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

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.

Quality Indicators in Adult Critical Care Medicine

Quality indicators are increasingly used in the intensive care unit (ICU) to compare and improve the quality of delivered healthcare. Numerous indicators have been developed and are related to multiple domains, most importantly patient safety, care timeliness and effectiveness, staff well-being, and patient/family-centered outcomes and satisfaction. In this review, we describe pertinent ICU quality indicators that are related to organizational structure (such as the availability of an intensivist 24/7 and the nurse-to-patient ratio), processes of care (such as ventilator care bundle), and outcomes (such as ICU-acquired infections and standardized mortality rate). We also present an example of a quality improvement project in an ICU indicating the steps taken to attain the desired changes in quality measures.

Improving 'Hand-Hygiene Compliance' among the Health Care Personnel in the Special Newborn Care Unit

OBJECTIVES

To improve the hand-hygiene (HH) compliance among the health care personnel from 69 to 85% by 4 mo plan-do-study-act (PDSA) cycles, based on the WHO's five moments of hand hygiene and to study the impact of HH compliance upon the health care-associated infections (HAI) rate in the authors' special newborn care unit.

METHODS

HH compliance study was undertaken based on the prioritization matrix. The barriers to HH compliance were identified and evaluated using fishbone analysis. An operational team was formed, and measures for improvement were chalked out. The baseline score was recorded through observation. A total of three PDSA cycles were carried out. Appropriate education and counseling regarding the WHO's five moments of hand hygiene were taught to the health care personnel. Interventions such as posters and supply of nonmedicated liquid hand soap, autoclaved paper towels, and alcohol-based hand sanitizer were provided. The effect of interventions on HH compliance was assessed at the end of each PDSA cycle. HAI data were collected and compared with the previous records.

RESULTS

The HH compliance recorded during baseline, PDSA 1, PDSA 2, and PDSA 3 are respectively, as follows: 69% (16.75 ± 3.46), 74.58% (43.07 ± 7.50; p = 0.043), 63.75% (24.43 ± 5.16; p = 0.083), and 84.70% (47.45 ± 10.59; p = 0.014). The sum of HH scores from the three PDSA cycles when compared to the baseline is significant (p = 0.022). The HAI rate decreased from 13.81 to 1000 patient days to 10.43 per 1000 patient days (p = 0.566).

CONCLUSION

HH compliance among health care personnel can be improved through information, education, and communication with constant monitoring.

Improving compliance with isolation measures in the operating room: a prospective simulation study comparing the effectiveness and costs of simulation-based training vs video-based training

BACKGROUND

Different isolation measures are required according to the routes of transmission of pathogens. Few studies have compared different forms of hygiene training in terms of efficiency and/or improvement of perception towards hygiene measures. This study aimed to evaluate the benefits of different forms of isolation training in the operating room, and their respective effects on the perception of hygiene measures by comparing simulation training with video-based training.

METHODS

This multi-centre, prospective, randomized, controlled trial compared hygiene knowledge, psychological safety and perception of training among healthcare workers after in-centre simulation training and conventional video-based training.

RESULTS

Neither type of training led to a significant improvement in knowledge or perceived psychological safety (F=0.235, P=0.629, η2=0.003). Participants in the simulation group reported higher levels of willingness to speak up in the depicted scenario compared with participants who received video-based training. Participants perceived the simulation-based training significantly more positively than the video-based training.

CONCLUSION

Clear definition of the goals of training based on the pre-existing level of knowledge of the participants is crucial. For future studies, it would be interesting to investigate the long-term effect and continuing benefits concerning the implementation of hygiene regulations after different types of training.

Quality Improvement Project to Improve Hand Hygiene Compliance in a Level III Neonatal Intensive Care Unit

This quality improvement project aimed to improve hand hygiene (HH) compliance in a Level III Neonatal Intensive Care Unit. The project was conducted over three Plan-Do-Study-Act (PDSA) cycles, with each cycle lasting two months. The interventions included healthcare worker (HCW) education on HH, repetition of education, and immediate feedback to HCWs. Compliance data were collected through covert observations of HCWs in the NICU. The overall compliance rate increased from 31.56% at baseline to 46.64% after the third PDSA cycle. The HH compliance was noted to be relatively low after touching patient care surroundings, at entry and exit from the NICU main unit, before wearing gloves and after removing gloves, at baseline and throughout the three PDSA cycles. HCW education alone did not result in significant improvements, highlighting the need for additional interventions. The study underscores the importance of involving NICU leadership and providing immediate feedback to promote HH compliance. Further efforts should focus on addressing the false sense of security associated with glove usage among HCWs, individual rewards and involving the healthcare staff in the shared goal of increasing HH compliance. Consideration of workload metrics and their impact on compliance could steer future interventions.

