UK handwashing initiative

Effects of the implementation of a hand hygiene education program among ICU professionals: an interrupted time-series analysis

Objective:

To evaluate the effects that a hand hygiene education program has on the compliance of health professionals in an ICU.

Methods:

This was a quasi-experimental study with an interrupted time-series design, conducted over a 12-month period: the 5 months preceding the implementation of a hand hygiene education program (baseline period); the 2 months of the intensive (intervention) phase of the program; and the first 5 months thereafter (post-intervention phase). Hand hygiene compliance was monitored by one of the researchers, unbeknownst to the ICU team. The primary outcome measure was the variation in the rate of hand hygiene compliance. We also evaluated the duration of mechanical ventilation (MV), as well as the incidence of ventilator-associated pneumonia (VAP) at 28 days and 60 days, together with mortality at 28 days and 60 days.

Results:

On the basis of 959 observations, we found a significant increase in hand hygiene compliance rates-from 31.5% at baseline to 65.8% during the intervention phase and 83.8% during the post-intervention phase, corresponding to prevalence ratios of 2.09 and 2.66, respectively, in comparison with the baseline rate (p < 0.001). Despite that improvement, there were no significant changes in duration of MV, VAP incidence (at 28 or 60 days), or mortality (at 28 or 60 days).

Conclusions:

Our findings indicate that a hand hygiene education program can increase hand hygiene compliance among ICU professionals, although it appears to have no impact on VAP incidence, duration of MV, or mortality.

Video didactic at the point of care impacts hand hygiene compliance in the neonatal intensive care unit (NICU)

OBJECTIVE

To increase the hand-washing (HW) duration of staff and visitors in the NICU to a minimum of 20 seconds as recommended by the CDC.

METHODS

Intervention included video didactic triggered by motion sensor to play above wash basin. Video enacted Centers for Disease Control and Prevention (CDC) HW technique in real time and displayed timer of 20 seconds. HW was reviewed from surveillance video. Swabs of hands plated and observed for qualitative growth (QG) of bacterial colonies.

RESULTS

In visitors, the mean HW duration at baseline was 16.3 seconds and increased to 23.4 seconds at the 2-week interval (p = .003) and 22.9 seconds at the 9-month interval (p < .0005). In staff, the mean HW duration at baseline was 18.4 seconds and increased to 29.0 seconds at 2-week interval (p = .001) and 25.7 seconds at the 9-month interval (p < .0005). In visitors, HW compliance at baseline was 33% and increased to 52% at the 2-week interval (p = .076) and 69% at the 9-month interval (p = .001). In staff, HW compliance at baseline was 42% and increased to 64% at the 2-week interval (p = .025) and 72% at the 9-month interval (p = .001). Increasing HW was significantly associated with linear decrease in bacterial QG.

CONCLUSIONS

The intervention significantly increased mean HW time, compliance with a 20-econd wash time and decreased bacterial QG of hands and these results were sustained over a 9-month period.

Screening of nasal carriage of methicillin-resistant Staphylococcus aureus during admission of patients to Frantz Fanon Hospital, Blida, Algeria

A study was performed of Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) strains isolated from nasal preoperative samples. Of 663 samples assessed, staphylococcus was detected in 143 (21.57%). The disc diffusion method (cefoxitin 30 μg), a screening test (oxacillin 6 μg/mL) and a search for Protein Binding Additional Penicillin 2 (PLP2a) allowed the detection and confirmation of resistance to methicillin for 36 strains, a rate of 5.43% of the total population studied. Eight MRSA carriers received care in the trauma service, 14 in cardiology, five in ear, nose and throat, four in neurosurgery and paediatrics, and one in SCI. Thirty-six methicillin-resistant of the nasal portage strains are in their great majority, 27 of 36, rather limited multi-R character (two to three families namely resistance: tetracyclines, fluoroquinolones, aminoglycosides, macrolides). One of the MRSA strains was found to have intermediate sensitivity to vancomycin.

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.

Flowers in the clinical setting: Infection risk or workload issue?

Healthcare-associated infection has become a topic of interest to the general public in the United Kingdom, kindled by media accounts of poor hygiene and the risks of cross-infection. In the spring of 2003, one of the broadsheet newspapers published an article debating the hygiene and infection risks associated with cut flowers brought into clinical areas. There were reports that in many wards this practice is no longer allowed because flowers are considered dirty, trigger allergies and the water is regarded as harbouring bacteria, leading to infection.

Discussion with infection control experts revealed that questions concerning the risks associated with flowers are among those most frequently asked. A literature search was undertaken to establish the evidence base, and a questionnaire study was performed with a purposive sample of 39 nurses to document how they manage flowers in the clinical setting. Empirical research studies were difficult to obtain. Early work had been undertaken to explore the added workload associated with maintaining fresh flowers and ways of reducing it. Later studies revealed that the water in flower vases and cut plants both harbour large numbers of Gram-negative pathogens.

