Kotter's 8-step change model to improve hand hygiene compliance in intensive care unit: A 41-month prospective longitudinal quality improvement study

BACKGROUND

Despite numerous studies assessing bundled interventions to enhance hand hygiene compliance (HHC), compliance rates persist at suboptimal levels. Our objective was to employ Kotter's Change Model (KCM) to enhance HHC and conduct a comprehensive process evaluation among medical staff within the intensive care unit (ICU).

METHODS

KCM was implemented at the ICU of Zhongnan Hospital of Wuhan University from March 2018 to August 2021, with a 41-month longitudinal monitoring of HHC. The primary outcome focused on the absolute monthly change in HHC. Secondary outcomes encompassed the HHC characteristics across different phases, varying trends in HHC concerning different hand hygiene opportunities and occupations, quarterly incidences of central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI).

RESULTS

This study included 20,222 hand hygiene actions and 24,195 opportunities. The overall HHC was 83.58 % (95 %CI, 83.11 %-84.04 %). Following the KCM implementation, HHC surged from 35.71 % (95 % CI, 22.99 %-50.83 %) to 87.75 % (95 % CI, 85.53 %-89.67 %), reflecting a notable increase of 145.73 %. The most rapid growth in HHC occurred post-patient contact, elevating from 35.29 % to 89.8 %. Despite escalating patient numbers and treatment complexities annually, the quarterly rates of CLABSI (0 ‰-3.53 ‰) and CAUTI (0.96 ‰-4.26 ‰) remained consistently low.

CONCLUSION

Utilizing KCM systematically alters healthcare providers' perception of hand hygiene, fostering an environment that advocates for and sustains improved HHC among ICU personnel.

IMPLICATIONS FOR CLINICAL PRACTICE

The Kotter's change model can be an effective framework for healthcare organizations to systematically improve and maintain hand hygiene compliance among healthcare providers, which can in turn help reduce healthcare-associated infections.

Process Evaluation of an Acute-Care Nurse-Centred Hand Hygiene Intervention in US Hospitals

This paper describes a process evaluation of a 'wise' intervention that took place in six acute care units in two medical-surgical teaching hospitals in the United States during 2016-2017. 'Wise' interventions are short, inexpensive interventions that depend on triggering specific psychological mechanisms to achieve behaviour change. This study sought to increase the hand hygiene compliance (HHC) rates before entering a patient's room among nurses. The intervention centred on the use of threat to professional identity to prompt improved HHC. Through questionnaires administered to intervention participants and the implementation facilitator, together with independent observation of intervention delivery, we examined whether the steps in the Theory of Change occurred as expected. We found that aspects of the implementation-including mode of delivery, use of incentives, and how nurses were recruited and complied with the intervention-affected reach and likely effectiveness. While components of the intervention's mechanisms of impact-such as the element of surprise-were successful, they ultimately did not translate into performance of the target behaviour. Performance was also not affected by use of an implementation intention as repeated performance of HHC over years of being a nurse has likely already established well-ingrained practices. Context did have an effect; the safety culture of the units, the involvement of the Nurse Managers, the level of accountability for HHC in each unit, and the hospitals themselves all influenced levels of engagement. These conclusions should have implications for those interested in the applicability of 'wise' interventions and those seeking to improve HHC in hospitals.

Impact of an educational intervention on hand hygiene practice among nursing students, with a focus on hand drying efficacy

Background

Hand hygiene and its significance for reducing the spread of infection is well evidenced and has been brought into sharp focus following the COVID-19 pandemic. Although a crucial clinical skill in ensuring safe healthcare, little is known regarding nursing students' effectiveness of hand hygiene practice.

Aim

The aim of this study was to evaluate the impact of an educational intervention on hand hygiene practice, designed by the research team for first year pre-registration nursing students. Particular emphasis was placed upon hand drying technique and time.

Methodology

825 nursing students were observed and assessed for their hand hygiene practice in a clinical suite at a university setting. Nursing students were observed for compliance against set outcome measures involving hand hygiene preparation, hand and wrist washing technique, hand drying technique and time. Data were analysed quantitatively using SPSS.

Results

The educational intervention had a significant impact on the clinical skills learning of nursing students. 779 students passed the assessment at the first attempt (94.4%). Of the 46 students that failed to meet the necessary criteria, 45 satisfied the criteria at the second attempt; giving an overall optimal compliance of 99.9%. 99.6% of students complied with recommended hand drying standards.

Conclusion

This study offers an important contribution to the development and delivery of nursing education programmes. The educational intervention improved compliance with recommended hand hygiene technique and practice. Lack of attention to hand drying may negate effective hand hygiene in healthcare.

Empowering health care workers with personalized data-driven feedback to boost hand hygiene compliance

BACKGROUND

Achieving high hand hygiene compliance among health care workers is a challenge, requiring effective interventions. This study investigated the impact of individualized feedback on hand hygiene compliance using an electronic monitoring system.

METHODS

A quasi-experimental intervention design with pretest-post-test was conducted in an orthopedic surgical ward. Participants served as their own controls. A 3-month baseline was followed by a 3-month intervention period. Hand hygiene events were recorded through sensors on dispensers, name tags, and near patient beds. Health care workers received weekly email feedback reports comparing their compliance with colleagues.

RESULTS

Nineteen health care workers (17 nurses, 2 doctors) were included. Hand hygiene compliance significantly improved by approximately 15% (P < .0001) across all rooms during the intervention. The most substantial improvement occurred in patient rooms (17%, P < .0001). Compliance in clean and contaminated rooms increased by 10% (P = .0068) and 5% (P = .0232). The average weekly email open rate for feedback reports was 46%.

CONCLUSIONS

Individualized feedback via email led to significant improvements in hand hygiene compliance among health care workers. The self-directed approach proved effective, and continuous exposure to the intervention showed promising results.

Using a Human Factors Framework to Assess Clinician Perceptions of and Barriers to High Reliability in Hand Hygiene

BACKGROUND

Hand hygiene (HH) is critical to prevent healthcare-associated infections (HAIs). Clinician perspectives on maintaining high reliability are poorly defined.

METHODS

We surveyed physicians, nurse practitioners, and physician assistants to understand perceptions of and barriers to high reliability in HH. The Systems Engineering Initiative for Patient Safety 2.0 model was used to develop an electronic survey exploring six human factors engineering (HFE) domains.

RESULTS

. Among 61 respondents, 70% perceived HH as "essential" to patient safety. While 87% reported alcohol-based hand rub (ABHR) availability as very effective in improving HH reliability, 77% reported dispensers to be "sometimes" or "often" empty. Clinicians in surgery/anesthesia were more likely than those in medical specialties to note skin irritation from ABHR (OR 4.94; 95% CI 1.37-17.81) and less likely to believe feedback was effective in improving HH (OR 0.26; 95% CI 0.08-0.88). One quarter of respondents indicated the layout of patient care areas was not conducive to performing HH. Staffing shortages and the pace and demands of work precluded HH for 15% and 11% of respondents, respectively.

CONCLUSIONS

Aspects of organizational culture, environment, tasks, and tools were identified as barriers to high reliability in HH. HFE principles can be applied to more effectively promote HH.

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.

Capability, Opportunity, Motivation, and Hand Hygiene Behavior in Healthcare Workers: A Structural Equation Modeling

Background

Hand hygiene among healthcare workers is the leading measure to reduce healthcare-associated infections. However, hand hygiene behavior is complex and not readily understood. This study aimed to identify the determinants and the underlying mechanism of hand hygiene behavior based on the capability, opportunity, motivation-behavior model.

Methods

A self-constructed questionnaire survey was conducted among healthcare workers in Chongqing, China. Capability, opportunity, and motivation were designed as independent variables, and hand hygiene behavior was measured as a dependent variable. Internal consistency reliability analysis and confirmatory factor analysis were applied to examine the reliability and validity of the questionnaire. Structural equation modeling was performed to explore the relationships among capability, opportunity, motivation, and hand hygiene behavior.

