Improving adherence to hand hygiene practice: a multidisciplinary approach

Hand hygiene knowledge, beliefs, and practices among healthcare professionals in the primary healthcare centers in Riyadh, Saudi Arabia: a cross-sectional study

Hand hygiene (HH) is vital for preventing healthcare-associated infections and ensuring patient safety. This study evaluated the knowledge, beliefs, and practices of healthcare professionals in primary healthcare centers (PHCs) in Riyadh, Saudi Arabia. A cross-sectional descriptive study was conducted using an online validated questionnaire based on the World Health Organization Hand Hygiene Knowledge Questionnaire. Data were analyzed to identify gaps and patterns across professional roles and demographics. A total of 221 healthcare professionals participated, 76% women and 24% men, 57% aged 30-39 years. Most had over 15 years of experience (33%), with nurses comprising the largest professional group. Nearly all participants (91%) had received HH training in the past 3 years, and 88% reported routine use of alcohol-based hand sanitizer. However, only 67% correctly identified the minimum time for alcohol-based sanitizer to kill germs, and misconceptions about hand rubbing efficacy persisted. The primary route of germ transmission was identified as healthcare workers' unclean hands. Most participants agreed that hand rubbing is faster than handwashing and emphasized HH after patient contact, exposure to body fluids, or contact with the patient's surroundings. Nearly all endorsed using both hand rubbing and handwashing for specific scenarios, such as before injections. This study highlights strong HH knowledge and adherence among healthcare workers in Riyadh PHCs, reflecting effective training programs. However, persistent misconceptions and knowledge gaps regarding germ transmission and hand rubbing efficacy require targeted interventions.

The Evolution Of Surgical Hands Anti-Sepsis: From Scrub To Rub

Surgical site infection (SSI) is the infection which affects the surgical incision site or deep tissues of the body and revealed within 30 days after surgery or within 1 year if implants are left inside body for treatment purpose [1]. The prevalence of SSI is 2.5%–41% globally but expected to be significantly higher in low-middle income countries where hospitals are often less equipped [2]. SSI is the leading cause of healthcare-associated infections which not only prolonged the hospital stay of admitted patients but also increase the treatment charges and may result in higher morbidity and mortality [3]. SSI can result from multiple factors pertaining to patient, surgeon, and operating environment but the most effective and low cost method to decrease the frequency of SSI is the optimum surgical hands anti-sepsis [4]. Routine handwashing removes visible physical contamination and transient skin flora; whereas surgical hand anti-sepsis is the additional use of anti-microbial product or alcohol based hand rub for preventing the growth of resident skin flora [5]. The hands of surgeon can harbor a variety of microorganisms. The most common resident skin flora are Staphylococcus Epidermidis, Staphylococcus Hominis, Coryneform bacteria, Pityrosporum, and coagulase negative Staphylococci. The resident flora is usually harmless but in sterile body cavities they can cause serious infections. The transient skin flora include Staphylococcus aureus, Gram-negative bacteria and yeast which can be acquired by members of surgical teams when they came in contact with patients or other objects which colonize them. The transient flora is the major pathogens responsible for SSI [6]. The commonly used hand anti-septic agents are iodine-iodophors, chlorhexadine gluconate, alcohol-containing preparation, para-chloro-meta-xylenol, and triclosan [7]. SSI is preventable and studies have shown that 30–70% of infections can be avoided with surgical handwashing [8-11]. Joseph Lister has indicated that handwashing can reduce the SSI from 45 to 15%. [12] Rang [13] reported that Semmelweis was successful in lowering infection rate from 18.3% to 1.3% through handwashing in his clinic. The World Health Organization (WHO) has developed Global Guidelines for the prevention of SSI which encompass a wide range of evidence based recommendations with special emphasis on hand hygiene, pre-surgical hand scrubbing (SHS) and rubbing techniques, and various anti-septic solutions [14, 15]. The two most commonly used pre-operative handwashing techniques are surgical hand scrubbing( SHS) and surgical hand rubbing (SHR). Hand scrubbing is the traditional technique of washing hands and forearm with anti-septic solution under running water, whereas hand rubbing involves cleaning hands and forearm with alcohol based solution without using any water [16]. The use of waterless-alcohol solutions for hand anti-sepsis instead of traditional hands washing with water is a major change in hand hygiene practices [17]. The WHO prefers hands rubbing with alcohol-based hand rubbing solutions particularly for third world countries for three reasons [18]. First, studies have confirmed that hand rubbing with aqueous alcohol is as effective as traditional handwashing in achieving pre-operative surgical hands anti-sepsis. Second, health facilities which cannot maintain the steady flow of tape water and the recommended quality and temperature of water, hand rubbing with waterless preparation is a good alternative. Third, usage of clean drinking water for hands scrubbing is discouraged to preserve clean water as studies have revealed that traditional hands scrubbing utilize 11 L of water per scrub [19]. The length of time for SHS and SHR depends upon manufacture’s recommendations but usually 2–5 min is sufficient as per the WHO guidelines. SHR is applied to dry hands only and in sufficient amount so that hands and forearm are wet throughout the SHR procedure. Apart from WHO other guidelines like Centers for Disease Control and Prevention(CDC) USA, Association of PeriOperative Registered Nurses (AORN) and Infection Prevention and Control Canada also endorse that alcohol-based hands rub can be used an effective alternative to handwashing [20, 21]. In a systematic review and meta-analysis by Feng et al. [16], it was documented that SHR had similar efficacy and cost-effectiveness as that of surgical hands washing with added advantages of easy application, dermal tolerance and less time consumption than traditional hand scrubbing with water. These advantages are extremely important for surgical teams which usually performed surgical hand anti-sepsis more frequently and in some cases on daily basis before performing surgeries. Hand rubbing anti-sepsis has been used in USA and some parts of Europe since long [22]. Overall the compliance of the healthcare workers to hand hygiene has been poor and reported to be <50% [23]. Hand rubbing with alcohol preparation has demonstrated an increase compliance of healthcare workers to hand hygiene guidelines [24]. Conclusion: Surgical hand anti-sepsis is the initial crucial step which can prevent and control SSI. Although alcohol based hands rub has many advantages over traditional hand scrubbing with water, implementation in a hospital setting can be a challenge due to resistance of the operating surgeons in changing their usual traditional practice. The WHO endorsed the use of multimodal hand hygiene improvement programs for the implementation of evidence based hand hygiene practice. These strategies include uninterrupted supply of alcohol based hand rub solutions, education, evaluation, feedback, reminders, and administrative support.

Effectiveness of sensing gloves-applied virtual reality education system on hand hygiene practice: A randomized controlled trial

BACKGROUND

We developed a virtual reality (VR) education system and evaluated its clinical utility for promoting hand hygiene practices.

METHODS

This prospective, 2-week, randomized controlled study conducted at Okayama University Hospital, Japan, from November 2023 to January 2024, involved 22 participants (18 medical students and 4 residents). A fully immersive 360° VR system (VIVE Pro Eye) using a head-mounted display and sensing gloves was used to develop 3 health care tasks in a virtual patient room-Environmental Cleaning, Gauze Exchange, and Urine Collection. After monitoring all participants' baseline usage data of portable hand-rubbing alcohol in the first week, we randomly assigned them into 1:1 groups (VR training and video lecture groups). The primary outcome was differences in hand-rubbed alcohol use before and after intervention.

RESULTS

Before the intervention, alcohol use did not significantly differ between both groups. After the intervention, a significant increase in alcohol use was observed in the VR training group (median: 8.2 g vs 16.2 g; P = .019) but not in the video lecture group.

CONCLUSIONS

Our immersive 360° VR education system enhanced hand hygiene practices. Infection prevention and control practitioners and digital technology experts must collaborate to advance the development of superior educational devices and content.

GLO GERM AND COVID-19: ILLUMINATING HYGIENE AND PROMOTING TRANSMISSION AWARENESS

Background

Maintaining effective surface hygiene and preventing contamination is of paramount importance. Our study introduces Glo Germ, a versatile product available in various forms, which possesses the unique ability to reveal hidden truths under ultraviolet light, enhance understanding of hygiene, and spread awareness of COVID-19 transmission and preventive measures.

