Hand washing and use of gloves while managing patients receiving mechanical ventilation in the ICU

Development of a competency for professional oral hygiene care of endotracheally-intubated patients in the intensive care unit: development and validity evidence

BACKGROUND

Professional oral care in the intensive care unit may reduce the incidence of Ventilator Associated Pneumonia, which increases the patient's mortality rate. This study aimed to develop a competency for professional oral hygiene care of endotracheally-intubated intensive-care patients.

METHODS

First, we developed a competency draft by reviewing the literature on oral hygiene care of patients in the intensive care unit. Next, we developed expert validity test questionnaires using this draft and conducted expert validity tests twice on 18 experts. We determined competency as a content validity index of 0.8 or more and received expert additive opinions about competency through an open-questionnaire expert validity test paper in this methodology study.

RESULTS

The content validity index ranged from 0.8 ~ 1.0 for all items. The competency of 'professionalism' comprised 2 sub-competencies with 7 behavioral indicators. 'POHC preparation' comprised 3 sub-competencies with 10 behavioral indicators. 'POHC implementation' comprised 3 sub-competencies with 6 behavioral indicators. 'POHC evaluation' comprised 2 sub-competencies with 8 behavioral indicators. Lastly 'Cooperation among experts' comprised 3 sub-competencies with 7 behavioral indicatiors.

CONCLUSIONS

To provide patients with high quality oral hygiene care, these competencies should be implemented, and oral hygiene care professionals and related medical personnel should form a cooperative system.

A multifaceted hand hygiene improvement program on the intensive care units of the National Referral Hospital of Indonesia in Jakarta

Background

Hand hygiene (HH) is considered to be the single most effective measure in preventing healthcare-associated infections. However, HH compliance rates among nurses and doctors in hospitals are often very low. Few studies have addressed HH compliance in Indonesia, performed interventions to increase HH compliance, and none have had long-term follow-up. We, therefore, addressed this issue by performing long-term follow-up after a multifaceted intervention in the intensive care unit (ICU) setting.

Methods

This was an observational, prospective, before-and-after intervention study (May–September 2014, February–April 2017). We measured HH knowledge and HH compliance before (at baseline) and directly after a multifaceted improvement program (post-intervention) and performed a re-evaluation three years later. The multifaceted improvement program included education, feedback, reminders, interviews and the use of role models. The study involved nurses and physicians working in two ICUs of the Dr. Cipto Mangunkusumo Hospital in Jakarta.

Results

A total of 97 at baseline, and 72 at post-intervention HH knowledge questionnaires were completed. There was a statistically significant improvement in the median overall HH knowledge score at post-intervention (from 15 to 22, p < 0.001). There was no significant difference between the two ICUs. The overall HH compliance was 27% at baseline and significantly improved to 77% post-intervention (p < 0.001). For all five HH moments, the compliance of nurses and physicians separately improved significantly from the baseline phase to the post-intervention phase (p < 0.001), except for ‘moment 3’ (after body fluid exposure), for which baseline rates were already high. Most of the compliance rates were significantly lower in both groups of healthcare workers upon follow-up three years later. Overall, the HH compliance of the nurses was significantly better than the physicians’ compliance (p = 0.005).

Conclusions

Our multifaceted improvement program, for nurses and physicians of the ICUs in the largest hospital of Indonesia, resulted in a significant improvement of the HH knowledge and HH compliance, but HH compliance levels waned over time after the intervention, indicating a need for continued monitoring and repeated interventions.

Trial registration

The study was registered at www.trialregister.nl (No: 5541). Candidate number: 23527, NTR number: NTR5541, Date registered NTR: 22-DECEMBER-2015.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0540-4) contains supplementary material, which is available to authorized users.

Utilizing Group-Based Contingencies to Increase Hand Washing in a Large Human Service Setting

Hand washing is the most important preventative measure for the reduction of contagious disease. Although hand washing is easy to perform, non-adherence is a ubiquitous problem. Several studies have demonstrated the effectiveness of multi-component intervention packages to improve hand washing among employees; however, interventions are limited to acute settings, are often implemented for a short period of time, and rarely, if ever, include information on long-term effectiveness. The purpose of the current study was to utilize a behavior analytic approach to determine the stimulus conditions under which hand washing should occur, and to assess and then implement a long-term monitoring system among direct care workers in a large, non-acute inpatient unit. A single-case repeated measures reversal design was used to evaluate the effectiveness of two interventions aimed at improving hand washing adherence. A lottery was found to be effective in increasing hand hygiene for 2-years with 170 staff.

The effect of a continuous educational program on handwashing compliance among healthcare workers in an intensive care unit

Handwashing is simple, cost-effective and the single most important measure in the prevention of transmission of multiple antibiotic-resistant bacteria, which can spread via the contaminated hands of healthcare workers (HCWs) in intensive care units (ICUs). Despite this simplicity and efficacy, compliance with handwashing protocols is unsatisfactory among HCWs in ICUs. No single interventional measure is successful in improving handwashing compliance.