Results

Four hundred and ninety-nine physicians and nurses were investigated. The Cronbach's α coefficients were above 0.764. Confirmatory factor analysis was confirmed with good data fitness. The structural equation modeling had a good fit (root mean square error of approximation=0.070, comparative fit index=0.960, Tucker-Lewis index=0.956). Both opportunity (β=0.265, p<0.05) and motivation (β=0.333, p<0.05) directly affected hand hygiene behavior. Both capability (β=0.194, p<0.001) and opportunity (β=0.719, p<0.001) were indirectly linked to hand hygiene behavior through motivation.

Conclusion

To improve hand hygiene behavior, more efforts need to be focused on resource provision and motivation enhancement in the future compared to training.

Improvement of Hand Hygiene Practices among the Healthcare Workers in a Neonatal Intensive Care Unit

BACKGROUND

Healthcare workers' (HCWs) hands become progressively colonized with potential pathogens during their patient care and act as a vehicle for transmission of microorganisms to other patients. Hand hygiene is undisputedly one of the most effective infection control measures. The objective of this study was to measure the hand hygiene (HH) compliance among the doctors and nurses before and after intervention. Methodology. This quasi-experimental (before and after) study was conducted from July 2019 to July 2020 in the neonatal intensive care unit in a tertiary hospital in Bangladesh. The doctors and nurses were observed for their compliance to HH before and after the intervention. Several group discussions were arranged, and posters on HH were attached as reminders at the workstations during the intervention period. Binary logistic regression analysis of the predictors for the outcome as HH noncompliance was performed.

RESULT

The overall compliance to HH was significantly increased in both before (from 42.9 to 83.8%, p=<0.0001) and after (28.5 to 95.9%, p=<0.000) patient contact, in both the case of high-risk and low-risk contacts (p=<0.000) following the intervention. A significant reduction in the frequency of inadequate HH (20.2 to 9.7%, p = .000) was documented. In logistic regression analysis, compliance to HH was found more after the intervention (aOR = 13.315, 95% CI: 7.248-24.458). Similarly, being a physician (aOR = 0.012, 95% CI: 0.005-0.030) and moments after patient contact (aOR = 0.114, 95% CI: 0.049-0.261), significant positive predictors for compliance to HH were found.

CONCLUSION

Significant improvements in HH compliance were achieved through a systemic, multidimensional intervention approach among the doctors and nurses in an intensive newborn care setting.

Direct hand hygiene observations and feedback increased hand hygiene compliance among nurses and doctors in medical and surgical wards - an eight-year observational study

BACKGROUND

The improvement of hand hygiene compliance (HHC) is critical to preventing healthcare-associated infections (HCAIs). The present study explored how direct observation and feedback influences HHC among nurses and doctors in surgical and medical wards, and whether these actions impact HCAI incidence.

METHODS

In this longitudinal observational study, HHC and the incidence of HCAIs were observed in six medical and seven surgical wards in a tertiary hospital in Finland from May 2013 to Dec 2020. Data of the observations of five hand hygiene (HH) moments were collected from the hospital HH and the HCAI monitoring registries. For statistical analyses a multivariable logistic regression analysis and a Poisson regression model were used.

FINDINGS

HH monitoring included 24 614 observations among nurses and 6 396 observations among doctors. In medical wards, HHC rates increased 10.8% - from 86.2% to 95.5%, and HCAI incidence decreased from 15.9 to 13.5 per 1000 patient days (p<0.0001). In surgical wards, HHC increased 32.7% - from 67.6% to 89.7%, and HCAI incidence decreased from 13.7 to 12.0 per 1000 patient days (p< 0.0001). The overall HHC increased significantly among nurses (17.8%) and doctors (65.8%). The HHC was better among nurses than doctors (in medical wards; OR 3.36; 95% CI 2.90-3.90, p<0.001 and in surgical wards; OR 9.85; 95% CI 8.97-10.8, p<0.001).

CONCLUSION

Direct observations and feedback of HH increased significantly HHC among nurses and doctors over an eight-year period. During the same period, the incidence of HCAIs significantly decreased in both medical and surgical wards.

Implementation of hand hygiene in health-care facilities: results from the WHO Hand Hygiene Self-Assessment Framework global survey 2019

BACKGROUND

Hand hygiene is at the core of effective infection prevention and control (IPC) programmes. 10 years after the development of the WHO Multimodal Hand Hygiene Improvement Strategy, we aimed to ascertain the level of hand hygiene implementation and its drivers in health-care facilities through a global WHO survey.

METHODS

From Jan 16 to Dec 31, 2019, IPC professionals were invited through email and campaigns to complete the online Hand Hygiene Self-Assessment Framework (HHSAF). A geospatial clustering algorithm selected unique health-care facilities responses and post-stratification weighting was applied to improve representativeness. Weighted median HHSAF scores and IQR were reported. Drivers of the HHSAF score were determined through a generalised estimation equation.

FINDINGS

3206 unique responses from 90 countries (46% WHO Member States) were included. The HHSAF score indicated an intermediate hand hygiene implementation level (350 points, IQR 248-430), which was positively associated with country income level and health-care facility funding structure. System Change had the highest score (85 points, IQR 55-100), whereby alcohol-based hand rub at the point of care has become standard practice in many health-care facilities, especially in high-income countries. Institutional Safety Climate had the lowest score (55 points, IQR 35-75). From 2015 to 2019, the median HHSAF score in health-care facilities participating in both HHSAF surveys (n=190) stagnated.

INTERPRETATION

Most health-care facilities had an intermediate level of hand hygiene implementation or higher, for which health-care facility funding and country income level were important drivers. Availability of resources, leadership, and organisational support are key elements to further improve quality of care and provide access to safe care for all.

FUNDING

WHO, Geneva University Hospitals and Faculty of Medicine, and WHO Collaborating Center on Patient Safety, Geneva, Switzerland.

What are healthcare workers' preferences for hand hygiene interventions? A discrete choice experiment

OBJECTIVES

To understand the key attributes in designing effective interventions for improving healthcare workers' (HCWs') hand hygiene compliance and HCWs' preference for these attributes.

DESIGN

A discrete choice experiment (DCE) was conducted with five attributes extracted from the framework of Total Quality Management that can be applied in the design of hand hygiene interventions. They were hand hygiene monitoring, open discussion, message framing, resources accessibility and top management involvement. An addition attribute, peer hand hygiene performance, was considered as a contextual factor. Data were analysed by a conditional logit model to evaluate how these attributes impact HCWs' hand hygiene compliance.

SETTING

The DCE was conducted with participants from a university hospital in Taichung.

PARTICIPANTS

HCWs involved in daily patient-care activities (N=387).

RESULTS

To enhance their compliance, HCWs had strong and consistent preferences in having open discussion of hand hygiene problems ([Formula: see text], [Formula: see text]), easy access to hand hygiene resources ([Formula: see text], [Formula: see text]) and top management involvement ([Formula: see text], [Formula: see text]). For hand hygiene monitoring ([Formula: see text], [Formula: see text]), HCWs preferred to be monitored by infection control staff over their department head if their peer hand hygiene performance was low. On the other hand, when the peer performance was high, monitoring by their department head could improve their hand hygiene compliance. Similarly, how educational messages were framed impacted compliance and also depended on the peer hand hygiene performance. When the peer performance was low, HCWs were more likely to increase their compliance in reaction to loss-framed educational messages ([Formula: see text],[Formula: see text]). When the peer performance was high, gain-framed messages that focus on the benefit of compliance were more effective in inducing compliance.

CONCLUSIONS

Each intervention design has its unique impact on HCWs' hand hygiene compliant behaviour. The proposed approach can be used to evaluate HCWs' preference and compliance of an intervention before it is implemented.

Updates on Infection Control in Alternative Health Care Settings

Patients increasingly receive care from a large spectrum of different settings, placing them at risk for exposure to pathogens by many different sources. Each health care environment has its own specific challenges, and thus infection control programs must be tailored to each specific setting. High-turnover outpatient settings may require additional considerations, such as establishing patient triage and follow-up protocols, and broadened cleaning and disinfection procedures. In nursing homes, infection control programs should focus on surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs.