Materials and Methods

A comprehensive study was conducted to assess different surface cleaning techniques' effectiveness. Glo Germ, containing a fluorescent dye activated by ultraviolet light, was used to visualize germ spread and compare disinfectant cleaners' efficacy. The study encompassed diverse surfaces and materials, aiming to identify optimal cleaning techniques for each context. Furthermore, a small illustrative study was conducted during a COVID-19 awareness presentation involving students. Glo Germ was applied to hands, revealing its subsequent spread to faces and surfaces. This visual experiment effectively emphasized hand hygiene and mask-wearing importance.

Results

Results indicated that while water alone achieved satisfactory cleaning results, using detergent and the appropriate cleaning tools further improved efficacy. Notably, adhering to consistent patterns and applying pressure during cleaning proved essential. The student demonstration showed how contaminants spread quickly, highlighting hand hygiene's significance and the potential extent of contamination through sneezing.

Conclusion

Glo Germ inclusion in these experiments highlights its potential in educating about surface cleaning and microbial transmission, offering an interactive and engaging approach to promoting personal hygiene and fostering illness prevention awareness.

Workflows and locations matter - insights from electronic hand hygiene monitoring into the use of hand rub dispensers across diverse hospital wards

Background

While healthcare-associated infections (HAIs) affect approximately 3.2-6.5% of hospitalised patients in the US and Europe, improving hand hygiene (HH) could reduce HAI rates. Investigating HH is time-consuming and not always objective, and comprehensive, unbiased data is needed to develop effective strategies. Using electronic tools can provide new and detailed insights on the determinants of HH.

Aim

To evaluate location-dependent usage of wall-mounted dispensers (WMDs) and point-of-care dispensers (POCs) using an electronic HH recording system.

Methods

In this retrospective study, hand rub volumes were anonymously recorded for 931,446 disinfections from 17 wards in nine German hospitals using the electronic monitoring system NosoEx®. Number of disinfections and rub volumes of WMDs/POCs by ward and room type were analysed.

Findings

Generally, WMDs were most prevalent. With >3 dispensers per bed and >20 disinfections per patient day, availability and use were highest in intensive care (ICU) and intermediate care (IMC), but here rub volumes from WMDs were lowest (∼2.0 mL). Although most dispensers are located in patient rooms (∼42%), they are more frequently used in hallways. In surgical ICUs, dispensers are often used in patient rooms, where contact with open wounds is common. About 3.6 mL of hand rub is used per disinfection in treatment rooms, the highest volume of all room types.

Conclusion

Dispenser use was dependent on location, room type, ward specialisation and workflow. Optimising the location of hand rub dispensers (HRDs)s is not the only solution to improve HH, but can help reduce inconvenience, achieve more ergonomic workflows and better meet user needs.

Hand hygiene compliance and improvement interventions in the Eastern Mediterranean Region: a systematic review and meta-analysis

Hand hygiene compliance among healthcare workers is crucial for preventing infections in healthcare settings. This systematic review and meta-analysis aimed to assess the compliance of healthcare workers in the Eastern Mediterranean region with hand hygiene guidelines and synthesize evidence on the success rate of strategies to improve hand hygiene. Five electronic databases (PubMed, CINAHL, Cochrane, Web of Science, and Scopus) were searched up to August 2020. Articles were included if they were conducted in the Eastern Mediterranean Region. A manual search was conducted for reference lists of included papers, and relevant additional references were reviewed. Two reviewers independently screened articles for inclusion, performed data extraction, and assessed quality. A meta-analysis was conducted to synthesize findings and determine the prevalence of hand hygiene compliance interventions. The search yielded 6678 articles. After removing duplicates and applying inclusion/exclusion criteria, 42 articles were included, of which 24 were meta-analyzed. The meta-analysis showed a compliance prevalence of 32% with significant heterogeneity (I2= 99.7% p <0.001). Interventions using the World Health Organization (WHO) guidelines were over two times more likely to improve compliance rates (OR= 2.26, [95% CI:(2.09 - 2.44)], I2= 95%, p<0.001) compared to no intervention. Other interventions were close to two times more likely to improve compliance rates (OR= 1.84, [95% CI:(1.66 - 2.04)], I2= 98% p= 0.001). Approximately two-thirds of healthcare providers in the Eastern Mediterranean region were non-compliant with standard hand hygiene practices, highlighting the need for increased efforts, awareness, observation, and control policies.

Alcohol-based decontamination of gloved hands: A randomized controlled trial

OBJECTIVE

The gold standard for hand hygiene (HH) while wearing gloves requires removing gloves, performing HH, and donning new gloves between WHO moments. The novel strategy of applying alcohol-based hand rub (ABHR) directly to gloved hands might be effective and efficient.

DESIGN

A mixed-method, multicenter, 3-arm, randomized trial.

SETTING

Adult and pediatric medical-surgical, intermediate, and intensive care units at 4 hospitals.

PARTICIPANTS

Healthcare personnel (HCP).

INTERVENTIONS

HCP were randomized to 3 groups: ABHR applied directly to gloved hands, the current standard, or usual care.

METHODS

Gloved hands were sampled via direct imprint. Gold-standard and usual-care arms were compared with the ABHR intervention.

RESULTS

Bacteria were identified on gloved hands after 432 (67.4%) of 641 observations in the gold-standard arm versus 548 (82.8%) of 662 observations in the intervention arm (P < .01). HH required a mean of 14 seconds in the intervention and a mean of 28.7 seconds in the gold-standard arm (P < .01). Bacteria were identified on gloved hands after 133 (98.5%) of 135 observations in the usual-care arm versus 173 (76.6%) of 226 observations in the intervention arm (P < .01). Of 331 gloves tested 6 (1.8%) were found to have microperforations; all were identified in the intervention arm [6 (2.9%) of 205].

CONCLUSIONS

Compared with usual care, contamination of gloved hands was significantly reduced by applying ABHR directly to gloved hands but statistically higher than the gold standard. Given time savings and microbiological benefit over usual care and lack of feasibility of adhering to the gold standard, the Centers for Disease Control and Prevention and the World Health Organization should consider advising HCP to decontaminate gloved hands with ABHR when HH moments arise during single-patient encounters.Trial Registration: NCT03445676.

Hand and Oral Hygiene Practices of South Korean Adolescents Before and During the COVID-19 Pandemic

Importance

Only a few studies have examined the long-term trends of hand and oral hygiene, especially among adolescents.

Objective

To investigate the 15-year trends in frequency of handwashing and toothbrushing and examine the factors associated with hand and oral hygiene, particularly during the COVID-19 pandemic.

Design, Setting, and Participants

This cross-sectional study, performed from January 1, 2008, to December 31, 2022, used general population-based data from 963 644 individuals in a national representative survey (Korea Youth Risk Behavior Web-based Survey [KYRBS]).

Exposure

COVID-19 pandemic.

Main Outcomes and Measures

Trends in hand and oral hygiene practices were measured by how frequently adolescents washed their hands and whether they fulfilled the recommended guidelines for toothbrushing. An interrupted time series analysis using linear and logistic regression models was performed to assess any associations with the COVID-19 pandemic. Hand and oral hygiene behaviors before and during the pandemic in each sociodemographic subgroup were also compared.

Results

In the 963 644 adolescents (495 697 [51.4%] male; mean [range] age, 15.01 [12-18] years) who participated in the KYRBS from 2008 to 2022, a 73.3% (95% CI, 59.4%-97.4%; P < .001) immediate increase was seen in overall hand hygiene behavior at the onset of the COVID-19 pandemic compared with the prepandemic period, with a sustained decrease thereafter (β = -0.018; 95% CI, -0.022 to -0.015; P < .001). Meanwhile, no immediate increase was observed in terms of overall oral hygiene behavior (0.1%; 95% CI, -0.9% to 1.1%; P = .82); however, there was a sustained decrease during the pandemic (β = -0.018; 95% CI, -0.020 to -0.016; P < .001). Older age, female sex, nonsmoking status, alcohol use, low household economic level, and poor school performance were significantly associated with poor hand hygiene during the pandemic.

Conclusions and Relevance

In this cross-sectional study of South Korean adolescents, an increase in the prevalence of hand hygiene was observed during the early pandemic; however, this prevalence decreased over time. Meanwhile, the decrease in the prevalence of oral hygiene was more pronounced during the pandemic. This study recommends stronger guidelines for adolescent health coaches, such as teachers or public health advisers, regarding hygiene behaviors, even after the COVID-19 pandemic ends.

