Implementing a multimodal intervention using local resources to improve hand hygiene compliance in a comprehensive specialized hospital in Mekelle, Northern Ethiopia

BACKGROUND

Hand hygiene (HH) is known to be the most effective practice to reduce Healthcare-associated infections (HAIs). The main barriers to HH practices among healthcare workers (HCWs) in Sub-Saharan Africa are heavy workload, infrastructural deficits, and poorly positioned facilities. There is limited data on HH compliance and particularly on the impact of the World Health Organization's (WHO) multimodal HH strategy in low- and middle-income countries. This study aimed to provide insights into a strategy to implement the WHO concept adapted to local conditions and obstacles encountered at a tertiary university hospital in Mekelle, Tigray, Ethiopia.

METHODS

We conducted a study aiming at increasing the quality of the HH practice of HCWs using the WHO HH improvement strategy. The study adopted a pre-and post-interventional design from April 2018 to May 2019. In the pre-intervention phase, a baseline infrastructural survey was made. The intervention consisted of in-house production of hand sanitizer and dispensers for every patient bed, staff education and motivation, and implementation of a multidisciplinary infection prevention committee. The intervention was followed by two one-week compliance observations of HH practice among HCWs within the six months post-intervention period and microbiological sample collection from HCWs' hands to assess the quality of HH.

RESULTS

We observed 269 (baseline), 737 (first follow-up) and 574 (second follow-up) indications for HH among HCWs. The overall baseline hand rub compliance was 4.8%, which significantly increased to 37.3% (first follow-up) and 56.1% (second follow-up) (p < 0.0001). Consistent and significant increases in hand rub compliance during the entire follow-up period were observed before touching a patient, after touching a patient, and after touching the patient's surroundings (all p < 0.01). Nurses and medical interns achieved consistent and significant increases in hand rub compliance during the entire follow-up period (all p < 0.01).

CONCLUSION

Implementing the WHO HH improvement strategy significantly increased HH compliance despite a shortage of water and other resources. Hand rub was accepted as the main HH method in the hospital. HH campaigns in developing settings profit from multimodal strategies, knowledge exchange and utilization of local resources.

Characteristics of Animal-assisted Interventions in the state of Lower Saxony, Germany, with a focus on hygiene in health care facilities

Animal-assisted Interventions (AAIs) are becoming increasingly popular. To date, information on the extent of AAIs in Germany is limited. With a focus on infection control measures in health care facilities (HCFs), two studies were conducted in Lower Saxony to gain knowledge about the structure, characteristics and frequency of AAIs. An online survey among AAI providers identified dogs as the most important animal species in AAI, which mainly operated in educational facilities (53%) and/or on own property (46%). Twenty-nine percent offered their services in HCFs. The majority (55%) of the animal handlers was highly trained in AAI, but their awareness of hygiene and infection control measures to prevent zoonotic disease transmission was limited. Nineteen percent of animal handlers dewormed dogs only when faecal examinations were positive and 13% of dogs received ectoparasiticides only when infestations were present. Raw meat diets were frequent (82%). There was little awareness among animal handlers about the possibility of a zoonotic transmission from the client to the animal. Thus, handling of therapy dogs often reflected that of a "normal" pet ownership and did not always account for the special situation in HCFs. A telephone survey in 148 hospitals showed that 28% of the hospitals had experiences with animal-assisted therapies or animal visits, but 22% of these were lacking regulations on handling these animal contacts. While 28% of all hospitals had regulations for assistance dogs only 5% were aware of a new law that grants people accompanied by an assistance dog broad admission rights to public spaces, including HCFs. With an expected further increase in popularity of AAIs high quality standards which include infection control measures and animal welfare should be adopted by all AAI providers and recipients. This will ensure a safe implementation of this complementary medicine, where both sides - the human and the animal - can benefit.