A continuous educational program was started in February 1998 by the department of infection control, emphasising the importance of handwashing in the prevention of nosocomial infections in the ICU. It took the form of posters, lectures and regular discussions. The posters were pasted in all the strategic areas of the ICU, displaying the indications and precise technique of handwashing. HCWs were directly observed for handwashing compliance, while working in the ICU. Each indication of handwashing was counted as an opportunity of handwashing.

Assessment of handwashing compliance was made once a year during the educational programme. In the final annual assessment in February 2002, out of 1,175 opportunities of handwashing, compliance was observed in 856 (72.8%) among all categories of staff. Highest compliance of 97.5% was recorded among nurses. The compliance among technicians was 47.7%, while the lowest compliance of 37.6% was observed among doctors (RR 2.591, p<0.0001). Opportunities of handwashing utilised with good technique were observed among 98.2% nurses. Handwashing compliance among females was significantly higher (76.2% versus 23.8%) than the male HCWs (RR 3.196, p<0.0001).

A comparative study of the yearly assessments made since the start of the educational program also revealed significant increases in handwashing compliance among nurses (p<0.0001) and technicians (p<0.001), while no statistically significant changes in the handwashing behaviour among doctors was observed during the study period (February 1998 to February 2002).

Disappointing handwashing compliance among doctors visiting and working in the ICU, despite their better understanding of hospital-acquired infections (HAI) and continuous educational programme remains a cause for concern. Additional efforts are required to discover more effective interventional measures to improve handwashing compliance among doctors.

Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis

OBJECTIVE

To evaluate the relative efficacy of the World Health Organization 2005 campaign (WHO-5) and other interventions to promote hand hygiene among healthcare workers in hospital settings and to summarize associated information on use of resources.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, Embase, CINAHL, NHS Economic Evaluation Database, NHS Centre for Reviews and Dissemination, Cochrane Library, and the EPOC register (December 2009 to February 2014); studies selected by the same search terms in previous systematic reviews (1980-2009).

REVIEW METHODS

Included studies were randomised controlled trials, non-randomised trials, controlled before-after trials, and interrupted time series studies implementing an intervention to improve compliance with hand hygiene among healthcare workers in hospital settings and measuring compliance or appropriate proxies that met predefined quality inclusion criteria. When studies had not used appropriate analytical methods, primary data were re-analysed. Random effects and network meta-analyses were performed on studies reporting directly observed compliance with hand hygiene when they were considered sufficiently homogeneous with regard to interventions and participants. Information on resources required for interventions was extracted and graded into three levels.

RESULTS

Of 3639 studies retrieved, 41 met the inclusion criteria (six randomised controlled trials, 32 interrupted time series, one non-randomised trial, and two controlled before-after studies). Meta-analysis of two randomised controlled trials showed the addition of goal setting to WHO-5 was associated with improved compliance (pooled odds ratio 1.35, 95% confidence interval 1.04 to 1.76; I(2)=81%). Of 22 pairwise comparisons from interrupted time series, 18 showed stepwise increases in compliance with hand hygiene, and all but four showed a trend for increasing compliance after the intervention. Network meta-analysis indicated considerable uncertainty in the relative effectiveness of interventions, but nonetheless provided evidence that WHO-5 is effective and that compliance can be further improved by adding interventions including goal setting, reward incentives, and accountability. Nineteen studies reported clinical outcomes; data from these were consistent with clinically important reductions in rates of infection resulting from improved hand hygiene for some but not all important hospital pathogens. Reported costs of interventions ranged from $225 to $4669 (£146-£3035; €204-€4229) per 1000 bed days.

CONCLUSION

Promotion of hand hygiene with WHO-5 is effective at increasing compliance in healthcare workers. Addition of goal setting, reward incentives, and accountability strategies can lead to further improvements. Reporting of resources required for such interventions remains inadequate.

Effects of hand hygiene education and individual feedback on hand hygiene behaviour, MRSA acquisition rate and MRSA colonization pressure among intensive care unit nurses

This study was conducted to increase the frequency and level of thoroughness of hand hygiene practice by nurses, and to assess the influence of the methicillin-resistant Staphylococcus aureus (MRSA) acquired incidence rate and the MRSA colonization pressure in a medical intensive care unit (MICU). A total of 24 MICU nurses received hand hygiene education and individual feedback of hand hygiene frequency and method after a session of education, and two posteducation evaluations were followed. The frequency of hand hygiene (P = 0.001) and the methodology score of hand hygiene increased significantly (P = 0.001). The MRSA acquisition rate decreased significantly, from 11.1% before the education to 0% after (P = 0.014). The MRSA colonization pressure decreased significantly from 39.5% to 8.6% after the education sessions (P = 0.001). This indicates that providing individual feedback after hand hygiene education was very effective in increasing nurses' hand hygiene frequency and improving hand hygiene method; furthermore, it was expected to decrease health care-associated infections.

Interventions to improve professional adherence to guidelines for prevention of device-related infections

BACKGROUND

Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections.

OBJECTIVES

To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence.

SEARCH METHODS

We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information.

MAIN RESULTS

We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I(2) up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times.

AUTHORS' CONCLUSIONS

The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.

