Successful implementation of the World Health Organization hand hygiene improvement strategy in a referral hospital in Mali, Africa

The Global Burden of Sepsis and Septic Shock

A dysregulated host response to infection causes organ dysfunction in sepsis and septic shock, two potentially fatal diseases. They continue to be major worldwide health burdens with high rates of morbidity and mortality despite advancements in medical care. The goal of this thorough review was to present a thorough summary of the current body of knowledge about the prevalence of sepsis and septic shock worldwide. Using widely used computerized databases, a comprehensive search of the literature was carried out, and relevant studies were chosen in accordance with predetermined inclusion and exclusion criteria. A narrative technique was used to synthesize the data that were retrieved. The review's conclusions show how widely different locations and nations differ in terms of sepsis and septic shock's incidence, prevalence, and fatality rates. Compared to high-income countries (HICs), low- and middle-income countries (LMICs) are disproportionately burdened more heavily. We talk about risk factors, comorbidities, and difficulties in clinical management and diagnosis in a range of healthcare settings. The review highlights the need for more research, enhanced awareness, and context-specific interventions in order to successfully address the global burden of sepsis and septic shock.

Healthcare workers' knowledge, attitude and practices on infection prevention and control in the context of the COVID-19 pandemic at the Faranah regional hospital and associated healthcare centers, Guinea

BACKGROUND

In response to the COVID-19 pandemic, WHO launched a strategic preparedness and response plan, outlining public health measures to support countries worldwide. Healthcare workers have an increased risk of becoming infected and their behaviour regarding infection prevention and control (IPC) influences infection dynamics. IPC strategies are important across the globe, but even more in low-resource settings where capacities for testing and treatment are limited. Our study aimed to assess and implement COVID-19 pandemic preparedness and response measures in Faranah, Guinea, primarily focusing on healthcare workers' IPC knowledge, attitude and practice (KAP).

METHODS

The study was conducted between April 2020 and April 2021 assessing IPC pandemic preparedness and response measures such as healthcare workers' KAP, alcohol-based handrub (ABHR) consumption and COVID-19 triaging in the Faranah Regional Hospital and two associated healthcare centres. The assessment was accompanied by IPC training and visual workplace reminders and done in pre- and post- phases to evaluate possible impact of these IPC activities.

RESULTS

The overall knowledge score in the Faranah Regional Hospital was 32.0 out of 44 at baseline, and did not change in the first, but increased significantly by 3.0 points in the second follow-up. The healthcare workers felt closer proximity to SARS-CoV-2 overtime in addition to higher stress levels in all study sites. There was significant improvement across the observed triaging practices. Hand hygiene compliance showed a significant increase across study sites leading to 80% in Faranah Regional Hospital and 63% in healthcare centers. The average consumption of ABHR per consultation was 3.29 mL with a peak in February 2020 of 23 mL.

CONCLUSION

Despite increased stress levels among HCWs, the ongoing IPC partnership well prepared the FRH in terms of triaging processes with a stronger impact on IPC practice than on theoretical knowledge. Throughout the pandemic, global shortages and surges in consumption did not affect the continuous ABHR provision of the FRH. This highlights local ABHR production as a key pandemic preparedness strategy.

Hand hygiene compliance and improvement interventions in the Eastern Mediterranean Region: a systematic review and meta-analysis

Hand hygiene compliance among healthcare workers is crucial for preventing infections in healthcare settings. This systematic review and meta-analysis aimed to assess the compliance of healthcare workers in the Eastern Mediterranean region with hand hygiene guidelines and synthesize evidence on the success rate of strategies to improve hand hygiene. Five electronic databases (PubMed, CINAHL, Cochrane, Web of Science, and Scopus) were searched up to August 2020. Articles were included if they were conducted in the Eastern Mediterranean Region. A manual search was conducted for reference lists of included papers, and relevant additional references were reviewed. Two reviewers independently screened articles for inclusion, performed data extraction, and assessed quality. A meta-analysis was conducted to synthesize findings and determine the prevalence of hand hygiene compliance interventions. The search yielded 6678 articles. After removing duplicates and applying inclusion/exclusion criteria, 42 articles were included, of which 24 were meta-analyzed. The meta-analysis showed a compliance prevalence of 32% with significant heterogeneity (I2= 99.7% p <0.001). Interventions using the World Health Organization (WHO) guidelines were over two times more likely to improve compliance rates (OR= 2.26, [95% CI:(2.09 - 2.44)], I2= 95%, p<0.001) compared to no intervention. Other interventions were close to two times more likely to improve compliance rates (OR= 1.84, [95% CI:(1.66 - 2.04)], I2= 98% p= 0.001). Approximately two-thirds of healthcare providers in the Eastern Mediterranean region were non-compliant with standard hand hygiene practices, highlighting the need for increased efforts, awareness, observation, and control policies.

Implementing a multimodal intervention using local resources to improve hand hygiene compliance in a comprehensive specialized hospital in Mekelle, Northern Ethiopia

BACKGROUND

Hand hygiene (HH) is known to be the most effective practice to reduce Healthcare-associated infections (HAIs). The main barriers to HH practices among healthcare workers (HCWs) in Sub-Saharan Africa are heavy workload, infrastructural deficits, and poorly positioned facilities. There is limited data on HH compliance and particularly on the impact of the World Health Organization's (WHO) multimodal HH strategy in low- and middle-income countries. This study aimed to provide insights into a strategy to implement the WHO concept adapted to local conditions and obstacles encountered at a tertiary university hospital in Mekelle, Tigray, Ethiopia.

METHODS

We conducted a study aiming at increasing the quality of the HH practice of HCWs using the WHO HH improvement strategy. The study adopted a pre-and post-interventional design from April 2018 to May 2019. In the pre-intervention phase, a baseline infrastructural survey was made. The intervention consisted of in-house production of hand sanitizer and dispensers for every patient bed, staff education and motivation, and implementation of a multidisciplinary infection prevention committee. The intervention was followed by two one-week compliance observations of HH practice among HCWs within the six months post-intervention period and microbiological sample collection from HCWs' hands to assess the quality of HH.

RESULTS

We observed 269 (baseline), 737 (first follow-up) and 574 (second follow-up) indications for HH among HCWs. The overall baseline hand rub compliance was 4.8%, which significantly increased to 37.3% (first follow-up) and 56.1% (second follow-up) (p < 0.0001). Consistent and significant increases in hand rub compliance during the entire follow-up period were observed before touching a patient, after touching a patient, and after touching the patient's surroundings (all p < 0.01). Nurses and medical interns achieved consistent and significant increases in hand rub compliance during the entire follow-up period (all p < 0.01).

CONCLUSION

Implementing the WHO HH improvement strategy significantly increased HH compliance despite a shortage of water and other resources. Hand rub was accepted as the main HH method in the hospital. HH campaigns in developing settings profit from multimodal strategies, knowledge exchange and utilization of local resources.

Unpacking nudge sensu lato: insights from a scoping review

Nudges may play an important role in improving infection prevention and control (IPC) in hospitals. However, despite the novelty of the framework, their objectives, strategies and implementation approaches are not new. This review aims to provide an overview of the methods typically used by nudge interventions in IPC in hospitals targeting healthcare workers (HCWs). The initial search in PubMed yielded nine hits. Consequently, the search criteria were broadened and a second search was conducted, introducing 'nudge sensu lato' which incorporates insights from sources beyond the traditional nudge framework while maintaining the same objectives, strategies and approaches. During the second search, PubMed, Epistemonikos, Web of Science and PsycInfo were searched in accordance with the PRISMA guidelines. Abstracts were screened, and reviewers from an interdisciplinary team read the full text of selected papers. In total, 5706 unique primary studies were identified. Of these, 67 were included in the review, and only four were listed as nudge sensu stricto, focusing on changing HCWs' hand hygiene. All articles reported positive intervention outcomes. Of the 56 articles focused on improving hand hygiene compliance, 71.4% had positive outcomes. For healthcare equipment disinfection, 50% of studies showed significant results. Guideline adherence interventions had a 66.7% significant outcome rate. The concept of nudge sensu lato was introduced, encompassing interventions that employ strategies, methods and implementation approaches found in the nudge framework. The findings demonstrate that this concept can enhance the scientific development of more impactful nudges. This may help clinicians, researchers and policy makers to develop and implement effective nudging interventions.

The barriers and facilitators to hand hygiene practices in Nigeria: A qualitative study: "There are so many barriers ... the barriers are limitless."

BACKGROUND

Health care associated infections (HCAIs) are a global challenge and hand hygiene is the primary measure to reduce these. In developing countries, patients are between 2 and 20 times more likely to acquire an HCAI compared with developed countries. Estimates of hand hygiene in Sub-Saharan Africa suggests 21% concordance. There are few studies investigating barriers and facilitators and those published tend to be surveys. This study aimed to understand barriers and facilitators to hand hygiene in a hospital in Nigeria.

METHODS

A theoretically underpinned in-depth qualitative interview study with thematic analysis of nurses and doctors working in surgical wards.

RESULTS

There were individual and institutional factors constituting barriers or facilitators: (1) knowledge, skills, and education, (2) perceived risks of infection to self and others, (3) memory, (4) the influence of others and (5) skin irritation. Institutional factors were (1) environment and resources and (2) workload and staffing levels.

CONCLUSIONS

Our study presents barriers and facilitators not previously reported and offers nuances and detail to those already reported in the literature. Although the primary recommendation is adequate resources, however small local changes such as gentle soap, simple skills and reminder posters and mentorship or support could address many of the barriers listed.