Hospital sanitary facilities on wards with high antibiotic exposure play an important role in maintaining a reservoir of resistant pathogens, even over many years

BACKGROUND

Hospitals with their high antimicrobial selection pressure represent the presumably most important reservoir of multidrug-resistant human pathogens. Antibiotics administered in the course of treatment are excreted and discharged into the wastewater system. Not only in patients, but also in the sewers, antimicrobial substances exert selection pressure on existing bacteria and promote the emergence and dissemination of multidrug-resistant clones. In previous studies, two main clusters were identified in all sections of the hospital wastewater network that was investigated, one K. pneumoniae ST147 cluster encoding NDM- and OXA-48 carbapenemases and one VIM-encoding P. aeruginosa ST823 cluster. In the current study, we investigated if NDM- and OXA-48-encoding K. pneumoniae and VIM-encoding P. aeruginosa isolates recovered between 2014 and 2021 from oncological patients belonged to those same clusters.

METHODS

The 32 isolates were re-cultured, whole-genome sequenced, phenotypically tested for their antimicrobial susceptibility, and analyzed for clonality and resistance genes in silico.

RESULTS

Among these strains, 25 belonged to the two clusters that had been predominant in the wastewater, while two others belonged to a sequence-type less prominently detected in the drains of the patient rooms.

CONCLUSION

Patients constantly exposed to antibiotics can, in interaction with their persistently antibiotic-exposed sanitary facilities, form a niche that might be supportive for the emergence, the development, the dissemination, and the maintenance of certain nosocomial pathogen populations in the hospital, due to antibiotic-induced selection pressure. Technical and infection control solutions might help preventing transmission of microorganisms from the wastewater system to the patient and vice versa, particularly concerning the shower and toilet drainage. However, a major driving force might also be antibiotic induced selection pressure and parallel antimicrobial stewardship efforts could be essential.

Impact of the state of emergency on trends in the care of three major diseases at Showa University Hospital, Japan: a retrospective and descriptive study

Introduction

This study aimed to examine the trends in patient consultations for three major diseases (cancer, heart disease, and stroke) at Showa University Hospital, Japan during the state of emergency for the Coronavirus 2019 (COVID-19) pandemic.

Methods

The present study was a retrospective and descriptive study of Showa University Hospital in Tokyo, Japan. Subjects were patients who had received medical treatment at Showa University Hospital and were diagnosed from 2017 to 2020. To examine the impact of the state of emergency, the number visits to hospital by the top three causes of death or other diseases were summarised from 21 weeks of data, from week 8 to week 28, for each year.

Results

Compared to the average of the previous 3 years, a comparison of the three periods before and after the state of emergency showed a V-shaped curve in 2020, with a large drop in the number of cancer patients during the state of emergency, both from within Tokyo and from outside the city.

Conclusions

This study showed a long-term decrease in cancer patient visits to Showa University Hospital since the beginning of the COVID-19 pandemic compared to the previous 3 years. It is also possible that medical care that would have been available may not have been provided due to the state of emergency, so it is necessary to follow up patients while keeping a close eye on measures other than infectious diseases.

[One year corona pandemic management in a 300-bed hospital : Report of the pandemic officer]

BACKGROUND

From the point of view of the pandemic officer of a 300-bed specialty care hospital, the first year of the SARS-CoV‑2 (Severe Acute Respiratory Syndrome Coronavirus Type 2) pandemic with all the challenges for daily clinical routine was reviewed on the basis of the data collected with the aim of making future pandemic management easier to plan.

METHODS

The Caritas Hospital St. Josef in Regensburg employs around 1330 employees and treats almost 20,000 inpatients annually. All records of the pandemic officer between 1 March 2020 and 28 February 2021 were included in the present descriptive study.

RESULTS

In all, 280 SARS-CoV-2-positive patients (mean age 68 ± 19 years) were treated during the observation period; 81% (n = 227) of these were treated as inpatients between November 2020 and February 2021. In addition to the analysis of these patients, an analysis of the test concept was carried out, both for the patients (53% of the tests in the so-called 2nd wave) and for the employees; 1633 PCR tests were carried out, with 5.6% of all employees being infected with SARS-CoV‑2 in the course of the pandemic. In addition, other measures such as reducing the surgical program and other general measures were evaluated.