Behaviour change interventions improve maternal and child nutrition in sub-Saharan Africa: A systematic review

Evidence that nutrition-specific and nutrition-sensitive interventions can improve maternal and child nutrition status in sub-Saharan Africa is inconclusive. Using behaviour change theory and techniques in intervention design may increase effectiveness and make outcomes more predictable. This systematic review aimed to determine whether interventions that included behaviour change functions were effective. Six databases were searched systematically, using MeSH and free-text terms, for articles describing nutrition-specific and nutrition-sensitive behaviour change interventions published in English until January 2022. Titles, abstracts and full-text papers were double-screened. Data extraction and quality assessments followed Centre for Reviews and Dissemination guidelines. Behaviour change functions of interventions were mapped onto the COM-B model and Behaviour Change Wheel. PROSPERO registered (135054). The search yielded 1193 articles: 79 articles met inclusion criteria, ranging from low (n = 30) to high (n = 11) risk of bias. Many that applied behaviour change theory, communication or counselling resulted in significant improvements in infant stunting and wasting, household dietary intake and maternal psychosocial measures. Interventions with >2 behaviour change functions (including persuasion, incentivisation, environmental restructuring) were the most effective. We recommend incorporating behaviour change functions in nutrition interventions to improve maternal and child outcomes, specifically drawing on the Behaviour Change Wheel, COM-B model (SORT B recommendation). To enhance the designs of these interventions, and ultimately improve the nutritional and psychosocial outcomes for mothers and infants in sub-Saharan Africa, collaborations are recommended between behaviour change and nutrition experts, intervention designers, policy makers and commissioners to fund and roll-out multicomponent behaviour change interventions.

Differences in observed and self-reported compliance with the 5 moments for hand hygiene as a function of healthcare workers' empathy

BACKGROUND

Hand hygiene at critical time-points (as established by the WHO model 'Five moments for hand hygiene') remains the leading measure for minimising the risk of healthcare-associated infections. While many interventions have been tested to improve hand hygiene compliance (HHC) of healthcare workers (HCWs), little is known about the relation between HHC and HCW empathy.

AIM

The aim of this study was to investigate the relation between moment-specific HHC rates and HCWs' empathy, at both individual and ward levels.

METHODS

HHC data was collected via observation and self-report, staffs' empathy levels were measured using an established questionnaire. The survey was conducted on 38 wards of three tertiary-care hospitals in Germany. Observation data was obtained via in-house observations which were conducted up to eight months before or after the survey.

FINDINGS

Evidence for the expected correlation between HCW empathy and moment-specific HHC was found for both observed HHC (Moment 1: r = .483, p = .031; Moment 2: r = 588, p = .006) and self-reported HHC (Moment 1: r = .093, p = .092; Moment 2: r = .145, p = .008). In analyses of variance the critical interaction effect between empathy (i.e., lower vs. higher empathy) and designated time-point of hand hygiene (i.e., before vs. after reference task) was also significant.

CONCLUSION

HCWs' empathy should be considered as an important factor in explaining differences between moment-specific HHC rates. In consequence, empathy comes into focus not only as a crucial factor for high-quality patient care, but as an important contributor to improving HHC, too.

What are the predictors of hand hygiene compliance in the intensive care unit? A cross-sectional observational study

Background:

Although appropriate hand hygiene (HH) practices are recognised as the most effective preventative strategy for infection, adherence is suboptimal. Previous studies in intensive care units (ICUs) have found differences in HH compliance between those moments that protect the patient, and those that protect the healthcare provider. However, such studies did not control for other variables known to impact HH compliance.

Aim:

To examine HH among healthcare workers (HCWs) in ICU settings, and identify whether there is a statistical difference in HH compliance between patient-protective and self-protective moments, while controlling for other variables known to influence HH compliance (i.e. professional role, unit and shift time).

Methods:

A cross-sectional observational study was conducted in four ICUs across three Irish hospitals. Compliance was assessed according to the WHO’s ‘five moments for hand hygiene’. HCW professional role, total number of ‘opportunities’ for HH and whether compliance was achieved were recorded.

Results:

A total of 712 HH opportunities were recorded, with an overall compliance rate of 56.9%. Logistic regression analysis revealed that physicians, allied healthcare professionals and auxiliary staff were less likely than nurses to engage in HH. HCWs were more likely to comply during night shifts compared to morning shifts, and with self-protective as compared to patient-protective HH moments.

Conclusion:

The information provided in this study provides a data-driven approach that ICUs can use to tailor HH interventions to where, when and for whom they are most required.

Long-term effectiveness evaluation of an action-research intervention to improve hand hygiene in an intensive care unit

OBJECTIVES

To evaluate the long-term effectiveness of an action research intervention aimed at improving hand hygiene in an intensive care unit of a public hospital in Italy.

METHODS

An observational, prospective before-after study was carried out.Compliance with hand hygiene was estimated by measuring the utilization of hand hygiene products before the intervention and four years after the end of the project. Products used were the following: detergent liquid soap, antiseptic liquid soap and alcohol-based hand gel. Endpoints were quantity consumed (in grams) for each product category. Quantitative consumptions per workshift were compared.

RESULTS

In 2017 the median consumption of antiseptic liquid soap and alcohol-based hand gel per workshift was significantly higher than in 2012 (111.5 g vs 72.5 g, p = 0.014, and 18.0 g vs 5.0 g, p < 0.001). Odds in favour of a higher value in 2017 were 1.99:1 (CI95%: 1.19:1 to 3.73:1) for antiseptic solution, and 5.39:1 (CI95%: 3.09:1 to 13.61:1) for antiseptic gel. Covariates were not associated with consumption of products, and this made it possible to compare the measurements in the two data collections.

CONCLUSIONS

Results of this study support the long-term effectiveness of the action research intervention to improve practices of hand hygiene in an intensive care setting.