Construction of a standardized training system for hospital infection prevention and control for new medical staff in internal medicine ICUs based on the Delphi method

In China, studies have shown nosocomial infections contribute to increased mortality rates, prolonged hospital stays, and added financial burdens for patients. Previous studies have demonstrated that effective infection control training can enhance the quality of infection control practices, particularly in intensive care unit (ICU) settings. However, there is currently no universally accepted training mode or program that adequately addresses the specific needs of ICU medical staff regarding nosocomial infection control. The objective of this study was to develop a standardized training system for preventing and controlling hospital-acquired infections among new medical staff in the internal medicine ICU. Our methodology encompassed an extensive literature review, technical interviews focusing on key events, semi-structured in-depth interviews, and two rounds of Delphi expert correspondence. We employed intentional sampling to select 16 experts for the Delphi expert consultation. Indicators were chosen based on an average importance score of >3.5 and a coefficient of variation of <0.25. The weight of each indicator was determined using the analytic hierarchy process. The efficacy of the two rounds of questionnaires was also evaluated. Our findings revealed that the questionnaires achieved a 100% effective recovery rate, with expert authority coefficients of 0.96 and 0.90. The Kendall coordination coefficients for the first-, second-, and third-level indicators in the initial round of expert consultation questionnaires were 0.440, 0.204, and 0.386 (P < 0.001), respectively. In the second round of expert consultation questionnaires, the Kendall coordination coefficients for the first, second, and third-level indicators were 0.562, 0.467, and 0.556 (P < 0.001), respectively. The final training model consisted of four first-level indicators (hospital infection prevention and control training content, training methods/forms, assessment content, and evaluation indicators), 26 second-level indicators, and 44 third-level indicators. In conclusion, the proposed standardized training system for infection prevention and control among new medical staff in the internal medicine ICU is both scientifically sound and practical, which can contribute to improved patient safety, reduced healthcare costs, and enhanced overall quality of care in internal medicine ICUs. Moreover, it can serve as a framework for future training projects.

Hand Hygiene Practices and Promotion in Public Hospitals in Western Sierra Leone: Changes Following Operational Research in 2021

Hand hygiene is the most important intervention for preventing healthcare-associated infections and can reduce preventable morbidity and mortality. We described the changes in hand hygiene practices and promotion in 13 public hospitals (six secondary and seven tertiary) in the Western Area of Sierra Leone following the implementation of recommendations from an operational research study. This was a "before and after" observational study involving two routine cross-sectional assessments using the WHO hand hygiene self-assessment framework (HHSAF) tool. The overall mean HHSAF score changed from 273 in May 2021 to 278 in April 2023; it decreased from 278 to 250 for secondary hospitals but increased from 263 to 303 for tertiary hospitals. The overall mean HHSAF score and that of the tertiary hospitals remained at the "intermediate" level, while secondary hospitals declined from "intermediate" to "basic" level. The mean score increased for the "system change" and "institutional safety climate" domains, decreased for "training and education" and "reminders in the workplace" domains, and remained the same for the "evaluation and feedback" domain. Limited resources for hand hygiene promotion, lack of budgetary support, and formalized patient engagement programs are the persistent gaps that should be addressed to improve hand hygiene practices and promotion.

Hand hygiene compliance and associated factors among healthcare workers in selected tertiary-care hospitals in Bangladesh

BACKGROUND

Hand hygiene (HH) is a fundamental element of patient safety. Adherence to HH among healthcare workers (HCWs) varies greatly depending on a range of factors, including risk perceptions, institutional culture, auditing mechanisms, and availability of HH supplies.

AIMS

This study aimed to evaluate HH compliance and associated factors among HCWs in selected tertiary-care hospitals in Bangladesh.

METHODS

During September 2020 to May 2021, we conducted non-participatory observations at 10 tertiary-care hospitals using the WHO's '5-moments for hand hygiene tool' to record HH compliance among physicians, nurses and cleaning staff. We also performed semi-structured interviews to determine the key barriers to complying with HH.

RESULTS

We observed 14,668 hand hygiene opportunities. The overall HH compliance was 25.3%, the highest among nurses (28.5%), and the lowest among cleaning staff (9.9%). HCWs in public hospitals had significantly higher odds of complying with HH practices than those in private hospitals (adjusted odds ratio: 1.73, 95% CI: 1.55-1.93). The odds of performing HH after touching a patient were 3.36 times higher compared with before touching a patient (95% CI: 2.90-3.90). The reported key barriers to performing HH were insufficient supplies (57.9%), skin reactions (26.3%), workload (26.3%) and lack of facilities (22.7%). Overall, observed HH supplies were available in 81.7% of wards for physicians and 95.1% of wards for nurses, however, no designated HH facilities were found for the cleaning staff.

CONCLUSIONS

HH compliance among HCWs fell significantly short of the standard for safe patient care. Inadequate HH supplies demonstrate a lack of prioritizing, promoting and investing in infection prevention and control.

Use of thermal imaging to measure the quality of hand hygiene

OBJECTIVES

Hand hygiene has long been promoted as the most effective way to prevent the transmission of infection. However, due to low compliance and low quality of hand hygiene reported in previous studies, constant monitoring of hand hygiene compliance and quality among healthcare workers is crucial. This study investigated the feasibility of using a thermal camera with an RGB camera to detect hand coverage of alcohol-based formulation, thereby monitoring the quality of hand rubbing.

METHODS

In total, 32 participants were recruited to participate in this study. Participants were required to perform four types of hand rubbing to achieve different coverage of the alcohol-based formulation. After each task, participants' hands were photographed under a thermal camera and an RGB camera, while an ultraviolet (UV) test was used to provide the ground truth of hand coverage of alcohol-based formulation. U-Net was used to segment areas exposed to alcohol-based formulation from thermal images, and system performance was evaluated by comparing differences in coverage between thermal images and UV images in terms of accuracy and Dice coefficient.

RESULTS

This system found promising results in terms of accuracy (93.5%) and Dice coefficient (87.1%) when observations took place 10 s after hand rubbing. At 60 s after hand rubbing, accuracy and Dice coefficient were 92.4% and 85.7%.

CONCLUSIONS

Thermal imaging has potential for accurate, constant and systematic monitoring of the quality of hand hygiene.

An interactive feedback system for increasing hand antisepsis adherence in stationary intensive care

BACKGROUND

Pathogens causing infections are in many cases transmitted via the hands of personnel. Thus, hand antisepsis has strong epidemiological evidence of infection prevention. Depending on various factors, hand antisepsis adherence ranges between 9.1% and 85.2%.

AIM

To evaluate a new transponder system that reminded medical staff to use an alcohol-based hand rub based on indication by giving real-time feedback, to detect hand antisepsis adherence.

METHODS

The monitoring system consisted of three components: a portable transponder detecting alcohol-based hand rub and able to give feedback; a beacon recognizing entries to and exits from the patient's surroundings; and a sensor placed at the hand-rub dispensers to count the number of hand rubs. With these components, the system provided feedback when hand antisepsis was not conducted although it was necessary according to moments 1, 4, and 5 of hand antisepsis. Adherence was measured in two use-cases with five phases, starting with the baseline measurement followed by intervention periods and phases without intervention to test the sustainability of the feedback.

FINDINGS

Using the monitoring system, hand antisepsis adherence was increased by up to 104.5% in comparison to the baseline measurement. When the intervention ceased, however, hand antisepsis adherence decreased to less than or equal to the baseline measurement.

CONCLUSION

A short-term intervention alone is not sufficient to lead to a long-term change in hand antisepsis adherence. Rather, permanent feedback and/or the integration in a multi-modal intervention strategy are necessary.

Stethoscopes or Maybe "Bacterioscopes" - Is hand Hygiene Solely Capable of Preventing Hospital-Associated Infections?