CONCLUSION

Many established processes had to be changed in the hospital during the pandemic. Both staff shortages due to SARS-CoV-2-positive employees and the quarantine measures of contact persons led to further tension in the already tight staffing levels, especially in the nursing care sector, and made patient care more difficult. The test concept in the hospital was very complex and asymptomatic tests in particular showed a low hit rate, while being associated with high personnel costs.

Understanding infection prevention behaviour in maternity wards: A mixed-methods analysis of hand hygiene in Zanzibar

RATIONALE

Although women in low- and middle-income countries are increasingly encouraged to give birth at facilities, healthcare-associated infection of both the mother and newborn remain common. An important cause of infection is poor hand hygiene. There is a need to understand how environmental, behavioural, and organisational factors influence hygiene practice.

OBJECTIVE

To understand variations between facilities and between people in hygiene behaviour and to explore potential intervention targets in four labour wards in Zanzibar.

METHODS

Site visits including observation of deliveries and of day-to-day workings of the facilities. Thirty-three semi-structured interviews, totalling more than 46 hours, with birth attendants, orderlies, managerial staff and mothers. Transcribed interviews and observation notes were read and coded by two authors. Themes were developed and analysed in light of existing research.

RESULTS

The physical preconditions for hand hygiene were met more regularly in the two highvolume facilities, where soap, water, gloves were almost always available. However, in all of the facilities, hand hygiene appeared impeded by poor ergonomics, like, for example, physical distance between water taps, gloves, or delivery beds. Recontamination of gloved hands following good hand hygiene was commonly observed, a pattern that the birth attendants attributed to high and unpredictable workload and equipment shortages. Interviews and focus groups suggested that birth attendants typically understood when and why hand hygiene should be implemented, and that they were aware of low handwashing rates among co-workers. In poorer performing facilities, managers were less inclined to visit wards and more likely to perceive hand hygiene as beyond their influence.

CONCLUSIONS

Observations and interviews suggest improvements in the ergonomic design of delivery rooms, including convenient availability of sinks, soap, hand gel, hand towels and gloves, may be a low-cost way to reduce the infection burden from poor hand hygiene.

[Personal preconditions for the prevention of nosocomial infections-guidelines of the German Commission for Hospital Hygiene and Infection Prevention (KRINKO), federal state hygiene regulations in Germany, and compliance by hospitals in Frankfurt am Main]

According to the amendment of the Infection Protection Act (2011), § 23, 8, all federal states in Germany had to pass their own hospital hygiene regulations, in which the need for hygiene specialists in a hospital is defined.This publication explains in its first part the differences between the nationwide Commission for Hospital Hygiene and Infection Prevention (KRINKO) regulations and the hygiene regulations of the different federal states (Hesse, Bavaria, etc.). All federal states - with the exception of Hesse (Hessian Hygiene Regulation, HHygVO) - refer to the relevant expert recommendations of KRINKO.In a second part of this publication, we highlight differences between KRINKO and HHygVO with the example of hospitals in the city of Frankfurt. In 2017, all Frankfurt hospitals had the necessary hygiene specialists (authorized hygiene practitioners, infection control nurses, authorized hygiene care nurses). However, the need for hospital hygienists could not be met, because there is an insufficient number of physician specialists for hospital hygiene available in Germany.The hospitals cannot solve this problem on their own - a political, superordinate decision and regulation must be made, i. e. by regulation and financial support for the advanced training of post-graduate physicians in hygiene. This is important since only experienced hospital hygienists can instruct or supervise hygiene specialists-in-training.

Four steps to clean hospitals: LOOK, PLAN, CLEAN and DRY

BACKGROUND

Now that cleaning and decontamination are recognized as integral to infection control, it is timely to examine the process in more detail. This is because cleaning practices vary widely within healthcare districts, and it is likely that both time and energy are needlessly wasted with ill-defined duties. Furthermore, inadequate cleaning will not reduce the risk of infection but may even enhance it. The process would benefit from a systematic appraisal, with each component placed within an evidence-based and ordered protocol.

METHODS

A literary search was performed on 'hospital cleaning', focusing on manual aspects of cleaning, pathogen reservoirs and transmission, hand hygiene, staff responsibilities and patient comfort.