Cross-infection and cases of clinical infection have never been documented, thus flowers have not been considered a risk, except to severely immunocompromised patients. However, scrutiny of the more general literature relating to Gram-negative sepsis indicated that cross-infection has been documented from a wide range of environmental sources and it is possible that it may take place from flowers via the hands of staff if they are not properly decontaminated. Nevertheless, these risks can be reduced by scrupulous attention to hand hygiene and commonsense measures.

Over half the nurses (n = 26, 66.6%) thought that flowers constituted an infection risk and a number of other disadvantages were cited. Most nurses (n = 31, 80%) were not in favour of flowers in the clinical setting and there was some evidence that this attitude was related to the amount of work generated, with infection and other risks used to justify it. Interest in the topic was considerable and the results can be used to stimulate discussion and emphasise the importance of controlling health-related infection.

Presenteeism Attitudes and Behavior Among Missouri Kindergarten to Twelfth Grade (K-12) School Nurses

Working while ill (presenteeism) with symptoms of influenza-like illness can contribute to outbreaks, but little is known about school nurse presenteeism. Missouri Association of School Nurses members (N = 396) were sent a survey in 2013/2014. A chi square test was conducted to compare having a school culture that encourages presenteeism versus actual sick leave policies. Multivariate logistic regression was conducted to delineate factors associated with presenteeism. In total, 133 school nurses participated (33.6% response rate). Almost half (42.1%, n = 56) reported presenteeism. Nurses were more likely to feel pressure to engage in presenteeism than reported punitive sick leave policies (14.3% vs. 3.8%, χ² = 18.3, p < .001). Presenteeism was associated with perceived pressure, odds ratio (OR) = 4.8, confidence interval (CI) = [1.5, 15.8], p < .01, and having a mild illness, OR = 3.6, CI = [1.4, 9.7], p = .01. Many school nurses engage in presenteeism, and this appears to be associated with organizational cultural norms rather than established sick leave policies.

A person-oriented approach to hand hygiene behaviour: Emotional empathy fosters hand hygiene practice

OBJECTIVES

Adopting a social-psychological approach, this research examines whether emotional empathy, an affective reaction regarding another's well-being, fosters hand hygiene as this affects other's health-related well-being extensively.

DESIGN

Three studies tested this notion: (a) a cross-sectional study involving a sample of health care workers at a German hospital, (b) an experiment testing the causal effect of empathy on hand hygiene behaviour and (c) an 11-week prospective study testing whether an empathy induction affected disinfectant usage frequency in two different wards of a hospital.

MAIN OUTCOME MEASURES

Self-reported hand hygiene behaviour based on day reconstruction method was measured in Study 1, actual hand sanitation behaviour was observed in Study 2 and disinfectant usage frequency in two different hospital wards was assessed in Study 3.

RESULTS

Study 1 reveals an association of empathy with hand hygiene cross-sectionally, Study 2 documents the causal effect of empathy on increased hand sanitation. Study 3 shows an empathy induction increases hand sanitiser usage in the hospital.

CONCLUSIONS

Increasing emotional empathy promotes hand hygiene behaviour, also in hospitals. Besides providing new impulses for the design of effective interventions, these findings bear theoretical significance as they document the explanatory power of empathy regarding a distal explanandum (hand hygiene).

A multimodal intervention to improve hand hygiene in ICUs in Buenos Aires, Argentina: a stepped wedge trial

ISSUE

Hand hygiene is a cost-effective measure to reduce microbial transmission (Teare EL, Cookson B, French GL, et al. UK handwashing initiative. J Hosp Infect. 1999;43:1-3.) and is considered to be the most important measure to prevent healthcare-associated infections (Pittet D, Allegranzi B, Sax H, Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006;6:641-52). Unfortunately, the compliance rate of healthcare workers (HCWs) with recommended hand hygiene procedures is less than expected.

INITIAL ASSESSMENT

In order to estimate the effect of a multimodal intervention on improving healthcare workers' compliance with hand hygiene in eleven intensive care units (ICUs) from 11 hospitals of Buenos Aires, a randomized cluster-stepped wedge trial was designed.

CHOICE OF SOLUTION AND IMPLEMENTATION

A multimodal intervention was designed based on practices characterized by being evidence-based, low cost and suggested by qualitative research: (i) leadership commitment, (ii) surveillance of materials needed to comply with hand hygiene and alcohol consumption, (iii) utilization of reminders, (iv) a storyboard of the project and (v) feedback (hand hygiene compliance rate).