Types of interventions used to improve hand hygiene compliance and prevent healthcare associated infection

Hand hygiene is regarded as the most effective means of preventing healthcare associated infection. However, systematic reviews provide limited evidence of effectiveness, a finding that is attributed to the poor quality of research designs, dubious outcome measures and flawed approaches to audit. The ability of interventions to improve hand hygiene compliance has not previously been questioned. This review categorises the types of interventions used to promote hand hygiene and discusses their plausibility, taking selected examples from previous systematic searches. Opinion leaders have emphasised the need for interventions to be underpinned by theory. This is an ambitious endeavour for infection control personnel based in National Health Service trusts. However, it is possible to offer pragmatic suggestions to promote compliance. Initiatives are most likely to be successful if needs analysis is undertaken at the outset to address local barriers and identify enablers to compliance, and if interventions are clearly justified by existing evidence, customised according to occupational group, consider health workers’ needs and preferences for training and updating, and avoid punishment.

A systematic review of hand hygiene improvement strategies: a behavioural approach

BACKGROUND

Many strategies have been designed and evaluated to address the problem of low hand hygiene (HH) compliance. Which of these strategies are most effective and how they work is still unclear. Here we describe frequently used improvement strategies and related determinants of behaviour change that prompt good HH behaviour to provide a better overview of the choice and content of such strategies.

METHODS

Systematic searches of experimental and quasi-experimental research on HH improvement strategies were conducted in Medline, Embase, CINAHL, and Cochrane databases from January 2000 to November 2009. First, we extracted the study characteristics using the EPOC Data Collection Checklist, including study objectives, setting, study design, target population, outcome measures, description of the intervention, analysis, and results. Second, we used the Taxonomy of Behavioural Change Techniques to identify targeted determinants.

RESULTS

We reviewed 41 studies. The most frequently addressed determinants were knowledge, awareness, action control, and facilitation of behaviour. Fewer studies addressed social influence, attitude, self-efficacy, and intention. Thirteen studies used a controlled design to measure the effects of HH improvement strategies on HH behaviour. The effectiveness of the strategies varied substantially, but most controlled studies showed positive results. The median effect size of these strategies increased from 17.6 (relative difference) addressing one determinant to 49.5 for the studies that addressed five determinants.

CONCLUSIONS

By focussing on determinants of behaviour change, we found hidden and valuable components in HH improvement strategies. Addressing only determinants such as knowledge, awareness, action control, and facilitation is not enough to change HH behaviour. Addressing combinations of different determinants showed better results. This indicates that we should be more creative in the application of alternative improvement activities addressing determinants such as social influence, attitude, self-efficacy, or intention.

The effectiveness of an evidence-based nursing care program to reduce ventilator-associated pneumonia in a Korean ICU

OBJECTIVES

This study has analysed VAP prevention strategies and concentrating on approaches proven to have been effective by previous studies, has developed a general and systematic intervention for preventing VAP.

METHOD

The VAP prevention program was composed of short-term interventions and long-term interventions. Using a time series design to verify the program's effectiveness, just before, just after, and 3 months after intervention, 27 convenient selected medical ICU nurses were surveyed for their awareness of VAP prevention and self-evaluation of VAP prevention performance as a subjective measure, and their VAP prevention performance was observed as an objective measure. The VAP incidence amongst ICU patients was measured during the 3 months before (n=80) and after (n=75) intervention.

RESULTS

That the program would raise nurses' VAP prevention awareness (p=.008) and would increase the nurses' subjective (p=.003) and objective (p≤.001) VAP prevention performance evaluations was supported. That incidences of VAP would decrease from a pre-intervention VAP rate of 17.382 (number of occurances/1000 ventilator days) to a post-intervention rate of 11.044, was not statistically significant (p=.074).

CONCLUSION

An intervention VAP prevention program promoted ICU nurses' VAP prevention awareness and performance and could therefore help decrease the VAP rate.

The role of education in the prevention and control of infection: a review of the literature

This paper discusses a literature review which was undertaken prior to a research study about student nurses' and midwives' experiences of learning infection control in clinical practice. Its aim is to identify the role of education in the prevention and control of infection, with a specific focus on compliance with infection control precautions and reduction in infection rates. It also identifies the methods used for teaching infection control. The review concludes that there is no rigorous and convincing evidence that education improves compliance with infection control precautions or reduces rates of infection, particularly in the long-term. Areas for future research are identified.

Interventions to improve hand hygiene compliance in patient care

BACKGROUND

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

OBJECTIVES

To update the review done in 2007, to assess the short and longer-term success of strategies to improve hand hygiene compliance and to determine whether a sustained increase in hand hygiene compliance can reduce rates of health care-associated infection.

SEARCH STRATEGY

We conducted electronic searches of: the Cochrane Central Register of Controlled Trials; the Cochrane Effective Practice and Organisation of Care Group specialised register of trials; MEDLINE; PubMed; EMBASE; CINAHL; and the BNI. Originally searched to July 2006, for the update databases were searched from August 2006 until November 2009.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series analyses meeting explicit entry and quality criteria used by the Cochrane Effective Practice and Organisation of Care Group were eligible for inclusion. Studies reporting indicators of hand hygiene compliance and proxy indicators such as product use were considered. Self-reported data were not considered a valid measure of compliance. Studies to promote hand hygiene compliance as part of a care bundle approach were included, providing data relating specifically to hand hygiene were presented separately. Studies were excluded if hand hygiene was assessed in simulations, non-clinical settings or the operating theatre setting.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed data quality.