The stethoscope remains an indispensable diagnostic tool for medical students. Improper stethoscope hygiene may cause bacterial infections, including hospital-associated infections (HAIs), which challenge the Polish medical system. The study's main objective was to evaluate the hygiene habits declared by medical students. Moreover, microbiological control with the characteristics of potentially pathogenic microorganisms was performed. The study included 66 medical students from the Faculty of Medicine at the Jagiellonian University Medical College in Cracow, Poland. The participants filled in an anonymous questionnaire. Stethoscope contamination was assessed through isolation, identification, testing of antibiotic resistance, and clonality of the isolates bacterial pathogens. The survey showed that only 30.3% of students cleaned their stethoscopes after each patient, and 1.5% never did this. Of the 66 stethoscopes tested, 100% were positive for bacterial growth. Staphylococcus spp. was the most frequently isolated contaminant (50.5%). The questionnaire results demonstrated the necessity of the validated procedures for cleaning the stethoscopes. Stethoscopes used by medical students are contaminated with numerous bacterial species, including multidrug-resistant organisms. The clonal structure of the MRSA and MRSE populations acquired from stethoscopes has been demonstrated. Our results confirm the possibility that these medical devices mediate the spread of hazardous pathogens in the hospital environment. Practical exercises are essential to forming the correct hygiene habits involving stethoscopes, which enable practicing and checking the correctness of the established skills.

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.

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.

Are there reasons behind high Handrub consumption? A French National in-depth qualitative assessment

Background

Hand hygiene (HH) is the most important measure for preventing healthcare-associated infections. A significant correlation between alcohol-based handrub consumption (AHRC) and observed HH compliance rates has been established. In France, publicly reported AHRC displayed a large heterogeneity across healthcare facilities (HCFs). We aimed to describe programmes for promoting HH in the top and medium AHRC scorers and to assess factors and drivers leading to a high AHRC score in a panel of French HCFs.

Methods

We performed a nationwide qualitative comparative case study based on in-depth semi-structured interviews in 16 HCFs with high, 4-year AHRC scores, and a sample of seven university hospitals (UHs) with medium AHRC scores. Infection Prevention and Control Team (IPC) members (n = 62), quality managers/chief executive officers (n = 23) and frontline workers (n = 6) were interviewed, using a grounded theory approach and an iterative thematic approach.

Results

Ninety-one interviews were performed. There was a large heterogeneity in IPC structures and objectives, with specific patterns associated with high AHRC that were more organisational than technical. Four areas emerged: (1) strong cohesive team structure with supportive and outcome-oriented work attitude, (2) IPC structure within the organization, (3) active support from the institution, (4) leadership and role model. Among high AHRC scorers, a good core IPC organisation, a proactive and flexible management, a frequent presence in the clinical wards, and working in a constructive safety climate were prominent.

Conclusion

We highlighted that IPC structure and activity is heterogeneous, with organisational and behavioural characteristics associated with high AHRC score. Beyond technical challenge, our work underlines the importance of strong structure of the IPC and behavioural approaches in implementing key IPC programmes.

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.

Gap between self-evaluation and actual hand hygiene compliance among health-care workers

Hand hygiene (HH) compliance among health-care workers has not satisfactorily improved despite multiple educative approaches. Between October 2019 and February 2020, we performed a self-evaluation test and a direct observation for the compliance of the 5 Moments for Hand Hygiene program advocated by the World Health Organization at two Japanese hospitals. Average percentages of self-evaluated HH compliance were as follows: (i) 76.9% for "Before touching a patient," (ii) 85.8% for "Before clean/aseptic procedures," (iii) 95.9% for "After body fluid exposure/risk," (iv) 84.0% for "After touching a patient," and (v) 69.2% for "After touching patient surroundings." On the other hand, actual HH compliance was 11.7% for "Before touching a patient" and 18.0% for "After touching a patient or patient surroundings." The present study demonstrated a big gap between self-evaluation and actual HH compliance among nurses working at hospitals, indicating the need of further providing the education in infection prevention.

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

Background

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

Methods

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

Results

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

Conclusion

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

Control of Healthcare-Associated Carbapenem-Resistant Acinetobacter baumannii by Enhancement of Infection Control Measures

Antimicrobial stewardship and infection control measures are equally important in the control of antimicrobial-resistant organisms. We conducted a retrospective analysis of the incidence rate of hospital-onset carbapenem-resistant Acinetobacter baumannii (CRAB) infection (per 1000 patient days) in the Queen Mary Hospital, a 1700-bed, university-affiliated teaching hospital, from period 1 (1 January 2007 to 31 December 2013) to period 2 (1 January 2014 to 31 December 2019), where enhanced infection control measures, including directly observed hand hygiene before meal and medication rounds to conscious patients, and the priority use of single room isolation, were implemented during period 2. This study aimed to investigate the association between enhanced infection control measures and changes in the trend in the incidence rate of hospital-onset CRAB infection. Antimicrobial consumption (defined daily dose per 1000 patient days) was monitored. Interrupted time series, in particular segmented Poisson regression, was used. The hospital-onset CRAB infection increased by 21.3% per year [relative risk (RR): 1.213, 95% confidence interval (CI): 1.162−1.266, p < 0.001], whereas the consumption of the extended spectrum betalactam-betalactamase inhibitor (BLBI) combination and cephalosporins increased by 11.2% per year (RR: 1.112, 95% CI: 1.102−1.122, p < 0.001) and 4.2% per year (RR: 1.042, 95% CI: 1.028−1.056, p < 0.001), respectively, in period 1. With enhanced infection control measures, the hospital-onset CRAB infection decreased by 9.8% per year (RR: 0.902, 95% CI: 0.854−0.953, p < 0.001), whereas the consumption of the extended spectrum BLBI combination and cephalosporins increased by 3.8% per year (RR: 1.038, 95% CI: 1.033−1.044, p < 0.001) and 7.6% per year (RR: 1.076, 95% CI: 1.056−1.097, p < 0.001), respectively, in period 2. The consumption of carbapenems increased by 8.4% per year (RR: 1.84, 95% CI: 1.073−1.094, p < 0.001) in both period 1 and period 2. The control of healthcare-associated CRAB could be achieved by infection control measures with an emphasis on directly observed hand hygiene, despite an increasing trend of antimicrobial consumption.

Hand Hygiene Auditing: Is It a Roadway to Improve Adherence to Hand Hygiene Among Hospital Personnel?

Background Over the years, there has been an increase in hospital-acquired infections (HAIs) among patients in India. One of the main reasons is a lack of compliance with infection control guidelines, such as hand hygiene. So the present study was conducted to determine the compliance of hand hygiene among healthcare workers in a private tertiary care teaching hospital in South India. Materials and methods The prospective observational study was carried out between April 2017 and March 2020. Nineteen areas were directly observed for hand hygiene (HH) compliance. At each location, HH audit was conducted for one hour per day for five days per month. HH complete adherence rate (HHCAR) and HH partial adherence rate (HHPAR) were analyzed. Results Nine hundred and twenty observation periods were completed during the entire study period. Overall, hand hygiene complete adherence rate was 29.9% (11,981/39,998); partial adherence rate was 45.3% (18,131/39,998) and the non-adherence rate was 24.7% (9886/39,998). A better adherence rate was seen among nurses (44.7%), followed by other staff (33.7%) and doctors (33.04%). Moment-specific adherence rates show almost equal adherence rates of 50.7%, 50.75%, and 50.1%, respectively, for moments 2, 3, and 4, and comparatively low for moments 1 and 5 (48.4% and 47.6%, respectively). Conclusion Despite adequate hand hygiene facilities, compliance remains low. Hand hygiene is a bundle care approach that needs to consider factors including healthcare staff, clinical, institutional, environmental, and behavioral changes. Multimodal interventions and multidisciplinary commitment are mandatory for sustained compliance.

Improving hand hygiene practices in two regional hospitals in Kenya using a continuous quality improvement (CQI) approach

Background

Hand hygiene (HH) is central in prevention of health care-associated infections. In low resource settings, models to improve HH compliance are needed. We implemented a continuous quality improvement (CQI) program targeting HH in two hospitals in Kenya.

Objective

To determine the impact of the HH CQI program and identify factors associated with HH compliance between 2018 and 2019.

Methods

A CQI project targeting the improvement of hand hygiene was implemented, including training and mentorship. Data were collected monthly between April 2018 and December 2019 in Thika and Kitale Hospitals. Healthcare workers trained on Infection Prevention and Control (IPC) observed and recorded HH opportunities and subsequent compliance among staff, including nurses, clinicians, and auxiliary staff, using the World Health Organization’s “My Five Moments for Hand Hygiene” tool. Covariates were explored using mixed-effects logistic regression with random department-level intercepts.