EVALUATION

The study enrolled 705 participants, comprising nurses (66.4%), physicians (25.8%) and other HCW (7.8%) along 9 months of observation. Compliance with hand hygiene in the control group was 66.0% (2354/3565) vs. 75.6% (5190/6864) in the intervention group. Univariate analysis showed an association between the intervention and hand hygiene compliance (odds ratio, OR 1.17; 95% confidence interval (CI), 1.13-1.22). The effect was still present after adjustment by calendar's time and providers' characteristics-age, gender and profession (OR 1.08; 95% CI, 1.03-1.14).

LESSONS LEARNED

His study supports that a multimodal intervention was effective to improve compliance with hand hygiene in ICUs.

Impact of health campaign on hand hygiene with alcohol-based hand rubs in a non-clinical setting

BACKGROUND

Hand hygiene has been acknowledged as the single most important measure to prevent nosocomial infections. Likewise, for non-clinical settings, hand hygiene is recognized as a key element to prevent the spread of infectious diseases, nevertheless poor compliance has been documented. The feasibility of hand hygiene interventions in open-community settings with adults is mostly unclear.

AIM

To investigate the acceptability and feasibility of a health campaign to promote hand hygiene with alcohol-based hand disinfectants at workplaces in a non-clinical setting.

METHODS

The surveys were conducted as part of a prospective, controlled intervention study with volunteers from the administration of the Ernst-Moritz-Arndt-University Greifswald, the municipality of Greifswald and the state of Mecklenburg-West Pomerania. Participants in the intervention group were provided with alcohol-based hand disinfection; the control group was unchanged. Eleven volunteers filled out an initial survey at the beginning of the intervention regarding demographic and health-related questions as well as questions about the type of work, and a survey after completion of the intervention to evaluate the study's impact on the participants' attitudes toward hand hygiene. Participants in the experimental group filled out a monthly questionnaire regarding their compliance with hand hygiene measures, feasibility of hand disinfection and possible side-effects.

FINDINGS

From 850 employees asked to participate, 134 were included in the study, and surveys from 129 participants (intervention: 64 vs control: 65) were accepted for analysis. Overall, datasets of 1230 person-months (79.46% of total possible follow-up surveys) were collected. Return rate and compliance remained high during the study period. Hand disinfection did not lead to skin problems in the majority of person-months. After the intervention, a majority of participants would favour a further use of hand disinfectants.

CONCLUSION

Campaigns that enforce the use of alcohol-based hand disinfectants can have a sustainable effect on the compliance with hand hygiene measures in non-clinical settings. Campaigns have been shown to be feasible and effective in the prevention of transmissible diseases, therefore employers should consider whether hand hygiene campaigns to introduce waterless hand rubs could be included in companies' health programmes.

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

BACKGROUND

In 2009, the World Health Organization recommended the use of a 'multi-faceted, multi-modal hand hygiene strategy' (Five Moments for Hand Hygiene) to improve hand hygiene compliance among healthcare workers. As part of this initiative, a training programme was implemented using an automated gaming technology training and audit tool to educate staff on hand hygiene technique in an acute healthcare setting.

AIM

To determine whether using this automated training programme and audit tool as part of a multi-modal strategy would improve hand hygiene compliance and technique in an acute healthcare setting.

METHODS

A time-series quasi-experimental design was chosen to measure compliance with the Five Moments for Hand Hygiene and handwashing technique. The study was performed from November 2009 to April 2012. An adenosine triphosphate monitoring system was used to measure handwashing technique, and SureWash (Glanta Ltd, Dublin, Ireland), an automated auditing and training unit, was used to provide assistance with staff training and education.

FINDINGS

Hand hygiene technique and compliance improved significantly over the study period (P < 0.0001).

CONCLUSION

Incorporation of new automated teaching technology into a hand hygiene programme can encourage staff participation in learning, and ultimately improve hand hygiene compliance and technique in the acute healthcare setting.

Cluster randomized trial to evaluate the effect of a multimodal hand hygiene improvement strategy in primary care

OBJECTIVE

To evaluate the effectiveness of a multimodal intervention in primary care health professionals for improved compliance with hand hygiene practice, based on the World Health Organization's 5 Moments for Health Hygiene.

DESIGN

Cluster randomized trial, parallel 2-group study (intervention and control).

SETTING

Primary healthcare centers in Madrid, Spain.

PARTICIPANTS

Eleven healthcare centers with 198 healthcare workers (general practitioners, nurses, pediatricians, auxiliary nurses, midwives, odontostomatologists, and dental hygienists). Methods. The multimodal hand hygiene improvement strategy consisted of training of healthcare workers by teaching sessions, implementation of hydroalcoholic solutions, and installation of reminder posters. The hand hygiene compliance level was evaluated by observation during regular care activities in the office visit setting, at the baseline moment, and 6 months after the intervention, all by a single external observer.