The role of metformin on lung cancer survival: the first systematic review and meta-analysis of observational studies and randomized clinical trials

PURPOSE

To assess the effects of metformin use on lung cancer (LC) survival according to summarized results from observational studies (OBs) and randomized clinical trials (RCTs).

METHODS

We systematically searched electronic databases and, to our knowledge, for the first time, RCTs were included in a systematic review and meta-analysis about the role of metformin on LC survival. We carried out meta-analyses separately for OBs and RCTs. Analyses for overall survival (OS) concerning OBs were stratified by studies with and without time-dependent approach. Subgroup analyses were adopted for OBs to identify the sources of heterogeneity. Included studies were assessed for quality.

RESULTS

We identified ten OBs and four RCTs. For OBs, metformin use was associated with improved OS for LC patients. Only two studies used time-dependent approach in which a higher ratio was found when compared to the non-use of the time-dependent analysis in eight studies. OBs were classified as high quality but the risk of bias was "unclear" in eight OBs due to absence of the time-dependent analysis. For RCTs, metformin use was not beneficial for OS and neither for progression-free survival. Heterogeneous quality was found among RCTs. Sources of bias that could alter significantly the results or raise doubts were identified in RCTs.

CONCLUSION

Time-dependent analysis should be considered an appropriate strategy for OBs focused on the metformin use for LC patients' survival, and further studies applying this approach are required. More well-designed RCTs are needed to provide consistent results for the association between metformin use and LC survival.

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.

Identifying interventions to improve hand hygiene compliance in the intensive care unit through co-design with stakeholders

Background: Despite the effectiveness of hand hygiene (HH) for infection control, there is a lack of robust scientific data to guide how HH can be improved in intensive care units (ICUs).  The aim of this study is to use the literature, researcher, and stakeholder opinion to explicate potential interventions for improving HH compliance in the ICU, and provide an indication of the suitability of these interventions. Methods: A four-phase co-design study was designed. First, data from a previously completed systematic literature review was used in order to identify unique components of existing interventions to improve HH in ICUs. Second, a workshop was held with a panel of 10 experts to identify additional intervention components. Third, the 91 intervention components resulting from the literature review and workshop were synthesised into a final list of 21 hand hygiene interventions. Finally, the affordability, practicability, effectiveness, acceptability, side-effects/safety, and equity of each intervention was rated by 39 stakeholders (health services researchers, ICU staff, and the public). Results: Ensuring the availability of essential supplies for HH compliance was the intervention that received most approval from stakeholders. Interventions involving role models and peer-to-peer accountability and support were also well regarded by stakeholders. Education/training interventions were commonplace and popular. Punitive interventions were poorly regarded. Conclusions: Hospitals and regulators must make decisions regarding how to improve HH compliance in the absence of scientific consensus on effective methods. Using collective input and a co-design approach, the guidance developed herein may usefully support implementation of HH interventions that are considered to be effective and acceptable by stakeholders.

Identifying interventions to improve hand hygiene compliance in the intensive care unit through co-design with stakeholders

Background: Despite the effectiveness of hand hygiene (HH) for infection control, there is a lack of robust scientific data to guide how HH can be improved in intensive care units (ICUs).  The aim of this study is to use the literature, researcher, and stakeholder opinion to explicate potential interventions for improving HH compliance in the ICU, and provide an indication of the suitability of these interventions. Methods: A four-phase co-design study was designed. First, data from a previously completed systematic literature review was used in order to identify unique components of existing interventions to improve HH in ICUs. Second, a workshop was held with a panel of 10 experts to identify additional intervention components. Third, the 91 intervention components resulting from the literature review and workshop were synthesised into a final list of 21 hand hygiene interventions. Finally, the affordability, practicability, effectiveness, acceptability, side-effects/safety, and equity of each intervention was rated by 39 stakeholders (health services researchers, ICU staff, and the public). Results: Ensuring the availability of essential supplies for HH compliance was the intervention that received most approval from stakeholders. Interventions involving role models and peer-to-peer accountability and support were also well regarded by stakeholders. Education/training interventions were commonplace and popular. Punitive interventions were poorly regarded. Conclusions: Hospitals and regulators must make decisions regarding how to improve HH compliance in the absence of scientific consensus on effective methods. Using collective input and a co-design approach, the guidance developed herein may usefully support implementation of HH interventions that are considered to be effective and acceptable by stakeholders.

Vaccination and the Prevention of Communicable Diseases in Healthcare Settings: Lessons from the Covid-19 Pandemic

With the number of Covid cases and Covid-related deaths continuing unabated, achieving a high vaccination coverage is essential to ensure the safety of staff and patients and resume normal hospital care admissions and operations. This article questions current strategies around vaccination in healthcare settings and proposes ways to understand and address vaccination hesitancy among staff. It offers insights on how to develop a multifaceted vaccination strategy, which takes into consideration vaccination hesitancy among healthcare professionals and community-specific factors. Drawing from social psychological theories, we suggest that the root of vaccination hesitancy lies in conflicting representations or cognitive polyphasia. In addition, we argue that current communication strategies mostly rely on rational arguments and ignores the importance of a more emotion-based approach.

Observation of Hand Hygiene Practices in Home Health Care

OBJECTIVE

To describe nurse hand hygiene practices in the home health care (HHC) setting, nurse adherence to hand hygiene guidelines, and factors associated with hand hygiene opportunities during home care visits.