Hand-hygiene-related clinical trials reported between 2014 and 2020: a comprehensive systematic review

BACKGROUND

There is general consensus that hand hygiene is the most effective way to prevent healthcare-associated infections. However, low rates of compliance amongst healthcare workers have been reported globally. The coronavirus disease 2019 pandemic has further emphasized the need for global improvement in hand hygiene compliance by healthcare workers.

AIM

This comprehensive systematic review provides an up-to-date compilation of clinical trials, reported between 2014 and 2020, assessing hand hygiene interventions in order to inform healthcare leaders and practitioners regarding approaches to reduce healthcare-associated infections using hand hygiene.

METHODS

CINAHL, Cochrane, EMbase, Medline, PubMed and Web of Science databases were searched for clinical trials published between March 2014 and December 2020 on the topic of hand hygiene compliance among healthcare workers. In total, 332 papers were identified from these searches, of which 57 studies met the inclusion criteria.

FINDINGS

Forty-five of the 57 studies (79%) included in this review were conducted in Asia, Europe and the USA. The large majority of these clinical trials were conducted in acute care facilities, including hospital wards and intensive care facilities. Nurses represented the largest group of healthcare workers studied (44 studies, 77%), followed by physicians (41 studies, 72%). Thirty-six studies (63%) adopted the World Health Organization's multi-modal framework or a variation of this framework, and many of them recorded hand hygiene opportunities at each of the 'Five Moments'. However, recording of hand hygiene technique was not common.

CONCLUSION

Both single intervention and multi-modal hand hygiene strategies can achieve modest-to-moderate improvements in hand hygiene compliance among healthcare workers.

Physicians' compliance for hand hygiene in medical outpatient clinics: automated hand-hygiene monitoring with touch sensor and wireless internet

BACKGROUND

Outpatient clinics are reservoirs for significant pathogens. Hand hygiene with alcohol-based hand rubs are measures currently in use to prevent horizontal transmission of infections. The extent of compliance with hand hygiene regulations is unclear and difficult to monitor.

METHODS

We built an automated monitoring system with a pressure sensor attached to the alcohol-based hand rubs containers. Wireless fidelity (WIFI)-assisted data collection took place over 9 weeks. Interventions included posters, email reminders and newsletters. Hand hygiene compliance before and after these interventions was evaluated.

RESULTS

Overall compliance with hand hygiene regulations was 6.48%; half of the physicians participating in our study performed hand hygiene at only 3.08% of patient visits. Twenty-four (17.9%) physicians performed hand hygiene with high compliance (≥10%), while 11.2% performed no hand hygiene at all. Physicians in academic positions and those with ≥20 years of experience performed hand hygiene less frequently than did other physicians. Compliance with hand hygiene regulations improved from 6.08% to 6.73% (P < .001) after intervention.

DISCUSSION

Compliance with hand hygiene among physicians in our outpatient clinics was very low and needs to improve.

CONCLUSIONS

Interventions improved the compliance somewhat, although additional interventions including education, training and feedback were suggested.

The effect of behavioural interventions targeting hand hygiene practices among nurses in high-income hospital settings: a systematic review

BACKGROUND

Hand hygiene is a critical behaviour for infection control but efforts to raise compliance among clinical professionals have been met with mixed success. The aim of this systematic review was to identify the effectiveness of the behaviour change techniques utilised in recent hand hygiene interventions that seek to improve hand hygiene compliance among nurses in hospitals in high-income countries. Nurses are at the frontline of healthcare delivery, and so improving their HH behaviour and thus increasing HHC rates will have a relatively large impact on reducing transmission and preventing healthcare acquired infections.

METHODS

High-quality studies among nurses in high-income countries were surveyed from the scientific literature, following PRISMA guidelines, to identify which kinds of behaviour change mechanisms have been used to effectively increase hand hygiene compliance. Only seven studies met all inclusion criteria. A formal meta-analysis was not conducted due to the heterogeneity of the included studies. Instead, the review analysed studies in line with the Intervention Component Analysis approach to identify which differences in intervention characteristics appear to be important. Analysis proceeded in two steps: first, the Effective Practice and Organization of Care Data Extraction Checklist was used to identify the study design and to describe the intervention, target population, setting, results, outcome measures, and analytic approach. The second step involved inferring the behavioural change techniques used in the complex study interventions. Following coding, logic models were then inferred for each study to identify the Theory of Change behind each intervention. These Theories of Change were then examined for suggestions as to which BCTs were likely to have been responsible for any effectiveness observed.

RESULTS

Goals and planning (to achieve specific ends), comparison of behaviour (to peers or some ideal) and feedback and monitoring (observing and providing feedback about behaviour or outcomes) were the most frequently used behaviour change technique groupings used across studies and within interventions.

CONCLUSION

The complexity of the interventions used and lack of sufficient studies makes assignment of responsibility for behaviour change to specific behaviour change techniques difficult. Delivery channels and activities identified in the study Theories of Change were also highly individualized and so difficult to compare. However, we identified a temporal shift in types of techniques used in these recent studies on HH interventions, as compared with studies from prior to the review period. These newer interventions did not focus on providing access to alcohol-based hand rub or trying to solely encourage administrative support. Instead, they had nurses create goals and plan how to best facilitate HH, compared both individuals' and the group's behaviour to others, and focused on providing feedback.

Birth attendants' hand hygiene compliance in healthcare facilities in low and middle-income countries: a systematic review

Background

With an increasing number of women delivering in healthcare facilities in Low and Middle Income Countries (LMICs), healthcare workers’ hand hygiene compliance on labour wards is pivotal to preventing infections. Currently there are no estimates of how often birth attendants comply with hand hygiene, or of the factors influencing compliance in healthcare facilities in LMICs.

Methods

We conducted a systematic review to investigate the a) level of compliance, b) determinants of compliance and c) interventions to improve hand hygiene during labour and delivery among birth attendants in healthcare facilities of LMICs. We also aimed to assess the quality of the included studies and to report the intra-cluster correlation for studies conducted in multiple facilities.

Results

We obtained 797 results across four databases and reviewed 71 full texts. Of these, fifteen met our inclusion criteria. Overall, the quality of the included studies was particularly compromised by poorly described sampling methods and definitions. Hand hygiene compliance varied substantially across studies from 0 to 100%; however, the heterogeneity in definitions of hand hygiene did not allow us to combine or compare these meaningfully. The five studies with larger sample sizes and clearer definitions estimated compliance before aseptic procedures opportunities, to be low (range: 1–38%). Three studies described two multi-component interventions, both were shown to be feasible.

Conclusions

Hand hygiene compliance was low for studies with larger sample sizes and clear definitions. This poses a substantial challenge to infection prevention during birth in LMICs facilities. We also found that the quality of many studies was suboptimal. Future studies of hand hygiene compliance on the labour ward should be designed with better sampling frames, assess inter-observer agreement, use measures to improve the quality of data collection, and report their hand hygiene definitions clearly.

Promoting Hand Sanitizer Use in a University Cafeteria

Handwashing is the most cost-efficient method to lower the risk of the transmission of infectious diseases. Especially before eating in public places like cafeterias, handwashing is recommended. Often, people do not wash their hands before eating because of the response effort associated with going to the bathroom. As an alternative way to improve hygiene, disinfection with a hand sanitizer gel is recommended. The current study used an A-B-C-A design (and a no-intervention control site) with prompts and feedback to increase the number of cafeteria patrons using hand sanitizer. Dispensers for hand sanitizer gel were placed at the entrance area of two halls of a university cafeteria. Intervention took place in one hall, whereas the other served as a control. After baseline, a poster explaining the usefulness of hand sanitizing was posted near the entrance of the cafeteria. This led to a doubling of the percentage of cafeteria patrons using the hand sanitizer, from 10.79% during baseline to 24.45%. A second poster provided feedback about the percentage of patrons sanitizing their hands and asked for more participation. This led to no further increases in hand sanitizing (23.73%). After all posters were removed, the percentage dropped to 15.63% in the mean. This research demonstrated that a simple, informative prompt can have a considerable impact on hand-sanitizing behavior. However, the role of feedback in such interventions remains questionable.

