Marketing hand hygiene in hospitals--a case study

SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute-care hospitals: 2022 Update

Previously published guidelines have provided comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing efforts to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection. This document updates the "Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals" published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Prevention of Clostridium difficile Infection and Associated Diarrhea: An Unsolved Problem

For many years, it has been known that Clostridium difficile (CD) is the primary cause of health-care-associated infectious diarrhea, afflicting approximately 1% of hospitalized patients. CD may be simply carried or lead to a mild disease, but in a relevant number of patients, it can cause a very severe, potentially fatal, disease. In this narrative review, the present possibilities of CD infection (CDI) prevention will be discussed. Interventions usually recommended for infection control and prevention can be effective in reducing CDI incidence. However, in order to overcome limitations of these measures and reduce the risk of new CDI episodes, novel strategies have been developed. As most of the cases of CDI follow antibiotic use, attempts to rationalize antibiotic prescriptions have been implemented. Moreover, to reconstitute normal gut microbiota composition and suppress CD colonization in patients given antimicrobial drugs, administration of probiotics has been suggested. Finally, active and passive immunization has been studied. Vaccines containing inactivated CD toxins or components of CD spores have been studied. Passive immunization with monoclonal antibodies against CD toxins or the administration of hyperimmune whey derived from colostrum or breast milk from immunized cows has been tried. However, most advanced methods have significant limitations as they cannot prevent colonization and development of primary CDI. Only the availability of vaccines able to face these problems can allow a resolutive approach to the total burden due to this pathogen.

The effectiveness of alcohol-based gel for hand sanitising in infection control

This article aims to evaluate the evidence relating to the effectiveness of alcohol-based gel for hand sanitising, or 'handrub', in infection control in healthcare settings with particular reference to renal nursing, as this has become pertinent due to the increasing reliance on evidence-based practice. There is a need to implement better infection control strategies and education, to reinforce knowledge among the public, health professionals and those at high risk of infection not only in renal nursing, but also in other areas of practice. Healthcare-associated infections (HCAIs) put patients' safety at risk, increase morbidity and mortality, extend the length of hospital admission and increase the cost to the NHS. There is evidence that the prevalence of HCAIs in England can be minimised through the use of different infection control measures. For example, alcohol-based handrub has been found to be associated with minimising the spread of gastrointestinal infections not only in hospital settings, but also in childcare centres. In addition, the UK national guidelines recommend regular handwashing (implementing the right technique) when hands are visibly dirty and hand disinfection with alcohol-based handrub when they are not visibly dirty. This should be before, in between and after different healthcare activities are performed.

The development of hand hygiene compliance imperatives in an emergency department

BACKGROUND

Monitoring results showing poor hand hygiene compliance in a major, busy emergency department prompted a quality improvement initiative to improve hand hygiene compliance.

PURPOSE

To identify, remove, and reduce barriers to hand hygiene compliance in an emergency department.

METHODS

A barrier identification tool was used to identify key barriers and opportunities associated with hand hygiene compliance. Hand hygiene imperatives were developed and agreed on with clinicians, and a framework for monitoring and improving hand hygiene compliance was developed.

RESULTS

Barriers to compliance were ambiguity about when to clean hands, the pace and urgency of work in some areas of the department, which left little time for hand hygiene and environmental and operational issues. Sore hands were a problem for some staff. Expectations of compliance were agreed on with staff, and changes were made to remove barriers. A monitoring tool was designed to monitor progress. Gradual improvement occurred in all areas, except in emergency situations, which require further improvement work.

CONCLUSIONS

The context of care and barriers to compliance should be reflected in hand hygiene expectations and monitoring. In the emergency department, the requirement to deliver urgent live-saving care can supersede conventional hand hygiene expectations.

Institutional review of the implementation and use of a Clostridium difficile infection bundle and probiotics in adult trauma patients

BACKGROUND

Clostridium difficile infection (CDI) is a common cause of healthcare associated infections contributing to morbidity and mortality. Our objective was to evaluate the impact of the implementation of a CDI bundle along with probiotic utilization.

METHODS

A retrospective review of trauma admissions from 2008 to 2014 was performed. The CDI bundle was implemented in stages from 2009 through 2014 with probiotics initiated in 2010. The bundle included changes in cleaning practices, education, screening, and contact precautions.