DESIGN

Observational study of nurse hand hygiene practices.

SETTING

and Participants: Licensed practical/vocational and registered nurses were observed in the homes of patients being served by a large nonprofit HHC agency.

METHODS

Two researchers observed 400 home care visits conducted by 50 nurses. The World Health Organization's "5 Moments for Hand Hygiene" validated observation tool was used to record opportunities and actual practices of hand hygiene, with 3 additional opportunities specific to the HHC setting. Patient assessment data available in the agency electronic health record and a nurse demographic questionnaire were also collected to describe patients and nurse participants.

RESULTS

A total of 2014 opportunities were observed. On arrival in the home was the most frequent opportunity (n = 384), the least frequent was after touching a patient's surroundings (n = 43). The average hand hygiene adherence rate was 45.6% after adjusting for clustering at the nurse level. Adherence was highest after contact with body fluid (65.1%) and lowest after touching a patient (29.5%). The number of hand hygiene opportunities was higher when patients being served were at increased risk of an infection-related emergency department visit or hospitalization and when the home environment was observed to be "dirty." No nurse or patient demographic characteristics were associated with the rate of nurse hand hygiene adherence.

CONCLUSIONS AND IMPLICATIONS

Hand hygiene adherence in HHC is suboptimal, with rates mirroring those reported in hospital and outpatient settings. The connection between poor hand hygiene and infection transmission has been well studied, and it has received widespread attention with the outbreak of SARS-CoV-2. Agencies can use results found in this study to better inform quality improvement initiatives.

Surgical handwashing practices of operating room staff: An observational study

OBJECTIVE

This descriptive and cross-sectional study aims to assess the surgical handwashing practices of operating room staff.

DESIGN

Single-blind study.

METHODS

The study was conducted with 66 staff (surgeons and operating room nurses) employed in the surgery department of a university hospital in Turkey. Data were collected using a Staff Information Form prepared in light of the literature to collect the participants' sociodemographic data and the Surgical Hand Washing Procedure Checklist developed according to the guidelines of the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO) and Association of Surgical Technologists (AST). The staff assigned to operating rooms were identified, and then, their surgical handwashing practices were observed by one of the researchers.

FINDINGS

Of the participants, 77.3% were dressed suitable to the operating room field, 56.1% appropriately wet both of their hands and forearms, and 72.7% used a sufficient amount of antiseptic solution (3-5 ml) in their palms. More than half of them (51.5%) inappropriately performed the procedure of surgical handwashing (applying an antiseptic solution to hands and arms with circular motions, starting from the fingertips up to 3-5 cm above their elbows for a minute), and 47% incorrectly performed the procedure of rinsing hands and arms while keeping the hands above the elbows under running water and passing arms through the water in one direction during this process.

CONCLUSION

In the study, it was determined that none of the team members completed the preparation, application and drying steps of the surgical handwashing procedure. Therefore, it is necessary to make arrangements that will facilitate the handwashing procedures of the personnel. Personnel-related problems, such as the duration of washing and drying methods, are possible to be avoided with periodic in-service training and with posters demonstrating the washing stages, which might lead to behavioural changes.

Development of a behaviour change intervention using a theory-based approach, Behaviour Centred Design, to increase nurses' hand hygiene compliance in the US hospitals

BACKGROUND

A behaviour change campaign is unlikely to be effective if its intervention is not carefully designed. While numerous frameworks are widely used to develop and evaluate interventions, the steps detailing how to create an intervention are not as clear because the process of linking behaviour analysis to the intervention design is seldom discussed. We document the application of the Behaviour Centred Design (BCD) approach to the development of an intervention to improve hand hygiene (HH) rates among nurses' hospital units in the USA.

METHODS

Intervention development is divided into the first three steps of the BCD approach: Assess, Build, and Create. The Assess step centres on understanding the target behaviour. The Build step expands the knowledge of the target behaviour and population through formative research which leads to a creative brief that explains the focus of the intervention. In the Create step, the creative brief guides the intervention design.

RESULTS

Drawing from the main findings of the Asses and Build steps, a focal insight was developed positing that nurses can rediscover the meaning and purpose of their role as a nurse and thus as a caregiver by practicing HH; in the process of cleaning their hands, nurses are living up to their ideal nurse-self. The focal insight was linked linguistically into a theory and change. The outcome was a simple intervention, called the Mainspring Intervention, which consisted of three major parts: a self-affirmation exercise to reduce defensiveness, a message that challenged nurses' perceptions about their HH practice, and an implementation intention activity to help nurses link HH behaviour to a cue.

CONCLUSIONS

We detailed the creation of an original HH intervention that used the BCD approach. The intervention is relatively simple compared to most HH initiatives in the literature, both in terms of having relatively few components to the intervention and relatively easy field implementation. This intervention will allow us to test how specific psychological processes contribute to the problem of low HH rates, how our proposed intervention changes these processes in the hospital setting, and how the expected change in nurses' cognition transforms over time because of the intervention.

Compliance measurement and observed influencing factors of hand hygiene based on COVID-19 guidelines in China

BACKGROUND

Higher requirement is put forward in the measurement of hand hygiene (HH) during a pandemic. This study aimed to describe HH compliance measurement and explore observed influencing factors with respect to coronavirus disease 2019 (COVID-19) guidelines in China.

