The problem with 'My Five Moments for Hand Hygiene'

Compliance with infection control practices among healthcare workers in radiology departments: a participant observation study and adenosine triphosphate assay evaluation of environmental cleanliness

Background

Increased risk of healthcare-associated infections (HAIs) in radiology departments has been reported in recent years. Optimal infection control practices (ICPs) are the key to controlling HAIs, but few studies have investigated the ICP compliance of healthcare workers (HCWs) in radiology departments.

Aim

To assess the level of ICP compliance of HCWs in a radiology department.

Methods

A participant observation supplemented with adenosine triphosphate (ATP) bioluminescence assay evaluation of environmental cleanliness was conducted. More than 1000 hand hygiene (HH) opportunities and 960 opportunities for the other core ICP elements were observed in different study units of a radiology department. An online checklist powered by eRub was used to record the HCWs' ICP performance. A total of 125 environmental samples were collected for ATP assay evaluation.

Results

In the participants observation, the overall performance score was 41.4%. The lowest score was found in HH (10.4%), followed by use of personal protective equipment (29.4%) and gloves (68.2%). The HH performance was significantly associated with study units (χ2 = 42.55, P < 0.001), professional groups (χ2 = 110.21, P < 0.001), and patient-to-staff ratio (F = 8.76, P < 0.001). With relative light units of ≤250 set as a pass benchmark, less than two-thirds of the environmental samples passed the ATP assay.

Conclusion

The overall ICP compliance among the HCWs in the radiology department was suboptimal. Revisions of current ICP guidelines and policies that are tailored to the setting-specific needs and barriers in radiology departments is necessary.

Hand hygiene adherence in intensive care units: comparison before and during the COVID-19 pandemic in a municipality of São Paulo state

BACKGROUND

This is a pioneering study on the assessment of a Brazilian municipality entire, comparing alcohol-based hand sanitizer consumption before and during the COVID-19 pandemic. Vilas-Boas et al reported a rise from 24.2mL/PD in 2018 to 46.6 in 2020, being for adult intensive care units the municipality exceeded most of the Brazilian states. However, observed a decline in some hospitals in 2021.

OBJECTIVE

Compare alcohol-based hand sanitizer use in intensive care units in a municipality in São Paulo state, before and during the coronavirus pandemic.

METHODS

Analytical retrospective study using indirect documentation, with data obtained from a notification spreadsheet for epidemiological indicators of healthcare-associated infection in the state. Data on monthly alcohol-based sanitizer use were collected from the intensive care units of public and private general hospitals of the municipality. Analysis was conducted using descriptive statistics and graphically with run charts. The Mann-Whitney test was applied to compare the median consumption of public and private hospitals, at a 5% significance level.

RESULTS

Adult, neonatal and pediatric intensive care units showed median increases in hand sanitizer use of 34.03 to 57.64, 31.53 to 48.66 and 34.38 to 60.35mL/patient-day, respectively. Private hospitals showed greater hand sanitizer use in the adult and pediatric intensive care units compared to public institutions.

CONCLUSION

The pandemic contributed to increasing hand sanitizer use in municipal intensive care units, but there is still room for improvement. More effort is needed to ensure that hand sanitizer use remains high.

The '5 Moments for Hand Hygiene': casting a critical eye on the implications for practice

The '5 Moments' approach is a time-space framework that delineates when hand hygiene should be performed and provides a resource for educators and auditors. It has become the dominant paradigm for organisations, practice, policy, and research in relation to hand hygiene. It is a concept that adopts the 'precautionary principle' that if the relative risk of a specific care task is unknown, a safe system must be to treat them on an equal level. However, a literal interpretation will frequently result in an extraordinary, implausible number of hand-hygiene opportunities and if this then becomes the standard to audit practice, within a policy document that espouses zero tolerance, it is likely to generate inauthentic data. If used effectively the 5 Moments concept provides an opportunity to enhance practice and reduce healthcare-associated infections but the healthcare provider organisation must embody a 'just culture' and collect the data in a climate of openness, transparency, and learning.

Perceptions of distinctions between patient and healthcare zones among intensive care unit nurses at a Korean tertiary hospital: A cross-sectional study

BACKGROUND

Intensive care unit (ICU) patients face higher infection risks from invasive procedures, highlighting the critical role of ICU nurses in infection prevention. Clear differentiation between the patient and healthcare zones is essential for effective hand hygiene and disinfection, yet research on this topic is limited.

AIM

To assess ICU nurses' perception of the concept of patient and healthcare zones and evaluate their similarity and accuracy in identifying the zones.