MAIN RESULTS

Four studies met the criteria for the review: two from the original review and two from the update. Two studies evaluated simple education initiatives, one using a randomized clinical trial design and the other a controlled before and after design. Both measured hand hygiene compliance by direct observation. The other two studies were both interrupted times series studies. One study presented three separate interventions within the same paper: simple substitutions of product and two multifaceted campaigns, one of which included involving practitioners in making decisions about choice of hand hygiene products and the components of the hand hygiene program. The other study also presented two separate multifaceted campaigns, one of which involved application of social marketing theory. In these two studies follow-up data collection continued beyond twelve months, and a proxy measure of hand hygiene compliance (product use) was recorded. Microbiological data were recorded in one study. Hand hygiene compliance increased for one of the studies where it was measured by direct observation, but the results from the other study were not conclusive. Product use increased in the two studies in which it was reported, with inconsistent results reported for one initiative. MRSA incidence decreased in the one study reporting microbiological data.

AUTHORS' CONCLUSIONS

The quality of intervention studies intended to increase hand hygiene compliance remains disappointing. Although multifaceted campaigns with social marketing or staff involvement appear to have an effect, there is insufficient evidence to draw a firm conclusion. There remains an urgent need to undertake methodologically robust research to explore the effectiveness of soundly designed and implemented interventions to increase hand hygiene compliance.

Implementing a unit-level intervention to reduce the probability of ventilator-associated pneumonia

BACKGROUND

Ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection and is associated with high morbidity and mortality rates for mechanically ventilated patients in the intensive care unit. Routine nursing interventions have been shown to reduce VAP rates.

OBJECTIVES

The purpose of this study was to evaluate the effectiveness of a unit-specific education intervention that emphasized hand hygiene, head-of-the-bed elevation, and oral care. The goals were to improve staff compliance with hand washing, head-of-the-bed elevation, and oral care; to decrease VAP rates, and to decrease number of ventilator days.

METHODS

Two-hour observations were conducted on a convenience sample of 100 ventilated patients not diagnosed with VAP and the clinical staff that interacted with them. Instrumentation included a compliance checklist, a demographic patient survey, and the Acute Physiology and Chronic Health Evaluation AEIV tool. Unit-specific educational interventions were designed and implemented on each participating unit.

RESULTS

: The VAP and the ventilator day rates did not improve significantly. There were no significant changes in clinician adherence to hand hygiene, provision of oral care, or patient positioning.

DISCUSSION

Despite implementation of both structured and creative education, team-based approach, and frequent staff reminders, patient outcomes and staff compliance did not improve significantly. Unit-based education interventions may not be the best strategy to facilitate change. Organizations with frequent changes in personnel and leadership may not have the unit-level infrastructure necessary to attain and sustain change.

Investigation into the effect of an alcohol-based hand product on infection rate in a nursing home setting

The study assessed the impact on nursing home (NH) resident infection rates of providing staff with a personal alcohol-based hand product (ABHP) with and without training on its use.

Fifteen North Wales NHs were recruited and randomly allocated into one of three groups. All monitored infection rates throughout the study period of 18 weeks (Phase I [weeks 1—9], Phase II [weeks 11—19]). NHs used liquid soap and water for hand washing throughout the study. Groups B and C introduced interventions during week ten: Group B were provided with personal ABHPs without training on use; Group C personal ABHPs with standard training from the sponsoring hand hygiene company. Infection rates between groups and pre- and post-intervention were compared.

Infection rates (per 1,000 bed days) for Phase I vs. Phase II of the study were: Group A: 6.99 vs. 7.16; Group B: 6.08 vs. 3.46; and Group C: 5.04 vs. 6.78 respectively. Change in infection rates in Groups B and C pre- and post-intervention did not reach statistical significance, p = 0.097 and p = 0.072 respectively.

Comparison of rates in non-intervention Group A with the intervention groups indicated a significantly lower rate after the intervention in Group B ( p = 0.035) but not Group C ( p = 0.765).

Findings are limited due to sample size; introduction of personal ABHPs with training did not reduce infection rates. This conflicts with other studies examining education and improvement of hand hygiene compliance. However, infection rates fell in NHs not receiving training, possibly mediated through a sense of `ownership' of the intervention.

Ventilator-associated pneumonia in adults in developing countries: a systematic review

BACKGROUND

Ventilator-associated pneumonia (VAP) is a leading cause of death in hospitalized patients, but there has been no systematic analysis of the incidence, microbiology, and outcome of VAP in developing countries or of the interventions most applicable in that setting.