METHODS

Compliance was measured as the percentage of compliant opportunities based on criteria for 17 moments. The criteria for compliance included HH behavior, procedure, duration, hand drying method, and the overall that counts them all. The observed influencing factors included different departments and areas and protection motivation. Descriptive analysis and logistic regression were performed.

RESULTS

The compliance of overall criteria, HH behavior, procedure, duration, and hand drying method were 79.44%, 96.71%, 95.74%, 88.93%, and 88.42%, respectively, which were significantly different from each other (P < .001). Meanwhile, the overall and hand drying method compliance in semi-contaminated areas (odds ratio [OR] = 1.829, P < .001; OR = 2.149, P = .001) and hygienic areas (OR = 1.689, P = .004; OR = 1.959, P = .015) were significantly higher than those in contaminated area. The compliance with HH behavior for the motivation of patient-protection (OR = 0.362, P < .001) was lower than that for the motivation of self-protection.

CONCLUSIONS

HH compliance was firstly measured using different criteria for 17 moments according to COVID-19 guidelines in China. The measurement of HH compliance needs clearer definition and comprehensive practice. Contaminated areas and motivation of patient-protection contribute to lower compliance, which may be addressed by allocating more human resources and increasing supervision and education.

[Infection control training for physicians to improve hand hygiene on surgical rounds : The more the better?]

BACKGROUND AND OBJECTIVE

A high level of hand hygiene compliance is the best way to prevent postoperative wound infections and is therefore an important starting point for interventions. Despite different campaigns the hand hygiene compliance of physicians remains to be improved. The aim was to analyze the effect of tailored and innovative interventions on the hand hygiene compliance of physicians.

METHODS

At first the hand hygiene compliance of physicians was monitored during their ward rounds at three different wards. Afterwards two different interventions were performed and 6 weeks after each intervention the hand hygiene compliance was monitored again.

RESULTS

The hand hygiene compliance of the control group (no intervention) did not change throughout the study. The ward where a small intervention was used showed an increase of hand hygiene compliance. Tailored intervention, however, resulted in a significant improvement of hand hygiene compliance in the ward where it was used.

DISCUSSION AND PROSPECTS

Training concerning hand hygiene has to be improved to increase the prevention of infections. Tailored interventions with a high amount of practical relevance are suited to increase the compliance with preventive procedures (e.g. hand hygiene compliance). To improve the infection prevention for physicians in the long term, a firm knowledge about the indications for hand hygiene procedures is needed. This can be ensured by infection control training with a practical focus, small memory aids and permanent support from infection prevention professionals.

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.

Understanding hand hygiene behaviour in the intensive care unit to inform interventions: an interview study

BACKGROUND

Improving hand hygiene (HH) compliance is one of the most important, but elusive, goals of infection control. The purpose of this study was to use the capability (C), opportunity (O), motivation (M), and behaviour (B; COM-B) model and the theoretical domains framework (TDF) to gain an understanding of the barriers and enablers of HH behaviours in an intensive care unit (ICU) in order to identify specific interventions to improve HH compliance.

METHODS

A semi-structured interview schedule was developed based upon the COM-B model. This schedule was used to interview a total of 26 ICU staff: 12 ICU nurses, 11 anaesthetic specialist registrars, and three anaesthetic senior house officers.

RESULTS

Participants were confident in their capabilities to carry out appropriate HH behaviours. The vast majority of participants reported having the necessary knowledge and skills, and believed they were capable of carrying out appropriate HH behaviours. Social influence was regarded as being important in encouraging HH compliance by the interviewees- particularly by nurses. The participants were motivated to carry out HH behaviours, and it was recognised that HH was an important part of their job and is important in preventing infection. It is recommended that staff are provided with targeted HH training, in which individuals receive direct and individualised feedback on actual performance and are provided guidance on how to address deficiencies in HH compliance at the bedside at the time at which the HH behaviour is performed. Modelling of appropriate HH behaviours by senior leaders is also suggested, particularly by senior doctors. Finally, appropriate levels of staffing are a factor that must be considered if HH compliance is to be improved.

CONCLUSIONS

This study has demonstrated that short interviews with ICU staff, founded on appropriate behavioural change frameworks, can provide an understanding of HH behaviour. This understanding can then be applied to design interventions appropriately tailored to the needs of a specific unit, which will have an increased likelihood of improving HH compliance.

Multidisciplinary Quality Improvement Intervention to Achieve Sustained Improvement in Hand Hygiene Reliability in a Pediatric Intensive Care Unit

Suboptimal hand hygiene (HH) remains a significant modifiable cause of healthcare-associated infections in the intensive care unit. We report a single-center, quality improvement project aimed at improving adherence to optimal HH among physicians, nurse practitioners, and nursing staff, and to sustain any improvement over time.

Addressing Hand Hygiene Compliance in a Low-Resource Neonatal Intensive Care Unit: a Quality Improvement Project

OBJECTIVE

Our goal for this study was to quantify healthcare provider compliance with hand hygiene protocols and develop a conceptual framework for increasing hand hygiene compliance in a low-resource neonatal intensive care unit.

MATERIALS AND METHODS

We developed a 3-phase intervention that involved departmental discussion, audit, and follow-up action. A 4-month unobtrusive audit during night and day shifts was performed. The audit results were presented, and a conceptual framework of barriers to and solutions for increasing hand hygiene compliance was developed collectively.

