Impact of an educational intervention on hand hygiene compliance and infection rate in a developing country neonatal intensive care unit

Effect of video camera monitoring feedback on hand hygiene compliance in neonatal intensive care unit, an interventional study

BACKGROUND

The purpose of this study was to determine whether use of a video camera surveillance system for hand hygiene (HH) monitoring, video-based education, and feedback could improve the HH compliance in a neonatal intensive care unit (NICU).

METHODS AND MATERIALS

This was an interventional before-after trial conducted in a level-III NICU between July 2019 and June 2020. HH compliance was measured using randomly selected video-camera footage in the baseline, intervention, and maintenance periods. After the baseline, an intervention consisting of feedback and education with video scenarios was implemented. The primary outcome was change in HH compliance. The compliance rates were analyzed as an interrupted time series (ITS) with a segmented regression model adjusted for autocorrelation for each study period.

RESULTS

We identified a total of 8335 HH indications. There were non significant increases in the total compliance rate (9.0%, 95% CI -2% to 20%) at the time of intervention and in the compliance rate after intervention (0.26%, 95% CI -0.31% to 0.84%) per day. The hand hygiene compliance before patient contact significantly increased (19.8%, 95% CI, 4.8%-34.8%). Incorrect glove use improved non-significantly with the intervention (-3.4%, 95% CI -13.4% to 6.7%).

CONCLUSION

In this study of HH monitoring using video-camera footage combined with an intervention including feedback and education, there were inconsistent improvements in HH compliance. However, these improvements were not sustained in the long term. Frequent feedback and education may be required to sustain high compliance.

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.

A modified hand washing method for resource limited settings

The Good Microbiological Practices & Procedures (GMPP) is the most significant risk control measure as per the fourth edition of the WHO laboratory biosafety manual. Among GMPP, one of the best practices is hand washing. WHO and other public health agencies have published several guidance documents on hand washing, that describe closing the tap using a disposable paper towel/tissue paper at the end of hand washing as one of the critical steps. In resource-limited settings, where disposable paper towels cannot be provided at all times, the staff is left with ambiguous instructions on how to close the tap. In this paper, a modified hand washing method is documented that doesn't necessitate the use of disposable paper towels. In this method, both hands and faucets remain in contact with soap for at least 40–60 s. The method was validated by the use of Glo Germ. A survey questionnaire was also designed and conducted for the lab staff (n = 12) of the two laboratories, where this method was implemented, to assess whether this hand washing method brought any improvement in their hand washing practices and implementation. All (100%) of the survey respondents reported that this method of hand washing is more applicable and implementable than the WHO-recommended hand washing technique. Eighty three percentage reported that this modified method of hand washing raised their hand washing compliance. The authors suggest that this hand washing method can be used in resource-limited laboratory settings as an effective GMPP to ensure infection control.

Discordance among Belief, Practice, and the Literature in Infection Prevention in the NICU

This study evaluates practices of infection control in the NICU as compared with the available literature. We aimed to assess providers’ awareness of their institutional policies, how strongly they believed in those policies, the correlation between institution size and policies adopted, years of experience and belief in a policy’s efficacy, and methods employed in the existing literature. An IRB-approved survey was distributed to members of the AAP Neonatal Section. A systematic review of the literature provided the domains of the survey questions. Data was analyzed as appropriate. A total of 364 providers responded. While larger NICUs were more likely to have policies, their providers are less likely to know them. When a policy is in place and it is known, providers believe in the effectiveness of that policy suggesting consensus or, at its worst, groupthink. Ultimately, practice across the US is non-uniform and policies are not always consistent with best available literature. The strength of available literature is adequate enough to provide grade B recommendations in many aspects of infection prevention. A more standardized approach to infection prevention in the NICU would be beneficial and is needed.

Quality Improvement Initiative to Improve Hand Hygiene Compliance in Indian Special Newborn Care Unit

Supplemental Digital Content is available in the text.

Pilot data on Hand hygiene (HH) compliance using a standard World Health Organisation checklist for 1-week suggested only 20% compliance. So, we planned a Quality Improvement study to improve HH compliance among health care providers in our Special Newborn Care Unit from 20% to 60% over 12 months.