RESULTS

The overall baseline compliance level was 8.1% (95% confidence interval [CI], 6.2-10.1), and the healthcare workers of the intervention group increased their hand hygiene compliance level by 21.6% (95% CI, 13.83-28.48) compared with the control group.

CONCLUSIONS

This study has demonstrated that hand hygiene compliance in primary healthcare workers can be improved with a multimodal hand hygiene improvement strategy.

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.

OBJECTIVES

To update the review done in 2007, to assess the short and longer-term success of strategies to improve hand hygiene compliance and to determine whether a sustained increase in hand hygiene compliance can reduce rates of health care-associated infection.

SEARCH STRATEGY

We conducted electronic searches of: the Cochrane Central Register of Controlled Trials; the Cochrane Effective Practice and Organisation of Care Group specialised register of trials; MEDLINE; PubMed; EMBASE; CINAHL; and the BNI. Originally searched to July 2006, for the update databases were searched from August 2006 until November 2009.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series analyses meeting explicit entry and quality criteria used by the Cochrane Effective Practice and Organisation of Care Group were eligible for inclusion. Studies reporting indicators of hand hygiene compliance and proxy indicators such as product use were considered. Self-reported data were not considered a valid measure of compliance. Studies to promote hand hygiene compliance as part of a care bundle approach were included, providing data relating specifically to hand hygiene were presented separately. Studies were excluded if hand hygiene was assessed in simulations, non-clinical settings or the operating theatre setting.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed data quality.

MAIN RESULTS

Four studies met the criteria for the review: two from the original review and two from the update. Two studies evaluated simple education initiatives, one using a randomized clinical trial design and the other a controlled before and after design. Both measured hand hygiene compliance by direct observation. The other two studies were both interrupted times series studies. One study presented three separate interventions within the same paper: simple substitutions of product and two multifaceted campaigns, one of which included involving practitioners in making decisions about choice of hand hygiene products and the components of the hand hygiene program. The other study also presented two separate multifaceted campaigns, one of which involved application of social marketing theory. In these two studies follow-up data collection continued beyond twelve months, and a proxy measure of hand hygiene compliance (product use) was recorded. Microbiological data were recorded in one study. Hand hygiene compliance increased for one of the studies where it was measured by direct observation, but the results from the other study were not conclusive. Product use increased in the two studies in which it was reported, with inconsistent results reported for one initiative. MRSA incidence decreased in the one study reporting microbiological data.

AUTHORS' CONCLUSIONS

The quality of intervention studies intended to increase hand hygiene compliance remains disappointing. Although multifaceted campaigns with social marketing or staff involvement appear to have an effect, there is insufficient evidence to draw a firm conclusion. There remains an urgent need to undertake methodologically robust research to explore the effectiveness of soundly designed and implemented interventions to increase hand hygiene compliance.

Effectiveness of a training programme to improve hand hygiene compliance in primary healthcare

BACKGROUND

Hand hygiene is the most effective measure for preventing infections related to healthcare, and its impact on the reduction of these infections is estimated at 50%. Non-compliance has been highlighted in several studies in hospitals, although none have been carried out in primary healthcare.

MAIN OBJECTIVE

To evaluated the effect of a "Hand Hygiene for the reduction of healthcare-associated infections" training program for primary healthcare workers, measured by variation from correct hand hygiene compliance, according to regulatory and specific criteria, 6 months after the baseline, in the intervention group (group receiving a training program) and in the control group (a usual clinical practice).

SECONDARY OBJECTIVES

-To describe knowledges, attitudes and behaviors as regards hand hygiene among the professionals, and their possible association with "professional burnout", stratifying the results by type of group (intervention and usual clinical practice).-To estimate the logistic regression model that best explains hand hygiene compliance.

METHODS/DESIGN

Experimental study of parallel groups, with a control group, and random assignment by Health Center.Area of study.- Health centers in north-eastern Madrid (Spain).Sample studied.- Healthcare workers (physicians, odontostomatologists, pediatricians, nurses, dental hygienists, midwife and nursing auxiliaries).Intervention.- A hand hygiene training program, including a theoretical-practical workshop, provision of alcohol-based solutions and a reminder strategy in the workplace.Other variables: sociodemographic and professional knowledges, attitudes, and behaviors with regard to hand hygiene.

STATISTICAL ANALYSIS

descriptive and inferential, using multivariate methods (covariance analysis and logistic regression).

DISCUSSION

This study will provide valuable information on the prevalence of hand hygiene non-compliance, and improve healthcare.

Hand hygiene compliance by physicians: marked heterogeneity due to local culture?

BACKGROUND

Physician compliance with hand hygiene guidelines often has been reported as insufficient.