RESULTS

A total of 1308 hand hygiene opportunities were observed. Among 1227 planned patient contacts, hand-washing events (707 [58.6%]), hand rub events (442 [36%]), and missed hand hygiene (78 [6.4%]) events were observed. The missed hand hygiene rate was 20% during resuscitation. Missed hand hygiene opportunities occurred 3.2 times (95% confidence interval, 1.9-5.3 times) more often during resuscitation procedures than during planned contact and 6.14 times (95% confidence interval, 2.36-16.01 times) more often when providers moved between patients. Structural and process determinants of hand hygiene noncompliance were identified through a root-cause analysis in which all members of the neonatal intensive care unit team participated. The mean hand-washing duration was 40 seconds. In 83% of cases, drying hands after washing was neglected. Hand recontamination after hand-washing was seen in 77% of the cases. Washing up to elbow level was observed in 27% of hand-wash events. After departmental review of the study results, hand rubs were placed at each bassinet to address these missed opportunities.

CONCLUSIONS

Hand hygiene was suboptimal during resuscitation procedures and between patient contacts. We developed a conceptual framework for improving hand hygiene through a root-cause analysis.

Improving Hand Hygiene Practices to Reduce CLABSI Rates: Nurses Education Integral for Success

How to cite this article: Myatra SN. Improving Hand Hygiene Practices to Reduce CLABSI Rates: Nurses Education Integral for Success. Indian J Crit Care Med 2019;23(7):291-293.

Impact of Nursing Education on CLABSI Rates: An Experience from a Tertiary Care Hospital in Eastern India

BACKGROUND AND AIMS

Central line associated bloodstream infections (CLABSI) have a higher incidence in the intensive care units of developing countries.

MATERIALS AND METHODS

The baseline CLABSI rate in intensive care unit (ICU) was evaluated for 6 months. An educational program for nurses on basic hand hygiene steps was conducted. Objective assessment tests were done to assess their knowledge and percentage of non-compliance with hand hygiene practice. CLABSI rate over the post-intervention 6 month period was assessed.

RESULTS

Thirty-four nurses were enrolled. The pre-intervention CLABSI rate was 12.5 per 1000 catheter days, pretest score 15.9 +/- 3.35 and 53.4% opportunities for hand hygiene were missed. Post workshop, there was significant (p=0.02) decrease in CLABSI rate i.e. 8.6, improvement in test score 17.76 +/- 2.1 (p=0.011) and missed opportunities decreased to 33.75%. 6 months post intervention, percentage of noncompliance with hand hygiene practice were 51.75% and test score was 17 ± 2.

DISCUSSION

The effectiveness of educational program on hand hygiene compliance was reflected in the improvement of posttest score, reduced number of missed opportunities and reduction of CLABSI rates in ICU. The posttest scores and hand hygiene compliance, however, decreased 6 months post-intervention necessitating repeated feedbacks and reminders.

CONCLUSION

Educational interventions on hand hygiene can have a significant impact in CLABSI control particularly in ICUs with a high infection rate and resource constraints.

HOW TO CITE THIS ARTICLE

Acharya Ranjita, Mishra SB, Ipsita S, Azim A. Impact of Nursing Education on CLABSI Rates: An Experience from a Tertiary Care Hospital in Eastern India. Indian J Crit Care Med 2019;23(7):316-319.

Impact of strategic planning, organizational culture imprint and care bundles to reduce adverse events in the ICU

OBJECTIVE

To evaluate the occurrence of adverse events during a multifaceted program implementation.

DESIGN

Cross-sectional secondary analysis.

SETTING

The respiratory-ICU of a large tertiary care center.

PARTICIPANTS

Retrospectively collected data of patients admitted from 1 March 2010 to 28 February 2014 (usual care period) and from 1 March 2014 to 1 March 2017 (multifaceted program period) were used.

INTERVENTIONS

The program integrated three components: (1) strategic planning and organizational culture imprint; (2) training and practice and (3) implementation of care bundles. Strategic planning redefined the respiratory-ICU Mission and Vision, its SWOT matrix (strengths, weaknesses, opportunities, threats) as well as its medium to long-term aims and planned actions. A 'Wear the Institution's T-shirt' monthly conference was given in order to foster organizational culture in healthcare personnel. Training was conducted on hand hygiene and projects 'Pneumonia Zero' and 'Bacteremia Zero'. Finally, actions of both projects were implemented.

MAIN OUTCOME MEASURES

Rates of adverse events (episodes per 1000 patient/days).

RESULTS

Out of 1662 patients (usual care, n = 981; multifaceted program, n = 681) there was a statistically significant reduction during the multifaceted program in episodes of accidental extubation ([Rate ratio, 95% CI] 0.31, 0.17-0.55), pneumothorax (0.48, 0.26-0.87), change of endotracheal tube (0.17, 0.07-0.44), atelectasis (0.37, 0.20-0.68) and death in the ICU (0.82, 0.69-0.97).

CONCLUSIONS

A multifaceted program including strategic planning, organizational culture imprint and care protocols was associated with a significant reduction of adverse events in the respiratory-ICU.