A Quality Improvement Initiative to Increase Hand Hygiene Awareness and Compliance in a Neonatal Intensive Care Unit in Haiti

INTRODUCTION

Healthcare-associated infections (HCAI) are major causes of morbidity, mortality, increased lengths of stay and are an economic burden on healthcare systems in resources-limited settings. This is especially true for neonates, who are more susceptible with underdeveloped immune systems. Hand hygiene (HH) is a key weapon against HCAI, yet globally, HH compliance remains substandard. This study sought to determine the compliance with HH among healthcare workers (HCWs) in a children's hospital neonatal intensive care unit (NICU) in Haiti.

METHODS

A HH educational intervention was performed in the NICU, including lectures and posters. Pre- and post-intervention HH data were collected on HCWs and parents using the World Health Organization '5 Moments for HH'. Data were analyzed using standard statistical analysis.

RESULTS

HH increased in all HCW roles but not in parents. Correct HH increased in all groups, including parents. HH was more likely to occur prior to patient contact than after patient contact. Correct HH was more likely to occur with alcohol-based hand rub than with soap and water.

CONCLUSION

This study demonstrates that an inexpensive and simple intervention can significantly increase HH compliance in a resource-limited NICU, which may lead to decreased rates of hospital-acquired sepsis. Parents, however, due to cultural norms as well as literacy and language barriers, need targeted educational interventions distinct from those that HCW benefit from.

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.

Impact of an Interventional Program on Improving Compliance of Hand Hygiene and Reducing Hospital-Acquired Infection in the Critical Care Unit

Introduction

This study aimed to determine the effect of a hand hygiene (HH) and awareness campaign on knowledge and compliance with HH practices among health-care workers working staff in the main intensive care units and also to evaluate the rates of hospital-acquired infection (HAI) before and after the intervention.

Methods

A prospective, interventional, pre-post design was utilized and carried out in three phases: the first stage was a 1-month preintervention stage to develop the foundation of the compliance rate of handwashing; the second stage was the interventional handwashing campaign; the third stage was the postintervention stage to improve the compliance rate of handwashing. Two instruments were used in this study: the HH Knowledge Questionnaire developed by the World Health Organization to assess HH knowledge and the Handwashing Questionnaire developed to evaluate HH washing.

Results

HH knowledge has been increased from preintervention (M = 11.84, standard deviation [SD] = 2.41) to postintervention (M = 18.80, SD = 2.93), and the effective compliance with HH practice was as low as 49% in June 2017 to 75% in February 2018. In addition, the HAI rate was dropped from 13.2% in June 2017 to 9% in February 2018. An inverse association was recognized between HH compliance and HAI rates.

Conclusions

These results recommend that reasonable approaches can decrease the HAI rate of intensive care units. A nationwide handwashing interventional program can be employed in all hospitals.

Onsite mentoring of special newborn care unit to improve the quality of newborn care

Background

It has been possible to set up special newborn care units (SNCUs) and to improve the survival of newborns in India. However, several challenges remain affecting their effective functioning. Different approaches have been attempted and several policies have also been implemented to address this issue.

Objectives

To evaluate the feasibility of implementing best practices in neonatal care by onsite mentoring in an SNCU over 4 months.

Methods

The mentoring team was from a tertiary care hospital in Karnataka. The SNCU was functioning at the district hospital, catering to approximately 3500 live births per year. Onsite mentoring was carried out from August 2016 to November 2016. This was a prospective implementation research. Framework focused on infection control, preterm care, care at birth, advocacy for infrastructure and resources, and facility-based refresher training.

Results

A total of 16 visits were done by the mentoring team and 2 weeks of in-house residency. There were improvements in hand hygiene compliance from 0% to 87.5%, in cleaner IV site (from 50% to 100%), decreased unnecessary oxygen administration (from 75% to 33.3%), decreased antibiotic usage (from 70.5% to 35.5%), decrease in the number of babies receiving >5 days of antibiotics (from 41.6% to 0%), and increased kangaroo mother care initiation rate from 0% to 41.6%. The facility got level IIA accreditation by the end of the intervention period.

Conclusions

Onsite mentorship program of SNCU is feasible and planning should be contextual. With the problems being uniform across most facilities, the model could be replicated across the country.

Hand hygiene in hospitals: an observational study in hospitals from two southern states of India

BACKGROUND

Hand hygiene is a simple and low-cost measure to reduce healthcare associated infection yet it has always been a concern in low as well as high resource settings across the globe. Poor hand hygiene during intra-partum and newborn care may result in sepsis, which is a major cause of death among newborns and puts a financial burden on already strained health systems.