COVID-19 and hand hygiene: the vital importance of hand drying

The significance of hand hygiene for preventing the transmission of microorganisms and reducing the spread of infection has been brought into sharp focus following the global coronavirus (COVID-19) pandemic. In the months since the initial outbreak, international public health campaigns and practitioner education has concentrated on hand washing and hand sanitising, with very little reference to hand drying, if any at all. However, hand drying is integral to effective hand hygiene, and is important in controlling the spread of microorganisms and maintaining healthy skin integrity. This research commentary will focus on two issues of importance with regards to hand drying: microbial transmission and skin irritation, with implications for healthcare practitioners and practice considered. It is argued that a more holistic approach to hand hygiene must be the ambition if health professional and public behaviour is to become embedded and sustained.

Simplifying the World Health Organization Protocol: 3 Steps Versus 6 Steps for Performance of Hand Hygiene in a Cluster-randomized Trial

BACKGROUND

In an experimental setting, a simplified, 3-step hand hygiene technique for applying alcohol-based hand rub was non inferior in terms of reduction of bacterial counts, as compared to the conventional World Health Organization 6-step technique. We therefore compared compliance and microbiological efficacy between both hand hygiene techniques in routine clinical practice.

METHODS

We performed a cluster-randomized trial from October-November 2015 at the University Hospital Basel, Switzerland: a tertiary, academic care center (ISRCTN45923734). We randomly assigned 12 wards to either the 3-step technique or the conventional 6-step technique of hand rubbing. The primary endpoints were compliance with the assigned technique and reduction of bacterial counts on the hands of health-care workers.

RESULTS

Overall, 2923 hand hygiene indications were observed, and compliance was 70.7% (2066/2923). Compliance with technique and indications was 51.7% (595/1151) and 75.9% (1151/1516) on wards assigned to the 3-step technique, respectively, as compared to 12.7% (116/915) and 65.0% (915/1407) on wards assigned to the 6-step technique (P < .001). The reduction factor (RF) of bacterial colony counts did not differ between techniques (median RF 0.97 log10 colony-forming units [CFU] [interquartile range 0.39-1.59] for the 3-step technique vs median RF 1.04 log10 CFU [interquartile range 0.49-1.52] for the 6-step technique; P = .629).

CONCLUSIONS

In a clinical setting, the simpler hand hygiene technique, consisting of 3 steps, resulted in higher compliance with both hand hygiene indications and technique, as compared to the 6 steps. As the results of the microbiological analyses exclude inferiority, the conventional 6 steps could be safely replaced by a simpler hand hygiene technique.

CLINICAL TRIALS REGISTRATION

ISRCTN45923734.

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.

Comparison of knowledge, attitudes and hand hygiene behavioral intention in medical and nursing students

Introduction

Hand hygiene is crucial to prevent cross infection. Healthcare students are in a prime position to learn hand hygiene skills. The aim of this study was to analyze hand hygiene behavioral intentions of healthcare students before and after contact with the patient and to compare the knowledge of and attitude towards hand hygiene between medical and nursing students.

Methods

In a descriptive survey research design, convenience selection of a sample of medical students (n=657) and nursing students (n=303) was done from modules taught by the Department of Preventive Medicine and Public Health in both Medicine and Nursing undergraduate degrees in four Spanish universities. The hand hygiene Questionnaire, a validated instrument to evaluate behavior, knowledge, and attitudes, was used.

Results

A significantly lower percentage of students reported always or almost always carrying out hand hygiene before contact with the patient or invasive procedures in comparison to the percentage complying after contact with secretions or with the patient. Although hand hygiene knowledge appears acceptable, its importance is not sufficiently valued.

Conclusions

There are deficiencies in behavioral intention, knowledge, and attitudes related to hand hygiene in medical and nursing students. Better results are observed among nursing students, especially those who have received specific training.

Hand hygiene promotion delivered by change agents-Two attitudes, similar outcome

OBJECTIVE

To assess the effect of peer-identified change agents (PICAs) compared to management-selected change agents (MSCAs) on hand hygiene behavior in acute care.

DESIGN

Randomized-controlled study.

SETTING

Two internal medicine wards of a public, university-affiliated, tertiary-care hospital in Malaysia.

METHODS

We randomly allocated 2 wards to hand hygiene promotion delivered either by PICAs (study arm 1) or by MSCAs (study arm 2). The primary outcome was hand hygiene compliance using direct observation by validated auditors. Secondary outcomes were hand hygiene knowledge and observations from ward tours.

RESULTS

Mean hand hygiene compliance in study arm 1 and study arm 2 improved from 48% (95% confidence interval [CI], 44%-53%) and 50% (95% CI, 44%-55%) in the preintervention period to 66% (63%-69%) and 65% (60%-69%) in the intervention period, respectively. We detected no statistically significant difference in hand hygiene improvement between the 2 study arms. Knowledge scores on hand hygiene in study arm 1 and study arm 2 improved from 60% and 63% to 98% and 93%, respectively. Staff in study arm 1 improved hand hygiene because they did not want to disappoint the efforts taken by the PICAs. Staff in study arm 2 felt pressured by the MSCAs to comply with hand hygiene to obtain good overall performance appraisals.

CONCLUSION

Although the attitude of PICAs and MSCAs in terms of leadership, mode of action and perception of their task by staff were very different, or even opposed, both PICAs and MSCAs effectively changed behavior of staff toward improved hand hygiene to comparable levels.

Moving beyond hand hygiene monitoring as a marker of infection prevention performance: Development of a tailored infection control continuous quality improvement tool

BACKGROUND

Infection control practice compliance is commonly monitored by measuring hand hygiene compliance. The limitations of this approach were recognized in 1 acute health care organization that led to the development of an Infection Control Continuous Quality Improvement tool.

METHODS

The Pronovost cycle, Barriers and Mitigation tool, and Hexagon framework were used to review the existing monitoring system and develop a quality improvement data collection tool that considered the context of care delivery.

RESULTS

Barriers and opportunities for improvement including ambiguity, consistency and feasibility of expectations, the environment, knowledge, and education were combined in a monitoring tool that was piloted and modified in response to feedback. Local adaptations enabled staff to prioritize and monitor issues important in their own workplace. The tool replaced the previous system and was positively evaluated by auditors. Challenges included ensuring staff had time to train in use of the tool, time to collect the audit, and the reporting of low scores that conflicted with a target-based performance system.

CONCLUSIONS

Hand hygiene compliance monitoring alone misses other important aspects of infection control compliance. A continuous quality improvement tool was developed reflecting specific organizational needs that could be transferred or adapted to other organizations.

"The role as a champion is to not only monitor but to speak out and to educate": the contradictory roles of hand hygiene champions

BACKGROUND

Implementation science experts define champions as "supporting, marketing, and driving through an implementation, overcoming indifference or resistance that the intervention may provoke in an organization." Many hospitals use designated clinical champions-often called "hand hygiene (HH) champions"-typically to improve hand hygiene compliance. We conducted an ethnographic examination of how infection control teams in the Veterans Health Administration (VHA) use the term "HH champion" and how they define the role.

METHODS

An ethnographic study was conducted with infection control teams and frontline staff directly involved with hand hygiene across 10 geographically dispersed VHA facilities in the USA. Individual and group semi-structured interviews were conducted with hospital epidemiologists, infection preventionists, multi-drug-resistant organism (MDRO) program coordinators, and quality improvement specialists and frontline staff from June 2014 to September 2017. The team coded the transcripts using thematic content analysis content based on a codebook composed of inductive and deductive themes.