Nurses' And Patients' Appraisals Show Patient Safety In Hospitals Remains A Concern

The Institute of Medicine concluded in To Err Is Human in 1999 that transformation of nurse work environments was needed to reduce patient harm. We studied 535 hospitals in four large states at two points in time between 2005 and 2016 to determine the extent to which their work environments improved, and whether positive changes were associated with greater progress in patient safety. Survey data from thousands of nurses and patients showed that patient safety remains a serious concern. Only 21 percent of study hospitals showed sizable improvements (of more than 10 percent) in work environment scores, while 7 percent had worse scores. For hospitals in which clinical care environments improved, patients and nurses reported improvements in patient safety indicators. These included increases in percentages of patients rating their hospital favorably (a change of 11 percent) and stating that they would definitely recommend the hospital (8 percent) and in percentages of nurses reporting excellent quality of care (15 percent) and giving the hospital a favorable grade on patient safety (15 percent). Where work environments deteriorated, fewer nurses (-19 percent) gave a favorable grade on patient safety. Failure to improve hospital work environments may be hampering progress on patient safety.

How often are health care personnel hands colonized with multidrug- resistant organisms? A systematic review and meta-analysis

BACKGROUND

Hands of health care personnel (HCP) can transmit multidrug-resistant organisms (MDROs), resulting in infections. Our aim was to determine MDRO prevalence on HCP hands in adult acute care and nursing facility settings.

METHODS

A systematic search of PubMed/MEDLINE, Web of Science, CINAHL, Embase, and Cochrane CENTRAL was performed. Studies were included if they reported microbiologic culture results following HCP hands sampling; included prevalent MDROs, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, Clostridium difficile, Acinetobacter baumannii, or Pseudomonas aeruginosa, and were conducted in acute care or nursing facility settings.

RESULTS

Fifty-nine articles comprising 6,840 hand cultures were included. Pooled prevalence for MRSA, P aeruginosa, A baumannii, and vancomycin-resistant Enterococcus were 4.26%, 4.59%, 6.18%, and 9.03%, respectively. Substantial heterogeneity in rates of pathogen isolation were observed across studies (I² = 81%-95%). Only 4 of 59 studies sampled for C difficile, with 2 of 4 finding no growth. Subgroup analysis of MRSA revealed the highest HCP hand contamination rates in North America (8.28%). Sample collection methods used were comparable for MRSA isolation (4%-7%) except for agar direct contact (1.55%).

CONCLUSIONS

Prevalence of common MDROs on HCP hands vary by pathogen, care setting, culture acquisition method, study design, and geography. When obtained at an institutional level, these prevalence data can be utilized to enhance knowledge, practice, and research to prevent health care-associated infections.

Impact of psychologically tailored hand hygiene interventions on nosocomial infections with multidrug-resistant organisms: results of the cluster-randomized controlled trial PSYGIENE

Background

Professional hand hygiene compliance represents a multifaceted behaviour with various determinants. Thus, it has been proposed to apply psychological frameworks of behaviour change to its promotion. However, randomized controlled trials of such approaches, which also assess nosocomial infections (NIs), are rare. This study analyses data of the PSYGIENE-trial (PSYchological optimized hand hyGIENE promotion), which has shown improvements in compliance after interventions tailored based on the Health Action Process Approach (HAPA), on rates of NIs with multidrug-resistant organisms (MDROs).

Methods

A parallel-group cluster-randomized controlled trial was conducted on all 10 intensive care units and two hematopoietic stem cell transplantation units at Hannover Medical School, a German tertiary care hospital. Educational training sessions for physicians and nurses (individual-level intervention) and feedback discussions with clinical managers and head nurses (cluster-level) were implemented in 2013. In the “Tailoring”-arm (n = 6 wards), interventions were tailored based on HAPA-components, which were empirically assessed and addressed by behaviour change techniques. As active controls, n = 6 wards received untailored educational sessions of the local “Clean Care is Safer Care”-campaign (Aktion Saubere Hände: “ASH”-arm). From 2013 to 2015 compliance was assessed by observation following the World Health Organization, while alcohol-based hand rub usage (AHRU) and NIs with multidrug-resistant gram-negative bacteria, Methicillin-resistant Staphylococcus aureus or Vancomycin-resistant Enterococcus were assessed following national surveillance protocols. Data were analysed at cluster-level.

Results

In the “Tailoring”-arm, interventions led to a decrease of 0.497 MDRO-infections per 1000 inpatient days from 2013 to 2015 (p = 0.015). This trend was not found in the “ASH”-arm (− 0 . 022 infections; p = 0.899). These patterns corresponded inversely to the trends in compliance but not in AHRU.

Conclusions

While interventions tailored based on the HAPA-model did not lead to a significantly lower incidence rate of MDRO-infections compared to control wards, a significant reduction, compared to baseline, was found in the second follow-up year in the “Tailoring”- but not the "ASH"-arm. This indicates that HAPA-tailored hand hygiene interventions may contribute to the prevention of NIs with MDRO. Further research should focus on addressing compliance by interventions tailored not only to wards, but also leaders, teams, and individuals.

Trial registration

German Clinical Trials Register/International Clinical Trials Registry Platform, DRKS00010960. Registered 19 August 2016-Retrospectively registered, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00010960. http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00010960.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0507-5) contains supplementary material, which is available to authorized users.