RESULTS

No articles providing an evidence-based practical approach to systematic cleaning in hospitals were identified. This review therefore proposes a simple four-step guide for daily cleaning of the occupied bed space. Step 1 (LOOK) describes a visual assessment of the area to be cleaned; Step 2 (PLAN) argues why the bed space needs preparation before cleaning; Step 3 (CLEAN) covers surface cleaning/decontamination; and Step 4 (DRY) is the final stage whereby surfaces are allowed to dry.

CONCLUSION

Given the lack of articles providing practical cleaning guidance, this review proposes a four-step protocol based on evidence if available, or justified where not. Each step is presented, discussed and risk-assessed. It is likely that a systematic cleaning process would reduce the risk of healthcare-associated infection for everyone, including outbreaks, in addition to heightened confidence in overall quality of care.

A Serratia marcescens outbreak in a neonatal intensive care unit was successfully managed by rapid hospital hygiene interventions and screening

AIM

Serratia marcescens is a rare, but important, pathogen in hospital-acquired infections, especially in neonatal units. Outbreaks may cause significant mortality among neonates. This study describes how an outbreak of S. marcescens was handled in a neonatal intensive care unit in Finland in June 2015.

METHODS

Tampere University Hospital is the only hospital that offers intensive care for preterm neonates in the Pirkanmaa health district area in Finland. Between June 9, 2015 and June 29, 2015, seven neonates were screened positive for S. marcescens in the hospital. We examined the management and outcomes, including environmental sampling.

RESULTS

Two of the seven neonates developed a bloodstream infection, and one with S. marcescens sepsis died after six days of antibiotic treatment. The outbreak was rapidly managed with active hospital hygiene interventions, including strict hand hygiene, cleaning, patient screening, contact precautions and education. Environmental sampling was limited to one water tap and a ventilator, and the results were negative. The outbreak was contained within three weeks, and no further cases appeared. The screening of healthcare workers was not necessary.

CONCLUSION

A S. marcescens outbreak caused significant morbidity in neonates and one death. Rapid hospital hygiene interventions and patient screening effectively contained the outbreak.

Trends in incidence and resistance patterns of Staphylococcus aureus bacteremia. Infect Dis (Lond) 2017;50:52-58. [PMID: 29161942 DOI: 10.1080/23744235.2017.1405276]

BACKGROUND

Staphylococcus aureus bacteremia (SAB) causes a significant burden on the population. Several infection control measures have been implemented in Pirkanmaa county to combat a local epidemic with methicillin-resistant Staphylococcus aureus (MRSA). We aimed to study the epidemiology of SAB and antibiotic resistance of S. aureus and the possible influence of improved infection control.

METHODS

Register data from 2005 to 2015 were retrospectively analysed to study the antimicrobial susceptibility, the incidence and mortality in SAB in a population-based setting.

RESULTS

The incidence of SAB increased during the study period from 21.6 to 35.8/100,000 population. The number of both health care-associated (HA) and community-associated (CA) cases has increased. The incidence of MSSA bacteremia increased from 19.9 to 35.2/100,000 population in Pirkanmaa in parallel to other parts of Finland. The incidence of MRSA bacteremia was 10-fold (4.5/100,000 population) higher in 2011 than in other parts of the country, but sank to the national level (0.59/100,000 population) in 2015. The fatality rate decreased from 22% to 17%. The proportion of penicillin-susceptible Staphylococcus aureus (PSSA) increased from 23.9% in 2008 to 43.1% in 2015.

CONCLUSION

The incidence of both HA and CA SAB has increased since 2005. Conversely, the proportion of MRSA and PRSA bacteremia has decreased. Promotion of infection control measures may have reduced the incidence of MRSA bacteremia but not the overall incidence of SAB. The rising proportion of PSSA enables the use of targeted, narrow spectrum antimicrobials.