RESULTS

4632 (49%) patients received antibiotics with 21% receiving probiotics. Probiotic use was associated with increased age, male sex, more severely injured, and antibiotic use. CDI incidence decreased from 11.2 to 4.8 per 1000 admissions, p = .03. Among patients who received antibiotics CDI incidence decreased from 2.2% to 0.7%, p = .01.

CONCLUSIONS

We report the largest series of a CDI bundle implementation including probiotics. During the period of adoption of these interventions, the incidence of CDI decreased significantly.

Hand hygiene compliance monitoring in anaesthetics: Feasibility and validity

Background:

Hand hygiene compliance scores in the anaesthetic department of an acute NHS hospital were persistently low.

Aims:

To determine the feasibility and validity of regular accurate measurement of HHC in anaesthetics and understand the context of care delivery, barriers and opportunities to improve compliance.

Methods:

The hand hygiene compliance of one anaesthetist was observed and noted by a senior infection control practitioner (ICP). This was compared to the World Health Organization five moments of hand hygiene and the organisation hand hygiene tool.

Findings:

In one sequence of 55 min, there were approximately 58 hand hygiene opportunities. The hand hygiene compliance rate was 16%. The frequency and speed of actions in certain periods of care delivery made compliance measurement difficult and potentially unreliable. During several activities, taking time to apply alcohol gel or wash hands would have put the patients at significant risk.

Discussion:

We concluded that hand hygiene compliance monitoring by direct observation was invalid and unreliable in this specialty. It is important that hand hygiene compliance is optimal in anaesthetics particularly before patient contact. Interventions which reduce environmental and patient contamination, such as cleaning the patient and environment, could ensure anaesthetists encounter fewer micro-organisms in this specialty.

Relationship between hospital ward design and healthcare-associated infection rates: a systematic review and meta-analysis

BACKGROUND

The influence of the hospital's infrastructure on healthcare-associated colonization and infection rates has thus far infrequently been examined. In this review we examine whether healthcare facility design is a contributing factor to multifaceted infection control strategies.

METHODS

We searched PubMed/MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) from 1990 to December 31^st, 2015, with language restriction to English, Spanish, German and French.

RESULTS

We identified three studies investigating accessibility of the location of the antiseptic hand rub dispenser. Each of them showed a significant improvement of hand hygiene compliance or agent consumption with the implementation of accessible dispensers near the patient bed. Nine eligible studies evaluated the impact of single-patient rooms on the acquisition of healthcare-associated colonization and infections in comparison to multi-bedrooms or an open ward design. Six of these studies showed a significant benefit of single-patient bedrooms in reducing the healthcare-associated colonization and infection rate, whereas three studies found that single-patient rooms are neither a protective nor risk factor. In meta-analyses, the overall risk ratio for acquisition of healthcare-associated colonization and infection was 0.55 (95% CI: 0.41 to 0.74), for healthcare-associated colonization 0.52 (95% CI: 0.32 to 0.85) and for bacteremia 0.64 (95% CI: 0.53 to 0.76), all in favor of patient care in single-patient bedrooms.

CONCLUSION

Implementation of single-patient rooms and easily accessible hand rub dispensers located near the patient's bed are beneficial for infection control and are useful parts of a multifaceted strategy for reducing healthcare-associated colonization and infections.

Delivering an infection control link nurse programme: improving practice

This is the second in a series of articles describing a research study that examined the efficacy of an infection control link nurse programme, which had an educational programme based upon adult learning theory, delivered using an action research approach. This article describes the results of a quantitative study that aimed to identify if the utilisation of this programme led to improvements in infection control practice at clinical level. Implications for practice are discussed.

Strategies to Prevent Methicillin-ResistantStaphylococcus aureusTransmission and Infection in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their methicillin-resistantStaphylococcus aureus(MRSA) prevention efforts. This document updates “Strategies to Prevent Transmission of Methicillin-ResistantStaphylococcus aureusin Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

A step-wise approach towards introduction of an alcohol based hand rub, and implementation of front line ownership- using a, rural, tertiary care hospital in central India as a model

BACKGROUND

Appropriate hand hygiene is a gold standard to combat healthcare associated infections (HAIs). The World Health Organization (WHO) has recommended alcohol based hand rub (ABHR) as the most effective tool to maintain hand hygiene. In resource poor settings commercially available ABHR is not "economically accessible". The objectives of this study were to assess the acceptability of, and to build confidence for an in-house prepared (based on WHO guidelines) alcohol based hand rub among healthcare workers (HCWs) using a rural, tertiary care hospital in central India as an example.