METHODS

We conducted non-participatory observations in newborn care units and labour rooms from secondary and tertiary level, public and private hospitals, as part of a baseline evaluation of a quality improvement collaborative across two southern states of India. We assessed hand hygiene compliance during examinations and common procedures, using tools adapted from internationally recommended checklists and World Health Organization's concept of five moments of hand hygiene. We assessed differences in compliance by type (public/private), level (secondary/tertiary) and case load (low/intermediate/high). Analysis was adjusted for clustering and weighted as appropriate.

RESULTS

We included 49 newborn care units (19 private, 30 public) and 35 labour rooms (5 private, 30 public) that granted permission. We observed 3661 contacts with newborns and their environment, 242 per-vaginal examinations and 235 deliveries. For the newborns, a greater proportion of contacts in private newborn units than public complied with all steps of hand hygiene (44% vs 12%, p < 0.001), and similarly in tertiary than secondary units (33% vs 12%, p < 0.001) but there was no evidence of a difference by case load of the facility (low load-28%; intermediate load-14%; high load- 24%, p = 0.246). The component with lowest compliance was glove usage where indicated (20%). For deliveries, hand hygiene compliance before delivery was universal in private facilities but seen in only about one-quarter of observations in public facilities (100% vs 27%, p = 0.012). Average overall compliance for hand-hygiene during per-vaginal examinations was 35% and we found no evidence of differences by type of facility.

CONCLUSION

Observed compliance with hand hygiene was low overall, although better in private than public facilities in both newborn units and labour rooms. Glove usage was a particular problem in newborn care units.

TRIAL REGISTRATION

Retrospectively registered with Clinical Trials Registry- India ( CTRI/2018/04/013014 ).

Impact of a multicomponent hand hygiene intervention strategy in reducing infection rates at a university hospital in Saudi Arabia

BACKGROUND AND AIMS

Few studies have reported the correlation between hand hygiene (HH) practices and infection rates in Saudi Arabia. This work was aimed to study the effect of a multicomponent HH intervention strategy in improving HH compliance and reducing infection rates at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia between January 2014 and December 2016.

METHODS

A yearlong multicomponent HH intervention, which included various strategies recommended by the World Health Organization, was introduced. HH compliance among staff and infection rates observed in the inpatient wards were assessed and compared at pre- and post-interventional phases.

RESULTS

There was a significant increase in mean HH compliance from 50.17% to 71.75% after the intervention (P < 0.05). Hospital-acquired infection (HAI) and catheter-associated urinary tract infection (CAUTI) rates decreased from 3.37 to 2.59 and from 3.73 to 1.75, respectively (P < 0.05). HH compliance was found to be negatively correlated with HAI (r = -0.278) and CAUTI (r = -0.523) rates.

CONCLUSIONS

Results show that multicomponent intervention is effective in improving HH compliance, and that an increase in HH compliance among hospital staff decreases infection rates. Further studies on cost-effectiveness of such a model could augment to these findings.

Predictors of hand hygiene practice among Saudi nursing students: A cross-sectional self-reported study

Hand hygiene is an important component of infection control, which is critical to ensuring patients’ safety in hospitals. Nursing students are regarded as healthcare workers in training and can also be vehicles of cross-contamination within the hospital. Thus, this study aimed to identify the predictors of hand hygiene practice among Saudi nursing students. A descriptive, cross-sectional, self-reported study was conducted among 198 Saudi nursing students. Knowledge, attitude, and practice of hand hygiene were assessed using the WHO Hand Hygiene Knowledge Questionnaire for Health-Care Workers and its adopted scales. A regression analysis was performed to identify the predictors of hand hygiene practice. The respondents demonstrated moderate knowledge of hand hygiene (mean 13.20 ± 2.80). The majority displayed a moderate attitude toward hand hygiene (52.1%), while only a few reported a poor attitude (13.1%). Approximately 68.7%, 29.8%, and 1.5% of the respondents reported moderate, good, and poor practice of hand hygiene, respectively. Having a good attitude toward hand hygiene, being male, being aware that hand hygiene is an effective intervention in preventing healthcare-associated infections (HAIs), attendance at hand hygiene trainings and seminars, and being in the lower academic level of nursing education were identified as predictors of better hand hygiene practice. The importance of ensuring a positive attitude toward hand hygiene and improving awareness of hand hygiene is emphasized, as are educational interventions. Educational interventions should be implemented to reinforce knowledge and instill a positive attitude toward hand hygiene.

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

ISSUE

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

INITIAL ASSESSMENT

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

CHOICE OF SOLUTION AND IMPLEMENTATION

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

EVALUATION

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

LESSONS LEARNED

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