspire friendly regional competition among communities vying for the highest proportion of citizens who show measles neutralizing antibodies in spot saliva samples. With global cooperation and relentless determination, we eradicated smallpox. Next up? Measles.

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

Background

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

Methods

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

Results

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

Conclusion

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

Hand hygiene compliance by direct observation in physicians and nurses: a systematic review and meta-analysis

BACKGROUND

Direct observation of hand hygiene compliance is the "gold standard" despite limitations and potential for bias. Previous literature highlights poorer hand hygiene compliance amongst physicians than nurses and suggests that covert monitoring may give better compliance estimates than overt monitoring.

AIM

This review aimed to explore differences in compliance between physicians and nurses further, and to analyse if compliance estimates differed when observations were covert rather than overt.

METHODS

A systematic search of databases PubMed, EMBASE, CENTRAL and CINAHL was performed. Experimental or observational studies in hospital settings in high-income countries published in English from 2010 onwards were included if estimates for both physicians and nurses using direct observation were reported. The search yielded 4814 studies, of which 105 were included.

FINDINGS

The weighted pooled compliance rate for nurses was 52% (95% CI 47% to 57%) and for doctors was 45% (95% CI 40% to 49%). Heterogeneity was considerable (I²=99%). The majority of studies were at moderate or high risk of bias. Random-effects meta-analysis of low risk of bias studies suggests higher compliance for nurses than physicians for both overt (difference of 7%, 95% CI for the difference 0.8% to 13.5%, p=0.027) and covert (difference of 7%, 95% CI 3% to 11%, p=0.0002) observation. Considerable heterogeneity was found in all analyses.

CONCLUSION

Wide variability in compliance estimates and differences in the methodological quality of hand hygiene studies were identified. Further research with meta-regression should explore sources of heterogeneity and improve the conduct and reporting of hand hygiene studies.

Improving Hand Hygiene Compliance of Intensive Care Unit by Using Pender's Model

Background

Hand hygiene (HH) compliance is an effective behavior in controlling hospital-acquired infection because the hand is the main means of transmitting infections in patient-medical staff communication as well as the inanimate environment. This study aimed to explore the effect of applying Pender's Health Promotion Model on the HH compliance of intensive care unit staff.

Methods

This quasi-experimental study with a single research group was conducted from January to July in 2019. The required data were collected from 90 staff of the intensive care units of Imam Reza Hospital in Mashhad, Iran through 1796 and 2343 opportunity of monitoring before and after the intervention. The data collection instruments were a standard HH observation form and a researcher-made HH questionnaire in the light of Pender's health promotion model. The data were statistically analyzed in SPSS using Paired-samples T-test and Chi-squared test.

Results

The mean age of the 90 included participants was 35.92 (± 6.5) years and the mean length of their work experience was 10 (±1.5). The hand hygiene index rose from 23% before the intervention to 41.4% after the intervention (p=0.001). Moreover, statistically significant differences were found in moments after touching surroundings (p=0.001), before and after touching a patient (p=0.001), and also in perceived barriers (p=0.015), interpersonal influences (p=0.008) and situational influences (p<0.001).

Conclusion

Pender's model showed to have improved the staff's HH compliance as a professional behavior.

Predictors of Self-Reported Hand Hygiene Performance among Nurses at Tertiary Care Hospitals in East Coast Malaysia

Background: Hand hygiene (HH) is the simplest and most effective way to reduce the incidence of healthcare-associated infections (HCAIs). Methods: This cross-sectional study aimed to determine factors associated with self-reported HH performance among nurses at Kelantan tertiary care hospitals. A sample of 438 registered nurses was selected through a stratified random sampling method. Self-reported HH performance was assessed using a validated WHO self-administered HH knowledge and perception questionnaire for healthcare workers. Results: A multiple linear regression analysis was performed to identify the predictors. The factors that significantly predicted self-reported HH performance among nurses included perception score (beta coefficient (β) = 0.260; 95% CI: 0.200, 0.417; p < 0.001), pediatric department (β = −0.104; 95% CI: −9.335, −2.467; p < 0.001), and orthopedic department (β = −5.957; 95% CI: −9.539, −0.720; p < 0.023), adjusted R² = 0.102; p < 0.001. Nurses with a strong perception and belief in HH were more likely to have better HH performance. Compared to pediatric and orthopedic, surgical departments were associated with better self-reported HH performance. Conclusions: This study showed the importance of factors that could improve the intervention’s performance in HH strategy. Lack of perception and HH program intervention in departments engaged in patient care could lead to poor HH practices, thus increasing HCAIs and antimicrobial resistance (AMR).