METHODS

A series of activities were developed and conducted based on the Precede-Proceed model, the Trans Theoretical model of behaviour change, Front line ownership and Social marketing. A modified WHO-ABHR formulation, the 'test product' and 'WHO product evaluation form' were used for self assessment of acceptability of the 'test product'. Confidence building activities, as finger tip culture, visual portrayal method and handmade posters, were used in high-risk wards for HAIs, to build confidence for the 'test product' in removing transient flora from the hands. A locally developed feedback from was used to evaluate the impact of the activities conducted.

RESULTS

Overall 183 HCWs were enrolled for the assessment of the 'test product' (130- doctors and 53 nurses). Out of these 83% (108/130) doctors and 94% (50/53) nurses were satisfied with the 'test product'. The confidence building activity was conducted with 116 participants (49 doctors). After single use of the 'test product', overall a significant reduction was observed for the CFUs on the blood agar plates (0.77 Log(10), p < 0.001). A complete reduction (100%) in colony forming units on incubated blood agar plates was seen for 13% (15/116) participants. Eighty two percent (95/116) participants expressed their confidence in the 'test product'.

CONCLUSION

The self reported acceptance level for the 'test product' was high. The use of finger tip culture coupled with the visual portrayal was perceived as a convincing and highly effective way to develop confidence in HCWs. Thus, is the foremost step towards successful introduction of ABHR and can be seen as a model for similar settings.

Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their Clostridium difficile infection (CDI) prevention efforts. This document updates “Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Determinants of Good Adherence to Hand Hygiene Among Healthcare Workers Who Have Extensive Exposure to Hand Hygiene Campaigns

Objective.

To quantify the different behavioral components of healthcare workers' motivation to comply with hand hygiene in a healthcare institution with a 10-year history of hand hygiene campaigning.

Design.

Cross-sectional study, by use of an anonymous, self-administered questionnaire.

Setting.

A 2,200-bed university teaching hospital.

Participants.

A stratified random sample of 2,961 medical and nursing staff.

Results.

A total of 1,042 questionnaires (35.2%) were returned. Of the respondents, 271 (26.0%) were physicians, 629 (60.4%) were nurses, and 141 (13.5%) were nursing assistants. Overall, 1,008 respondents provided information about sex; 718 (71.2%) of these were women. Respondents provided demographic information and data about various behavioral, normative, and control beliefs that determined their intentions with respect to performing hand hygiene. Among behavioral beliefs, the perception that healthcare-associated infections are severe for patients was highly ranked as a determinant of behavior by 331 (32.1%) of the respondents, and the perception that hand hygiene is effective at preventing these infections was ranked highly by 891 respondents (86.0%). Among normative beliefs, perceived social pressure from patients to perform hand hygiene was ranked highly by 760 respondents (73.7%), pressure from superiors was ranked highly by 687 (66.8%), pressure from colleagues was ranked highly by 596 (57.9%), and pressure from the person perceived to be most influential was ranked highly by 687 (68.8%). Among control beliefs, the perception that hand hygiene is relatively easy to perform was rated highly by 670 respondents (65.1%). High self-reported rates of adherence to hand hygiene (defined as performance of proper hand hygiene during 80% or more of hand hygiene opportunities) was independently associated with female sex, receipt of training in hand hygiene, participation in a previous hand hygiene campaign, peer pressure from colleagues, perceived good adherence by colleagues, and the perception that hand hygiene is relatively easy to perform.

Conclusions.

In a setting with a long tradition of hand hygiene campaigns, behavioral beliefs are strongly in favor of hand hygiene, but adherence is driven by peer pressure and the perception of high self-efficacy, rather than by reasoning about the impact of hand hygiene on patient safety. Female sex, training, and campaign exposure increased the likelihood of compliance with hand hygiene. This additional insight can help to shape future promotional activity.

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.

Strategies to Prevent Transmission of Methicillin-ResistantStaphylococcus aureusin Acute Care Hospitals

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). Our intent in this document is to highlight practical recommendations in a concise format to assist acute care hospitals in their efforts to prevent transmission of methicillin-resistantStaphylococcus aureus(MRSA). Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary, Introduction, and accompanying editorial for additional discussion.