Qualitative assessment of hand hygiene knowledge, attitudes and practices among healthcare workers prior to the implementation of the WHO Hand Hygiene Improvement Strategy at Faranah Regional Hospital, Guinea

Healthcare-associated infections are a serious burden globally. Few qualitative studies have explored healthcare workers' knowledge, attitudes and practices of hand hygiene. Prior to the implementation of the World Health Organization's Hand Hygiene Improvement Strategy at Faranah Regional Hospital in the Upper Region of Guinea in December 2018, we conducted a qualitative baseline assessment of knowledge, attitudes and practices of hand hygiene among healthcare workers to guide future hand hygiene interventions. The qualitative study consisted of direct observations, In-Depth Interviews (IDIs) and Focus Group Discussions (FGDs). We found that the 2013-16 Ebola outbreak had had a pivotal impact on healthcare workers' knowledge, attitudes and practices. The severity of the disease and the training provided for infection control were responsible for their knowledge acquisition and adoption of good attitudes and practices. However, negligence, resulting in poor hand hygiene practices, rose after the outbreak, once the "cue of fear" that had motivated workers for their own self-protection had waned. Our results suggest that local capacity building through training and availability of hand hygiene materials would be a sustainable approach to enhance hand hygiene culture at the hospital. Our study suggests that there is a need for a high and long-term commitment of authorities and healthcare workers at all levels for a sustainable hand hygiene culture.

SafeHANDS: A Multimodal Hand Hygiene Intervention in a Resource-Limited Neonatal Unit

BACKGROUND

Hand hygiene (HH) is a cornerstone of programmes to prevent healthcare associated infections (HAI) globally, but HH interventions are seldom reported from African neonatal units.

METHODS

We conducted a quasi-experimental study evaluating the impact of a multi-modal intervention (SafeHANDS) on HH compliance rates, alcohol-based handrub (ABHR) usage, the Hand Hygiene Self-Assessment Framework (HHSAF) score, and healthcare-associated bloodstream infection (HA-BSI) rates at a 132-bed South African neonatal unit (4 wards and 1 neonatal intensive care unit [NICU]). The intervention included a campaign logo, HH training, maternal education leaflets, ABHR bottles for staff, and the setting of HH performance targets with feedback. Three 5-month study phases were completed in July 2020 (baseline), December 2020 (early) and May 2021 (intensive).

RESULTS

A total of 2430 HH opportunities were observed: 1002 (41.3%) at baseline, 630 (25.9%) at early and 798 (32.8%) at intensive study phases. At baseline, the overall neonatal unit HH compliance rate was 61.6%, ABHR use was 70 mL/patient day, and the baseline HHSAF score was 'basic' (165). The overall neonatal unit HH compliance rate was unchanged from baseline to intensive phases (617/1002 [61.6%] vs. 497/798 [62.3%]; p = 0.797). The ABHR use remained similar between phases (70 versus 73 mL/patient day). The HHSAF score improved to 'intermediate' level (262). There was no change in the neonatal unit HA-BSI rate.

CONCLUSION

Despite improvement in the HHSAF score, no improvement in overall HH compliance rates, ABHR usage, or HA-BSI rates was observed. Future HH interventions in resource-limited neonatal units should incorporate implementation science and behaviour modification strategies to better understand the barriers and facilitators of HH best practice.

Effectiveness and sustainability of the WHO multimodal hand hygiene improvement strategy in the University Hospital Bouaké, Republic of Côte d'Ivoire in the context of the COVID-19 pandemic

Introduction

The most frequent adverse events in healthcare are healthcare-associated infections, whose burden is highest in resource-limited settings. In addition, low resource settings often lack Hand Hygiene (HH) knowledge and reliable supply to disinfectant, a necessity emphasized by the past West African Ebola Epidemic and the ongoing COVID-19 pandemic. PASQUALE aims to increase patient safety by introducing the WHO multimodal HH strategy in the University Hospital Bouaké, Côte d’Ivoire.

Methods

Assessment of HH knowledge, perception and compliance was performed 12 months before, right after the intervention and at a ten months interval using questionnaires for knowledge and perception and direct observation for compliance. The intervention consisted of a HH training and the introduction of local production of alcohol-based hand-rub. In the absence of a control group, the effectiveness of the intervention was assessed by a before-and-after study.

Results

Baseline knowledge score was 14/25, increased significantly to 17/25 (p < 0.001) upon first and decreased to 13/25 in second follow-up. Compliance showed a significant increase from 12.7% to 36.8% (p < 0.001) in first and remained at 36.4% in second follow-up. Alcohol-based hand-rub production and consumption almost doubled after first confirmed COVID-19 case in Côte d’Ivoire.

Conclusion

The WHO HH improvement strategy is an effective and pandemic-adaptable method to increase long-term HH compliance. This study emphasizes that the implementation of the strategy to build a robust system is of utmost importance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-01032-4.

Infection prevention and control in tertiary care hospitals of Bangladesh: results from WHO infection prevention and control assessment framework (IPCAF)

INTRODUCTION

Infection prevention and control (IPC) in healthcare settings is imperative for the safety of patients as well as healthcare providers. To measure current IPC activities, resources, and gaps at the facility level, WHO has developed the Infection Prevention and Control Assessment Framework (IPCAF). This study aimed to assess the existing IPC level of selected tertiary care hospitals in Bangladesh during the COVID-19 pandemic using IPCAF to explore their strengths and deficits.

METHODS

Between September and December 2020, we assessed 11 tertiary-care hospitals across Bangladesh. We collected the information from IPC focal person and/or hospital administrator from each hospital using the IPCAF assessment tool.. The score was calculated based on eight core components and was used to categorize the hospitals into four distinct IPC levels- Inadequate, Basic, Intermediate, and Advanced. Key performance metrics were summarized within and between hospitals.

RESULTS

The overall median IPCAF score was 355.0 (IQR: 252.5-397.5) out of 800. The majority (73%) of hospitals scored as 'Basic' IPC level, while only 18% of hospitals were categorized as 'Intermediate'. Most hospitals had IPC guidelines as well as environments, materials and equipments. Although 64% of hospitals had IPC orientation and training program for new employees, only 30% of hospitals had regular IPC training program for the staff. None of the hospitals had an IPC surveillance system with standard surveillance case definitions to track HAIs. Around 90% of hospitals did not have an active IPC monitoring and audit system. Half of the hospitals had inadequate staffing considering the workload. Bed occupancy of one patient per bed in all units was found in 55% of hospitals. About 73% of hospitals had functional hand hygiene stations, but sufficient toilets were available in only 37% of hospitals.

CONCLUSION

The majority of sampled tertiary care hospitals demonstrate inadequate IPC level to ensure the safety of healthcare workers, patients, and visitors. Quality improvement programs and feedback mechanisms should be implemented to strengthen all IPC core components, particularly IPC surveillance, monitoring, education, and training, to improve healthcare safety and resilience.

Level of Hand Hygiene Compliance and Its Associated Factors Among Health Care Workers at Eka Kotebe General Hospital, Addis Ababa, Ethiopia

BACKGROUND

Poor hand hygiene is an important source of infection, but maintaining hand hygiene is the most important measure to prevent infections. Hand hygiene compliance and its associated factors are not well recognized in Ethiopia. Therefore, this study was intended to determine hand hygiene compliance and its associated factors among health care workers in Eka Kotebe General Hospital.

METHODS

A cross-sectional study was conducted among health care workers at Eka Kotebe General Hospital. A self-administered questionnaire supplemented by a World Health Organization Hand Hygiene Technical Reference Manual was used to collect data. Data was entered using Epi Info 7.2.0.1 and exported to SPSS 23 for analysis. The data were analyzed using descriptive and inferential statistics. Statistical significance was determined using a P-value of ⩽.05 with a 95% confidence interval.

RESULTS

Hand hygiene compliance among healthcare workers was 22.2%. Hand hygiene training (AOR = 2.9, 95% CI: 1.13-7.52), presence of hand hygiene indication poster (AOR = 3.38, 95% CI: 1.18-9.66), hand hygiene promotion by IPC team (AOR = 4.2, 95% CI: 2.53-8.58)), working experience ⩾5 years of a health care providers (AOR = 3.96, 95% CI: 1.12-13.9), being midwife (AOR = 17.1, 95% CI: 2.8-10), being nurse (AOR = 5.3, 95% CI: 2.09-7.8) by profession, and presence of water (AOR = 2.50, 95% CI: 2.20-11.78) were significantly associated factors to hand hygiene compliance.

CONCLUSION

The level of hand hygiene compliance among health care providers was found to be low. Training about hand hygiene, the presence of hand hygiene indication posters, hand hygiene promotion by the IPC team, working experience of health care providers, being a nurse and midwife, and the presence of water were independent predictors of hand hygiene compliance. Health care workers need to be given training on hand hygiene as well as hand hygiene facilities shall be installed and supplied by the hospital in a sustained manner.

Is the World Health Organization Multimodal Hand Hygiene Improvement Strategy applicable and effective at the primary care level in resource-limited settings? A quantitative assessment in healthcare centers of Faranah, Guinea

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The World Health Organization Multimodal Hand Hygiene Improvement Strategy is appropriate to improve compliance and knowledge.

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This tool is valid at the primary care level in low-resource settings when adapted.

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Primary care settings need to emphasize the amount of alcohol-based hand rub required and the hand hygiene technique.

Background

The World Health Organization Multimodal Hand Hygiene Improvement Strategy aims at reducing healthcare-associated infections; however, evidence of applicability and effectiveness at the primary care level is scarce, especially in healthcare centers in resource-limited settings. The objectives of this study were to improve hand hygiene knowledge and compliance at two healthcare centers in the region of Faranah, Guinea, to increase the availability of alcohol-based hand rub (ABHR), and to assess the effectiveness of the strategy at the primary care level.

Methods

Knowledge, perceptions, and compliance were assessed prior to the intervention and compared to those of two follow-up assessments, immediately and 6 months after the intervention. The intervention consisted of training and the supply of ABHR. The monthly consumption of ABHR was monitored.