RESULTS

A total of 173 healthcare workers participated in interviews from the 10 VHA facilities. All hand hygiene programs at each facility used the term HH champion to define a core element of their hand hygiene programs. While most described the role of HH champions as providing peer-to-peer coaching, delivering formal and informal education, and promoting hand hygiene, a majority also included hand hygiene surveillance. This conflation of implementation strategies led to contradictory responsibilities for HH champions. Participants described additional barriers to the role of HH champions, including competing priorities, staffing hierarchies, and turnover in the role.

CONCLUSIONS

Healthcare systems should consider narrowly defining the role of the HH champion as a dedicated individual whose mission is to overcome resistance and improve hand hygiene compliance-and differentiate it from the role of a "compliance auditor." Returning to the traditional application of the implementation strategy may lead to overall improvements in hand hygiene and reduction of the transmission of healthcare-acquired infections.

Hand hygiene - social network analysis of peer-identified and management-selected change agents

Background

Hand hygiene compliance can be improved by strategies fostering collaborative efforts among healthcare workers (HCWs) through change agents. However, there is limited information about how change agents shape the social networks of work teams, and how this relates to organisational culture. The objectives of this study were to describe the influence of peer-identified change agents (PICAs) and management-selected change agents (MSCAs) on hand hygiene, perception of their leadership style by peers, and the role of the organisational culture in the process of hand hygiene promotion.

Methods

This study, stratified in pre-, during, and post-intervention periods, was conducted between February 2017 and March 2018 in two wards at a tertiary care hospital in Malaysia. Hand hygiene promotion was facilitated either by PICAs (study arm 1) or MSCAs (study arm 2), and the two wards were randomly allocated to one of the two interventions. Outcomes were: 1) perceived leadership styles of PICAs and MSCAs by staff, vocalised during question and answer sessions; 2) the social network connectedness and communication patterns between HCWs and change agents by applying social network analysis; and 3) hand hygiene leadership attributes obtained from HCWs in the post-intervention period by questionnaires.

Results

Hand hygiene compliance in study arm 1 and study arm 2 improved by from 48% (95% CI: 44–53%) to 66% (63–69%), and from 50% (44–55%) to 65% (60–69%), respectively. There was no significant difference between the two arms. Healthcare workers perceived that PICAs lead by example, while MSCAs applied an authoritarian top-down leadership style. The organisational culture of both wards was hierarchical, with little social interaction, but strong team cohesion. Position and networks of both PICAs and MSCAs were similar and generally weaker compared to the leaders who were nominated by HCWs in the post-intervention period. Healthcare workers on both wards perceived authoritative leadership to be the most desirable attribute for hand hygiene improvement.

Conclusion

Despite experiencing successful hand hygiene improvement from PICAs, HCWs expressed a preference for the existing top-down leadership structure. This highlights the limits of applying leadership models that are not supported by the local organisational culture.

Effect of Frequency of Changing Point-of-Use Reminder Signs on Health Care Worker Hand Hygiene Adherence: A Cluster Randomized Clinical Trial

IMPORTANCE

Although hand hygiene (HH) is considered the most effective strategy for preventing hospital-acquired infections, HH adherence rates remain poor.

OBJECTIVE

To examine whether the frequency of changing reminder signs affects HH adherence among health care workers.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized clinical trial in 9 US Department of Veterans Affairs acute care hospitals randomly assigned 58 inpatient units to 1 of 3 schedules for changing signs designed to promote HH adherence among health care workers: (1) no change; (2) weekly; and (3) monthly. Hand hygiene rates among health care workers were documented at entry and exit to patient rooms during the baseline period from October 1, 2014, to March 31, 2015, of normal signage and throughout the intervention period of June 8, 2015, to December 28, 2015. Data analyses were conducted in April 2018.

INTERVENTIONS

Hospital units were randomly assigned into 3 groups: (1) no sign changes throughout the intervention period, (2) signs changed weekly, and (3) signs changed monthly.

MAIN OUTCOMES AND MEASURES

Hand hygiene adherence as measured by covert observation. Interrupted time series analysis was used to examine changes in HH adherence from baseline through the intervention period by group.

RESULTS

Among 58 inpatient units, 19 units were assigned to the no change group, 19 units were assigned to the weekly change group, and 20 units were assigned to the monthly change group. During the baseline period, 9755 HH opportunities were observed at room entry and 10 095 HH opportunities were observed at room exit. During the intervention period, a total of 15 855 HH opportunities were observed at room entry, and 16 360 HH opportunities were observed at room exit. Overall HH adherence did not change from baseline compared with the intervention period at either room entry (4770 HH events [48.9%] vs 3057 HH events [50.1%]; P = .14) or exit (6439 HH events [63.8%] vs 4087 HH events [65.2%]; P = .06). In units that changed signs weekly, HH adherence declined from baseline at room entry (-1.9% [95% CI, -2.7% to -0.8%] per week; P < .001) and exit (-0.8% [95% CI, -1.5% to 0.1%] per week; P = .02). No significant changes in HH adherence were observed in other groups.

CONCLUSIONS AND RELEVANCE

The frequency of changing reminder signs had no effect on HH rates overall. Units assigned to change signs most frequently demonstrated worsening adherence. Considering the abundance of signs in the acute care environment, the frequency of changing signs did not appear to provide a strong enough cue by itself to promote behavioral change.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02223455.

Interventions to improve healthcare workers' hand hygiene compliance: A systematic review of systematic reviews

OBJECTIVE

To synthesize the existing evidence base of systematic reviews of interventions to improve healthcare worker (HCW) hand hygiene compliance (HHC).

METHODS

PRISMA guidelines were followed, and 10 information sources were searched in September 2017, with no limits to language or date of publication, and papers were screened against inclusion criteria for relevance. Data were extracted and risk of bias was assessed.

RESULTS

Overall, 19 systematic reviews (n=20 articles) were included. Only 1 article had a low risk of bias. Moreover, 15 systematic reviews showed positive effects of interventions on HCW HHC, whereas 3 reviews evaluating monitoring technology did not. Findings regarding whether multimodal rather than single interventions are preferable were inconclusive. Targeting social influence, attitude, self-efficacy, and intention were associated with greater effectiveness. No clear link emerged between how educational interventions were delivered and effectiveness.

CONCLUSIONS

This is the first systematic review of systematic reviews of interventions to improve HCW HHC. The evidence is sufficient to recommend the implementation of interventions to improve HCW HHC (except for monitoring technology), but it is insufficient to make specific recommendations regarding the content or how the content should be delivered. Future research should rigorously apply behavior change theory, and recommendations should be clearly described with respect to intervention content and how it is delivered. Such recommendations should be tested for longer terms using stronger study designs with clearly defined outcomes.

The effect of eye images and a social norms message on healthcare provider hand hygiene adherence

BACKGROUND

Depictions of eye images and messages encouraging compliance with social norms have successfully motivated behavioral change in a variety of experimental and applied settings. We studied the effect of these 2 visual cues on hand hygiene adherence in a cohort of hospital-based healthcare providers participating in an electronic monitoring and feedback program.

METHODS

Prospective, quasi-experimental study utilizing an interrupted time-series design. Intervention placards depicting an image of eyes, a social norms message, or a control placard were placed near soap and alcohol-based hand-rub dispensers on 2 hospital units. Placards were alternated every 10 days. Hand hygiene opportunities and adherence rates were assessed electronically via the CenTrak Hand Hygiene Compliance Solution.

RESULTS

A total of 166 nurses and certified nursing assistants (74 on a medical-surgical unit and 92 on a progressive care unit) were monitored electronically over the 4-month study period. In total, 184,172 electronic observations were collected (110,903 on a medical-surgical unit and 73,269 on a progressive care unit). The median daily number of electronic observations was 1,471 (interquartile range, 1,337-1,584). The preintervention baseline hand hygiene adherence rate was 70%. No statistically significant increase in hand hygiene adherence was observed as a result of either intervention.