Results

Hand hygiene compliance improved from 27% at baseline to 44% after 21 months. Indication/moment for HH was significantly associated with compliance. Adjusting for site, professional category and department, compliance was higher after a moment of body fluid exposure (aOR 1.43, 95% CI 1.17–1.74, p value < 0.001) and lower before an aseptic procedure (aOR 0.12, 95% CI 0.08–0.17, p value < 0.001) compared to after patient contact. Wearing of gloves often replaced proper HH in surgical departments, which although not significant, had lower compliance compared to departments for internal medicine (aOR 0.93, 95% CI 0.85–1.02). Adjusted HH compliance from all quarters improved from baseline, but comparing each quarter to the previous quarter, the improvement fluctuated over time.

Conclusion

Training and mentorship on the importance of HH for all moments is needed to improve overall HH compliance. CQI with regular monitoring and feedback of HH performance can be an effective approach in improving HH compliance in public hospitals in Kenya.

Impact of a multimodal intervention on compliance with hand hygiene among health care workers of a tertiary hospital

BACKGROUND AND OBJECTIVE

Hand hygiene (HH) is the simplest and most effective measure for the prevention of infection related to healthcare. Despite this, compliance in healthcare professionals continues to be suboptimal. The aim of this study is to assess the impact of an expanded World Health Organization (WHO) multimodal strategy on HH compliance in healthcare personnel.

MATERIAL AND METHODS

A quasi-experimental before-after study was designed, carrying out the expanded WHO multimodal strategy in 2018, aimed at professionals in a tertiary hospital. In this strategy, apart from applying the 5 pillars of the WHO, a video was made, the administration of the WHO perceptions questionnaire and an incentive to the service/unit with better compliance, adding to the training a modality of practical workshops. The compliance percentages for 2017 and 2018 were compared.

RESULTS

In 2017, 1056 opportunities were observed, registering 631 HH actions, with global compliance of 60% (95% CI 56.7-62.7). In 2018, with 1481 opportunities observed and 1111 HH actions, compliance was 75% (95% CI 72.7-77.2) (P<.001). This compliance increased in all professional categories and in all indications.

CONCLUSIONS

The application of an expanded multimodal strategy has a positive impact on HH compliance. Strategies should be directed to the categories with the worst compliance and continuously over time.

Evaluation of potentiality of traditional hygienic practices for the mitigation of the 2019-2020 Corona Pandemic

The coronavirus outbreak threatens global well-being, costing thousands of lives and an unstable economy. Traditional hand-washing (HaWa) with clean water and hand-washing sanitizers (HaWaSas) are among WHO recommended practices against the outbreaks. HaWaSa and HaWa lacked proper quality monitoring evaluation that may pose health risks. The current study investigates the potential of traditional hygienic practices adopted to mitigate the 2019-2020 Pandemic. It involved assessing the effectiveness of 15 HaWaSa collected from the Dodoma market. Thirty volunteered participants were subjected to different hygienic practices involving HaWa and HaWaSa. The obtained hand-swabbed samples were subjected to the streak plate technique for inoculation, followed by counting colonies. The results revealed that, among the collected HaWaSa brands, only 33.3% were certified by the Tanzania Bureau of Standards (TBS). In the setting under no hand-wash, each client had a different number of colony counts. HaWa did not eliminate all colonies since water acted as a secondary source while only one sanitizer proved effective. The p-values obtained in either setting were greater than 0.05, indicating that each variable was independent. Despite global awareness and fighting against the Coronavirus Disease 2019 (Covid-19) outbreak, quality monitoring of all diagnostic tools, preventive HaWaSa, and related drugs should be prioritized for human safeguard.

Clinical Epidemiology, Risk Factors, and Control Strategies of Klebsiella pneumoniae Infection

Klebsiella species cause infections at multiple sites, including lung, urinary tract, bloodstream, wound or surgical site, and brain. These infections are more likely to occur in people with preexisting health conditions. Klebsiella pneumoniae (K. pneumoniae) has emerged as a major pathogen of international concern due to the increasing incidences of hypervirulent and carbapenem-resistant strains. It is imperative to understand risk factors, prevention strategies, and therapeutic avenues to treat multidrug-resistant Klebsiella infections. Here, we highlight the epidemiology, risk factors, and control strategies against K. pneumoniae infections to highlight the grave risk posed by this pathogen and currently available options to treat Klebsiella-associated diseases.

Electronic Monitoring Systems for Hand Hygiene: Systematic Review of Technology

BACKGROUND

Hand hygiene is one of the most effective ways of preventing health care-associated infections and reducing their transmission. Owing to recent advances in sensing technologies, electronic hand hygiene monitoring systems have been integrated into the daily routines of health care workers to measure their hand hygiene compliance and quality.

OBJECTIVE

This review aims to summarize the latest technologies adopted in electronic hand hygiene monitoring systems and discuss the capabilities and limitations of these systems.

METHODS

A systematic search of PubMed, ACM Digital Library, and IEEE Xplore Digital Library was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were initially screened and assessed independently by the 2 authors, and disagreements between them were further summarized and resolved by discussion with the senior author.

RESULTS

In total, 1035 publications were retrieved by the search queries; of the 1035 papers, 89 (8.60%) fulfilled the eligibility criteria and were retained for review. In summary, 73 studies used electronic monitoring systems to monitor hand hygiene compliance, including application-assisted direct observation (5/73, 7%), camera-assisted observation (10/73, 14%), sensor-assisted observation (29/73, 40%), and real-time locating system (32/73, 44%). A total of 21 studies evaluated hand hygiene quality, consisting of compliance with the World Health Organization 6-step hand hygiene techniques (14/21, 67%) and surface coverage or illumination reduction of fluorescent substances (7/21, 33%).

CONCLUSIONS

Electronic hand hygiene monitoring systems face issues of accuracy, data integration, privacy and confidentiality, usability, associated costs, and infrastructure improvements. Moreover, this review found that standardized measurement tools to evaluate system performance are lacking; thus, future research is needed to establish standardized metrics to measure system performance differences among electronic hand hygiene monitoring systems. Furthermore, with sensing technologies and algorithms continually advancing, more research is needed on their implementation to improve system performance and address other hand hygiene-related issues.

Brought to Light: How Ultraviolet Disinfection Can Prevent the Nosocomial Transmission of COVID-19 and Other Infectious Diseases

The novel coronavirus disease 2019 (COVID-19) pandemic has brought to light the role of environmental hygiene in controlling disease transmission. Healthcare facilities are hot spots for infectious pathogens where physical distancing and personal protective equipment (PPE) are not always sufficient to prevent disease transmission. Healthcare facilities need to consider adjunct strategies to prevent transmission of infectious pathogens. In combination with current infection control procedures, many healthcare facilities are incorporating ultraviolet (UV) disinfection into their routines. This review considers how pathogens are transmitted in healthcare facilities, the mechanism of UV microbial inactivation and the documented activity of UV against clinical pathogens. Emphasis is placed on the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) as well as multidrug resistant organisms (MDROs) that are commonly transmitted in healthcare facilities. The potential benefits and limitations of UV technologies are discussed to help inform healthcare workers, including clinical studies where UV technology is used in healthcare facilities.

An exploratory qualitative study of caregivers' knowledge, perceptions and practices related to hospital hygiene in rural Niger

Background

The risk of healthcare-associated infections is exacerbated by poor hygiene practices in health care facilities and can contribute to increased patient morbidity and mortality. In low-income settings, caregivers play a key role in maintaining proper hygiene during inpatient stays. We aimed to explore caregivers' knowledge, perceptions and practices related to hospital hygiene in a rural, sub-Saharan African setting.

Methods

We conducted an exploratory qualitative study among caregivers of children admitted to an inpatient therapeutic feeding center in Madarounfa, Niger. Individual interviews with 28 caregivers of hospitalized children were conducted to explore their knowledge, perceptions and practices of hygiene in the health facility.