Results

Baseline knowledge increased from a score of 11/25 at baseline to 16/25 at first follow-up; it then decreased to 15/25 at the second follow-up. Compliance showed an increase from 15.6% to 84.4% (P < 0.001) at the first follow-up. At the second follow-up, compliance was lower than at the first follow-up (53.2%, P < 0.001), but still more than two times higher than at baseline (P < 0.001). ABHR consumption averaged 0.77 ml per consultation.

Conclusions

The World Health Organization hand hygiene strategy is an appropriate method to improve compliance and knowledge at the primary care level, but needs some adjustment: the inclusion of observation of the correctness of hand hygiene action, as well as training emphasizing the amount of ABHR to use.

Compliance to hand hygiene and its determinant factors among Community Health Care Providers in Community Clinics: an observational study in Bangladesh

Background

Healthcare-associated infections caused by poor hand hygiene (HH) practices can affect both the care seekers and the health care providers (HCPs) while providing primary health care. No study has been conducted on the compliance of HH practices among the primary level HCPs in Bangladesh.

Objective

The study aimed to assess the compliance rates of HH and its determinant factors among Community Health Care Providers (CHCPs) in Community Clinics (CC).

Methods

A cross-sectional study was conducted from September 2019 to February 2020 among 150 randomly selected CHCPs with functional HH facilities in Patuakhali district, Bangladesh. Structured interviews and observation tools were used to collect data.

Results

Good HH compliance among CHCPs was found to be 16.7% (95% CI: 11.3-21.3). Out of all 1218 possible HH opportunities, only 255 (20.9%) resulted in any HH action. Presence of 70% alcohol-based hand sanitiser at the point of care (aOR: 6.4, 95% CI: 1.1-38.3), HH training (aOR: 4.6, 95% CI: 1.1-18.9), displayed visual cues (aOR: 4.4, 95% CI: 1.1-17.7), knowledge about HH (aOR: 3.8, 95% CI: 1.1-13.6) and number of HH opportunities (aOR: 0.6, 95% CI: 0.4-0.8) were factors associated with HH compliance.

Discussion

Overall HH compliance among CHCPs was relatively low. It was recommended to implement multimodal HH improvement strategies, including a continuous training program, supply of alcohol-based hand rub, reminder, provision of five moments of HH in the training modules and feedback on HH performance.

Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: a qualitative study

Background

Healthcare associated infections (HAIs) are the most frequent adverse outcome in healthcare delivery worldwide. In conflict-affected settings HAIs, in particular surgical site infections, are prevalent. Effective infection prevention and control (IPC) is crucial to ending avoidable HAIs and an integral part of safe, effective, high quality health service delivery. However, armed conflict and widespread violence can negatively affect the quality of health care through workforce shortages, supply chain disruptions and attacks on health facilities and staff. To improve IPC in these settings it is necessary to understand the specific barriers and facilitators experienced locally.

Methods

In January and February of 2020, we conducted semi-structured interviews with hospital staff working for the International Committee of the Red Cross across eight conflict-affected countries (Central African Republic, South Sudan, Democratic Republic of the Congo, Mali, Nigeria, Lebanon, Yemen and Afghanistan). We explored barriers and facilitators to IPC, as well as the direct impact of conflict on the hospital and its’ IPC programme. Data was analysed thematically.

Results

We found that inadequate hospital infrastructure, resource and workforce shortages, education of staff, inadequate in-service IPC training and supervision and large visitor numbers are barriers to IPC in hospitals in this study, similar to barriers seen in other resource-limited settings. High patient numbers, supply chain disruptions, high infection rates and attacks on healthcare infrastructures, all as a direct result of conflict, exacerbated existing challenges and imposed an additional burden on hospitals and their IPC programmes. We also found examples of local strategies for improving IPC in the face of limited resources, including departmental IPC champions and illustrated guidelines for in-service training.

Conclusions

Hospitals included in this study demonstrated how they overcame certain challenges in the face of limited resources and funding. These strategies present opportunities for learning and knowledge exchange across contexts, particularly in the face of the current global coronavirus pandemic. The findings are increasingly relevant today as they provide evidence of the fragility of IPC programmes in these settings. More research is required on tailoring IPC programmes so that they can be feasible and sustainable in unstable settings.

Mixed methods study evaluating the implementation of the WHO hand hygiene strategy focusing on alcohol based handrub and training among health care workers in Faranah, Guinea

Introduction

The most frequent adverse health events in healthcare worldwide are healthcare-associated infection. Despite ongoing implementation of the WHO multimodal Hand Hygiene (HH) Improvement Strategy, healthcare-associated infection rate continues to be twofold higher in low- than in high-income countries. This study focused on continued evaluation of HH compliance and knowledge. The mixed method approach, with inclusion of patients and care-givers, provided insight into challenges and facilitators of the WHO HH Improvement Strategy, and highlighted improvement points.

Methods

An uncontrolled, before-and–after intervention, mixed methods study in Faranah Regional Hospital was conducted from December 2017 to August 2019. The intervention implemented the WHO HH Strategy including HH training for healthcare workers (HCWs), and the relaunch of the local production of alcohol-based handrub (ABHR). A baseline assessment of HH knowledge, perception and compliance of HCWs was done prior to the intervention and compared to two follow-up assessments. The second follow-up assessment was complemented by a qualitative component.

Results

Overall compliance six months post-intervention was 45.1% and significantly higher than baseline but significantly lower than in first follow-up. Knowledge showed similar patterns of improvement and waning. The perception survey demonstrated high appreciation of the intervention, such as local production of ABHR. HCW’s were concerned about overconsuming of ABHR, however simultaneous quantitative measurements showed that consumption in fact was 36% of the estimated amount needed for sufficient HH compliance. Potential fields for improvement identified by HCWs to enhance sustainability were permanent ABHR availability, having a dedicated person with ownership over continuous simulation HH trainings including simulations to improve technique.

Conclusion

The study shows that the WHO multimodal HH strategy has a positive effect on HCW compliance and knowledge. Improvement points identified by local staff like sensitization on appropriate ABHR amount per HH action should be considered for sustainable HH improvement.

Barriers and Opportunities for Sustainable Hand Hygiene Interventions in Rural Liberian Hospitals

Hand hygiene is central to hospital infection control. During the 2014–2016 West Africa Ebola virus disease epidemic in Liberia, gaps in hand hygiene infrastructure and health worker training contributed to hospital-based Ebola transmission. Hand hygiene interventions were undertaken post-Ebola, but many improvements were not sustainable. This study characterizes barriers to, and facilitators of, hand hygiene in rural Liberian hospitals and evaluates readiness for sustainable, locally derived interventions to improve hand hygiene. Research enumerators collected data at all hospitals in Bong and Lofa counties, Liberia, in the period March–May 2020. Enumerators performed standardized spot checks of hand hygiene infrastructure and supplies, structured observations of hand hygiene behavior, and semi-structured key informant interviews for thematic analysis. During spot checks, hospital staff reported that handwashing container water was always available in 89% (n = 42) of hospital wards, piped running water in 23% (n = 11), and soap in 62% (n = 29). Enumerators observed 5% of wall-mounted hand sanitizer dispensers (n = 8) and 95% of pocket-size dispensers (n = 53) to be working. In interviews, hospital staff described willingness to purchase personal hand sanitizer dispensers when hospital-provided supplies were unavailable. Low-cost, sustainable interventions should address supply and infrastructure-related obstacles to hospital hand hygiene improvement.

Infection prevention and control (IPC) implementation in low-resource settings: a qualitative analysis

BACKGROUND

The coronavirus disease-2019 (COVID-19) pandemic has again demonstrated the critical role of effective infection prevention and control (IPC) implementation to combat infectious disease threats. Standards such as the World Health Organization (WHO) IPC minimum requirements offer a basis, but robust evidence on effective IPC implementation strategies in low-resource settings remains limited. We aimed to qualitatively assess IPC implementation themes in these settings.

METHODS

Semi-structured interviews were conducted with IPC experts from low-resource settings, guided by a standardised questionnaire. Applying a qualitative inductive thematic analysis, IPC implementation examples from interview transcripts were coded, collated into sub-themes, grouped again into broad themes, and finally reviewed to ensure validity. Sub-themes appearing ≥ 3 times in data were highlighted as frequent IPC implementation themes and all findings were summarised descriptively.

RESULTS

Interviews were conducted with IPC experts from 29 countries in six WHO regions. Frequent IPC implementation themes including the related critical actions to achieve the WHO IPC core components included: (1) To develop IPC programmes: continuous advocacy with leadership, initial external technical assistance, stepwise approach to build resources, use of catalysts, linkages with other programmes, role of national IPC associations and normative legal actions; (2) To develop guidelines: early planning for their operationalization, initial external technical assistance and local guideline adaption; (3) To establish training: attention to methods, fostering local leadership, and sustainable health system linkages such as developing an IPC career path; (4) To establish health care-associated (HAI) surveillance: feasible but high-impact pilots, multidisciplinary collaboration, mentorship, careful consideration of definitions and data quality, and "data for action"; (5) To implement multimodal strategies: clear communication to explain multimodal strategies, attention to certain elements, and feasible but high-impact pilots; (6) To develop monitoring, audit and feedback: feasible but high-impact pilots, attention to methods such as positive (not punitive) incentives and "data for action"; (7) To improve staffing and bed occupancy: participation of national actors to set standards and attention to methods such as use of data; and (8) To promote built environment: involvement of IPC professionals in facility construction, attention to multimodal strategy elements, and long-term advocacy.

CONCLUSIONS

These IPC implementation themes offer important qualitative evidence for IPC professionals to consider.