1. Burden of HAIs caused by MRSA in acute care facilities

a. In the United States, the proportion of hospital-associatedS. aureusinfections that are caused by strains resistant to methicillin has steadily increased. In 2004, MRSA accounted for 63% ofS. aureusinfections in hospitals.

b. Although the proportion ofS. aureus–associated HAIs among intensive care unit (ICU) patients that are due to methicillin-resistant strains has increased (a relative measure of the MRSA problem), recent data suggest that the incidence of central line–associated bloodstream infection caused by MRSA (an absolute measure of the problem) has decreased in several types of ICUs since 2001. Although these findings suggest that there has been some success in preventing nosocomial MRSA transmission and infection, many patient groups continue to be at risk for such transmission.

c. MRSA has also been documented in other areas of the hospital and in other types of healthcare facilities, including those that provide long-term care.

A systematic approach for the location of hand sanitizer dispensers in hospitals

Compliance with hand hygiene practices is directly affected by the accessibility and availability of cleaning agents. Nevertheless, the decision of where to locate these dispensers is often not explicitly or fully addressed in the literature. In this paper, we study the problem of selecting the locations to install alcohol-based hand sanitizer dispensers throughout a hospital unit as an indirect approach to maximize compliance with hand hygiene practices. We investigate the relevant criteria in selecting dispenser locations that promote hand hygiene compliance, propose metrics for the evaluation of various location configurations, and formulate a dispenser location optimization model that systematically incorporates such criteria. A complete methodology to collect data and obtain the model parameters is described. We illustrate the proposed approach using data from a general care unit at a collaborating hospital. A cost analysis was performed to study the trade-offs between usability and cost. The proposed methodology can help in evaluating the current location configuration, determining the need for change, and establishing the best possible configuration. It can be adapted to incorporate alternative metrics, tailored to different institutions and updated as needed with new internal policies or safety regulation.

Reducing hospital associated infection: a role for social marketing

PURPOSE

Although hand hygiene is seen as the most important method to prevent the transmission of hospital associated infection in the UK, hand hygiene compliance rates appear to remain poor. This research aims to assess the degree to which social marketing methodology can be adopted by a particular organisation to promote hand hygiene compliance.

DESIGN/METHODOLOGY/APPROACH

The research design is based on a conceptual framework developed from analysis of social marketing literature. Data collection involved taped interviews given by nursing staff working within a specific Hospital Directorate in Manchester, England. Supplementary data were obtained from archival records of the hand hygiene compliance rates.

FINDINGS

Findings highlighted gaps in the Directorate's approach to the promotion of hand hygiene compared to what could be using social marketing methodology. Respondents highlighted how the Directorate failed to fully optimise resources required to endorse hand hygiene practice and this resulted in poorer compliance.

PRACTICAL IMPLICATIONS

From the experiences and events documented, the study suggests how the emergent phenomena could be utilised by the Directorate to apply a social marketing approach which could positively influence hand hygiene compliance.

ORIGINALITY/VALUE

The paper seeks to explore the use of social marketing in nursing to promote hand hygiene compliance and offer a conceptual framework that provides a way of measuring the strength of the impact that social marketing methodology could have.

Improving hand hygiene adherence among nursing staff

This quasi-experimental study explored initial and sustained effects of educational and behavioral interventions on hand hygiene adherence and the relationships between hand hygiene adherence and health care-associated infections. Education paired with positive reinforcement behavioral interventions significantly improved hand hygiene adherence after the first month (χ² = 4.27; P = .039); however, the improvement was not sustained over 6 months. There were no significant differences in infection rates between the treatment and control groups.

Point-of-care hand hygiene: preventing infection behind the curtain

Best practices for hand hygiene provide indications for performance of hand hygiene at specific points in time during patient care. For hand hygiene to prevent infections, hand hygiene resources must be readily available to health care workers whenever required. This article reviews practices and recommendations intended to facilitate hand hygiene behavior at the point of care (POC) within the health care setting. Key aspects of POC hand hygiene include the provision of alcohol-based hand rub products, integration of dispensing solutions within the patient zone, consideration of patient care workflow, and dispenser designs that optimize acceptance and usage.

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.

Prevention of endemic healthcare-associated Clostridium difficile infection: reviewing the evidence

OBJECTIVES

Clostridium difficile is the most common infectious cause of healthcare-associated diarrhea. Because of the increasing incidence and severity of endemic C. difficile infection (CDI), interventions to prevent healthcare-associated CDI are essential. We undertook a systematic review of interventions to reduce healthcare-associated CDI.