METHODS

We reviewed MEDLINE (January 1966-April 2007) and bibliographies of the retrieved articles for all observational or interventional studies that examined the incidence, microbiology, outcome, and prevention of VAP in ventilated adults in developing countries. We evaluated the rates of VAP using the National Healthcare Safety Network (NHSN) definitions and the impact of VAP on the intensive care unit (ICU) length of stay (LOS) and mortality, and the impact of interventions used to reduce VAP rates.

RESULTS

The rates of VAP varied from 10 to 41.7 per 1000 ventilator-days and were generally higher than NHSN benchmark rates. Gram-negative bacilli were the most common pathogens (41-92%), followed by Gram-positive cocci (6-58%). VAP was associated with a crude mortality that ranged from 16% to 94% and with increased ICU LOS. Only a small number of VAP intervention studies were performed; these found that staff education programs, implementation of hand hygiene, and VAP prevention practice guidelines, and/or implementation of sedation protocol were associated with a significant reduction in VAP rates. Only one interventional study was a randomized controlled trial comparing two technologies, the rest were sequential observational. This study compared a heat and moisture exchanger (HME) to a heated humidifying system (HHS) and found no difference in VAP rates.

CONCLUSIONS

Based on the existing literature, the rate of VAP in developing countries is higher than NHSN benchmark rates and is associated with a significant impact on patient outcome. Only a few studies reported successful interventions to reduce VAP. There is a clear need for additional epidemiologic studies to better understand the scope of the problem. Additionally, more work needs to be done on strategies to prevent VAP, probably with emphasis on practical, low-cost, low technology, easily implemented measures.

Measuring handwashing performance in health service audits and research studies

Handwashing is regarded as the most effective way of controlling healthcare-associated infection. A search of the literature identified 42 intervention studies seeking to increase compliance in which the data were collected by directly observing practice. The methods used to undertake observation were so poorly described in most studies that it is difficult to accept the findings as reliable or as valid indicators of health worker behaviour. Most studies were limited in scope, assessing the frequency of handwashing in critical care units. The ethical implications of watching health workers during close patient contact were not considered, especially when observation was covert or health workers were misinformed about the purpose of the study. Future studies should take place in a range of clinical settings to increase the generalizability of findings. Observation should be timed to capture a complete picture of 24h activity and should include all health workers in contact with patients because all have the potential to contribute to cross-infection. Reported details of observation should include: vantage of data collectors; inter-rater reliability when more than one individual is involved; and attempts to overcome the impact of observation on usual health worker behaviour. Ideally an additional data collection method should be used to corroborate or refute the findings of observation, but no well-validated method is presently available.

Interventions to improve hand hygiene compliance in patient care

BACKGROUND

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

OBJECTIVES

To assess the short and longer-term success of strategies to improve hand hygiene compliance and to determine whether a sustained increase in hand hygiene compliance can reduce rates of health care-associated infection.

SEARCH STRATEGY

We conducted electronic searches of: the Cochrane Central Register of Controlled Trials; the Cochrane Effective Practice and Organisation of Care Group specialised register of trials; MEDLINE; PubMed; EMBASE; CINAHL; and the BNI. All databases were searched to July 2006; MEDLINE was searched from 1980, CINAHL from its inception, and the remainder from 1990 until July 2006.

SELECTION CRITERIA

Randomised controlled trials; controlled clinical trials; controlled before and after studies; and interrupted time series analyses meeting explicit entry and quality criteria used by the Cochrane Effective Practice and Organisation of Care Group. Studies reporting proxy indicators of hand hygiene compliance were considered. Studies to promote compliance with universal precautions were included providing data relating specifically to hand hygiene were presented separately.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed data quality.

MAIN RESULTS

Two studies met the criteria for review. One was a randomised controlled trial. The other was a controlled before and after study. Both were poorly controlled. Statistically significant post-intervention increase in hand washing was reported in one study up to four months after the intervention. In the other there was no post-intervention increase in hand hygiene compliance.

AUTHORS' CONCLUSIONS

There is little robust evidence to inform the choice of interventions to improve hand hygiene. It appears that single interventions based on short, 'one off' teaching sessions are unlikely to be successful, even short-term. There is a need to undertake methodologically robust research to explore the effectiveness of soundly designed interventions to increase hand hygiene compliance.

The CleanYourHandsCampaign: critiquing policy and evidence base

Handwashing is considered to be the most effective way of reducing cross-infection. Rates of healthcare-associated infection and the incidence of meticillin-resistant Staphylococcus aureus are higher in the UK than in many other European countries. The government has responded by introducing the 'CleanYourHandsCampaign' throughout England and Wales, based on the success of the approach employed in Geneva. Alcohol hand rub is placed at every bedside in acute hospitals, ward housekeepers should replenish supplies and feedback on compliance is provided to health workers. Posters and other promotional materials are used to remind health workers and visitors to use the hand rub. Patients are encouraged to ask health workers if they have cleaned their hands before contact. In this paper we argue that the evidence base underpinning the CleanYourHandsCampaign is incomplete. Alcohol hand rub is acknowledged as a useful adjunct to hand hygiene but it is not effective in all circumstances. There is some evidence to support the use of feedback on performance to encourage compliance but no evidence that promotional materials such as posters or patient reminders are effective. The ethics of encouraging hospital patients to take responsibility for their own safety is questioned. Much of the success in Geneva must be attributed to the attention given to contextual factors within the organization that encouraged hand rub use, especially hospital-wide 'ownership' of the initiative by managers and senior health professionals. A customized intervention from another country that fails to consider local organizational factors likely to influence the implementation of the campaign is unlikely to be effective. It is concluded that although hand hygiene is of undoubted importance, undue emphasis should not be placed on it as a 'quick fix' to solve the unacceptably high rates of healthcare-associated infection in National Health Service hospitals.