Evaluation of compliance to the World Health Organization's five moments of hand hygiene: Cross-sectional observation of healthcare professionals

Background

Human hands are home to thousands of microorganisms, which may be transmitted to surfaces that the hands come into contact with. When in contact with people who are ailing or have weakened immune systems, some of these microorganisms can cause infections and disease. Correct hand hygiene goes a long way in eradicating these potentially infective microorganisms and forms the cornerstone of infection prevention and control (IPC) within healthcare facilities and beyond. The healthcare industry is constantly challenged by healthcare-associated infections (HAIs) and their negative effects on patient safety and clinical outcomes. Hospitals in Pretoria are facing similar challenges posed by HAIs and there is no report available on compliance of healthcare professionals (HCPs) to the World Health Organization's (WHO) 'five moments of hand hygiene'. Healthcare professional's compliance to all of the five moments of hand hygiene, particularly within the patient zone, is crucial in mitigating and reducing the spread of contact-based infections in the healthcare setting.

Methods

A quantitative longitudinal design was used in a covert direct observation of HCP compliance to the WHO's five moments of hand hygiene. The observations were conducted over 4 weeks in three hospitals, covering 25 wards, inclusive of four adult critical care units using the WHO's 'five moments of hand hygiene' observation form.

Results

A total of 1906 hand hygiene opportunities were directly observed in three hospitals. Hand hygiene compliance was 17.26% (n = 329). Allied health professionals had higher compliance (23.02%) than medical (19.26%) and nursing professionals (15.76%). The moment before patient contact had the lowest compliance (8.21%) as compared with all other moments.

Conclusions

In general, HCPs had low compliance to the five moments of hand hygiene within the patient zone. Allied health professionals had higher compliance than medical and nursing professionals. Compliance in public hospitals was lower than in private hospitals. Critical care units had higher compliance compared to general wards. Healthcare professionals better complied to the moments meant for their safety as compared to those indicated for patient safety.

The Effectiveness of Interventions in Improving Hand Hygiene Compliance: A Meta-Analysis and Logic Model

Background

Despite the availability of various guidelines, rules, and strategies, hand hygiene adherence rates among healthcare workers are reported significantly lower than expected. The aim of this meta-analysis is to determine the most effective interventions to improve hand hygiene and to develop a logic model based on the characteristics of the most effective interventions.

Methods

A literature search was conducted on PubMed, ProQuest, Web of Knowledge, Scopus, Cochrane Library, and ScienceDirect databases up to December 21, 2019, with no time limit. Randomized clinical trials which had designed interventions to improve hand hygiene were reviewed. Data were extracted independently by two authors. All statistical analyses were performed using Comprehensive Meta-Analysis (CMA) software (version 2.0). A random-effects model was used to estimate odds ratios.

Results

Although 14 studies were initially reviewed, only 12 studies entered the meta-analysis, since they had identified percentage rates of hand hygiene compliance. The most effective intervention (odds ratio 18.4, 95% CI (13.6–24.8)) was a multilevel strategy that influenced the determinants of hand hygiene behavior at individual, interpersonal, and organizational levels. Following this, a theory-driven logic model was mapped out to promote hand hygiene, based on situational analysis.

Conclusion

This study suggests that designing integrated interventions based on a multilevel socioecological approach has the greatest potential to improve hand hygiene compliance in healthcare workers. The logical model proposed in this study can thus provide a useful guide for designing and conducting future experimental research.

Hand Hygiene during the Early Neonatal Period: A Mixed-Methods Observational Study in Healthcare Facilities and Households in Rural Cambodia

BACKGROUND

Globally, infections are the third leading cause of neonatal mortality. Predominant risk factors for facility-born newborns are poor hygiene practices that span both facilities and home environments. Current improvement interventions focus on only one environment and target limited caregivers, primarily birth attendants and mothers. To inform the design of a hand hygiene behavioural change intervention in rural Cambodia, a formative mixed-methods observational study was conducted to investigate the context-specific behaviours and determinants of handwashing among healthcare workers, and maternal and non-maternal caregivers along the early newborn care continuum.

METHODS

Direct observations of hygiene practices of all individuals providing care to 46 newborns across eight facilities and the associated communities were completed and hand hygiene compliance was assessed. Semi-structured interactive interviews were subsequently conducted with 35 midwives and household members to explore the corresponding cognitive, emotional and environmental factors influencing the observed key hand hygiene behaviours.

RESULTS

Hand hygiene opportunities during newborn care were frequent in both settings (n = 1319) and predominantly performed by mothers, fathers and non-parental caregivers. Compliance with hand hygiene protocol across all caregivers, including midwives, was inadequate (0%). Practices were influenced by the lack of accessible physical infrastructure, time, increased workload, low infection risk perception, nurture-related motives, norms and inadequate knowledge.

CONCLUSIONS

Our findings indicate that an effective intervention in this context should be multi-modal to address the different key behaviour determinants and target a wide range of caregivers.

Effect of Wearing a Novel Electronic Wearable Device on Hand Hygiene Compliance Among Health Care Workers: A Stepped-Wedge Cluster Randomized Clinical Trial

Importance

Hand hygiene (HH) is essential to prevent hospital-acquired infections.

Objective

To determine whether providing real-time feedback on a simplified HH action improves compliance with the World Health Organization's "5 Moments" and the quality of the HH action.

Design, Setting, and Participants

This open-label, cluster randomized, stepped-wedge clinical trial was conducted between June 1, 2017, and January 6, 2018 (with a follow-up in March 2018), in a geriatric hospital of the University of Geneva Hospitals, Switzerland. All 12 wards and 97 of 306 eligible health care workers (HCWs) volunteered to wear a novel electronic wearable device that delivered real-time feedback on duration of hand rubbing and application of a hand-sized customized volume of alcohol-based handrub (ABHR).

Interventions

This study had 3 sequential periods: baseline (no device), transition (device monitoring without feedback), and intervention (device monitoring and feedback). The start of the transition period was randomly allocated based on a computer-generated block randomization.

Main Outcomes and Measures

The primary outcome was HH compliance, according to the direct observation method during intervention as compared with baseline. Secondary outcomes included the volume of ABHR and duration of hand rubbing measured by the device during intervention as compared with transition.

Results

All wards and respective HCWs were evenly assigned to group 1 (26 participants), 2 (22 participants), 3 (25 participants), or 4 (24 participants). Twelve HCWs did not fully complete the intervention but were included in the analysis. During 759 observation sessions, 6878 HH opportunities were observed. HH compliance at intervention (62.9%; 95% CI, 61.1%-64.7%) was lower than at baseline (66.6%; 95% CI, 64.8%-68.4%). After adjusting for covariates, HH compliance was not different between periods (odds ratio, 1.03; 95% CI, 0.75-1.42; P = .85). Days since study onset (OR, 0.997; 95% CI, 0.994-0.998; P < .001), older age (OR, 0.97; 95% CI, 0.95-0.99; P = .015), and workload (OR, 0.29; 95% CI, 0.20-0.41; P < .001) were independently associated with reduced HH compliance. The median (interquartile range) volume of ABHR and duration of hand rubbing in transition and intervention increased from 1.12 (0.76-1.68) mL to 1.71 (1.01-2.76) mL and from 6.5 (4.5-10.5) seconds to 8 (4.5-15.5) seconds, respectively. There were no serious adverse events.

Conclusions and Relevance

The use of this device did not change HH compliance, but increased the duration of hand rubbing and volume of ABHR used by HCWs.

Trial Registration

isrctn.org Identifier: ISRCTN25430066.

Addressing the global challenge of access to supplies during COVID-19

The current COVID-19 pandemic has presented unprecedented challenges for health care facilities worldwide. Global production and shipping routes were disrupted, and health care institutions, even in high resource areas, found themselves lacking the basic supplies for effective infection prevention and control. One major hurdle was the global access to supplies, particularly N95/FFP2 masks and alcohol-based hand rub (ABHR) for performing hand hygiene.

This chapter explores how the lack of masks and ABHR were addressed through local production and the disinfection and reuse of disposable N95 masks. Although the global situation is no longer dire, the pandemic is currently still underway, and access to sufficient and high-quality supplies still is an important challenge faced by health care institutions.

Previously, local production was mainly promoted by the World Health Organization (WHO) as a social business venture for helping developing countries. Disposable mask reuse was barely studied until this pandemic, because there was never really a need to. Thus the literature in these fields are mostly quite new. This chapter reviews the introduction and state of the art of the field, the evidence for hand hygiene and masking in the literature, the global situation since the pandemic and strategies that countries have taken to adapt. It then concentrates further on the specifics of local production, both for ABHR and for masks, and on the issues surrounding mask reuse. The chapter concludes with putting these technologies in the larger context of the pandemic, and how learning how the world tried to implement solutions can teach us lessons for future emergencies.

Hand hygiene compliance among healthcare workers in Ghana’s health care institutions: An observational study

Objective

To assess hand hygiene compliance in selected primary hospitals in Ghana.

Design

A cross-sectional health facility-based observational study was conducted in primary health care facilities in five regions in Ghana. A total of 546 healthcare workers including doctors, nurses, midwives and laboratory personnel from 106 health facilities participated in the study.

Main outcome measures

The main outcome measures included availability of hand hygiene materials and alcohol job aids; compliance with moments of hand hygiene; and compliance with steps in hygienic hand washing. These were assessed using descriptive statistics.

Results

The mean availability of hand hygiene material and alcohol job aids was 75% and 71% respectively. This was described as moderately high, but less desirable. The mean hand hygiene compliance with moments of hand hygiene was 51%, which was also described asmoderately high, but less desirable. It was observed that, generally, hand hygiene was performed after procedures than before. However, the mean compliance with steps in hygienic hand washing was 86%, which was described as high and desirable.

Conclusion

Healthcare workers are generally competent in performance of hygienic hand washing. However, this does not seem to influence compliance with moments of hand hygiene. Efforts must therefore be made to translate the competence of healthcare workers in hygienic hand washing into willingness to comply with moments of hand hygiene, especially contact with patients.

Healthcare Workers' Knowledge and Attitudes Regarding the World Health Organization's "My 5 Moments for Hand Hygiene": Evidence From a Vietnamese Central General Hospital

Objectives:

Although the World Health Organization (WHO) initiative “My 5 Moments for Hand Hygiene” has been lauded as effective in preventing hospital-associated infections, little is known about healthcare workers (HCWs)’ hand hygiene behavior. In this study, we sought to assess knowledge and attitudes towards the concepts in this initiative, as well as associated factors, among Vietnamese HCWs at a general hospital.