METHODS

A descriptive survey was conducted at a 2,732-bed tertiary hospital in Korea from 28 July to 27 August 2022. Participants were recruited from various ICUs through flyers. 225 questionnaires-with illustrations 27 item locations for three ICU scenarios-were made available at nursing stations for voluntary completion. Participants were asked to classify items into the patient zone or the healthcare zone. Similarity scores reflected participant agreement, while accuracy scores measured the proportion of correct answers. Participants' free-text opinions regarding zone classification were analysed thematically.

FINDINGS

104 nurses participated voluntarily. Average similarity and accuracy were 84.7% and 82.7%, respectively. The top 8 items, with over 97% similarity and accuracy, were all frequently in contact with ICU patients (e.g., pulse oximeter, Levin tube, central line, urine bag, and patient bed). The bottom 7 items, with less than 80%, included the glucometer, flashlight, trolley, and sink. Participants with higher education levels had significantly higher similarity (p = .044) and accuracy (p = .033), whereas those already familiar with the patient-zone concept had significantly higher accuracy (p = .009). From the free-text analysis, participants considered factors beyond proximity to the patient, such as patient contact, room type, and distance.

CONCLUSIONS

To address zone classification challenges, clear criteria for patient and healthcare zones, space redesign, and educational programs are recommended. Further research is necessary to improve greater clarity and consensus regarding patient and healthcare zones to enhance infection control practices.

Advanced theoretical-applied model based on the PD approach in the light of healthcare-associated infections: what have we achieved so far?

Healthcare-associated infections remain a persistent concern despite decades of research and intervention efforts. Adherence to infection prevention and control guidelines by health professionals remains a challenge, necessitating innovative strategies. The Positive Deviance (PD) approach, rooted in harnessing localized solutions, holds promise but lacks comprehensive frameworks and empirical validation to bolster its theoretical underpinnings. This perspective article serves a dual purpose: first, to examine the unique challenges of applying the PD approach in the context of HAIs; and second, to introduce a robust theoretical-applied model developed in response to these challenges. This article addresses these gaps through a multi-faceted model developed in a mixed-methods study across three Israeli governmental hospitals and comprises four essential components that address the identified gaps in existing research. This article enriches the dialog on PD's applicability in HAIs by providing a robust model that not only offers solutions but reshapes the approach to healthcare hygiene and safety. It responds to critical gaps highlighted in the literature, offering tailored interventions by practical, context-specific solutions to improve adherence to IPC guidelines in the long term. Methodological clarity is also a key focus, offering a toolkit for practical implementation. This bottom-up approach empowers HPs to drive change, fostering a culture of innovation and improvement in healthcare settings.

Hand hygiene with interventions: an observational study from a tertiary care institute over 2 years

Background

Appropriate adherence to hand hygiene (HH) practices by health care workers (HCWs) reduces the transmission of pathogens and subsequently the incidence of hospital acquired infections (HAIs), in health care settings. Strict monitoring and auditing of this simple and cost-effective intervention is very important, as it significantly contributes in reducing the HAIs.

Material and methods

A retrospective observational study, evaluating the HH audits from June 2021 till May 2023 in a tertiary health care facility in North India. HH audits were conducted in the ICUs and wards daily, by the trained infection control nurses (ICNs), using direct observation method based on World health organization (WHO) hand hygiene observational forms. HH total adherence (HHTAR), partial adherence (HHPAR) and complete adherence rate (HHCAR) were analyzed in Microsoft Excel sheet. HHTAR rates were compared among different profession, moments and the month wise trend was also observed over the period.

Results

A total of 24,740 HH opportunities were observed. The compliance rate for HHCAR, HHPAR and HHTAR were 20.3%, 41.5% and 61.4% respectively. Overall better compliance was reported from the ICUs, profession-specific compliance was highest among nurses (62.8%) and doctors (61.5%). Significant increase in adherence rate was appreciated post intervention 46.1% to 67.3%, (p value < 0.01).

Conclusions

Continuous monitoring and reinforcement with timely feedback for intervention and regular auditing is a necessity to improve and maintain the appropriate HH practices among the HCWs. Low- and middle-income countries need to focus more on this simple and promising measure to combat the increasing HAI rates.

Impact of conducting hand hygiene audit in COVID-19 care locations of India-A large scale national multicentric study - HHAC study

PURPOSE

Hand hygiene (HH), the core element in infection prevention in healthcare, especially for multidrug resistant organism's transmission. The role of HH audits and HH adherence rates in the COVID-19 pandemic, especially in resource limited settings, are yet to be established.