METHODS

We searched multiple computerized databases, and manually searched for relevant articles to determine which interventions are useful in preventing CDI. Studies were required to be controlled in design and to report the incidence of endemic CDI as an outcome. Data on the patient population, intervention, study design, and outcomes were abstracted and reviewed using established criteria.

RESULTS

Few randomized controlled trials exist in the area of CDI prevention. The interventions with the greatest evidence for the prevention of CDI include antimicrobial stewardship, glove use, and disposable thermometers. Environmental decontamination also may decrease CDI rates, although the level of evidence is not as strong as for the other proven interventions. Treatment of asymptomatic carriage of C. difficile is not recommended. There is insufficient evidence to make a recommendation for or against the use of probiotics. In cases of known or suspected CDI, hand hygiene with soap and water is preferred over use of waterless alcohol hand rub. Many nonrandomized trials included in our analysis used multiple interventions concurrently, making the independent role of each preventive strategy difficult to determine. We chose to include only studies that focused on endemic CDI because studies of outbreaks have used multiple strategies, making it difficult to measure the relative efficacy of each strategy. Environmental disinfection and probiotics need to be studied further to evaluate their roles in the prevention of CDI. Although there have been no studies assessing the utility of isolation and cohorting for the prevention of endemic CDI specifically, it is a widely used intervention for containment of this and other similar multidrug-resistant pathogens.

CONCLUSIONS

Antimicrobial stewardship, glove use, hand hygiene, and disposable thermometers should be routinely used for the prevention of CDI. Environmental disinfection and probiotics should be studied further for their role in reducing CDI.

Clostridium difficile colitis: a retrospective study of incidence and severity before and after institution of an alcohol-based hand rub policy

BACKGROUND

Clostridium difficile-associated diarrhea is a leading cause of hospital-acquired diarrhea. We sought to determine whether the institution of a hospital-wide alcohol-based hand rub (ABHR) policy was associated with an increase in the incidence and/or severity of health care facility-onset, health care facility-associated C difficile diarrhea (CDAD).

METHODS

We used a retrospective chart review analysis to compare incidence rates of CDAD before and after implementation of the ABHR policy. We also compared rates of sepsis, colectomy, and death in patients with CDAD before and after implementation of the ABHR policy.

RESULTS

The incidence rate of CDAD was 3.98 per 10,000 patient-days after implementation of the ABHR policy, compared with 4.96 per 10,000 patient-days before implementation (P = .0036). The crude mortality rate in patients diagnosed with CDAD was 10.7% after implementation, compared with 13.3% before implementation (P = .275). The rate of sepsis in patients diagnosed with CDAD was 19.6% after implementation, compared with 5.2% before implementation (P < .0001).

CONCLUSION

Our data provide no evidence of an increased CDAD rate after implementation of an ABHR policy at our institution. The rate of sepsis in patients diagnosed with CDAD did rise, indicating increased severity of illness in patients with C difficile infection.

Recognition and prevention of hospital-associated enteric infections in the intensive care unit

The objectives of this article were to review the causes and extent of hospital-associated infectious diarrhea and associated risks in the general hospital ward and intensive care unit (ICU), to compare microorganisms with similar symptoms to aid in recognition that will lead to timely and appropriate treatment and control measures, and to propose infection prevention protocols that could decrease human process errors in the ICU. This literature review describes epidemiology, comparison of microbial characteristics for potential hospital-associated enteric pathogens, diagnosis, and prevention, especially if important in the ICU, and particularly in regard to Clostridium difficile. Enteric organisms that most commonly cause hospital-associated infectious diarrhea in acute care settings and the ICU are C. difficile, rotavirus, and norovirus, although others may also be important, particularly in developing countries. To recognize and control infectious diarrhea successfully in the ICU, intensivists should be aware that epidemiology, risks, and prevention measures may differ between these microorganisms. In addition, intensivists should be ready to implement systems changes related to notification, isolation precautions and prevention, and environmental cleaning in the ICU.

Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands

BACKGROUND

Alcohol-based hand rubs (ABHRs) are an effective means of decreasing the transmission of bacterial pathogens. Alcohol is not effective against Clostridium difficile spores. We examined the retention of C. difficile spores on the hands of volunteers after ABHR use and the subsequent transfer of these spores through physical contact.

METHODS

Nontoxigenic C. difficile spores were spread on the bare palms of 10 volunteers. Use of 3 ABHRs and chlorhexidine soap-and-water washing were compared with plain water rubbing alone for removal of C. difficile spores. Palmar cultures were performed before and after hand decontamination by means of a plate stamping method. Transferability of C. difficile after application of ABHR was tested by having each volunteer shake hands with an uninoculated volunteer.