Obstacles to the successful introduction of an electronic hand hygiene monitoring system, a cohort observational study

Background

Hand hygiene (HH) compliance remains low in many intensive care units (ICU). Technology has been suggested to improve HH compliance.We describe the introduction of an electronic HH surveillance and intervention system into the general ICU of a tertiary care teaching hospital, the obstacles to success and reasons for the system's ultimate failure and removal.

Methods

The system was based on radiofrequency transmitters in patient areas, on HH dispensers, and individual personal bracelets. The transmitters were connected to a central computer. The system was designed to detect entry and exit from patient areas and provide real time alerts of missed HH performance.A staff satisfaction questionnaire was administered followed by validation of system accuracy. Electronic data were compared to human observer data collected during defined observation periods.

Results

Data from 41 questionnaires revealed low satisfaction rate (21/41, 51%). Low system accuracy (31/41, 76%) and inconvenience (18/41, 44%) being the most frequent reasons.During 44 one hour observation periods the observer recorded more HH opportunities and performances than the electronic system (mean number of HH opportunities/hour 10.9 ± 7.6 vs 6.8 ± 6.9, p < 0.001, correlation r = 0.75, p < 0.001, and performances/hour 8.7 ± 3.9 vs 6.0 ± 3.1, p < 0.001, correlation r = 0.60, p < 0.001, respectively). Correlation between observer and HH electronic system was very low (correlation coefficient r = 0.03, p = 0.91).

Conclusions

The electronic HH system was not accepted by ICU staff principally due to inaccuracy and inconvenience. Inaccuracies were verified by direct observations. In order for an electronic HH system to succeed we suggest it must be highly accurate and comfortable to use.

Psychometric evaluation of a measure of factors influencing hand hygiene behaviour to inform intervention

BACKGROUND

Although the hand hygiene (HH) procedure is simple, the related behaviour is complex and is not readily understood, explained or changed. There is a need for practical tools to provide data that can guide healthcare managers and practitioners not only on the 'what' (the standards that must be met), but also the 'how' (guidance on how to achieve the standards).

AIM

To develop a valid questionnaire to evaluate attitudes to the factors that influence engagement in HH behaviour that can be readily completed, administered and analysed by healthcare professionals to identify appropriate intervention strategies. Construct validity was assessed using confirmatory factor analysis, predictive validity was assessed through comparison with self-reported HH behaviour, and convergent validity was assessed through direct unit-level observation of HH behaviour.

METHODS

The Capability, Opportunity, Motivation-Behaviour (COM-B) model was used to design a 25-item questionnaire that was distributed to intensive care unit (ICU) personnel in Ireland. Direct observation of HH behaviour was carried out at two ICUs.

FINDINGS

In total, 292 responses to the survey (response rate 41.0%) were included in the analysis. Confirmatory factor analysis resulted in a 17-item questionnaire. Multiple regression revealed that a model including capability, opportunity and motivation was a significant predictor of self-reported behavioural intention [F(3,209)=22.58, P<0.001]. However, the opportunity factor was not found to make a significant contribution to the regression model.

CONCLUSION

The COM-B HH questionnaire is reliable and valid, and provides data to support the development and evaluation of HH interventions that meet the needs of specific healthcare units.

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

OBJECTIVE

To investigate the effects of friendly competition on hand hygiene compliance as part of a multimodal intervention program.

DESIGN

Prospective observational study in which the primary outcome was hand hygiene compliance. Differences were analyzed using the Pearson χ2 test. Odds ratios (ORs) with 95% confidence interval were calculated using multilevel logistic regression.

SETTING

Observations were performed in 9 public hospitals and 1 rehabilitation center in Rotterdam, Netherlands.ParticipantsFrom 2014 to 2016, at 5 time points (at 6-month intervals) in 120 hospital wards, 20,286 hand hygiene opportunities were observed among physicians, nurses, and other healthcare workers (HCWs).InterventionThe multimodal, friendly competition intervention consisted of mandatory interventions: monitoring and feedback of hand hygiene compliance and optional interventions (ie, e-learning, kick-off workshop, observer training, and team training). Hand hygiene opportunities, as formulated by the World Health Organization (WHO), were unobtrusively observed at 5 time points by trained observers. Compliance data were presented to the healthcare organizations as a ranking.

RESULTS

The overall mean hand hygiene compliance at time point 1 was 42.9% (95% confidence interval [CI], 41.4-44.4), which increased to 51.4% (95% CI, 49.8-53.0) at time point 5 (P<.001). Nurses showed a significant improvement between time points 1 and 5 (P<.001), whereas the compliance of physicians and other HCWs remained unchanged. In the multilevel logistic regressions, time points, type of ward, and type of HCW showed a significant association with compliance.

CONCLUSION

Between the start and the end of the multimodal intervention program in a friendly competition setting, overall hand hygiene compliance increased significantly.

Promoting and sustaining a historical and global effort to prevent sepsis: the 2018 World Health Organization SAVE LIVES: Clean Your Hands campaign

Sepsis is estimated to affect more than 30 million patients with potentially five million deaths every year worldwide. Prevention of sepsis, as well as early recognition, diagnosis and treatment, can’t be overlooked to mitigate this global public health threat. World Health Organization (WHO) promotes hand hygiene in health care through its annual global campaign, SAVE LIVES: Clean Your Hands campaign on 5 May every year. The 2018 campaign targets sepsis with the overall theme “It’s in your hands; prevent sepsis in health care”.