METHODS

A nationwide multicenter study was conducted in India, involving public, private, teaching and non-teaching COVID healthcare facilities (COVID-HCFs) using the IBhar mobile application based on WHO's hand hygiene audit tool. The HH adherence rates (HHAR) such as complete HHAR (HHCAR), total HHAR (HHTAR), profession specific HHAR, WHO's 5 HH moment specific HHAR and associated variables were measured over 6 month duration (June-December 2021).

RESULTS

A total of 2,01,829 HH opportunities were available and the HHCAR and HHTAR were 27.3% and 59.7%. The HHTAR was significantly higher in the west zone (72.2%), private institutes (65.6%), non-teaching institutes (67.7%), nurses (61.6%), HH moments 2 (71.8%) and 3 (72.1%), and morning shift (61.4%). The HHTAR was better in non-COVID HCFs (65.4%) than COVID-HCFs (57.8%) as well as non-COVID ICUs (68.1%) than COVID ICUs (58.7%). The HHTAR was increased from month 1 to month 6 except a small decrease in the month of December.

CONCLUSIONS

The hand hygiene adherence is comparable with adherence rate during COVID-19 pandemic in western countries as well as the resource limited settings. The use of gloves during the pandemic and simplified HH techniques and their influence over the HH adherence to be studied further. The sustainable adherence rate over long duration needs to be ensured by continuing the HH audit using multimodal interventions.

Developing a design-based concept to improve hand hygiene in the neonatal intensive care unit

BACKGROUND

Hand hygiene (HH) is the most critical measure in the prevention of nosocomial infections in the neonatal intensive care unit (NICU). Improving and sustaining adequate HH compliance rates, however, remains a significant challenge. Using a behavioral change framework and nudge theory, we developed a design-based concept aimed at facilitating and stimulating HH behavior.

METHODS

Concept development was initiated by selecting a theoretical framework after which contextual field studies aimed at discovering causes for poor compliance were conducted. Potential solutions were brainstormed upon during focus group sessions. Low-fidelity prototypes were tested regarding feasibility, usability, and acceptability. A final concept was crafted drawing from findings from each design phase.

RESULTS

Complying with recommended HH guidelines is unrealistic and infeasible due to frequent competing (clinical) priorities requiring HH. The concept "Island-based nursing," where a patient room is divided into two geographical areas, namely, the island and general zone, was created. HH must be performed upon entering and exiting the island zone, and after exposure to any surface within the general zone. Reminding of HH is prompted by illuminated demarcation of the island zone, serving as the concept's nudge.

CONCLUSIONS

Island zone demarcation facilitates and economizes HH indications in an innovative and intuitive manner.

IMPACT

Although hand hygiene (HH) is the single most important element in the prevention of nosocomial infections in neonates, improving and sustaining adequate HH compliance rates remains a significant challenge. Complying with recommended HH guidelines was found to be unrealistic and infeasible due to the significant amount of time required for HH in a setting with a high workload and many competing (clinical) priorities. The concept of "Island-based nursing," under which the primary HH indication is upon entering and exiting the island zone, facilitates and economizes HH indications in an innovative and user-friendly manner.

Compliance with hand hygiene practices among nursing staff in secondary healthcare hospitals in Kuwait

Background

Hand hygiene (HH) among healthcare workers, especially nurses, is the main preventive measure to control healthcare associated infections but compliance with hand hygiene (CwHH) remains low in various settings including Kuwait. This study aimed to assess the knowledge of, attitudes towards, and CwHH among nursing staff in secondary care hospitals in Kuwait.

Methods

A cross-sectional study was conducted on nursing staff in all six secondary care hospitals in Kuwait. Data on knowledge of, attitudes towards, and self-reported CwHH were collected through a self-administered questionnaire that was developed based on WHO’s questionnaire, while the data on actual compliance were objectively collected through direct observation of nurses during routine care by two independent observers using WHO’s observation form.

Results

Of 829 nurses approached, 765 (92.2%) responded and participated. Of all participants, 524 (68.5%) were able to list “My Five Moments for Hand Hygiene” fully and appropriately. However, several misconceptions (e.g. air circulation in hospital is the main route of infection) about HH were found among the nurses. CwHH was (25.0%) by direct observation while self-reported compliance was (69.5%) each varied significantly (p < 0.001) between different hospitals. Female nurses compared to male nurses and non-Arab compared to Arab nationalities were more likely to report CwHH in multivariable analysis. Several items on knowledge of and attitudes towards HH were also associated with self-reported CwHH.

Conclusion

Observed CwHH among nursing staff in secondary care hospitals in Kuwait was low, which highlights the need to make more efforts to improve HH practices. Interventions that have been used elsewhere and found to be effective may be tested in Kuwait. Despite the good overall knowledge on HH among nurses, there are several misconceptions that need to be corrected.