METHODS

The study was conducted in 2 hospitals (Hadassah Ein Kerem [EK] and Mt Scopus [MS]) in Jerusalem, Israel. Covert observations were conducted during morning rounds by trained observers. The data were recorded as the percentage of times that hand hygiene was applied out of the total contacts with patients. After the observational step, an intervention-providing an alcohol gel and encouraging its use-was instituted in several wards.

RESULTS

Physicians' compliance with hand hygiene averaged 77% at MS and 33% at EK (P < .001), and was characterized by a marked additional heterogeneity among wards. Rates of adherence ranged from as low as 4% in a gynecology ward to as high as 96% in a neonatal unit. Availability of a handwashing basin in the room and seniority status of the physician were associated with higher compliance rates but explained only a small part of the variation. Compliance improved significantly in 2 wards exposed to the intervention.

CONCLUSION

The remarkable heterogeneity in physicians' hand hygiene compliance among sites within the same institution is consistent with an important role of the local ward culture.

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.

OBJECTIVES

To assess the short and longer-term success of strategies to improve hand hygiene compliance and to determine whether a sustained increase in hand hygiene compliance can reduce rates of health care-associated infection.

SEARCH STRATEGY

We conducted electronic searches of: the Cochrane Central Register of Controlled Trials; the Cochrane Effective Practice and Organisation of Care Group specialised register of trials; MEDLINE; PubMed; EMBASE; CINAHL; and the BNI. All databases were searched to July 2006; MEDLINE was searched from 1980, CINAHL from its inception, and the remainder from 1990 until July 2006.

SELECTION CRITERIA

Randomised controlled trials; controlled clinical trials; controlled before and after studies; and interrupted time series analyses meeting explicit entry and quality criteria used by the Cochrane Effective Practice and Organisation of Care Group. Studies reporting proxy indicators of hand hygiene compliance were considered. Studies to promote compliance with universal precautions were included providing data relating specifically to hand hygiene were presented separately.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed data quality.

MAIN RESULTS

Two studies met the criteria for review. One was a randomised controlled trial. The other was a controlled before and after study. Both were poorly controlled. Statistically significant post-intervention increase in hand washing was reported in one study up to four months after the intervention. In the other there was no post-intervention increase in hand hygiene compliance.

AUTHORS' CONCLUSIONS

There is little robust evidence to inform the choice of interventions to improve hand hygiene. It appears that single interventions based on short, 'one off' teaching sessions are unlikely to be successful, even short-term. There is a need to undertake methodologically robust research to explore the effectiveness of soundly designed interventions to increase hand hygiene compliance.

Behavioural considerations for hand hygiene practices: the basic building blocks

Hand hygiene is considered to be the most effective measure to prevent microbial pathogen cross-transmission and healthcare-associated infections. In October 2005, the World Health Organization (WHO) World Alliance for Patient Safety launched the first Global Patient Safety Challenge 2005-2006, 'Clean Care is Safer Care', to tackle healthcare-associated infection on a large scale. Within the Challenge framework, international infection control experts and consultative taskforces met to develop new WHO Guidelines on Hand Hygiene in Healthcare. The taskforce was asked to explore aspects underlying hand hygiene behaviour that may influence its promotion among healthcare workers. The dynamics of behavioural change are complex and multi-faceted, but are of vital importance when designing a strategy to improve hand hygiene compliance. A reflection on challenges to be met and areas for future research are also proposed.

The Lowbury lecture: behaviour in infection control

The majority of healthcare-associated infections result from cross-transmission related to inappropriate patient-care practices. Improving practices frequently implies modifying healthcare workers' behaviour, a key challenge of today's infection control. To improve healthcare workers' compliance with practices, infection control should learn from the behavioural sciences. Social cognitive models can help to improve our understanding of human behaviour. Cognitive determinants that shape behaviour are acquired through the socialization process and are susceptible to change. Some models have been applied to evaluate predictors of health behaviour but, so far, none have been successfully applied to explain behaviour in the field of infection control. Successful strategies to improve infection control practices result from their multidimensional aspect. Similarly, social models that include several levels of cognitive determinants have more chance of success to explain change in behaviour. Concrete examples applied to infection control issues are presented, including special references to hand hygiene behaviour. The theory of ecological perspective, based on the idea that behaviour is viewed as being affected by and affecting multiple levels of influence, and that it both influences and is influenced by the social environment, seems promising to explain behaviour modification. Studies are needed to assess the key determinants of infection control practices and behaviour promotion among the different populations of healthcare workers, and to implement and evaluate the impact of the different components of multimodal programmes to promote optimal infection control practices.