Findings

Caregivers described a broad understanding of hygiene and reported knowledge of its importance in the hospital, particularly to prevent disease transmission and protect child health. Hygiene was perceived as a collective rather than individual responsibility. Caregivers reported on the poor hygiene practice of others and cited a lack of space and hygiene materials as barriers to correct hygiene practice. Caregivers described educational sessions and informal sharing with other caregivers as tools to gain knowledge and improve practice.

Conclusion

This exploratory study is unique in describing the perspective of caregivers in a low-resource hospital setting, a group often underrepresented when designing health interventions to improve hospital hygiene. Our findings suggest a strong knowledge of hospital hygiene among caregivers in this setting, with positive perception of its importance in health promotion. Poor individual practice was reported but may be improved through additional education and provision of hygiene materials.

Compliance with hygiene practices among healthcare workers at an academic hospital emergency department

Introduction

Healthcare-associated infections (HCAIs) are an important contributor to patient morbidity and mortality. Healthcare workers (HCWs) hands are the chief mode of transmission of HCAIs. The emergency centre (EC) is frequently the first point of contact for patients within the health care system. The aim of this study is to determine compliance with hygiene practices among healthcare workers at a tertiary hospital EC.

Methods

Hygiene practices of staff were observed over a six-week period. Data pertaining to compliance rates with hand cleansing and other hygiene practices was collected. Consent was obtained retrospectively to avoid influencing participant behaviour.

Results

From a total of 477 potential hygiene opportunities, compliance with hand hygiene was only 34.4% (n = 164). Hand cleansing with an alcohol-based hand rub was observed in 87 (26.7%) of the 326 (68.3%) opportunities where it was indicated, while handwashing with soap and water was observed in 35 (23.2%) of the 151 opportunities where this was indicated. Compliance to each of the six steps of handwashing ranged between 62.2% and 83.5%, with there being a gradual deterioration in compliance from step one through to step six. Compliance with ‘bare below the elbows’ was observed in 242 (50.7%) opportunities while disposable surgical gloves were worn on 85 (44.7%) of the 190 opportunities where this was indicated.

Conclusion

Compliance with hygiene practices among EC HCWs is suboptimal. Various strategies including ongoing systematic training and regular audits may improve overall hygiene practices among EC staff.

Soap versus sanitiser for preventing the transmission of acute respiratory infections in the community: a systematic review with meta-analysis and dose-response analysis

OBJECTIVE

To compare the effectiveness of hand hygiene using alcohol-based hand sanitiser to soap and water for preventing the transmission of acute respiratory infections (ARIs) and to assess the relationship between the dose of hand hygiene and the number of ARI, influenza-like illness (ILI) or influenza events.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and trial registries were searched in April 2020.

INCLUSION CRITERIA

We included randomised controlled trials that compared a community-based hand hygiene intervention (soap and water, or sanitiser) with a control, or trials that compared sanitiser with soap and water, and measured outcomes of ARI, ILI or laboratory-confirmed influenza or related consequences.

DATA EXTRACTION AND ANALYSIS

Two review authors independently screened the titles and abstracts for inclusion and extracted data.

RESULTS

Eighteen trials were included. When meta-analysed, three trials of soap and water versus control found a non-significant increase in ARI events (risk ratio (RR) 1.23, 95% CI 0.78 to 1.93); six trials of sanitiser versus control found a significant reduction in ARI events (RR 0.80, 95% CI 0.71 to 0.89). When hand hygiene dose was plotted against ARI relative risk, no clear dose-response relationship was observable. Four trials were head-to-head comparisons of sanitiser and soap and water but too heterogeneous to pool: two found a significantly greater reduction in the sanitiser group compared with the soap group and two found no significant difference between the intervention arms.

CONCLUSIONS

Adequately performed hand hygiene, with either soap or sanitiser, reduces the risk of ARI virus transmission; however, direct and indirect evidence suggest sanitiser might be more effective in practice.

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.

Predictors of Self-Reported Hand Hygiene Performance among Nurses at Tertiary Care Hospitals in East Coast Malaysia

Background: Hand hygiene (HH) is the simplest and most effective way to reduce the incidence of healthcare-associated infections (HCAIs). Methods: This cross-sectional study aimed to determine factors associated with self-reported HH performance among nurses at Kelantan tertiary care hospitals. A sample of 438 registered nurses was selected through a stratified random sampling method. Self-reported HH performance was assessed using a validated WHO self-administered HH knowledge and perception questionnaire for healthcare workers. Results: A multiple linear regression analysis was performed to identify the predictors. The factors that significantly predicted self-reported HH performance among nurses included perception score (beta coefficient (β) = 0.260; 95% CI: 0.200, 0.417; p < 0.001), pediatric department (β = −0.104; 95% CI: −9.335, −2.467; p < 0.001), and orthopedic department (β = −5.957; 95% CI: −9.539, −0.720; p < 0.023), adjusted R² = 0.102; p < 0.001. Nurses with a strong perception and belief in HH were more likely to have better HH performance. Compared to pediatric and orthopedic, surgical departments were associated with better self-reported HH performance. Conclusions: This study showed the importance of factors that could improve the intervention’s performance in HH strategy. Lack of perception and HH program intervention in departments engaged in patient care could lead to poor HH practices, thus increasing HCAIs and antimicrobial resistance (AMR).

Assessment on Hand Hygiene Knowledge and Practices Among Pre-school Children in Klang Valley

Background. Pre-school children are at a higher risk to acquire infectious diseases such as hand, foot and mouth disease due to their immature immune system. Good hand hygiene prevents transmission of infectious diseases. This study aimed to determine the knowledge and practices of hand hygiene among pre-schoolers. Methods. In this prospective, multi-center study, the pre-schools were selected according to the selection criteria. A questionnaire consisting of socio-demographics, knowledge and practices of hand hygiene were administered via face-to-face interview during the pre- and post-intervention period. A total of 435 pre-schoolers aged 5 and 6 years old from 2 pre-schools within Klang Valley, School P (test group) and School C (control group) were involved in this study. The test group was provided with comprehensive hand hygiene education including video on proper handwashing technique during the 2 months intervention period, whereas the control group did not receive any form of intervention. The data were statistically analyzed using descriptive analysis and independent t-test. Results. Majority of pre-schoolers gained knowledge of handwashing from their parents. However, only 63% demonstrated good handwashing technique. Test group were significantly better (P < 0.05) in handwashing technique and hand hygiene routine score. Conclusion. A comprehensive hand hygiene education program should include proper handwashing facilities, resources, and awareness of the care-givers in instilling and sustaining good hand hygiene behavior.

Exploring determinants of hand hygiene among hospital nurses: a qualitative study

BACKGROUND

The present research is a qualitative one aiming to determine factors affecting hand-hygiene behavior of the nursing staff in Shariati Hospital of Tehran, Iran.

METHODS

This was a qualitative study performed using content analysis approach. Considering the aim of the study, 16 in-depth semi-structured interviews were held with the nursing staff of Shariati Hospital of Tehran University of Medical Sciences. A convenient sampling was performed and continued until data saturation and until no new codes and categories were obtained. Data were analyzed through a qualitative content analysis based on the Graham and landsman method. Directed qualitative content analysis was done in order to analyze the data.

RESULTS

The results of this study revealed 3 main themes in the Theory of Planned Behavior (TPB) (attitude, subjective norms and perceived behavioral control) and 8 main themes in the outside the framework (environment, perceptions, life style, morality, education, organizational culture, salience and personality).

CONCLUSION

Due to the other factors also found in this study, an integration of theories and models for designing of interventions is recommended to increase adherence to hand hygiene behavior.