RESULTS

Plain water rubbing reduced palmar culture counts by a mean (+/- standard deviation [SD]) of 1.57 +/- 0.11 log10 colony-forming units (CFU) per cm2, and this value was set as the zero point for the other products. Compared with water washing, chlorhexidine soap washing reduced spore counts by a mean (+/- SD) of 0.89 +/- 0.34 log10 CFU per cm2; among the ABHRs, Isagel accounted for a reduction of 0.11 +/- 0.20 log10 CFU per cm2 (P = .005), Endure for a reduction of 0.37 +/- 0.42 log10 CFU per cm2 (P = .010), and Purell for a reduction of 0.14 +/- 0.33 log10 CFU per cm2 (P = .005). There were no statistically significant differences between the reductions achieved by the ABHRs; only Endure had a reduction statistically different from that for water control rubbing (P = .040). After ABHR use, handshaking transferred a mean of 30% of the residual C. difficile spores to the hands of recipients.

CONCLUSIONS

Hand washing with soap and water is significantly more effective at removing C. difficile spores from the hands of volunteers than are ABHRs. Residual spores are readily transferred by a handshake after use of ABHR.

Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile

OBJECTIVE

To evaluate common hand hygiene methods for efficacy in removing Clostridium difficile.

DESIGN

Randomized crossover comparison among 10 volunteers with hands experimentally contaminated by nontoxigenic C. difficile.

METHODS

Interventions included warm water with plain soap, cold water with plain soap, warm water with antibacterial soap, antiseptic hand wipes, alcohol-based handrub, and a control involving no intervention. All interventions were evaluated for mean reduction in colony-forming units (CFUs) under 2 contamination protocols: "whole hand" and "palmar surface." Results were analyzed according to a Bayesian approach, by using hierarchical models adjusted for multiple observations.

RESULTS

Under the whole-hand protocol, the greatest adjusted mean reductions were achieved by warm water with plain soap (2.14 log(10) CFU/mL [95% credible interval (CrI), 1.74-2.54 log(10) CFU/mL]), cold water with plain soap (1.88 log(10) CFU/mL [95% CrI, 1.48-2.28 log(10) CFU/mL), and warm water with antibacterial soap (1.51 log(10) CFU/mL [95% CrI, 1.12-1.91 log(10) CFU/mL]), followed by antiseptic hand wipes (0.57 log(10) CFU/mL [95% CrI, 0.17-0.96 log(10) CFU/mL]). Alcohol-based handrub (0.06 log(10) CFU/mL [95% CrI, -0.34 to 0.45 log(10) CFU/mL]) was equivalent to no intervention. Under the palmar surface protocol, warm water with plain soap, cold water with plain soap, and warm water with antibacterial soap again yielded the greatest mean reductions, followed by antiseptic hand wipes (26.6, 26.6, 26.6, and 21.9 CFUs per plate, respectively), when compared with alcohol-based handrub. Hypothenar (odds ratio, 10.98 [95% CrI, 1.96-37.65]) and thenar (odds ratio, 6.99 [95% CrI, 1.25-23.41]) surfaces were more likely than fingertips to remain heavily contaminated after handwashing.

CONCLUSIONS

Handwashing with soap and water showed the greatest efficacy in removing C. difficile and should be performed preferentially over the use of alcohol-based handrubs when contact with C. difficile is suspected or likely.

[Hand hygiene: scientific evidence and common sense]

Hand washing was rightly considered a measure of personal hygiene for centuries. Today there is enough scientific evidence showing that a simple and inexpensive measure can help significantly reduce clinical infections. In spite of this, published studies show that hand hygiene only takes place between 15% and 50% of the instances in which it should be done. In order to support countries in setting priorities to deal with infections related to health care, the World Health Organization has developed a campaign to improve compliance with hand hygiene. Fundamental elements of the campaign include staff training, change of habits, motivating health professionals, and enabling access to effective products at the point of patient care. At institutional level, healthcare managers need to make a firm commitment, and make hand hygiene one of the quality assurance objectives of their organisations.