Standard precautions and post exposure prophylaxis for preventing infections

In health care set up, risk of acquiring infection by both patients and health care worker (HCW) from each other is fairly high. Despite progress, hospital acquired infections (HAI) are a problem in both developed and developing countries and are an important cause of death. Many different microbes cause HAI in both patients and HCW; these include various commensals, pathogenic bacteria, viruses, parasites, and fungi. Among these HIV, hepatitis B, and hepatitis C are of major significance to HCW. 'Standard precautions' have now replaced the term 'universal precautions', and are designed to reduce the risk of transmission of microorganisms in health care set-up from both recognized and unrecognized sources. Ultimate aim is to reduce the risk of disease transmission in the healthcare setting, both to the patient and the provider, and thus reduce morbidity. This applies to all patients, regardless of their diagnosis and expands the coverage of universal precautions by recognizing that any body fluid may contain contagious and harmful microorganisms. This article reviews the standard precautions and discusses current guidelines on post exposure prophylaxis (PEP).

Hand hygiene: improved standards and practice for hospital care

PURPOSE OF REVIEW

To review the most recently published literature on hand hygiene practices in healthcare settings.

RECENT FINDINGS

Adherence with recommendations for hand hygiene remains low, but key factors of noncompliance have been identified and corrective actions proposed. Current guidelines recommend the use of alcohol-based handrub formulations as the new standard of care, thus requiring a system change in most hospitals. In addition, healthcare worker education and motivation are obviously important to modify hand hygiene behavior and must be part of multimodal strategies to enhance compliance in hospitals. Compliance improvement is associated with reduced infection rates and resistance spread. Handrub application according to recommended practices is an alternative to conventional surgical handscrubbing with antiseptic soap and water for surgical hand preparation.

SUMMARY

System change must be addressed in most hospitals where alcohol-based handrubbing has not become a standard of care. Strategies to improve hand hygiene compliance must be multimodal and include staff education and motivation, the use of performance indicators, and hospital management support. Successful campaigns will result in reduced infection rates, antimicrobial resistance spread, and enhance patient safety.

Use of an alcohol-based hand rub and quality improvement interventions to improve hand hygiene in a Russian neonatal intensive care unit

BACKGROUND

Hand hygiene (HH) is critical to infection control, but compliance is low. Alcohol-based antiseptics may improve HH. HH practices in Russia are not well described, and facilities are often inadequate.

SETTING

Four 6-bed units in a neonatal intensive care unit in St. Petersburg, Russia.

METHODS

Prospective surveillance of HH compliance, nosocomial colonization, and antibiotic administration was performed from January until June 2000. In February 2000, alcohol-based hand rub was provided for routine HH use. Eight weeks later, a quality improvement intervention was implemented, consisting of review of interim data, identification of opinion leaders, posting of colonization incidence rates, and regular feedback. Means of compliance, colonization, and antibiotic use were compared for periods before and after each intervention.

RESULTS

A total of 1,027 events requiring HH were observed. Compliance was 44.2% before the first intervention, 42.3% between interventions, and 48% after the second intervention. Use of alcohol rose from 15.2% of HH indications to 25.2% between interventions and 41.5% after the second intervention. The incidence of nosocomial colonization (per 1,000 patient-days) with Klebsiella pneumoniae was initially 21.5, decreased to 4.7, and then was 3.2 in the final period. Rates of antibiotic and device use also decreased.

CONCLUSIONS

HH may have increased slightly, but the largest effect was a switch from soap and water to alcohol which may have been associated with decreased cross-transmission of Klebsiella, although this may have been confounded by lower device use. Alcohol-based antiseptic may be an improvement over current practices, but further research is required.

Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.

Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.

Nonantibibiotic measures for the prevention of Gram-positive infections

While Gram-negative bacteria remain a leading cause of nosocomial infections such as ventilator-associated pneumonia and catheter-associated urinary tract infections, Gram-positive cocci are now responsible for a large majority of surgical site and bloodstream infections. A shift has occurred during the last decade and multidrug-resistant micro-organisms have become predominant in most referral centers. Severe infections with Gram-positive micro-organisms such as methicillin-resistant Staphylococcus aureus, coagulase-negative staphylococci, vancomycin-resistant enterococci, penicillin-resistant Streptococcus pneumoniae and, more recently, glycopeptide intermediate S. aureus are now regularly reported to be associated with increased morbidity and represent a true health problem in many institutions. The importance of nonantimicrobial measures to prevent infections and further spread is reviewed in this paper. New evidence of the effectiveness of basic infection control measures that have been regarded of little importance during the last two decades by the exponential progress of technologically sophisticated medicine, is discussed.