A pilot project: handwashing educational intervention decreases incidence of respiratory and diarrheal illnesses in a rural Malawi orphanage

Children who live in orphanages represent a population particularly vulnerable to transmissible diseases. Handwashing interventions have proven efficacy for reducing the rate of transmission of common infectious diseases. Few studies have analyzed the delivery of health interventions for children in orphanages in sub-Saharan Africa. To address this gap, we conducted an ecological assessment and piloted a handwashing intervention in an orphanage in rural Malawi, focusing on caregiver knowledge and behaviors, child handwashing behaviors, and disease incidence. A secondary study aim was to demonstrate program feasibility for a future randomized controlled trial. Orphanage caregivers participated in a three-module educational intervention on handwashing based on WHO recommendations and workshops on how to teach the curriculum to children. Seventeen orphanage caregivers and 65 children were monitored for handwashing behavior and child disease incidence. Friedman's tests were conducted to compare changes in caregiver knowledge and behaviors. Child handwashing behaviors and surveillance of child disease incidence were measured pre- and post-intervention. There were significant increases in caregiver hand hygiene knowledge. At six months post-intervention, handwashing with soap increased significantly among caregivers (p < 0.001) and was observed in children. The incidence of acute respiratory infections decreased from 30% to 6% post-intervention, resulting in an 80% decrease. The incidence of diarrhea decreased from 9.2% to 6.2% post-intervention, resulting in a 33% decrease. A brief educational intervention may improve handwashing knowledge and behaviors and help to decrease the incidence of common infectious diseases in an orphanage in rural Malawi. In addition, the caregiver uptake of the intervention demonstrated feasibility for future studies.

The Effects of Social Determinants on Public Health Emergency Preparedness Mediated by Health Communication: The 2015 MERS Outbreak in South Korea

The influence of social determinants and health communication on Public health emergency preparedness (PHEP) as well as the mediating effect of health communication were investigated with respect to the 2015 Middle East Respiratory Syndrome (MERS) outbreak in South Korea. Data were collected through a survey six months after the de facto end of the outbreak and a total of 855 subjects completed the surveys and were included in the analysis. The results suggested that the public's preventive (hand hygiene) and avoidance (avoiding hospitals even when sick) behaviors that were frequently practiced during the pandemic were influenced by their social determinants both direct and indirect pathways. Health communication such as information seeking and processing mediated the effect of social determinants on the behaviors and information seeking was found to have the most significant mediating effect on the relationship between the practice of both preventive and avoidance behaviors and social determinants such as education and age. The results of the present study will deepen our understanding of PHEP by identifying key factors that influence the public's behavioral responses as well as providing information to public health emergency management and health risk communication officials to implement strategies necessary in improving PHEP.

Hand hygiene compliance in Dutch general practice offices

BACKGROUND

Hand hygiene (HH) is considered one of the most important measures to prevent healthcare-associated infections (HAI). Most studies focus on HH compliance within the hospital setting, whereas little is known for the outpatient setting. The aim of this study was to evaluate compliance with HH recommendations in general practitioners (GPs) office, based on World Health Organization (WHO) guideline.

METHODS

An observational study was conducted at five Dutch GPs-practices in September 2017. We measured HH compliance through direct observation using WHO's 'five moments of hand hygiene' observation tool. All observations were done by one trained professional.

RESULTS

We monitored a total of 285 HH opportunities for 30 health care workers (HCWs). The overall compliance was 37%. Hand hygiene compliance was 34, 51 and 16% for general practitioners, practice assistants, and nurses, respectively. It varies between 63% after body fluid exposure and no HH performance before-, during and after home visit of a patient (defined as moment 5). The preferred method of HH was soap and water (63%) versus 37% for alcohol-based hand rub (ABHR). The median time of disinfecting hands was 8 s (range 6-11 s) for HCWs in our study.

CONCLUSIONS

HH compliance among HCWs in Dutch GPs was found to be low, especially with regard to home visits. The WHO recommended switch from hand wash to ABHR was not implemented by the majority of HCWs in 5 observed GPs offices.

Hand Sanitizer an Alternative to Hand Washing—A Review of Literature

Aim:

COVID-19 is a new illness and a big threat to global health. No specific antiviral agents are available for its treatment. The finest approach to manage this threat is to clean our hands properly. Washing hands under running water is a better way to stop the spread of infections than using a hand sanitizer. The aim of the study is to show that washing hands is efficacious than using a dab of alcohol-based hand sanitizer.

Materials and Methods:

A search was performed using three databases, PubMed, Scopus, and Google Scholar published from 2010 to 2019. The keywords for the survey were “hand-washing,” “hand sanitizer,” and “effective.” After the relevant articles were found, the critical appraisal was made to select those that were suitable for the systematic review. The inclusion criteria of the study were surveys, clinical studies, no sample size restrictions, and only English papers. Any conference abstracts, case reports, and unpublished data were excluded from this study.

Results:

On the basis of the keywords, 22 relevant articles were found, and of those, 17 articles were selected for the systematic review.

Conclusion:

This study evaluated that washing hands with soap and water are more practical and efficacious than using the sanitizer on greasy and soiled hands. An alcohol-based sanitizer, if used correctly and in appropriate volume, can disseminate certain type of micro-organisms.

Hand hygiene in surgery in Benin: opportunities and challenges

Background

Hand Hygiene (HH) has been described as the cornerstone and starting point in all infection control. Compliance to HH is a fundamental quality indicator. The aim of this study was to investigate the HH compliance among Health-care Workers (HCWs) in Benin surgical care units.

Methods

A multicenter prospective observational study was conducted for two months. The World Health Organization (WHO) Hand Hygiene Observation Tool was used in obstetric and gastrointestinal surgery through six public hospitals in Benin. HH compliance was calculated by dividing the number of times HH was performed by the total number of opportunities. HH technique and duration were also observed.

Results

A total of 1315 HH opportunities were identified during observation period. Overall, the compliance rate was 33.3% (438/1315), without significant difference between professional categories (nurses =34.2%; auxiliaries =32.7%; and physicians =32.4%; p = 0.705). However, compliance rates differed (p < 0.001) between obstetric (49.4%) and gastrointestinal surgery (24.3%). Generally, HCWs were more compliant after body fluid exposure (54.5%) and after touching patient (37.5%), but less before patient contact (25.9%) and after touching patient surroundings (29.1%).

HCWs were more likely to use soap and water (72.1%) compared to the alcohol based hand rub solution (27.9%). For all of the WHO five moments, hand washing was the most preferred action. For instance, hand rub only was observed 3.9% after body fluid exposure and 16.3% before aseptic action compared to hand washing at 50.6 and 16.7% respectively. Duration of HH performance was not correctly adhered to 94% of alcohol hand rub cases (mean duration 9 ± 6 s instead of 20 to 30 s) and 99.5% of hand washing cases (10 ± 7 s instead of the recommended 40 to 60 s). Of the 432 HCWs observed, 77.3% followed HH prerequisites (i.e. no artificial fingernails, no jewellery). We also noted a lack of permanent hand hygiene infrastructures such as sink, soap, towels and clean water.

Conclusion

Compliance in surgery was found to be low in Benin hospitals. They missed two opportunities out of three to apply HH and when HH was applied, technique and duration were not appropriate. HH practices should be a priority to improve patient safety in Benin.

Impact of an automated hand hygiene monitoring system combined with a performance improvement intervention on hospital-acquired infections

OBJECTIVE

Hand hygiene adherence has been associated with reductions in nosocomial infection. We assessed the effect of improvements in electronically measured hand hygiene adherence on the incidence of hospital-acquired infections.

METHODS

This quasi-experimental study was conducted in a 555-bed urban safety-net level I trauma center. The preintervention period was January 2015 through June 2016. Baseline electronic hand hygiene data collection took place from April through June 2016. The intervention period was July 2016 through December 2017. An electronic hand hygiene system was installed in 4 locations in our hospital. Performance improvement strategies were implemented that included education, troubleshooting, data dissemination, and feedback. Adherence rates were tracked over time. Rates of hospital-acquired infections were evaluated in the intervention units and in control units selected for comparison. The intervention period was subdivided into the initial and subsequent 9-month periods and were compared to the baseline period.

RESULTS

Electronically measured hand hygiene rates improved significantly from baseline to intervention, from 47% 77% adherence. Rates >70% continued to be measured 18 months after the intervention. Interrupted time series analysis indicated a significant effect of hand hygiene on healthcare facility-onset Clostridioides difficile infection rates during the first 9 months of the intervention. This trend continued during the final 9 months of the intervention but was nonsignificant. No effects were observed for other hospital-acquired infection rates.

CONCLUSIONS

Implementation of electronic hand hygiene monitoring and performance improvement interventions resulted in reductions in hospital-onset Clostridioides difficile infection rates.