Failure of a poster-based educational programme to improve compliance with peripheral venous catheter care in a tertiary hospital. A clinical audit

The objective of this audit was to determine the prevalence of recording the date and time of insertion of peripheral venous catheters (PVCs) in a tertiary hospital setting, and whether this could be improved by a simple poster-based educational programme. The two-phase point prevalence audit covered 1109 adult inpatients at the Royal Darwin Hospital, Australia. The presence or otherwise of a PVC was recorded, along with whether the date and time of insertion of the device was recorded in situ, in the bedside chart or in the clinical notes. Background demographic data were collected along with any identifiable risk factors for catheter-associated bacteraemia. The process was then repeated in the same hospital units following implementation of a simple poster-based educational programme. The prevalence of any dating method (in situ, in the bedside chart or in the clinical notes) was low, at 13.4% and 16.1% in the pre- and post-intervention groups respectively. This difference was not statistically significant (P=0.27). Independent of the poster campaign, patients with risk factors for catheter-associated bacteraemia were more likely to have the insertion date recorded compared to those without (P=0.03). Given the potential cost of catheter-associated bacteraemia to the patient, hospital and community, it is surprising that compliance with an in-house infection control recommendation was so poor. A poster-based education programme alone had little effect in improving the situation.

Clostridium difficile infection in solid organ transplant recipients

PURPOSE OF REVIEW

To provide a general understanding of Clostridium difficile infection with a focus on recent publications that evaluate the disease in solid organ transplant recipients.

RECENT FINDINGS

The incidence of C. difficile infection is increasing worldwide. Epidemics due to a hypervirulent C. difficile strain are associated with an escalating severity of disease. New evidence further supports basing initial treatment choice on disease severity.

SUMMARY

C. difficile is a significant pathogen in solid organ transplant recipients. Multiple risk factors are found in this population that may result in more severe disease. A high index of suspicion is necessary for the early diagnosis and treatment of C. difficile infection in transplant recipients. Metronidazole and vancomycin show equivalent efficacy in the treatment for mild-to-moderate disease, but vancomycin has demonstrated superiority in the treatment of severe disease. Surgical intervention is also an important consideration in the treatment of solid organ transplant recipients with severe colitis. Rigorous infection control practices are essential for preventing the spread of C. difficile within the hospital environment.

Reduction of health care associated infection risk in neonates by successful hand hygiene promotion

OBJECTIVES

Hand hygiene promotion interventions rarely result in sustained improvement, and an assessment of their impact on individual infection risk has been lacking. We sought to measure the impact of hand hygiene promotion on health care worker compliance and health care-associated infection risk among neonates.

METHODS

We conducted an intervention study with a 9-month follow-up among all of the health care workers at the neonatal unit of the Children's Hospital, University of Geneva Hospitals, between March 2001 and February 2004. A multifaceted hand hygiene education program was introduced with compliance assessed during successive observational surveys. Health care-associated infections were prospectively monitored, and genotypic relatedness of bloodstream pathogens was assessed by pulsed-field gel electrophoresis. A comparison of observed hand hygiene compliance and infection rates before, during, and after the intervention was conducted.

RESULTS

A total of 5325 opportunities for hand hygiene were observed. Overall compliance improved gradually from 42% to 55% across study phases. This trend remained significant after adjustment for possible confounders and paralleled the measured increase in hand-rub consumption (from 66.6 to 89.2 L per 1000 patient-days). A 9-month follow-up survey showed sustained improvement in compliance (54%), notably with direct patient contact (49% at baseline vs 64% at follow-up). Improved compliance was independently associated with infection risk reduction among very low birth weight neonates. Bacteremia caused by clonally related pathogens markedly decreased after the intervention.

CONCLUSIONS

Hand hygiene promotion, guided by health care workers' perceptions, identification of the dynamics of bacterial contamination of health care workers' hands, and performance feedback, is effective in sustaining compliance improvement and is independently associated with infection risk reduction among high-risk neonates.

Clinical effectiveness of alcohol-based products in increasing hand hygiene compliance and reducing infection rates: a systematic review

Reducing the incidence of healthcare-associated infection represents a major challenge. This systematic review of the evidence base considers the clinical effectiveness of incorporating an alcohol-based hand hygiene product into procedures aimed at improving compliance with hand hygiene guidelines, and thereby reducing the incidence of healthcare-associated infections. Multi-component interventions that included alcohol-based products were as effective as those that did not, both in achieving sustained hand hygiene compliance and in reducing infection rates. However, a number of difficulties were encountered in assessing hand hygiene studies: the problem of attributing efficacy to an alcohol-based product when used in a multi-component intervention; the variability inherent in the design of such studies; and how to use data from uncontrolled, unblinded studies in the assessment.