Multicentre study on hand hygiene facilities and practice in the Mediterranean area: results from the NosoMed Network

Hand hygiene literature is scarce in the southern Mediterranean area. In order to establish a baseline position, a study was performed in four Mediterranean countries. Seventy-seven hospital wards in 22 hospitals were enrolled and information on hand hygiene practice and facilities were collected. The overall compliance rate was very low (27.6%), and was significantly higher where the perceived risk was considered to be high. Intensive care units showed the highest level of compliance. Analysis by country indicated higher compliance in Egypt (52.8%) and Tunisia (32.3%) compared with Algeria (18.6%) and Morocco (16.9%). Facilities for hand hygiene, particularly consumables, were shown to be deficient. Multi-approach programmes combining the production of official local recommendations, education and regular evaluation of hand hygiene practice are much needed to improve the present situation.

Isolation of patients in single rooms or cohorts to reduce spread of MRSA in intensive-care units: prospective two-centre study

BACKGROUND

Hospital-acquired infection due to meticillin-resistant Staphylococcus aureus (MRSA) is common within intensive-care units. Single room or cohort isolation of infected or colonised patients is used to reduce spread, but its benefit over and above other contact precautions is not known. We aimed to assess the effectiveness of moving versus not moving infected or colonised patients in intensive-care units to prevent transmission of MRSA.

METHODS

We undertook a prospective 1-year study in the intensive-care units of two teaching hospitals. Admission and weekly screens were used to ascertain the incidence of MRSA colonisation. In the middle 6 months, MRSA-positive patients were not moved to a single room or cohort nursed unless they were carrying other multiresistant or notifiable pathogens. Standard precautions were practised throughout. Hand hygiene was encouraged and compliance audited.

FINDINGS

Patients' characteristics and MRSA acquisition rates were similar in the periods when patients were moved and not moved. The crude (unadjusted) Cox proportional-hazards model showed no evidence of increased transmission during the non-move phase (0.73 [95% CI 0.49-1.10], p=0.94 one-sided). There were no changes in transmission of any particular strain of MRSA nor in handwashing frequency between management phases.

INTERPRETATION

Moving MRSA-positive patients into single rooms or cohorted bays does not reduce crossinfection. Because transfer and isolation of critically ill patients in single rooms carries potential risks, our findings suggest that re-evaluation of isolation policies is required in intensive-care units where MRSA is endemic, and that more effective means of preventing spread of MRSA in such settings need to be found.

Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs

The etiology of nosocomial infections, the frequency of contaminated hands with the different nosocomial pathogens, and the role of health care workers' hands during outbreaks suggest that a hand hygiene preparation should at least have activity against bacteria, yeasts, and coated viruses. The importance of efficacy in choosing the right hand hygiene product is reflected in the new Centers for Disease Control and Prevention guideline on hand hygiene (J. M. Boyce and D. Pittet, Morb. Mortal. Wkly. Rep. 51:1-45, 2002). The best antimicrobial efficacy can be achieved with ethanol (60 to 85%), isopropanol (60 to 80%), and n-propanol (60 to 80%). The activity is broad and immediate. Ethanol at high concentrations (e.g., 95%) is the most effective treatment against naked viruses, whereas n-propanol seems to be more effective against the resident bacterial flora. The combination of alcohols may have a synergistic effect. The antimicrobial efficacy of chlorhexidine (2 to 4%) and triclosan (1 to 2%) is both lower and slower. Additionally, both agents have a risk of bacterial resistance, which is higher for chlorhexidine than triclosan. Their activity is often supported by the mechanical removal of pathogens during hand washing. Taking the antimicrobial efficacy and the mechanical removal together, they are still less effective than the alcohols. Plain soap and water has the lowest efficacy of all. In the new Centers for Disease Control and Prevention guideline, promotion of alcohol-based hand rubs containing various emollients instead of irritating soaps and detergents is one strategy to reduce skin damage, dryness, and irritation. Irritant contact dermatitis is highest with preparations containing 4% chlorhexidine gluconate, less frequent with nonantimicrobial soaps and preparations containing lower concentrations of chlorhexidine gluconate, and lowest with well-formulated alcohol-based hand rubs containing emollients and other skin conditioners. Too few published data from comparative trials are available to reliably rank triclosan. Personnel should be reminded that it is neither necessary nor recommended to routinely wash hands after each application of an alcohol-based hand rub. Long-lasting improvement of compliance with hand hygiene protocols can be successful if an effective and accessible alcohol-based hand rub with a proven dermal tolerance and an excellent user acceptability is supplied, accompanied by education of health care workers and promotion of the use of the product.