Knowledge, Attitudes, and Perceptions Towards Hand Hygiene of Optometry Students Pre- and Peri-COVID-19 at a Tertiary Institution in Johannesburg, South Africa

PURPOSE

Limited research has been completed relating to the knowledge, attitudes and practices (KAP) towards hand hygiene in optometry. The necessity of identifying possible gaps in the cycle of the optometric examination that may have an impact on standard hygiene practices is essential, especially seen in the context of the COVID-19 pandemic. The purpose of the study was to determine if optometry students' KAP towards hand hygiene changed pre- and peri-COVID-19 to minimize the risk of possible infection it may have for their patients, family, and themselves.

PATIENTS AND METHODS

A cross-sectional purposeful sample study was completed among optometry students at a training institution in Johannesburg, South Africa, pre- (2019) and peri-COVID-19 (2022). The WHO hand hygiene knowledge and perception questionnaires for health care workers were adapted and used in the current study. Statistical analyses were performed to test for significant changes between the two groups.

RESULTS

There was a significant change (p < 0.01) in the use of alcohol-based hand rub (ABHR) in 2022 (87.2%) compared to 2019 (46.5%), although only 41% of students peri-COVID-19 (2022), were aware that a minimum of 20 seconds is required to effectively clean hands. Students, both pre-COVID-19 (63.8%) and peri-COVID-19 (81.8%) perceived performing a hand hygiene regime during an optometric examination to be problematic. A significant peri-COVID-19 (2022) change in perception (p < 0.01) regarding the importance of completing required hand hygiene practices in front of a patient during examination was seen.

CONCLUSION

The COVID-19 pandemic provided a unique opportunity to research a possible change in KAP towards hand hygiene practices in optometry students that have not been investigated before. Students were more aware of the impact of hand hygiene practices and the perception thereof, especially by patients and fellow students during the peri-COVID-19 (2022) period. An important finding was the difficulty that students experienced to perform a hand hygiene regime during an optometric examination.

Comparing human to electronic observers to monitor hand hygiene compliance in an intensive care unit

Objective

We sought to determine whether an electronic hand hygiene (HH) system could monitor HH compliance at similar rates to direct human observation.

Methods

This 4-year proof-of-concept study was conducted in an intensive care unit (ICU) of a private tertiary-care hospital in São Paulo, Brazil, where electronic HH systems were installed in 2 rooms. HH compliance was reported respectively using direct observation and electronic counter devices with an infrared system for detecting HH opportunities.

Results

In phase 1, HH compliance by human observers was 56.3% (564 of 1,001 opportunities), while HH compliance detected by the electronic observer was 51.0% (515 of 1,010 opportunities). In phase 2, human observers registered 484 HH opportunities with a HH compliance rate of 64.7% (313 of 484) versus 70.6% (346 of 490) simultaneously detected by the electronic system. In addition, an enhanced HH electronic system monitored activity 24 hours per day and HH compliance without the presence of a human observer was 40.3% (10,642 of 26,421 opportunities), providing evidence for the Hawthorne effect.

Conclusions

The electronic HH monitoring system had good correlation with human HH observation, but compliance was remarkably lower when human observers were not present due to the Hawthorne effect (25%-30% absolute difference). Electronic monitoring systems can replace direct observation and can markedly reduce the Hawthorne effect.

Translating a theory-based positive deviance approach into an applied tool: Mitigating barriers among health professionals (HPs) regarding infection prevention and control (IPC) guidelines

Background

Although a wide range of intervention programs and methods have been implemented to increase health professionals’ (HPs) adherence with infection prevention and control (IPC) guidelines and decrease the incidence of healthcare associated infections (HAIs), a significant discrepancy remains between the guidelines and their implementation in practice.

Objectives

This study proposes an applied tool based on the integrated theoretical framework of the positive deviance (PD) approach for developing more effective interventions to mitigate this discrepancy.

Methods

A qualitative study guided by the PD approach based on data from two sources: (1) in-depth archival analysis of systematic review articles, and (2) integration and synthesis of findings based on an extensive empirical study we conducted, involving 250 HPs (nurses, physicians, support staff and cleaning staff) from three governmental hospitals in Israel, over 35 months (January 2017 to November 2020).

Results

The barriers faced by HPs were classified into four main categories: (1) individual-motivational, (2) social-cultural, (3) organizational, and (4) work environment and resource-centered. For each barrier, we constructed a set of questions based on the PD approach. For each question, we adapted and applied methodological tools (e.g., in-depth interviews, focus groups, social network maps, video clips and simulations) to help solve the problem.

Conclusion

Translating a theory-based approach into an applied tool that offers step-by-step actions can help researchers and practitioners adopt and implement the approach within intervention programs to mitigate barriers.