The CleanYourHandsCampaign: critiquing policy and evidence base

Handwashing is considered to be the most effective way of reducing cross-infection. Rates of healthcare-associated infection and the incidence of meticillin-resistant Staphylococcus aureus are higher in the UK than in many other European countries. The government has responded by introducing the 'CleanYourHandsCampaign' throughout England and Wales, based on the success of the approach employed in Geneva. Alcohol hand rub is placed at every bedside in acute hospitals, ward housekeepers should replenish supplies and feedback on compliance is provided to health workers. Posters and other promotional materials are used to remind health workers and visitors to use the hand rub. Patients are encouraged to ask health workers if they have cleaned their hands before contact. In this paper we argue that the evidence base underpinning the CleanYourHandsCampaign is incomplete. Alcohol hand rub is acknowledged as a useful adjunct to hand hygiene but it is not effective in all circumstances. There is some evidence to support the use of feedback on performance to encourage compliance but no evidence that promotional materials such as posters or patient reminders are effective. The ethics of encouraging hospital patients to take responsibility for their own safety is questioned. Much of the success in Geneva must be attributed to the attention given to contextual factors within the organization that encouraged hand rub use, especially hospital-wide 'ownership' of the initiative by managers and senior health professionals. A customized intervention from another country that fails to consider local organizational factors likely to influence the implementation of the campaign is unlikely to be effective. It is concluded that although hand hygiene is of undoubted importance, undue emphasis should not be placed on it as a 'quick fix' to solve the unacceptably high rates of healthcare-associated infection in National Health Service hospitals.

Patients’ feelings about hand washing, MRSA status and patient information

The purpose of this study was to explore patient opinion about asking healthcare professionals to wash their hands before a clinical procedure and to explore if methicillin-resistant Staphylococcus aureus (MRSA) status and access to patient information about infection control would influence the patients' anxiety about asking. A descriptive survey was undertaken using a semi-structured questionnaire. The questionnaire was distributed to a randomized convenience sample of 185 inpatients across all departments of an acute NHS Trust hospital (response rate 58.9%). Spearman's rank order and Kendall Tau-b tests were used to analyse specific correlations. Respondents were more confident than anxious about being involved in a campaign that empowered patients to ask staff to wash their hands. Patients were more anxious to ask if their previous admission episodes were fewer, if their knowledge of MRSA was high and if there was less information about infection control available. Patients who had contracted MRSA in the past were less anxious, as they had a better understanding of the disease. In addition, more patients felt less anxious about asking staff to wash their hands if staff wore a badge saying 'It's OK to ask'.

Translating infection prevention evidence into practice using quantitative and qualitative research

Infection control professionals and hospital epidemiologists, using the valid methods of applied epidemiology-surveillance, benchmarking, intervention, evaluation--have largely been responsible for dramatically reducing the incidence of health care-associated infections over the past several decades. However, we believe that the field of infection control can--and should--also be a leader in understanding how research findings can be efficiently and effectively translated into clinical practice. Unfortunately, there is no current reliable information about which preventive practices are being used in US hospitals to prevent common device-related infections. If we are to understand how best to translate research into practice, the reasons hospitals are using some preventive practices-or are not-must be explored more fully. This article provides a framework for one proposed research endeavor to promote the successful translation of proven infection prevention practices and a subsequent decrease in health care-associated infections. In addition, we hope that this article will stimulate increased interest and research in identifying strategies that will successfully move evidence from the peer-reviewed literature to the patient's bedside.

Evidence-based model for hand transmission during patient care and the role of improved practices

Hand cleansing is the primary action to reduce health-care-associated infection and cross-transmission of antimicrobial-resistant pathogens. Patient-to-patient transmission of pathogens via health-care workers' hands requires five sequential steps: (1) organisms are present on the patient's skin or have been shed onto fomites in the patient's immediate environment; (2) organisms must be transferred to health-care workers' hands; (3) organisms must be capable of surviving on health-care workers' hands for at least several minutes; (4) handwashing or hand antisepsis by the health-care worker must be inadequate or omitted entirely, or the agent used for hand hygiene inappropriate; and (5) the caregiver's contaminated hand(s) must come into direct contact with another patient or with a fomite in direct contact with the patient. We review the evidence supporting each of these steps and propose a dynamic model for hand hygiene research and education strategies, together with corresponding indications for hand hygiene during patient care.