CONCLUSION

Displaying eye images or a social norms message in the hospital environment did not result in measurable improvements in HH adherence in a cohort of healthcare providers participating in an electronic monitoring and feedback program.

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.

Testing a novel audit and feedback method for hand hygiene compliance: A multicenter quality improvement study

OBJECTIVE

Although most hospitals report very high levels of hand hygiene compliance (HHC), the accuracy of these overtly observed rates is questionable due to the Hawthorne effect and other sources of bias. In the study, we aimed (1) to compare HHC rates estimated using the standard audit method of overt observation by a known observer and a new audit method that employed a rapid (&lt;15 minutes) "secret shopper" method and (2) to pilot test a novel feedback tool.

DESIGN

Quality improvement project using a quasi-experimental stepped-wedge design.

SETTING

This study was conducted in 5 acute-care hospitals (17 wards, 5 intensive care units) in the Midwestern United States.

METHODS

Sites recruited a hand hygiene observer from outside the acute-care units to rapidly and covertly observe entry and exit HHC during the study period, October 2016-September 2017. After 3 months of observations, sites received a monthly feedback tool that communicated HHC information from the new audit method.

RESULTS

The absolute difference in HHC estimates between the standard and new audit methods was ~30%. No significant differences in HHC were detected between the baseline and feedback phases (OR, 0.92; 95% CI, 0.84-1.01), but the standard audit method had significantly higher estimates than the new audit method (OR, 9.83; 95% CI, 8.82-10.95).

CONCLUSIONS

HHC estimates obtained using the new audit method were substantially lower than estimates obtained using the standard audit method, suggesting that the rapid, secret-shopper method is less subject to bias. Providing feedback using HHC from the new audit method did not seem to impact HHC behaviors.

Evaluation of Barriers to Audit-and-Feedback Programs That Used Direct Observation of Hand Hygiene Compliance: A Qualitative Study

IMPORTANCE

Audit and feedback based on direct observation is a common strategy to improve hand hygiene compliance, but the optimal design and delivery of this intervention are poorly defined.

OBJECTIVE

To describe barriers encountered by audit-and-feedback programs for hand hygiene across acute care hospitals within the Veterans Health Administration.

DESIGN, SETTING, AND PARTICIPANTS

A qualitative study was conducted at a geographically diverse convenience sample of 10 acute care hospitals within the Veterans Health Administration. Participants included 108 infection prevention team personnel and frontline staff. All data were collected between June 30, 2014, and March 18, 2015. Data were analyzed between September 6, 2017, and January 5, 2018.

MAIN OUTCOMES AND MEASURES

Barriers to audit and feedback for hand hygiene compliance were evaluated. Semistructured interviews of key personnel were performed through site visits at 6 locations and telephone interviews with 4 sites. Focus groups were conducted with frontline staff. Interviews and focus groups were audio recorded and transcribed. All transcripts were analyzed using thematic content analysis.

RESULTS

Overall, 108 individuals participated in the study. Semistructured interviews were conducted with 38 individuals, who were predominantly infection prevention team members. Focus group interviews were conducted with 70 frontline hospital staff members. Surveillance activities at all 10 sites made use of a variety of staff members with the intention of covertly collecting direct observations on hand hygiene compliance. Monitoring programs were challenging to maintain because of constraints on time and personnel. Both auditors and frontline staff expressed skepticism about the accuracy of compliance data based on direct observations. Auditors expressed concern about the Hawthorne effect, while frontline staff were worried that their compliance was not visible to auditors. In most hospitals, approaches to monitoring hand hygiene compliance produced friction between frontline staff and infection prevention teams. The feedback process for audit results did not consistently reach frontline staff and, in many hospitals, did not seem to facilitate improvement efforts.

CONCLUSIONS AND RELEVANCE

Auditing hand hygiene compliance with direct observation was problematic across these acute care hospitals. Auditing was perceived to collect inaccurate data and created tension with frontline staff, and the feedback process did not appear to encourage positive change. Strategies are needed to collect more reliable hand hygiene data and facilitate multidisciplinary collaboration toward improved compliance.

Effect of electronic real-time prompting on hand hygiene behaviors in health care workers

BACKGROUND

Poor hand hygiene by health care workers is a major cause of nosocomial infections. This research evaluated the ability of an electronic monitoring system with real-time prompting capability to change hand hygiene behaviors.

METHODS

Handwashing activity was measured by counting dispenser activations on a single nursing unit before, during, and after installation of the system. The effect of changing the prompt duration on hand hygiene performance was determined by a cluster-randomized trial on 3 nursing units with 1 acting as control. Sustainability of performance and participation was observed on 4 nursing units over a year. All staff were eligible to participate.

RESULTS

Between June 2015 and December 2016, a total of 459,376 hand hygiene opportunities and 330,740 handwashing events from 511 staff members were recorded. Dispenser activation counts were significantly influenced by use of the system (χ²[3] = 75.76; P < .0001). Hand hygiene performance dropped from 62.61% to 24.94% (odds ratio, 0.36; 95% confidence interval, 0.34-0.38) when the prompting feature was removed. Staff participation had a negative trajectory of -0.72% (P < .001), whereas change in average performance was -0.18% (P < .001) per week for the year.

CONCLUSIONS

Use of electronic monitoring with real-time prompts of 20 seconds' duration nearly doubles handwashing activity and causes handwashing to occur sooner after entering a patient room. These improvements are sustainable over a year.

How a smiley protects health: A pilot intervention to improve hand hygiene in hospitals by activating injunctive norms through emoticons

Hand hygiene practice in hospitals is unfortunately still widely insufficient, even though it is known that transmitting pathogens via hands is the leading cause of healthcare-associated infections. Previous research has shown that improving knowledge, providing feedback on past behaviour and targeting social norms are promising approaches to improve hand hygiene practices. The present field experiment was designed to direct people on when to perform hand hygiene and prevent forgetfulness. This intervention is the first to examine the effect of inducing injunctive social norms via an emoticon-based feedback system on hand hygiene behaviour. Electronic monitoring and feedback devices were installed in hospital patient rooms on top of hand-rub dispensers, next to the doorway, for a period of 17 weeks. In the emoticon condition, screens at the devices activated whenever a person entered or exited the room. Before using the alcohol-based hand-rub dispenser, a frowny face was displayed, indicating that hand hygiene should be performed. If the dispenser was subsequently used, this picture changed to a smiley face to positively reinforce the correct behaviour. Hand hygiene behaviour in the emoticon rooms significantly outperformed the behaviour in three other tested conditions. The strong effect in this field experiment indicates that activating injunctive norms may be a promising approach to improve hand hygiene behaviour. Theoretical and practical implications of these findings are discussed.

Iterative co-creation for improved hand hygiene and aseptic techniques in the operating room: experiences from the safe hands study

BACKGROUND

Hand hygiene and aseptic techniques are essential preventives in combating hospital-acquired infections. However, implementation of these strategies in the operating room remains suboptimal. There is a paucity of intervention studies providing detailed information on effective methods for change. This study aimed to evaluate the process of implementing a theory-driven knowledge translation program for improved use of hand hygiene and aseptic techniques in the operating room.

METHODS

The study was set in an operating department of a university hospital. The intervention was underpinned by theories on organizational learning, culture and person centeredness. Qualitative process data were collected via participant observations and analyzed using a thematic approach.

RESULTS

Doubts that hand-hygiene practices are effective in preventing hospital acquired infections, strong boundaries and distrust between professional groups and a lack of psychological safety were identified as barriers towards change. Facilitated interprofessional dialogue and learning in "safe spaces" worked as mechanisms for motivation and engagement. Allowing for the free expression of different opinions, doubts and viewing resistance as a natural part of any change was effective in engaging all professional categories in co-creation of clinical relevant solutions to improve hand hygiene.

CONCLUSION

Enabling nurses and physicians to think and talk differently about hospital acquired infections and hand hygiene requires a shift from the concept of one-way directed compliance towards change and learning as the result of a participatory and meaning-making process. The present study is a part of the Safe Hands project, and is registered with ClinicalTrials.gov (ID: NCT02983136 ). Date of registration 2016/11/28, retrospectively registered.

Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections

PURPOSE

To test the effectiveness of a central venous catheter (CVC) insertion strategy and a hand hygiene (HH) improvement strategy to prevent central venous catheter-related bloodstream infections (CRBSI) in European intensive care units (ICUs), measuring both process and outcome indicators.

METHODS

Adult ICUs from 14 hospitals in 11 European countries participated in this stepped-wedge cluster randomised controlled multicentre intervention study. After a 6 month baseline, three hospitals were randomised to one of three interventions every quarter: (1) CVC insertion strategy (CVCi); (2) HH promotion strategy (HHi); and (3) both interventions combined (COMBi). Primary outcome was prospective CRBSI incidence density. Secondary outcomes were a CVC insertion score and HH compliance.

RESULTS

Overall 25,348 patients with 35,831 CVCs were included. CRBSI incidence density decreased from 2.4/1000 CVC-days at baseline to 0.9/1000 (p < 0.0001). When adjusted for patient and CVC characteristics all three interventions significantly reduced CRBSI incidence density. When additionally adjusted for the baseline decreasing trend, the HHi and COMBi arms were still effective. CVC insertion scores and HH compliance increased significantly with all three interventions.

CONCLUSIONS

This study demonstrates that multimodal prevention strategies aiming at improving CVC insertion practice and HH reduce CRBSI in diverse European ICUs. Compliance explained CRBSI reduction and future quality improvement studies should encourage measuring process indicators.

The effects of care bundles on patient outcomes: a systematic review and meta-analysis

BACKGROUND

Care bundles are a set of three to five evidence-informed practices performed collectively and reliably to improve the quality of care. Care bundles are used widely across healthcare settings with the aim of preventing and managing different health conditions. This is the first systematic review designed to determine the effects of care bundles on patient outcomes and the behaviour of healthcare workers in relation to fidelity with care bundles.

METHODS

This systematic review is reported in line with the PRISMA statement for reporting systematic reviews and meta-analyses. A total of 5796 abstracts were retrieved through a systematic search for articles published between January 1, 2001, to February 4, 2017, in the Cochrane Central Register for Controlled Trials, MEDLINE, EMBASE, British Nursing Index, CINAHL, PsychInfo, British Library, Conference Proceeding Citation Index, OpenGrey trials (including cluster-randomised trials) and non-randomised studies (comprising controlled before-after studies, interrupted time series, cohort studies) of care bundles for any health condition and any healthcare settings were considered. Following the removal of duplicated studies, two reviewers independently screen 3134 records. Three authors performed data extraction independently. We compared the care bundles with usual care to evaluate the effects of care bundles on the risk of negative patient outcomes. Random-effect models were used to further explore the effects of subgroups.

RESULTS

In total, 37 studies (6 randomised trials, 31 controlled before-after studies) were eligible for inclusion. The effect of care bundles on patient outcomes is uncertain. For randomised trial data, the pooled relative risk of negative effects between care bundle and control groups was 0.97 [95% CI 0.71 to 1.34; 2049 participants]. The relative risk of negative patient outcomes from controlled before-after studies favoured the care bundle treated groups (0.66 [95% CI 0.59 to 0.75; 119,178 participants]). However, using GRADE, we assessed the certainty of all of the evidence to be very low (downgraded for risk of bias, inconsistency, indirectness).

CONCLUSIONS

Very low quality evidence from controlled before-after studies suggests that care bundles may reduce the risk of negative outcomes when compared with usual care. By contrast, the better quality evidence from six randomised trials is more uncertain.

TRIAL REGISTRATION

PROSPERO, CRD42016033175.

Interventions to Improve Hand Hygiene Compliance in the ICU: A Systematic Review

OBJECTIVES

To synthesize the literature describing interventions to improve hand hygiene in ICUs, to evaluate the quality of the extant research, and to outline the type, and efficacy, of interventions described.

DATA SOURCES

Systematic searches were conducted in November 2016 using five electronic databases: Medline, CINAHL, PsycInfo, Embase, and Web of Science. Additionally, the reference lists of included studies and existing review papers were screened.

STUDY SELECTION

English language, peer-reviewed studies that evaluated an intervention to improve hand hygiene in an adult ICU setting, and reported hand hygiene compliance rates collected via observation, were included.

DATA EXTRACTION

Data were extracted on the setting, participant characteristics, experimental design, hand hygiene measurement, intervention characteristics, and outcomes. Interventional components were categorized using the Behavior Change Wheel. Methodological quality was examined using the Downs and Black Checklist.

DATA SYNTHESIS

Thirty-eight studies were included. The methodological quality of studies was poor, with studies scoring a mean of 8.6 of 24 (SD= 2.7). Over 90% of studies implemented a bundled intervention. The most frequently employed interventional strategies were education (78.9%), enablement (71.1%), training (68.4%), environmental restructuring (65.8%), and persuasion (65.8%). Intervention outcomes were variable, with a mean relative percentage change of 94.7% (SD= 195.7; range, 4.3-1155.4%) from pre to post intervention.

CONCLUSIONS

This review demonstrates that best practice for improving hand hygiene in ICUs remains unestablished. Future research employing rigorous experimental designs, careful statistical analysis, and clearly described interventions is important.

Poor Hand Hygiene Procedure Compliance among Polish Medical Students and Physicians-The Result of an Ineffective Education Basis or the Impact of Organizational Culture?

Objective: The objective of the study was to examine the knowledge of Polish physicians and medical students about the role of hand hygiene (HH) in healthcare-associated infection (HAI) prevention. Study design: A survey was conducted using an author-prepared questionnaire, which was filled out on the first day of hospital work (or internship) by newly admitted physicians who had worked in other hospitals and students of different medical schools in Poland. Methods: 100 respondents participated in the study: 28 students, 18 medical interns and 54 physicians. Results: As many as 3/4 of physicians and students did not use the HH techniques correctly. The respondents declared that they perform HH in the following situations: 74.4% of respondents before an aseptic task; 60.8% before patient contact; 57.0% after patient contact; 11.5% after body fluid exposure risk, and only two respondents (1.1%) after contact with patient surroundings. 64% of respondents declared that their supervisor checked their knowledge of the HH technique when they were touching patients, but their supervisors checked the five instances for HH only in the case of 27 respondents (27%). Students experienced any control of HH in the workplace less often. Interns and physicians mentioned that the most important preventive action in HAI is HH, but for students it is the use of gloves. Conclusions: The level of knowledge and skills of physicians and students in the field of HH is insufficient. Deficiencies in skills and knowledge of HH were identified as early as at the level of the first internship.

Interventions to improve hand hygiene compliance in patient care

BACKGROUND

Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure. This is an update of a previously published review.

OBJECTIVES

To assess the short- and long-term success of strategies to improve compliance to recommendations for hand hygiene, and to determine whether an increase in hand hygiene compliance can reduce rates of health care-associated infection.

SEARCH METHODS

We conducted electronic searches of the Cochrane Register of Controlled Trials, PubMed, Embase, and CINAHL. We conducted the searches from November 2009 to October 2016.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series analyses (ITS) that evaluated any intervention to improve compliance with hand hygiene using soap and water or alcohol-based hand rub (ABHR), or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened citations for inclusion, extracted data, and assessed risks of bias for each included study. Meta-analysis was not possible, as there was substantial heterogeneity across studies. We assessed the certainty of evidence using the GRADE approach and present the results narratively in a 'Summary of findings' table.