Current practices and evaluation of barriers and facilitators to surgical site infection prevention measures in Jimma, Ethiopia

Objective:

Surgical site infections (SSIs) greatly burden healthcare systems around the world, particularly in low- and middle-income countries. We sought to employ the Systems Engineering Initiative for Patient Safety (SEIPS) model to better characterize SSI prevention practices and factors affecting adherence to prevention guidelines at Jimma University Medical Center (JUMC).

Design:

Our cross-sectional study consisted of semistructured interviews designed to elicit perceptions of and barriers and facilitators to SSI prevention among surgical staff and observations of current preoperative, perioperative, and postoperative SSI prevention practices in surgical cases. Interviews were recorded, manually transcribed, and thematically coded within the SEIPS framework. Trained observers recorded compliance with the World Health Organization’s SSI prevention recommendations.

Setting:

A tertiary-care hospital in Jimma, Ethiopia.

Participants:

Surgical nurses, surgeons, and anesthetists at JUMC.

Results:

Within 16 individual and group interviews, participants cited multiple barriers to SSI prevention including shortages of water and antiseptic materials, lack of clear SSI guidelines and training, minimal Infection Prevention Control (IPC) interaction with surgical staff, and poor SSI tracking. Observations from nineteen surgical cases revealed high compliance with antibiotic prophylaxis (94.7%), hand scrubbing (100%), sterile gloves and instrument use (100%), incision site sterilization (100%), and use of surgical safety checklist (94.7%) but lower compliance with preoperative bathing (26.3%), MRSA screening (0%), and pre- and postoperative glucose (0%, 10.5%) and temperature (57.9%, 47.3%) monitoring.

Conclusions:

Utilizing the SEIPS model helped identify institution-specific barriers and facilitators that can inform targeted interventions to increase compliance with currently underperformed SSI prevention practices at JUMC.

Neonatal Staphylococcus aureus acquisition at a tertiary intensive care unit

BACKGROUND

In this study, we explored the role of colonization in health care workers (HCWs) in transmission of methicillin-susceptible Staphylococcus aureus (MSSA) to neonates at a level IV neonatal intensive care unit (NICU).

METHODS

All available screening and clinical MSSA isolates, from the period March 2015 through April 2016, isolated from HCWs and neonates at the level IV NICU, were included. MSSA isolates were initially genotyped using spa typing, and for the most prevalent spa types, whole-genome sequencing (WGS) was performed.

RESULTS

From March 2015 through April 2016, 159 neonates and 115 HCWs were found positive for MSSA, and all isolates were typed by means of spa typing. Twenty-three spa types were found in both HCWs and neonates. Within the most prevalent spa types (t002, t015 and t2787), 4 WGS clusters of genetically indistinguishable MSSA isolates were found in which 4 HCWs and 35 neonates were involved. A total of 10 neonates included in the 4 WGS clusters suffered from bacteremia.

CONCLUSIONS

We showed that HCWs carried the same MSSA isolates as those found in neonates, and that HCWs might serve as a reservoir for transmission of MSSA to neonates. Ten neonates suffered from a bacteremia caused by a MSSA previously detected in a HCW.

Impact of an automated hand hygiene monitoring system combined with a performance improvement intervention on hospital-acquired infections

OBJECTIVE

Hand hygiene adherence has been associated with reductions in nosocomial infection. We assessed the effect of improvements in electronically measured hand hygiene adherence on the incidence of hospital-acquired infections.

METHODS

This quasi-experimental study was conducted in a 555-bed urban safety-net level I trauma center. The preintervention period was January 2015 through June 2016. Baseline electronic hand hygiene data collection took place from April through June 2016. The intervention period was July 2016 through December 2017. An electronic hand hygiene system was installed in 4 locations in our hospital. Performance improvement strategies were implemented that included education, troubleshooting, data dissemination, and feedback. Adherence rates were tracked over time. Rates of hospital-acquired infections were evaluated in the intervention units and in control units selected for comparison. The intervention period was subdivided into the initial and subsequent 9-month periods and were compared to the baseline period.

RESULTS

Electronically measured hand hygiene rates improved significantly from baseline to intervention, from 47% 77% adherence. Rates >70% continued to be measured 18 months after the intervention. Interrupted time series analysis indicated a significant effect of hand hygiene on healthcare facility-onset Clostridioides difficile infection rates during the first 9 months of the intervention. This trend continued during the final 9 months of the intervention but was nonsignificant. No effects were observed for other hospital-acquired infection rates.

CONCLUSIONS

Implementation of electronic hand hygiene monitoring and performance improvement interventions resulted in reductions in hospital-onset Clostridioides difficile infection rates.