Nonpharmaceutical Measures for Pandemic Influenza in Nonhealthcare Settings-Personal Protective and Environmental Measures

There were 3 influenza pandemics in the 20th century, and there has been 1 so far in the 21st century. Local, national, and international health authorities regularly update their plans for mitigating the next influenza pandemic in light of the latest available evidence on the effectiveness of various control measures in reducing transmission. Here, we review the evidence base on the effectiveness of nonpharmaceutical personal protective measures and environmental hygiene measures in nonhealthcare settings and discuss their potential inclusion in pandemic plans. Although mechanistic studies support the potential effect of hand hygiene or face masks, evidence from 14 randomized controlled trials of these measures did not support a substantial effect on transmission of laboratory-confirmed influenza. We similarly found limited evidence on the effectiveness of improved hygiene and environmental cleaning. We identified several major knowledge gaps requiring further research, most fundamentally an improved characterization of the modes of person-to-person transmission.

Improving Hand Hygiene Compliance in Nursing Homes: Protocol for a Cluster Randomized Controlled Trial (HANDSOME Study)

BACKGROUND

Hand hygiene compliance is considered the most (cost-)effective measure for preventing health care-associated infections. While hand hygiene interventions have frequently been implemented and assessed in hospitals, there is limited knowledge about hand hygiene compliance in other health care settings and which interventions and implementation methods are effective.

OBJECTIVE

This study aims to evaluate the effect of a multimodal intervention to increase hand hygiene compliance of nurses in nursing homes through a cluster randomized controlled trial (HANDSOME study).

METHODS

Nursing homes were randomly allocated to 1 of 3 trial arms: receiving the intervention at a predetermined date, receiving the identical intervention after an infectious disease outbreak, or serving as a control arm. Hand hygiene was evaluated in nursing homes by direct observation at 4 timepoints. We documented compliance with the World Health Organization's 5 moments of hand hygiene, specifically before touching a patient, before a clean/aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching patient surroundings. The primary outcome is hand hygiene compliance of the nurses to the standards of the World Health Organization. The secondary outcome is infectious disease incidence among residents. Infectious disease incidence was documented by a staff member at each nursing home unit. Outcomes will be compared with the presence of norovirus, rhinovirus, and Escherichia coli on surfaces in the nursing homes, as measured using quantitative polymerase chain reaction.

RESULTS

The study was funded in September 2015. Data collection started in October 2016 and was completed in October 2017. Data analysis will be completed in 2020.

CONCLUSIONS

HANDSOME studies the effectiveness of a hand hygiene intervention specifically for the nursing home environment. Nurses were taught the World Health Organization's 5 moments of hand hygiene guidelines using the slogan "Room In, Room Out, Before Clean, After Dirty," which was developed for nursing staff to better understand and remember the hygiene guidelines. HANDSOME should contribute to improved hand hygiene practice and a reduction in infectious disease rates and related mortality.

TRIAL REGISTRATION

Netherlands Trial Register (NTR6188) NL6049; https://www.trialregister.nl/trial/6049.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17419.

Accurate Measurement of Handwash Quality Using Sensor Armbands: Instrument Validation Study

BACKGROUND

Hand hygiene is a crucial and cost-effective method to prevent health care-associated infections, and in 2009, the World Health Organization (WHO) issued guidelines to encourage and standardize hand hygiene procedures. However, a common challenge in health care settings is low adherence, leading to low handwashing quality. Recent advances in machine learning and wearable sensing have made it possible to accurately measure handwashing quality for the purposes of training, feedback, or accreditation.

OBJECTIVE

We measured the accuracy of a sensor armband (Myo armband) in detecting the steps and duration of the WHO procedures for handwashing and handrubbing.

METHODS

We recruited 20 participants (10 females; mean age 26.5 years, SD 3.3). In a semistructured environment, we collected armband data (acceleration, gyroscope, orientation, and surface electromyography data) and video data from each participant during 15 handrub and 15 handwash sessions. We evaluated the detection accuracy for different armband placements, sensor configurations, user-dependent vs user-independent models, and the use of bootstrapping.

RESULTS

Using a single armband, the accuracy was 96% (SD 0.01) for the user-dependent model and 82% (SD 0.08) for the user-independent model. This increased when using two armbands to 97% (SD 0.01) and 91% (SD 0.04), respectively. Performance increased when the armband was placed on the forearm (user dependent: 97%, SD 0.01; and user independent: 91%, SD 0.04) and decreased when placed on the arm (user dependent: 96%, SD 0.01; and user independent: 80%, SD 0.06). In terms of bootstrapping, user-dependent models can achieve more than 80% accuracy after six training sessions and 90% with 16 sessions. Finally, we found that the combination of accelerometer and gyroscope minimizes power consumption and cost while maximizing performance.

CONCLUSIONS

A sensor armband can be used to measure hand hygiene quality relatively accurately, in terms of both handwashing and handrubbing. The performance is acceptable using a single armband worn in the upper arm but can substantially improve by placing the armband on the forearm or by using two armbands.

Assessment of hand hygiene facilities and staff compliance in a large tertiary health care facility in northern Nigeria: a cross sectional study

Background

The burden of healthcare-associated infection (HAI) is 2 to 18 times higher in developing countries. However, few data are available regarding infection prevention and control (IPC) process indicators in these countries. We evaluated hand hygiene (HH) facilities and compliance amongst healthcare workers (HCW) in a 600-bed healthcare facility in Northcentral Nigeria providing tertiary care service for a catchment population of about 20 million.

Methods

An in-house facility assessment tool and the World Health Organization (WHO) direct observation method were used to assess the HH facilities and compliance, respectively. Factors associated with good compliance were determined by multivariate analysis.

Results

The facility survey was carried out in all 46 clinical units of the hospital. 72% of the units had no poster or written policy on HH; 87% did not have alcohol-based hand rubs; 98% had at least one handwash sink; 28% had flowing tap water all day while 72% utilized cup and bucket; and 58% had no hand drying facilities. A total of 406 HH opportunities were observed among 175 HCWs. The overall compliance was 31%, ranging from 18% among ward attendants to 82% among medical students. Based on WHO “5 moments” for HH, average compliance was 21% before patient contact, 23% before aseptic procedure, 63% after body fluid exposure risk, 41% after patient contact and 40% after contact with patients’ surrounding. Being a medical student was independently associated with high HH compliance, adjusted odds ratio: 13.87 (1.70–112.88).

Conclusions

Availability of HH facilities and HCW compliance in a large tertiary hospital in Nigeria is poor. Our findings confirm that HCWs seem more sensitized to their risk of exposure to potential pathogens than to the prevention of HAI cross-transmission. Inadequate HH facilities probably contributed to the poor compliance. Specific measures such as improved facilities, training and monitoring are needed to improve HH compliance.

"Infection prevention and control idea challenge" contest: a fresh view on medical education and problem solving

Background

Healthcare-associated infections (HAIs) challenge modern medicine. Considering their high prevalence in Iran, we aimed to provide knowledge on the subject, and to teach about the importance of infection prevention and control (IPC) to a broad audience of pre-graduate healthcare professionals, focusing on education as the cornerstone of IPC.

Main body

We invited Iranian medical students to present ideas on “how to reduce HAIs.” Projects were eligible if being original and addressing the call. Accepted projects were quality assessed using a scoring system. Forty-nine projects were submitted, of which 37 met the inclusion criteria. They had a mean score of 69.4 ± 18.3 out of the maximum possible score of 115. Four reviewers assessed the 37 projects for clinical applicability, impact on patient safety, and innovation, and selected the best 12 to compete at the 2nd International Congress on Prevention Strategies for Healthcare-associated Infections, Mashhad, Iran, 2018. The competition took place in three rounds. The selected teams presented their projects in the first round and debated one by one in a knockout manner, while the jury reviewed their scientific content and presentation skills. In the second round, the top 5 projects competed for reaching the final stage, in which the teams presented their ideas in front of a panel of international IPC experts to determine the first three ranks. At the end of the contest, the participants gained valuable criticisms on how to improve their ideas. Moreover, by its motivating atmosphere, the contest created an excellent opportunity to promote IPC in medical schools.

Conclusions

Using innovation contests in pre-graduates is an innovative education strategy. It sensitizes medical students to the challenges of IPC and antimicrobial resistance and drives them to think about solutions. By presenting and defending their innovations, they deepen their understanding on the topic and generate knowledge transfer in both ways, from students to teachers and vice versa.