Marketing hand hygiene in hospitals--a case study

Hand hygiene of healthcare workers is frequently poor despite the efforts of infection control teams to promote hand decontamination as the most important method to prevent transmission of hospital-acquired infections. In this case study, we describe how principles of societal marketing were applied to improve hand hygiene. Pre-marketing analysis of strengths, weaknesses, opportunities and threats to implementation; attention to product, price, promotion and placement; and post-marketing 'customer' surveys were the essential components of the marketing strategy and its implementation. Placement of an alcohol-based gel decontaminant (Spirigel) at the bedside of every patient was widely welcomed in the hospital, and has played a major role in improving hand hygiene of healthcare workers. In the twelve months following the implementation, the decontaminant was used at least 440,000 times. The cost of purchasing the decontaminant was approximately 5000 pounds sterling. Following the introduction of Spirigel, there was a consistent reduction in the proportion of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) in each of the quarters of 2000-2001 compared with 1999-2000. In the period 1999-2000, nearly 50% of the MRSA were hospital acquired compared with 39% in 2000-2001. Similarly, the average incidence of Clostridium difficile associated diarrhoea (CDAD) decreased in each of the quarters in 2000-2001 following the introduction of Spirigel. During this period, there was an average incidence of 9.5 cases of CDAD/1000 admissions compared with 11.5 cases of CDAD/1000 admissions in 1999-2000. This represents a 17.4% reduction in the incidence of CDAD. However, this reduction was not statistically significant (P=0.2). Our case study demonstrates that principles of societal marketing methods can be used effectively to promote and sustain hand hygiene in hospitals. Improvement in hand hygiene will lead to considerable reduction in hospital-acquired infections.

Infection control in the ICU

Nosocomial infections (NIs) now concern 5 to 15% of hospitalized patients and can lead to complications in 25 to 33% of those patients admitted to ICUs. The most common causes are pneumonia related to mechanical ventilation, intra-abdominal infections following trauma or surgery, and bacteremia derived from intravascular devices. This overview is targeted at ICU physicians to convince them that the principles of infection control in the ICU are based on simple concepts and that the application of preventive strategies should not be viewed as an administrative or constraining control of their activity but, rather, as basic measures that are easy to implement at the bedside. A detailed knowledge of the epidemiology, based on adequate surveillance methodologies, is necessary to understand the pathophysiology and the rationale of preventive strategies that have been demonstrated to be effective. The principles of general preventive measures such as the implementation of standard and isolation precautions, and the control of antibiotic use are reviewed. Specific practical measures, targeted at the practical prevention and control of ventilator-associated pneumonia, sinusitis, and bloodstream, urinary tract, and surgical site infections are detailed. Recent data strongly confirm that these strategies may only be effective over prolonged periods if they can be integrated into the behavior of all staff members who are involved in patient care. Accordingly, infection control measures are to be viewed as a priority and have to be integrated fully into the continuous process of improvement of the quality of care.

Irritancy of the skin disinfectant n-propanol

Hand disinfection with short-chain aliphatic alcohols, so-called "rub-ins" is the method of choice for cross-infection prevention in health care environments, but their irritant potential is not well known. Skin tolerance is a major compliance factor, and a high proportion of health care workers suffer from low-grade irritant contact dermatitis. Therefore, assessment of the irritancy of the skin disinfectant n-propanol 60%, and comparative 100% and 0% solutions, was performed in the setting of experimental low-grade ICD. ICD was induced by overnight patch exposure to H2O, and to 0.3% sodium dodecyl sulfate (SDS), in 12 probands, followed by repeated open exposure to the test substances. Outcome variables were transepidermal water loss (TEWL), and skin surface capacitance. On skin sites pre-irritated by SDS, all n-propanol concentrations (100%, 60%, 0%) increased TEWL. However, a clear divergence appeared between pure n-propanol, and the lower concentrations. In contrast to pure n-propanol, n-propanol 60% and 0% had no significant effect on TEWL on H2O-pre-irritated skin sites. Capacitance of pre-irritated skin sites was increased by exposure to H2O-containing n-propanol solutions (60% and 0%). These results show a clear difference between the irritant potential of n-propanol 100% on one side, and n-propanol 60% and 0% on the other side. The level of pre-existent skin irritation is a pertinent factor in susceptibility to irritation, as the irritant potential of n-propanol 60%, the concentration used in daily practice, and n-propanol 0% (water) became significant only on detergent-irritated skin. Thus, preventive skin care may be a constructive approach in increasing tolerance of modern hand disinfection practices.

Compliance with hand disinfection and its impact on hospital-acquired infections

Hand hygiene prevents cross-infection in hospitals, but adherence to guidelines is poor among healthcare workers. Although some interventions to improve compliance have been successful, none had achieved lasting improvement until very recently. Reasons for non-compliance with recommendations occur at individual, group and institutional levels. The complexity of the process of behavioural change would suggest that the application of multimodal, multidisciplinary strategies are necessary. Both easy access to hand hygiene in a timely fashion and skin protection appear necessary prerequisites for satisfactory hand hygiene behaviour. Alcohol-based hand-rub may be superior to traditional handwashing as it requires less time, acts faster, irritates hands less often, and recently proved significantly to contribute to sustained improvement in compliance associated with decreased infection rates. This paper reviews barriers to appropriate hand hygiene and describes the results of the first successful experience of sustained hand hygiene promotion and its effectiveness on hospital-acquired infection.