Increase in methicillin-resistant Staphylococcus aureus acquisition rate and change in pathogen pattern associated with an outbreak of severe acute respiratory syndrome

Background. An outbreak of severe acute respiratory syndrome (SARS) occurred in our 22-bed intensive care unit (ICU; Prince of Wales Hospital, Hong Kong, HKSAR, China) from 12 March to 31 May 2003, when only patients with SARS were admitted. This period was characterized by the upgrading of infection control precautions, which included the wearing of gloves and gowns all the time, an extensive use of steroids, and a change in antibiotic prescribing practices. The pattern of endemic pathogenic organisms, the rates of acquisition of methicillin-resistant Staphylococcus aureus (MRSA), and the rates of ventilator-associated pneumonia (VAP) were compared with those of the pre-SARS and post-SARS periods.

Methods. Data on pathogenic isolates were obtained from the microbiology department (Prince of Wales Hospital). Data on MRSA acquisition and VAP rates were collected prospectively. MRSA screening was performed for all ICU patients. A case of MRSA carriage was defined as an instance in which MRSA was recovered from any site in a patient, and cases were classified as imported or ICU-acquired if the first MRSA isolate was recovered within 72 h of ICU admission or after 72 h in the ICU, respectively.

Results. During the SARS period in the ICU, there was an increase in the rate of isolation of MRSA and Stenotrophomonas and Candida species but a disappearance of Pseudomonas and Klebsiella species. The MRSA acquisition rate was also increased: it was 3.53% (3.53 cases per 100 admissions) during the pre-SARS period, 25.30% during the SARS period, and 2.21% during the post-SARS period (P < .001). The VAP rate was high, at 36.5 episodes per 1000 ventilator-days, and 47% of episodes were caused by MRSA.

Conclusions. A SARS outbreak in the ICU led to changes in the pathogen pattern and the MRSA acquisition rate. The data suggest that MRSA cross-transmission may be increased if gloves and gowns are worn all the time.

Acinetobacter outbreaks, 1977-2000

This review of Acinetobacter outbreaks summarizes factors related to the presence and recognition of organism transmission and describes the implementation of control and prevention measures directed at limiting spread. Exogenous transmission of Acinetobacter should be considered when infections are endemic and when case rates increase. Increasing or new antimicrobial resistances in a collection of isolates also suggest transmission, and transmission can be definitively confirmed when isolates are found to be indistinguishable from or related to one another by a discriminatory genotyping test. An investigation for a common source should be conducted. When a common source cannot be found and eliminated, or once an endemically transmitted organism is established, containment or prevention efforts may require aggressive interventions, complex interventions, or both. Colonization at multiple sites, the relative ease of induction of antibiotic resistance in the organism following patient exposure to multiple drugs, and long-term environmental survival provide enhanced opportunities for the transmission of Acinetobacter between and among patients. New approaches and interventional trials are needed to define effective measures for the prevention and control of Acinobacter infections.

Use of an alcohol-based hand rub and quality improvement interventions to improve hand hygiene in a Russian neonatal intensive care unit

BACKGROUND

Hand hygiene (HH) is critical to infection control, but compliance is low. Alcohol-based antiseptics may improve HH. HH practices in Russia are not well described, and facilities are often inadequate.

SETTING

Four 6-bed units in a neonatal intensive care unit in St. Petersburg, Russia.

METHODS

Prospective surveillance of HH compliance, nosocomial colonization, and antibiotic administration was performed from January until June 2000. In February 2000, alcohol-based hand rub was provided for routine HH use. Eight weeks later, a quality improvement intervention was implemented, consisting of review of interim data, identification of opinion leaders, posting of colonization incidence rates, and regular feedback. Means of compliance, colonization, and antibiotic use were compared for periods before and after each intervention.

RESULTS

A total of 1,027 events requiring HH were observed. Compliance was 44.2% before the first intervention, 42.3% between interventions, and 48% after the second intervention. Use of alcohol rose from 15.2% of HH indications to 25.2% between interventions and 41.5% after the second intervention. The incidence of nosocomial colonization (per 1,000 patient-days) with Klebsiella pneumoniae was initially 21.5, decreased to 4.7, and then was 3.2 in the final period. Rates of antibiotic and device use also decreased.

CONCLUSIONS

HH may have increased slightly, but the largest effect was a switch from soap and water to alcohol which may have been associated with decreased cross-transmission of Klebsiella, although this may have been confounded by lower device use. Alcohol-based antiseptic may be an improvement over current practices, but further research is required.

Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.

Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.

Compliance with hand disinfection and its impact on hospital-acquired infections

Hand hygiene prevents cross-infection in hospitals, but adherence to guidelines is poor among healthcare workers. Although some interventions to improve compliance have been successful, none had achieved lasting improvement until very recently. Reasons for non-compliance with recommendations occur at individual, group and institutional levels. The complexity of the process of behavioural change would suggest that the application of multimodal, multidisciplinary strategies are necessary. Both easy access to hand hygiene in a timely fashion and skin protection appear necessary prerequisites for satisfactory hand hygiene behaviour. Alcohol-based hand-rub may be superior to traditional handwashing as it requires less time, acts faster, irritates hands less often, and recently proved significantly to contribute to sustained improvement in compliance associated with decreased infection rates. This paper reviews barriers to appropriate hand hygiene and describes the results of the first successful experience of sustained hand hygiene promotion and its effectiveness on hospital-acquired infection.