Methods:

A structured questionnaire was administered to HCWs at a central Vietnamese general hospital in 2015. Multiple logistic regression analysis was used to identify factors associated with HCWs’ knowledge and attitudes towards hand hygiene.

Results:

Of 120 respondents, 65.8% and 67.5% demonstrated appropriate knowledge and a positive attitude, respectively, regarding all 5 hand hygiene moments. Logistic regression indicated better knowledge of hand hygiene in workers who were over 30 years old, who were direct HCWs (rather than managers), who had frequent access to clinical information, and who received their clinical information from training. Those who worked in infectious and tropical disease wards, who had frequent access to clinical information, and who received information from training were more likely to have a positive attitude towards hand hygiene than their counterparts.

Conclusions:

Although many Vietnamese HCWs displayed moderate knowledge and positive attitudes towards the WHO hand hygiene guidelines, a key gap remained. Regular education and training programs are needed to increase knowledge and to improve attitudes and practices towards hand hygiene. Furthermore, a combination of multimodal strategies and locally-adapted interventions is needed for sustainable hand hygiene adherence.

Status of Infection Prevention and Control in Tanzanian Primary Health Care Facilities: Learning From Star Rating Assessment

Background

The WHO estimates 10–30% of hospital admissions are associated with poor infection prevention and control (IPC). There are no reliable data on IPC status in Tanzanian healthcare facilities; hence the Star Rating Assessment (SRA) was established to address this. This study compared the health facility performances on adherence to IPC principles using baseline and reassessment data of SRA.

Methods

A retrospective analysis of data from eight randomly selected regions across Tanzania. Data was gathered from an SRA database in which records of baseline assessments (2015/16) and reassessments (2017/18) were documented. Each healthcare facility's ownership and service level were investigated as independent variables.

Results

A total of 2,131 healthcare facilities at baseline and 2,185 at reassessment were analysed. Median adherence to IPC principles increased from 31% (IQR: 20%, 46%) to 57% (IQR: 41.4%, 73.2%) after interventions (p<0.001).

Privately-owned facilities had higher adherence to IPC principles compared to publicly-owned facilities during baseline (p<0.001) however, the difference was not significant after intervention (p=0.751). On average, hospitals scored highest followed by health centres and then dispensaries during both assessments.

Being a privately-owned facility was a predictor of attaining a recommended IPC score of 80% at baseline (POR=1.92 CI=1.06–3.48) but not after the intervention. Facility level was not a predictor during baseline assessment; however after intervention hospitals were twice as likely to attain the recommended score compared to dispensaries (POR=2.27 CI=1.15–4.45).

Conclusion

Assessment and rating of quality and organization of health services plus management support to healthcare facilities, leads to improved adherence to IPC principles.

Evaluating infection prevention and control programs in Austrian acute care hospitals using the WHO Infection Prevention and Control Assessment Framework

Background

Infection prevention and control (IPC) is crucial for patient safety. The World Health Organization (WHO) has released various tools to promote IPC. In 2018, the WHO released the Infection Prevention and Control Assessment Framework (IPCAF) that enables acute care healthcare facilities to evaluate IPC structures and practices. Data regarding IPC implementation in Austria are scarce. To deliver insights into this topic and promote the IPCAF within the Austrian IPC community, we decided to invite all Austrian hospitals participating in the German nosocomial infection surveillance system to conduct a self-assessment using the WHO IPCAF.

Methods

The IPCAF follows the eight WHO core components of IPC. A German translation of the IPCAF was sent to 127 Austrian acute care hospitals. The survey period was from October to December 2018. Participation in the survey, data entry and transfer to the German national reference center for surveillance of healthcare-associated infections was on a voluntary basis.

Results

Altogether, 65 Austrian hospitals provided a complete dataset. The overall median IPCAF score of all hospitals was 620 (of a possible maximum score of 800), which corresponded to an advanced level of IPC. Of the 65 hospitals, 38 achieved an advanced IPC level. Deeper analysis of the different core components yielded diverse results. Scores were lowest for core components on multimodal strategies for implementation of IPC interventions, and IPC education and training. Around 26% (n = 17) of hospitals reported that the local IPC team was not steadily supported by an IPC committee. Senior clinical staff was not present in the IPC committee in 23% (n = 15) of hospitals. Only 26% (n = 17) of hospitals reported employing at least one IPC professional per ≤250 beds. Surveillance for multidrug-resistant pathogens was not conducted in 26% (n = 17) of hospitals.

Conclusions

Implementation of IPC key aspects is generally at a high level in Austria. However, potentials for improvement were demonstrated, most prominently with regard to staffing, IPC education and training, effective implementation of multimodal strategies, and involvement of professional groups. Our survey demonstrated that the IPCAF is a useful tool for IPC self-assessment and can uncover deficits even in a high-income setting like Austria.

The effect of a 5-year hand hygiene initiative based on the WHO multimodal hand hygiene improvement strategy: an interrupted time-series study

Background

A World Health Organization (WHO) guideline-based multimodal hand hygiene (HH) initiative was introduced hospital-wide to a nonteaching Japanese hospital for 5 years. The objective of this study was to assess the effect of this initiative in terms of changes in alcohol-based hand rub (ABHR) consumption and the Hand Hygiene Self-Assessment Framework (HHSAF) score.

Methods

The consumption of monthly hospital-wide ABHR was calculated in L per 1000 patient days (PDs). The change in ABHR consumption was analysed by an interrupted time series analysis with a pre-implementation period of 36 months and an implementation period of 60 months. The correlation between annual ABHR consumption and the HHSAF score was estimated using Pearson’s correlation coefficients.

Results

The annual ABHR consumption was 4.0 (L/1000 PDs) to 4.4 in the pre-implementation period and 10.4 to 34.4 in the implementation period. The HHSAF score was 117.5 (out of 500) in the pre-implementation period and 267.5 to 445 in the implementation period. A statistically significant increase in the monthly ABHR consumption (change in slope: + 0.479 L/1000 PDs, p <  0.01) was observed with the implementation of the initiative. Annual ABHR consumption was strongly correlated with the annual HHSAF score (r = 0.971, p <  0.01).

Conclusions

A 5-year WHO-based HH initiative significantly increased ABHR consumption. Our study suggested that the HHSAF assessment can be a good process measure to improve HH in a single facility, as ABHR consumption increased with the HHSAF score.

Determining the ideal prevention strategy for multidrug-resistance organisms in resource-limited countries: a cost-effectiveness analysis study

The aim of this study was to determine the most cost-effective strategy for the prevention and control of multidrug-resistant organisms (MDROs) in intensive care units (ICUs) in areas with limited health resources. The study was conducted in 12 ICUs of four hospitals. The total cost for the prevention of MDROs and the secondary attack rate (SAR) of MDROs for each strategy were collected retrospectively from 2046 subjects from January to December 2017. The average cost-effectiveness ratio (CER), incremental cost-effectiveness ratio (ICER) and cost-effectiveness acceptability curve were calculated. Hand hygiene (HH) had the lowest total cost (2149.6 RMB) and SAR of MDROs (8.8%) while single-room isolation showed the highest cost (33 700.2 RMB) and contact isolation had the highest SAR of MDROs (31.8%). The average cost per unit infection prevention was 24 427.8 RMB, with the HH strategy followed by the environment disinfection strategy (CER = 21 314.67). HH had the highest iterative cost effect under willingness to pay less than 2000 RMB. Due to the low cost for repeatability and obvious effectiveness, we conclude that HH is the optimal strategy for MDROs infections in ICUs in developing countries. The cost-effectiveness of the four prevention strategies provides some reference for developing countries but multiple strategies remain to be examined.

Implementation of the WHO hand hygiene strategy in Faranah regional hospital, Guinea

BACKGROUND

Healthcare-associated infections are the most frequent adverse events in healthcare worldwide, with limited available evidence suggesting highest burden in resource-limited settings. Recent Ebola epidemics emphasize the disastrous impact that spread of infectious agents within healthcare facilities can have, accentuating the need for improvement of infection control practices. Hand hygiene (HH) measures are considered to be the most effective tool to prevent healthcare-associated infections. However, HH knowledge and compliance are low, especially in vulnerable settings such as Guinea. The aim of PASQUALE (Partnership to Improve Patient Safety and Quality of Care) was to assess knowledge and compliance with HH and improve HH by incorporating the WHO HH Strategy within the Faranah Regional Hospital (FRH), Guinea.

METHODS

In a participatory approach, a team of FRH staff and leadership was invited to identify priorities of the hospital prior to the start of PASQUALE. The local hygiene committee was empowered to increase its activities and take ownership of the HH improvement strategy. A baseline assessment of knowledge, perception and compliance was performed months before the intervention. The main intervention consisted of local alcohol-based-hand-rub (ABHR) production, with final product efficacy testing, in conjunction with a training adapted to the needs identified in the baseline assessment. A follow-up assessment was conducted directly after the training. Effectiveness of the intervention was assessed via uncontrolled before-and-after comparison.

RESULTS

Baseline knowledge score (13.0/25) showed a significant increase to 19.0/25 in follow-up. Baseline-Compliance was 23.7% and increased significantly to 71.5% in follow-up. Compliance rose significantly across all professional groups except for midwifes and in all indications for HH, with the largest in the indication "Before aseptic tasks". The increase in compliance was associated with the intervention and remained significant after adjusting for confounders. The local pharmacy successfully supplies the entire hospital. The local supply resulted in a ten-fold increase of monthly hospital disinfectant consumption.

CONCLUSION

The WHO HH strategy is an adaptable and effective method to improve HH knowledge and compliance in a resource-limited setting. Local production is a feasible method for providing self-sufficient supply of ABHR to regional hospitals like the FRH. Participatory approaches like hygiene committee ownership builds confidence of sustainability.