Improving adherence to hand hygiene practice: a multidisciplinary approach

Hand hygiene prevents cross-infection in hospitals, but health-care workers' adherence to guidelines is poor. Easy, timely access to both hand hygiene and skin protection is necessary for satisfactory hand hygiene behavior. Alcohol- based hand rubs may be better than traditional handwashing as they require less time, act faster, are less irritating, and contribute to sustained improvement in compliance associated with decreased infection rates. This article reviews barriers to appropriate hand hygiene and risk factors for noncompliance and proposes strategies for promoting hand hygiene.

Hand Hygiene Revisited: Lessons from the Past and Present

Hand hygiene is the most effective measure to prevent cross-transmission of microorganisms. Adequate hand hygiene can be achieved by standard handwashing--with water alone or with soap--or by the use of an alcohol-based hand-rub solution. Despite considerable efforts, compliance with this simple infection-control measure remains low. Factors predicting non-compliance have been extensively studied, and include physician status, procedures associated with a high risk of cross-transmission, and an important workload. Future interventions to improve compliance should consider complex behavioral theories and the use of multimodal and multidisciplinary strategies. We believe that one of the key components of these interventions should be the wide use of alcohol-based hand-rub, which is microbiologically effective and less time-consuming than standard handwashing.

Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme

BACKGROUND

Hand hygiene prevents cross infection in hospitals, but compliance with recommended instructions is commonly poor. We attempted to promote hand hygiene by implementing a hospital-wide programme, with special emphasis on bedside, alcohol-based hand disinfection. We measured nosocomial infections in parallel.

METHODS

We monitored the overall compliance with hand hygiene during routine patient care in a teaching hospital in Geneva, Switzerland, before and during implementation of a hand-hygiene campaign. Seven hospital-wide observational surveys were done twice yearly from December, 1994, to December, 1997. Secondary outcome measures were nosocomial infection rates, attack rates of methicillin-resistant Staphylococcus aureus (MRSA), and consumption of handrub disinfectant.

FINDINGS

We observed more than 20,000 opportunities for hand hygiene. Compliance improved progressively from 48% in 1994, to 66% in 1997 (p<0.001). Although recourse to handwashing with soap and water remained stable, frequency of hand disinfection substantially increased during the study period (p<0.001). This result was unchanged after adjustment for known risk factors of poor adherence. Hand hygiene improved significantly among nurses and nursing assistants, but remained poor among doctors. During the same period, overall nosocomial infection decreased (prevalence of 16.9% in 1994 to 9.9% in 1998; p=0.04), MRSA transmission rates decreased (2.16 to 0.93 episodes per 10,000 patient-days; p<0.001), and the consumption of alcohol-based handrub solution increased from 3.5 to 15.4 L per 1000 patient-days between 1993 and 1998 (p<0.001).

INTERPRETATION

The campaign produced a sustained improvement in compliance with hand hygiene, coinciding with a reduction of nosocomial infections and MRSA transmission. The promotion of bedside, antiseptic handrubs largely contributed to the increase in compliance.

Disinfectants that do

Biocides are helpful in different healthcare settings to reduce or eradicate harmful pathogens on the skin, medical devices, and in the environment. This article reviews recent advances in hand hygiene, instrument sterilization, decolonization with mupirocin, and the challenges posed by environmental contamination, and prion disease. Do biocides induce resistance?

Improving compliance with hand hygiene in hospitals

Hand hygiene prevents cross-infection in hospitals, but compliance with recommended instructions often is poor among healthcare workers. Although some previous interventions to improve compliance have been successful, none has achieved lasting improvement. This article reviews reported barriers to appropriate hand hygiene and factors associated with poor compliance. Easy access to hand hygiene in a timely fashion and the availability of skin-care lotion both appear to be necessary prerequisites for appropriate hand-hygiene behavior. In particular, in high-demand situations, hand rub with an alcohol-based solution appears to be the only alternative that allows a decent compliance. The hand-hygiene compliance level does not rely on individual factors alone, and the same can be said for its promotion. Because of the complexity of the process of change, it is not surprising that solo interventions often fail, and multimodal, multidisciplinary strategies are necessary. A framework that includes parameters to be considered for hand-hygiene promotion is proposed, based on epidemiologically driven evidence and review of the current knowledge. Strategies for promotion in hospitals should include reasons for noncompliance with recommendations at individual, group, and institutional levels. Potential tools for change should address each of these elements and consider their interactivity.