The effectiveness of interventions aimed at increasing handwashing in healthcare workers - a systematic review

Handwashing is widely accepted as being key to the prevention of hospital-acquired infection but the frequency of handwashing by healthcare workers has been found to be low. A systematic critical literature review was conducted to establish the effectiveness of interventions aimed at increasing compliance with handwashing in healthcare workers. The results showed that one-off educational interventions have a very short-term influence on handwashing behaviour. Use of strategically placed reminders, or asking patients to remind staff of the need to conduct handwashing can have a modest but more sustained effect. Feedback of performance can increase levels of handwashing but if feedback is not repeated regularly, then this effect is not maintained over long periods. Automated sinks increase the quality of handwashing but healthcare workers can be discouraged from using these because of the additional time involved. Provision of moisturized soaps appears to make little difference to handwashing behaviour but providing 'dry' hand rubs near patient beds may lead to a minimal increase in the frequency with which staff decontaminate their hands. Multifaceted approaches which combine education with written material, reminders and continued feedback of performance can have an important effect on handwashing compliance and rates of hospital-acquired infection.

Improving adherence to hand hygiene practice: a multidisciplinary approach

Hand hygiene prevents cross-infection in hospitals, but health-care workers' adherence to guidelines is poor. Easy, timely access to both hand hygiene and skin protection is necessary for satisfactory hand hygiene behavior. Alcohol- based hand rubs may be better than traditional handwashing as they require less time, act faster, are less irritating, and contribute to sustained improvement in compliance associated with decreased infection rates. This article reviews barriers to appropriate hand hygiene and risk factors for noncompliance and proposes strategies for promoting hand hygiene.

Hand Hygiene Revisited: Lessons from the Past and Present

Hand hygiene is the most effective measure to prevent cross-transmission of microorganisms. Adequate hand hygiene can be achieved by standard handwashing--with water alone or with soap--or by the use of an alcohol-based hand-rub solution. Despite considerable efforts, compliance with this simple infection-control measure remains low. Factors predicting non-compliance have been extensively studied, and include physician status, procedures associated with a high risk of cross-transmission, and an important workload. Future interventions to improve compliance should consider complex behavioral theories and the use of multimodal and multidisciplinary strategies. We believe that one of the key components of these interventions should be the wide use of alcohol-based hand-rub, which is microbiologically effective and less time-consuming than standard handwashing.

Disinfectants that do

Biocides are helpful in different healthcare settings to reduce or eradicate harmful pathogens on the skin, medical devices, and in the environment. This article reviews recent advances in hand hygiene, instrument sterilization, decolonization with mupirocin, and the challenges posed by environmental contamination, and prion disease. Do biocides induce resistance?

Hand hygiene-beliefs or science?

Over a century has passed since Ignaz P. Semmelweis demonstrated the association between hand hygiene and nosocomial infections, but this simple procedure is still not recognized by many healthcare workers as one of the most important measures to prevent cross-transmission of microorganisms. A relatively large amount of research has been done, in particular to try to understand why compliance remains so low, in order to implement successful promotion campaigns. This research has generated a fair amount of strong scientific data which are sometimes misunderstood and misused because of myths or certain beliefs. Observational or intervention studies have consistently shown a number of risk factors associated with non-compliance, such as high workload, professional category, or type of ward. Others are thought to be barriers to adequate compliance but have not yet been properly assessed. These include skin irritation due to hand hygiene agents, lack of knowledge of hand hygiene recommendations, or lack of institutional policy. Future interventions to promote hand hygiene will need to address these risk factors, and target the individual healthcare worker, as well as the group or institution if a significant degree of success is to be achieved.

Improving compliance with hand hygiene in hospitals

Hand hygiene prevents cross-infection in hospitals, but compliance with recommended instructions often is poor among healthcare workers. Although some previous interventions to improve compliance have been successful, none has achieved lasting improvement. This article reviews reported barriers to appropriate hand hygiene and factors associated with poor compliance. Easy access to hand hygiene in a timely fashion and the availability of skin-care lotion both appear to be necessary prerequisites for appropriate hand-hygiene behavior. In particular, in high-demand situations, hand rub with an alcohol-based solution appears to be the only alternative that allows a decent compliance. The hand-hygiene compliance level does not rely on individual factors alone, and the same can be said for its promotion. Because of the complexity of the process of change, it is not surprising that solo interventions often fail, and multimodal, multidisciplinary strategies are necessary. A framework that includes parameters to be considered for hand-hygiene promotion is proposed, based on epidemiologically driven evidence and review of the current knowledge. Strategies for promotion in hospitals should include reasons for noncompliance with recommendations at individual, group, and institutional levels. Potential tools for change should address each of these elements and consider their interactivity.