Hand Hygiene Compliance in the ICU: A Systematic Review

OBJECTIVES

To synthesize the literature describing compliance with World Health Organization hand hygiene guidelines in ICUs, to evaluate the quality of extant research, and to examine differences in compliance levels across geographical regions, ICU types, and healthcare worker groups, observation methods, and moments (indications) of hand hygiene.

DATA SOURCES

Electronic searches were conducted in August 2018 using Medline, CINAHL, PsycInfo, Embase, and Web of Science. Reference lists of included studies and related review articles were also screened.

STUDY SELECTION

English-language, peer-reviewed studies measuring hand hygiene compliance by healthcare workers in an ICU setting using direct observation guided by the World Health Organization's "Five Moments for Hand Hygiene," published since 2009, were included.

DATA EXTRACTION

Information was extracted on study location, research design, type of ICU, healthcare workers, measurement procedures, and compliance levels.

DATA SYNTHESIS

Sixty-one studies were included. Most were conducted in high-income countries (60.7%) and in adult ICUs (85.2%). Mean hand hygiene compliance was 59.6%. Compliance levels appeared to differ by geographic region (high-income countries 64.5%, low-income countries 9.1%), type of ICU (neonatal 67.0%, pediatric 41.2%, adult 58.2%), and type of healthcare worker (nursing staff 43.4%, physicians 32.6%, other staff 53.8%).

CONCLUSIONS

Mean hand hygiene compliance appears notably lower than international targets. The data collated may offer useful indicators for those evaluating, and seeking to improve, hand hygiene compliance in ICUs internationally.

Effect of using portable alcohol-based handrub on nurses' hand hygiene compliance and nasal carriage of staphylococcus aureus in a low-income health setting

BACKGROUND

Low hand-hygiene compliance (HHC) in low-income countries due to deficient hand hygiene resources may increase nasal carriage of S. aureus, a causative agent of health care-associated infections. The study aimed to assess the effect of using locally available portable alcohol-based handrub (ABHR) regarding nurses' HHC and nasal carriage of S. aureus.

METHODS AND DESIGN

Nonrandomized interventional design. Seventy-two (72) of 86 nurses were provided with portable ABHR to use during patient care (intervention group). The remaining 14 nurses constituted the control group. Evaluation was done via HHC observation per WHO 5-moments of HH, determining S. aureus nasal carriage prevalence and HH guideline knowledge assessment via a self-response questionnaire.

RESULTS

In the intervention group, HHC improved from 48.9% to 67.7% (P < .001) especially for hand-hygiene before and after patient contact. Hand-hygiene by handrubbing improved from 16 to 105 moments. There was positive feedback to portable ABHR use from nurses. S. aureus nasal carriage significantly decreased from 30.6% to 21% (P < .031). Negative carriage of S. aureus was significantly associated with increase in HHC (P < .001). Despite the low preintervention HHC, nurses showed considerably high levels of knowledge on relevance of hand hygiene.

CONCLUSIONS

Portable ABHR use was associated with improved HHC and reduced S. aureus nasal carriage prevalence. As nurses' knowledge of HH guidelines was high, provision of portable ABHR compensated for deficient facility HH resources resulting in improved HHC, which effected reduction in nasal carriage of S. aureus among nurses.

Product dose considerations for real-world hand sanitiser efficacy

BACKGROUND

Alcohol based hand rubs (ABHR) are extremely effective at reducing microbial contamination and have an essential role in best practice hand hygiene described by the World Health Organization.

METHODS

We determined ABHR drying time when performing hand hygiene in a laboratory setting. Which was followed by identifying the amount of ABHR needed for complete hand coverage. When the aforementioned was analyzed real-time data were gathered to examine the amount used for hand hygiene in a hospital setting. In parallel hands of healthcare workers (HCWs) were monitored for drying time and perception on ABHR use.

RESULTS

In 86% (24,446,397/28,280,383) of the events a single dose of ABHR was used on clinical wards. Twenty-four HCWs expected hand hygiene to take 7.5 seconds (median; range 3-30 seconds). Forty-three HCWs show that 1.5 mL ABHR dose achieves the desired drying time according to World Health Organization guidelines (av. median 26 seconds), but is consistently perceived to have a longer drying time than expected (av. median 18 seconds). In-vivo results (n = 10) indicate that 2.25 mL ABHR is required for adequate coverage (82%-90%) of both sides of the hand.

CONCLUSIONS

Results indicate that set standards for the use of ABHR do not match "in-vivo" behaviour of HCWs. Perceived drying times are shorter than actual drying time. The needed drying time to reach acceptable antimicrobial efficacy of ABHRs should be revisited.

Sustained effects of a multimodal campaign aiming at hand hygiene improvement on compliance and healthcare-associated infections in a large gynaecology/obstetrics tertiary-care centre in Vietnam

Background

Hung Vuong Hospital (HVH) is a 900-bed maternity hospital in Ho-Chi-Minh-City, Vietnam. Due to low compliance, a quasi-experimental, observational study was conducted with the aim to improve hand hygiene.

Methods

A multimodal promotion strategy was established in 2010 and further developed towards ongoing, repetitive and inventive campaigns including patient participation. Hand hygiene compliance was monitored by direct observation and healthcare-associated infections (HAIs) by applying standard definitions.

Results

Between 2010 and 2018, a total of 43,711 hand hygiene opportunities were observed. Compliance improved from 21.5% (95%CI: 20.2–22.8%) in 2010 to 75.1% (73.9–76.2%) in 2018 (incidence rate ratio, IRR , 1.10; 95%CI, 1.10–1.11). This was achieved through increasing recourse to alcohol-based hand rubbing. A total of 554,720 women were admitted to HVH during the study period for 353,919 deliveries (198,679 vaginal; 155,240 by C-section) and 257,127 surgical procedures. The HAI-incidence decreased significantly from 1.10 episodes per 1000 patient-days in 2010 to 0.45 per 1000 patient-days in 2018 (IRR 0.85; 95%CI, 0.79–0.90). Significant improvement was observed also for surgical site infections after gynaecological surgery (IRR 0.95; 95%CI, 0.92–0.99) and endometritis after abortion (IRR 0.80; 95%CI, 0.68–0.93).

Conclusions

A multimodal strategy aiming at behaviour change significantly improved and sustained hand hygiene, which contributed to the reduction of healthcare-associated infections.

Evaluation of hand hygiene compliance over the years, in an intensive care unit of a north Delhi hospital preparing for accreditation: A 3-year study

INTRODUCTION

World Health Organization (WHO) initiated a global movement to achieve universal health coverage (UHC). Hand hygiene (HH) is critical for achieving UHC as it is a practical and evidence-based approach with a gaugeable impact on the quality of care and patient safety in healthcare.

MATERIAL AND METHODS

A cross-sectional observational study was conducted in an intensive care unit of a government hospital spanning a period of 3 years. WHO single-observer direct observation technique was used and HH compliance was noted. The results were compared over the years since the hospital was preparing to undergo a National Accreditation Board for Hospitals and Healthcare (NABH) assessment.

RESULTS

The overall compliance significantly increased over the years (P < 0.0001). HH compliance for hand rub (HR) and hand wash (HW) was compared among doctors, nurses, and ICU technicians, respectively. HR compliance remained more or less the same over the years (P = 0.4738) while HW compliance significantly improved (P < 0.0001).

CONCLUSIONS

This is one of the first studies from our country evaluating HH compliance over the years in a healthcare setup undergoing accreditation. During the course of the study, we observed a significant increase in HH compliance. This can be attributed to the unflinching support of our hospital's administration and relentless efforts of our infection control team. This is our first step initiative towards improving HH and thus preventing healthcare-associated infections (HCAIs) in our setup.

Multimodal intervention program to improve hand hygiene compliance: effectiveness and challenges

BACKGROUND

Hand hygiene (HH) is considered the most important measure to tackle the transmission of healthcare-associated pathogens. However, compliance with recommendations is usually low and effective improvement strategies are needed. We aimed to assess the effectiveness of an intervention targeting hand hygiene promotion among healthcare workers (HCWs).

METHODS

We conducted a pre-post interventional study design in the university hospital Sahloul, Sousse, Tunisia, from January 2015 to December 2016. The intervention program consisted of training sessions and distribution of posters of hand hygiene guidelines. To assess the evolution of HH observance at pre- and post-intervention, the same observation form was distributed and collected at healthcare workers' workplace.

RESULTS

Of the 1201 and 1057 opportunities for hand hygiene observed among all categories of HCWs, overall compliance enhanced significantly from 32.1 to 39.4% (p < 0.001) respectively at pre- and post-intervention. Nurses were the most compliant with a significant improvement from 34.1 to 45.7% (p < 0.001) respectively at pre- and post-intervention. Furthermore, analysis by department showed significant improvement of compliance in orthopedic department (p < 0.001), maxillofacial-surgery department (p < 0.001), pediatrics department (p = 0.013), and emergencies (p = 0.038).

CONCLUSION

This study showed the feasibility and effectiveness of a health-setting-based intervention to enhance hand hygiene observance in the context of a developing country.