MAIN RESULTS

This review includes 26 studies: 14 randomised trials, two non-randomised trials and 10 ITS studies. Most studies were conducted in hospitals or long-term care facilities in different countries, and collected data from a variety of healthcare workers. Fourteen studies assessed the success of different combinations of strategies recommended by the World Health Organization (WHO) to improve hand hygiene compliance. Strategies consisted of the following: increasing the availability of ABHR, different types of education for staff, reminders (written and verbal), different types of performance feedback, administrative support, and staff involvement. Six studies assessed different types of performance feedback, two studies evaluated education, three studies evaluated cues such as signs or scent, and one study assessed placement of ABHR. Observed hand hygiene compliance was measured in all but three studies which reported product usage. Eight studies also reported either infection or colonisation rates. All studies had two or more sources of high or unclear risks of bias, most often associated with blinding or independence of the intervention.Multimodal interventions that include some but not all strategies recommended in the WHO guidelines may slightly improve hand hygiene compliance (five studies; 56 centres) and may slightly reduce infection rates (three studies; 34 centres), low certainty of evidence for both outcomes.Multimodal interventions that include all strategies recommended in the WHO guidelines may slightly reduce colonisation rates (one study; 167 centres; low certainty of evidence). It is unclear whether the intervention improves hand hygiene compliance (five studies; 184 centres) or reduces infection (two studies; 16 centres) because the certainty of this evidence is very low.Multimodal interventions that contain all strategies recommended in the WHO guidelines plus additional strategies may slightly improve hand hygiene compliance (six studies; 15 centres; low certainty of evidence). It is unclear whether this intervention reduces infection rates (one study; one centre; very low certainty of evidence).Performance feedback may improve hand hygiene compliance (six studies; 21 centres; low certainty of evidence). This intervention probably slightly reduces infection (one study; one centre) and colonisation rates (one study; one centre) based on moderate certainty of evidence.Education may improve hand hygiene compliance (two studies; two centres), low certainty of evidence.Cues such as signs or scent may slightly improve hand hygiene compliance (three studies; three centres), low certainty of evidence.Placement of ABHR close to point of use probably slightly improves hand hygiene compliance (one study; one centre), moderate certainty of evidence.

AUTHORS' CONCLUSIONS

With the identified variability in certainty of evidence, interventions, and methods, there remains an urgent need to undertake methodologically robust research to explore the effectiveness of multimodal versus simpler interventions to increase hand hygiene compliance, and to identify which components of multimodal interventions or combinations of strategies are most effective in a particular context.

Impact of a Successful Speaking Up Program on Health-Care Worker Hand Hygiene Behavior

Background:

Health-care worker (HCW) hand hygiene (HH) is the cornerstone of efforts to reduce hospital infections but remains low. Real-time mitigation of failures can increase process reliability to > 95% but has been challenging to implement for HH.

Objective:

To sustainably improve HCW HH to > 95%.

Methods:

A hospital-wide quality improvement initiative to improve HH was initiated in February 2012. HCW HH behavior was measured by covert direct observation utilizing multiple-trained HCW volunteers. HH compliance was defined as correct HH performed before and after contact with the patient or the patient’s care area. Interventions focusing on leadership support, HCW knowledge, supply availability, and culture change were implemented using quality improvement science methodology. In February 2014, the hospital began the Speaking Up for Safety Program, which trained all HCWs to identify and mitigate HH failures at the moment of occurrence and addressed known barriers to speaking up.

Results:

Between January 1, 2012, and January 31, 2016, there were 30,514 HH observations, averaging 627 observations per month (9% attending physicians, 12% resident physicians, 46% nurses, 33% other HCW types). HCW HH gradually increased from 75% to > 90% by December 2014. After the Speaking Up for Safety Program, HCW HH has been > 95% for 20 months. Physician HH compliance has been above 90% for over a year.

Conclusion:

Creating a specific process for staff to speak up and prevent HH failures, as part of a multimodal improvement effort, can sustainably increase HCW HH above 95%.

Hand Hygiene: An Update

The medical field has long recognized the importance of hand hygiene in preventing health care-associated infections, yet studies indicate that this important task is performed only 40% of the time. Health care workers cite several barriers to optimal performance of hand hygiene, but the time required to perform this task is foremost among them. Introduction of alcohol-based hand rubs, bundled interventions, and incorporation of technologies designed to monitor and promote hand hygiene all represent promising advances in this field.

Patient engagement with surgical site infection prevention: an expert panel perspective

Despite remarkable developments in the use of surgical techniques, ergonomic advancements in the operating room, and implementation of bundles, surgical site infections (SSIs) remain a substantial burden, associated with increased morbidity, mortality and healthcare costs. National and international recommendations to prevent SSIs have been published, including recent guidelines by the World Health Organization, but implementation into clinical practice remains an unresolved issue. SSI improvement programs require an integrative approach with measures taken during the pre-, intra- and postoperative care from the numerous stakeholders involved. The current SSI prevention strategies have focused mainly on the role of healthcare workers (HCWs) and procedure related risk factors. The importance and influence of patient participation is becoming an increasingly important concept and advocated as a means to improve patient safety. Novel interventions supporting an active participative role within SSI prevention programs have not been assessed. Empowering patients with information they require to engage in the process of SSI prevention could play a major role for the implementation of recommendations. Based on available scientific evidence, a panel of experts evaluated options for patient involvement in order to provide pragmatic recommendations for pre-, intra- and postoperative activities for the prevention of SSIs. Recommendations were based on existing guidelines and expert opinion. As a result, 9 recommendations for the surgical patient are presented here, including a practice brief in the form of a patient information leaflet. HCWs can use this information to educate patients and allow patient engagement.

Hand hygiene among healthcare workers: A qualitative meta summary using the GRADE-CERQual process

BACKGROUND

Hand hygiene is considered an effective and potentially modifiable infection control behaviour among healthcare workers (HCW). Several meta-studies have been published that compare quantitatively expressed findings, but limited efforts have been made to synthesise qualitative research.

OBJECTIVES

This paper provides the first report of integrated findings from qualitative research reports on hand hygiene compliance among HCW worldwide that employs the GRADE-CERQual process of quality assessment.

METHODS

We conducted database searches and identified 36 reports in which authors conducted qualitative or mixed methods research on hand hygiene compliance among HCW. We used Dedoose analysis software to facilitate extraction of relevant excerpts. We applied the GRADE-CERQual process to describe relative confidence as high, moderate or low for nine aggregate findings.

FINDINGS

Highest confidence findings included that HCW believe they have access to adequate training, and that management and resource support are sometimes lacking. Individual, subjective criteria also influence hand hygiene.

DISCUSSION

These results suggest the need for further investigation into healthcare cultures that are perceived as supportive for infection control. Surveillance processes have potential, especially if information is perceived by HCW as timely and relevant.

Experiences of hand hygiene among acute care nurses: An interpretative phenomenological analysis

Objective:

Occurrences of healthcare-associated infections are associated with substantial direct and indirect costs. Improvement in hand hygiene among acute care nurses has potential to reduce incidence of healthcare-associated infections. Findings from reviews of intervention research have not conclusively identified components that are more or less efficient or effective. Much prior qualitative research has focused on descriptive analysis of policies and practices rather than providing interpretive explorations of how individuals’ perceptions of hygiene might drive practices.

Methods:

We conducted qualitative interview research with eight nurses in the United States who were employed in various patient-care roles. We analyzed the data using an interpretative phenomenological analysis methodology to explore how nurses described their perceptions of, and experiences with, hygiene. We developed themes that explored individual, workplace, and management influences on perception of hygiene.

Results:

Developed themes include practical hygiene, risky business, and hygiene on trial; the latter theme described the conflict between how nurses perceived their own hygiene practices and how they felt hospital management perceived these practices. Other findings included that participants distinguished between policy-mandated use of sanitizer and a personal sense of cleanliness; the latter was more likely to be associated with scrubbing or removal of contaminants than with use of protectants.

Conclusion:

While participants asserted support for facility hand hygiene policies, their behavior in certain instances might be mediated by broadly defined emergent situations and a belief that it is not currently possible to establish a causal link between an healthcare-associated infections and a specific individual or occurrence. Researchers and infection prevention practitioners might consider soliciting greater input from nurses in planning hand hygiene improvement interventions, to encourage ownership, and emphasizing detailed cases as training content to take advantage of individuals’ sensory responses to hygiene.