Behavioural Determinants of Hand Washing and Glove Recontamination before Aseptic Procedures at Birth: A Time-and-Motion Study and Survey in Zanzibar Labour Wards

Recent research calls for distinguishing whether the failure to comply with World Health Organisation hand hygiene guidelines is driven by omitting to rub/wash hands, or subsequently recontamination of clean hands or gloves prior to a procedure. This study examined the determinants of these two behaviours. Across the 10 highest-volume labour wards in Zanzibar, we observed 103 birth attendants across 779 hand hygiene opportunities before aseptic procedures (time-and-motion methods). They were then interviewed using a structured cross-sectional survey. We used mixed-effect multivariable logistic regressions to investigate the independent association of candidate determinants with hand rubbing/washing and avoiding glove recontamination. After controlling for confounders, we found that availability of single-use material to dry hands (OR:2.9; CI:1.58–5.14), a higher workload (OR:29.4; CI:12.9–67.0), more knowledge about hand hygiene (OR:1.89; CI:1.02–3.49), and an environment with more reminders from colleagues (OR:1.20; CI:0.98–1.46) were associated with more hand rubbing/washing. Only the length of time elapsed since donning gloves (OR:4.5; CI:2.5–8.0) was associated with avoiding glove recontamination. We identified multiple determinants of hand washing/rubbing. Only time elapsed since washing/rubbing was reliably associated with avoiding glove recontamination. In this setting, these two behaviours require different interventions. Future studies should measure them separately.

Assessment of hand hygiene facilities and staff compliance in a large tertiary health care facility in northern Nigeria: a cross sectional study

Background

The burden of healthcare-associated infection (HAI) is 2 to 18 times higher in developing countries. However, few data are available regarding infection prevention and control (IPC) process indicators in these countries. We evaluated hand hygiene (HH) facilities and compliance amongst healthcare workers (HCW) in a 600-bed healthcare facility in Northcentral Nigeria providing tertiary care service for a catchment population of about 20 million.

Methods

An in-house facility assessment tool and the World Health Organization (WHO) direct observation method were used to assess the HH facilities and compliance, respectively. Factors associated with good compliance were determined by multivariate analysis.

Results

The facility survey was carried out in all 46 clinical units of the hospital. 72% of the units had no poster or written policy on HH; 87% did not have alcohol-based hand rubs; 98% had at least one handwash sink; 28% had flowing tap water all day while 72% utilized cup and bucket; and 58% had no hand drying facilities. A total of 406 HH opportunities were observed among 175 HCWs. The overall compliance was 31%, ranging from 18% among ward attendants to 82% among medical students. Based on WHO “5 moments” for HH, average compliance was 21% before patient contact, 23% before aseptic procedure, 63% after body fluid exposure risk, 41% after patient contact and 40% after contact with patients’ surrounding. Being a medical student was independently associated with high HH compliance, adjusted odds ratio: 13.87 (1.70–112.88).

Conclusions

Availability of HH facilities and HCW compliance in a large tertiary hospital in Nigeria is poor. Our findings confirm that HCWs seem more sensitized to their risk of exposure to potential pathogens than to the prevention of HAI cross-transmission. Inadequate HH facilities probably contributed to the poor compliance. Specific measures such as improved facilities, training and monitoring are needed to improve HH compliance.

Implementation strategies for infection prevention and control promotion for nurses in Sub-Saharan Africa: a systematic review

Background

Despite impressive reductions in infectious disease burden within Sub-Saharan Africa (SSA), half of the top ten causes of poor health or death in SSA are communicable illnesses. With emerging and re-emerging infections affecting the region, the possibility of healthcare-acquired infections (HAIs) being transmitted to patients and healthcare workers, especially nurses, is a critical concern. Despite infection prevention and control (IPC) evidence-based practices (EBP) to minimize the transmission of HAIs, many healthcare systems in SSA are challenged to implement them. The purpose of this review is to synthesize and critique what is known about implementation strategies to promote IPC for nurses in SSA.

Methods

The databases, PubMed, Ovid/Medline, Embase, Cochrane, and CINHAL, were searched for articles with the following criteria: English language, peer-reviewed, published between 1998 and 2018, implemented in SSA, targeted nurses, and promoted IPC EBPs. Further, 6241 search results were produced and screened for eligibility to identify implementation strategies used to promote IPC for nurses in SSA. A total of 61 articles met the inclusion criteria for the final review. The articles were evaluated using the Joanna Briggs Institute’s (JBI) quality appraisal tools. Results were reported using PRISMA guidelines.

Results

Most studies were conducted in South Africa (n = 18, 30%), within the last 18 years (n = 41, 67%), and utilized a quasi-experimental design (n = 22, 36%). Few studies (n = 14, 23%) had sample populations comprising nurses only. The majority of studies focused on administrative precautions (n = 36, 59%). The most frequent implementation strategies reported were education (n = 59, 97%), quality management (n = 39, 64%), planning (n = 33, 54%), and restructure (n = 32, 53%). Penetration and feasibility were the most common outcomes measured for both EBPs and implementation strategies used to implement the EBPs. The most common MAStARI and MMAT scores were 5 (n = 19, 31%) and 50% (n = 3, 4.9%) respectively.

Conclusions

As infectious diseases, especially emerging and re-emerging infectious diseases, continue to challenge healthcare systems in SSA, nurses, the keystones to IPC practice, need to have a better understanding of which, in what combination, and in what context implementation strategies should be best utilized to ensure their safety and that of their patients. Based on the results of this review, it is clear that implementation of IPC EBPs in SSA requires additional research from an implementation science-specific perspective to promote IPC protocols for nurses in SSA.

Hand hygiene compliance and associated factors among health care providers in Central Gondar zone public primary hospitals, Northwest Ethiopia

Background

Poor hand hygiene compliance is one in all the leading contributory factors to healthcare-associated infections. This is an important source of complications across the continuum of care and poses a serious threat to people admitted to hospitals. However, the magnitude and associated factors of hand hygiene compliance in public primary hospitals were not well investigated in Ethiopia. Therefore, this study was conducted to assess hand hygiene compliance and associated factors among health care providers in Central Gondar Zone public primary hospitals, Northwest Ethiopia.

Methods

An Institutional based cross-sectional study was conducted from March to April 2019 among health care providers. The data were collected using self-administered questionnaires and observational checklists. Using Epi Info 3.1, data was entered and analyzed using SPSS version 23. The data were analyzed using descriptive statistics and logistic regression models. A p-value less than 0.05 with 95% confidence interval was used to declare statistical significance.

Results

Of 335 study participants, 50 (14.9%), had good hand hygiene compliance. Training on hand hygiene (AOR = 8.07, 95%CI: 2.91, 22.39), availability of adequate soap and water for hand hygiene (AOR = 5.10, 95%CI: 1.93, 13.52), availability of alcohol-based hand rub (AOR = 3.23, 95%CI: 1.32, 7.92), knowledge about hand hygiene (AOR = 6.74, 95%CI: 2.96, 15.34) and attitude towards hand hygiene (AOR = 2.15, 95%CI: 1.04, 4.46) were factors associated with hand hygiene compliance.

Conclusion

The overall level of hand hygiene compliance among health care providers was poor. Training, availability of adequate soap and water, availability of alcohol-based hand rub, knowledge on hand hygiene, and attitude of health care providers were significantly associated with hand hygiene compliance.

Effectiveness of hand hygiene promotional program based on the WHO multimodal hand hygiene improvement strategy, in terms of compliance and decontamination efficacy in an indian tertiary level neonatal surgical intensive care unit

Background

The WHO Multimodal Hand Hygiene Improvement Strategy (MHHIS) has been proposed to improve the Hand Hygiene (HH) compliance of the WHO recommendations on HH.Therefore, the current study was planned in our neonatal unit with the objective of evaluating the effectiveness of a Hand Hygiene Promotional Program (HHPP) based on the WHO MHHIS, in terms of compliance and decontamination efficacy among the health-care workers (HCWs) in the unit.

Objective

The objective of the study was to evaluate the effectiveness of the WHO MHHIS on HH compliance and decontamination efficacy.

Methods

The HHPP was carried out in our neonatal surgical intensive care unit from July to August 2013. A pre-intervention phase consisted of assessment of ward infrastructure, HH knowledge and perception, determination of HH compliance and collection of hand rinse samples from the HCWs before and after handwashing. Intervention phase consisted of changing traditional to elbow-operated taps, display of posters and reminders, placement of soaps in water draining trays, autoclaved single-use paper towels for hand drying, availability of hand rubs and training sessions for health-care providers. In the post-intervention phase, all the assessments and observations of pre-intervention phase were repeated.

Results

HHPP resulted in a significant increase in overall HH compliance from 26.6% (95% confidence interval [CI] 23.9-29.3) to 65.3% (95% CI 62.4-68.2) (P < 0.001) and reduction in load of microorganisms (P = 0.013). There was a significant improvement in HH knowledge (P < 0.001), and perception surveys revealed high appreciation of each strategy component by the participants.

Conclusion

To the best of our knowledge, this is the first study about the effect of implementation of the WHO MHHIS from an Indian hospital. HHPP was found to be effective in terms of HH compliance and decontamination efficacy. Its implementation is highly recommended to promote HH in a developing country like India.

Hand hygiene in low- and middle-income countries

A panel of experts was convened by the International Society for Infectious Diseases (ISID) to overview evidence based strategies to reduce the transmission of pathogens via the hands of healthcare workers and the subsequent incidence of hospital acquired infections with a focus on implementing these strategies in low- and middle-income countries. Existing data suggests that hospital patients in low- and middle-income countries are exposed to rates of healthcare associated infections at least 2-fold higher than in high income countries. In addition to the universal challenges to the implementation of effective hand hygiene strategies, hospitals in low- and middle-income countries face a range of unique barriers, including overcrowding and securing a reliable and sustainable supply of alcohol-based handrub. The WHO Multimodal Hand Hygiene Improvement Strategy and its associated resources represent an evidence-based framework for developing a locally-adapted implementation plan for hand hygiene promotion.

A national survey on the implementation of key infection prevention and control structures in German hospitals: results from 736 hospitals conducting the WHO Infection Prevention and Control Assessment Framework (IPCAF)

Background

Healthcare-associated infections (HAI) pose a burden on healthcare providers worldwide. To prevent HAI and strengthen infection prevention and control (IPC) structures, the WHO has developed a variety of tools and guidelines. Recently, the WHO released the Infection Prevention and Control Assessment Framework (IPCAF), a questionnaire-like tool designed for assessing IPC structures at the facility level. The IPCAF reflects the eight WHO core components of IPC. Data on the implementation of IPC measures in German hospitals are scarce. Therefore, it was our objective to utilize the IPCAF in order to gather information on the current state of IPC implementation in German hospitals, as well as to promote the IPCAF to a broad audience.

Methods

The National Reference Center for Surveillance of Nosocomial Infections (NRZ) sent a translated version of the IPCAF to 1472 acute care hospitals in Germany. Data entry and transfer to the NRZ was done electronically between October and December 2018. The IPCAF was conceived in a way that depending on the selected answers a score was calculated, with 0 being the lowest possible and 800 the highest possible score. Depending on the overall score, the IPCAF allocated hospitals to four different “IPC levels”: inadequate, basic, intermediate, and advanced.

Results

A total of 736 hospitals provided a complete dataset and were included in the data analysis. The overall median score of all hospitals was 690, which corresponded to an advanced level of IPC. Only three hospitals (0.4%) fell into the category “basic”, with 111 hospitals (15.1%) being “intermediate” and 622 hospitals (84.5%) being “advanced”. In no case was the category “inadequate” allocated. More profound differences were found between the respective core components. Components on multimodal strategies and workload, staffing, ward design and bed occupancy revealed the lowest scores.

Conclusions

IPC key aspects in general are well established in Germany. Potentials for improvement were identified particularly with regard to workload and staffing. Insufficient implementation of multimodal strategies was found to be another relevant deficit. Our survey represents a successful attempt at promoting the IPCAF and encouraging hospitals to utilize WHO tools for self-assessment.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0532-4) contains supplementary material, which is available to authorized users.

Hand hygiene practices among healthcare workers in a newborn unit of a tertiary referral hospital in Kenya

Background:

Health care-associated infection (HCAI) is a significant cause of morbidity and mortality among hospitalised patients, particularly neonates. Compliance with hand hygiene (HH) recommendations is the simplest and most effective measure in preventing this infection.

Objectives:

To determine the HH practices among healthcare workers (HCWs) in the newborn unit of a tertiary referral hospital in Kenya, their knowledge and perceptions regarding HCAI and importance of HH, and barriers to the recommended HH practices.

Methods:

A descriptive cross-sectional study was conducted to evaluate the HCWs’ compliance with the World Health Organization (WHO) ‘5 Moments for Hand Hygiene’ and a structured self-administered questionnaire adopted from the WHO knowledge and perception of HCW questionnaires was used to answer the secondary objectives.

Results:

The overall HH compliance rate was 15%. HCWs were twice more likely to take a HH action ‘after’ than ‘before’ a patient care procedure (odds ratio [OR] = 2.05; 95% confidence interval [CI] = 1.02–4.19; P = 0.03). Nurses and nursing students had statistically significant lower compliance (OR 0.41; 95% CI = 0.18-0.91; p=0.016) and (OR 0.21; 95% CI = 0.06-0.70; p = 0.004) respectively, compared to the doctors. More than half (52%) of the HCWs were unaware of the five moments/indication for HH. Lack of supplies, forgetfulness and use of gloves were the commonly cited barriers to HH compliance.

Discussion:

HH compliance rate among HCWs in the newborn unit of the tertiary referral hospital was very low. The observed and reported barriers to optimal HH compliance demonstrate a necessity for the adoption of the WHO recommended multimodal HH improvement strategy in this unit.

Barriers to hand hygiene practices among health care workers in sub-Saharan African countries: A narrative review

BACKGROUND

Hand hygiene (HH) is the primary measure in the prevention of health care-associated infections; however, from published studies, compliance of health care workers (HCWs) to HH guidelines is low. There is currently no review on HH compliance rates in developing countries, specifically sub-Saharan Africa (SSA), or the barriers to compliance. We therefore, through a narrative review, sought to identify the compliance with and the barriers to HH in SSA.

METHODS

From 3 databases, we performed a search of peer-reviewed studies from SSA, conducted among HCWs, published in the English language between 2005 and 2017. Only studies that reported HH compliance and/or barriers were included.

RESULTS

A total of 278 articles were identified, and the final sample of 27 articles was analyzed in full length. Overall, the HH compliance rate was estimated to be 21.1%, and doctors had better compliance irrespective of the type of patient contact. The main barriers identified were heavy workload, infrastructural deficit (eg, lack of water, soap, hand sanitizers, and blocked/leaking sinks), and poorly positioned facilities.

CONCLUSIONS

HH compliance is poor among SSA HCWs. There is a need for more reports of HH compliance in SSA, and emphasis needs to be placed on surgical wards in which surgical site infections-the most common form of health care-associated infections in SSA-are most likely to occur. Barriers identified in this review are consistent with the findings of studies conducted elsewhere; however, it appears that heavy workload, infrastructural deficit, and poorly positioned facilities are more likely in developing countries.

Implementation science in low-resource settings: using the interactive systems framework to improve hand hygiene in a tertiary hospital in Ghana

Quality issue

Low-resource clinical settings often face obstacles that challenge the implementation of recommended evidence-based practices (EBPs). Implementation science approaches are useful in identifying barriers and developing strategies to address them.

Initial assessment

Ridge Regional Hospital (RRH), a tertiary referral hospital in Accra, Ghana experienced a spike in rates of neonatal sepsis and launched a quality improvement (QI) initiative that identified poor adherence to hand hygiene in the neonatal intensive care unit as a potential source of infections.

Choice of solution

A multi-modal change package of World Health Organization-recommended solutions was created to address this issue.

Implementation

To ensure that the outputs of the QI effort were adopted within the organization, leaders at RRH and Kybele, Inc. used an implementation science framework called the ‘Interactive Systems Framework for Dissemination and Implementation’ (ISF) to create a package of locally acceptable implementation strategies. The ISF has never been used before to guide implementation in low-resource settings.

Evaluation

Hand hygiene compliance rose from 67% to 92% overall, including a 36% increase during the night shifts—a group of healthcare workers with typically very low levels of compliance.

Lessons learned

The drastic improvement in adherence to hand hygiene suggests the potential value of the joint use of QI and implementation science to promote the creation and application of contextually appropriate EBPs in low-resource settings. Our results also suggest that using an implementation framework such as the ISF could rapidly increase the uptake of other evidence-based interventions in low-resource settings.

Validity of hand hygiene compliance measurement by observation: A systematic review

BACKGROUND

Hand hygiene is monitored by direct observation to improve practice, but this approach can potentially cause information, selection, and confounding bias, threatening the validity of findings. The aim of this study was to identify and describe the potential biases in hand hygiene compliance monitoring by direct observation; develop a typology of biases and propose improvements to reduce bias; and increase the validity of compliance measurements.

METHODS

This systematic review of hospital-based intervention studies used direct observation to monitor health care workers' hand hygiene compliance.

RESULTS

Seventy-one publications were eligible for review. None was free of bias. Selection bias was present in all studies through lack of data collection on the weekends (n = 61, 86%) and at night (n = 46, 65%) and observations undertaken in single-specialty settings (n = 35, 49%). We observed inconsistency of terminology, definitions of hand hygiene opportunity, criteria, tools, and descriptions of the data collection. Frequency of observation, duration, or both were not described or were unclear in 58 (82%) publications. Observers were trained in 56 (79%) studies. Inter-rater reliability was measured in 26 (37%) studies.

CONCLUSIONS

Published research of hand hygiene compliance measured by direct observation lacks validity. Hand hygiene should be measured using methods that produce a valid indication of performance and quality. Standardization of methodology would expedite comparison of hand hygiene compliance between clinical settings and organizations.

Effectiveness and core components of infection prevention and control programmes in long-term care facilities: a systematic review

BACKGROUND

Infection prevention and control (IPC) is a measure to prevent healthcare-associated infections in healthcare settings. There is limited evidence of the effectiveness of IPC programmes in long-term care facilities (LTCFs).

AIM

To review and analyse the effectiveness and the components of IPC programmes in LTCFs for older adults.

METHODS

Electronic databases (PubMed, EMBASE, CINAHL and Cochrane CENTRAL) were searched systematically for English-language articles assessing IPC interventions in LTCFs, published over the last decade (2007-2016). The components of IPC programmes were analysed based on the World Health Organization (WHO) manuals for improving IPC activities. Two reviewers independently assessed the quality of studies using the Cochrane risk-of-bias tool and the risk-of-bias assessment tool for non-randomized studies.

FINDINGS

Seventeen studies met the eligibility criteria; 10 studies were randomized trials (58.8%) and the others were non-randomized trials to examine the impact of IPC programmes on infection and/or performance outcomes of healthcare workers. None of the included studies implemented all of the WHO core components. Behavioural change strategies using education, monitoring and feedback were reported to be successful interventions for reducing the threat of healthcare-associated infections. Generally, studies using four or more elements of the WHO multi-modal strategy reported significant reductions in infection rates.

CONCLUSIONS

There is some evidence for the effectiveness of IPC interventions using education, monitoring, feedback and four or more elements of the WHO multi-modal strategy to control healthcare-associated infections in LTCFs.

Evaluation of a program to improve hand hygiene in Kenyan hospitals through production and promotion of alcohol-based Handrub - 2012-2014

Although critical to prevent healthcare-associated infections, hand hygiene (HH) compliance is poor in resource-limited settings. In 2012, three Kenyan hospitals began onsite production of alcohol-based handrub (ABHR) and HH promotion. Our aim is to determine the impact of local production of ABHR on HH compliance and perceptions of ABHR. We observed 25,738 HH compliance opportunities and conducted 15 baseline and post-intervention focus group discussions. Hand Hygiene compliance increased from 28% (baseline) to 38% (post-intervention, p = 0.0003). Healthcare workers liked the increased accessibility of ABHR, but disliked its smell, feel, and sporadic availability. Onsite production and promotion of ABHR resulted in modest HH improvement. Enhancing the quality of ABHR and addressing logistical barriers could improve program impact.