Bibles as a possible source of pathogens in hospitals? A pilot observation

It is a century-old tradition of furnishing Bibles in the bedside drawers of hospitalized patients. But since the books cannot be disinfected, it might be possible that bacterial pathogens survive on the bibles. The aim of this study was to determine whether Bibles in patient's rooms can act as a vehicle for the spread of nosocomial infections from one to the next patient. We took samples from 50 Bibles in various general wards of the hospital. During the same period, we took contact samples of 99 hymnals from the hospital chapel. The hospital chapel is visited by patients from all departments of the hospital. As expected, microorganisms were detected on all books. They were mainly apathogenic organisms. Molds (Aspergillus spp.) were identified on the surfaces of five books. Two Bibles showed pathogen bacteria in a low number. No invasive infections with those pathogens could be documented during the investigation period, retrospectively. In conclusion, our results do not support Bibles as a possible source of nosocomial infections.

Improvement of infection control management by routine molecular evaluation of pathogen clusters

BACKGROUND

Undetected pathogen clusters can often be a source of spreading in-hospital infections. Unfortunately, detection of clusters can be problematic because epidemiological connection is not always easily established. Infection prevention and control (IPC) measures, however, are most effective when applied at the earliest possible stage.

AIM

The goal of our study was to evaluate the benefits of routine use of molecular typing techniques for IPC management in a large University teaching hospital.

METHODS

We implemented daily routine molecular typing of pathogen clusters using cost-effective standard methods such as random amplified polymorphic DNA PCR, multiple-locus variable number tandem repeat analysis, and spa-typing over a 4-year study period (2012-2015).

FINDINGS

Four pathogen clusters were evaluated: (I) 14 cases of Clostridium difficile in a peripheral ward, (II) 17 cases of methicillin-resistant Staphylococcus aureus (MRSA) in two intensive-care units (ICUs), (III) 21 cases of multidrug-resistant Klebsiella pneumoniae within one department, and (IV) 6 cases of vancomycin-resistant Enterococcus faecium in an interdisciplinary ICU. Typing revealed that cluster I was not caused by an outbreak strain but was likely due to different endogenous infections. Clusters III and IV showed a classical space-time clustering of point source outbreaks. Cluster II represented a prolonged temporal cluster, which would have gone undetected without molecular typing because of large intercase intervals.

CONCLUSION

Implementing daily routine molecular typing is effective for detecting and analyzing pathogen clusters. Falsely suspected outbreaks can be quickly resolved, whereas actual outbreaks can be identified faster, so that targeted IPC measures can be applied earlier.

Prevalence of multidrug-resistant organisms in refugee patients, medical tourists and domestic patients admitted to a German university hospital

BACKGROUND

Patients with contact to healthcare-system in high-prevalence countries (HPC) and refugee patients in hospital settings (REF) have previously been identified to be at risk of carrying multidrug-resistant organisms (MDRO). Comparative studies addressing the epidemiology of MDRO in patients transferred from hospitals abroad (ABROAD) and REF are lacking but are necessary to introduce refined infection control measures.

METHODS

From December 2015 to June 2016, 117 REF, 84 ABROAD and 495 patients admitted to intensive care unit, with no refugee history or pre-treatment abroad (ICU), at University Hospital Frankfurt, Germany (UHF) were screened for MDRO on day of admittance. Data within these groups were compared and set in an epidemiological context.

RESULTS

52.1% (95% confidence interval = 42.7-61.5) of REF and 41.6% (31.0-52.9) of ABROAD, were positive for at least one MDRGN, respectively. In contrast, 7.9% (5.6-10.6) of ICU were positive for MDRGN. Thereof, 0.9% (0.0-4.7) of REF, 15.5% (8.5-25.0) of ABROAD and 0% (0.0-0.7) of ICU were positive for at least one MDRGN with carbapenem resistance (CR). In total, 19 MDRGN with CR were detected in ABROAD, with the most frequent species with CR being A. baumannii with 42.1% (20.3-66.5). Regarding MRSA, 10.3% (5.4-17.2) of REF, 5.9% (1.9-13.3) of ABROAD and a significantly lower proportion 1.4% (0.6-2.9) of ICU, respectively, were tested positive.

CONCLUSIONS

Both REF and ABROAD pose a relevant hospital hygiene risk. High prevalence of MDRGN with CR in ABROAD was observed. Concise screening and infection control guidelines are needed in patient cohorts with increased risk for MDRO carriage.

Use of a fluorescent marker for assessing hospital bathroom cleanliness

A fluorescent marker was used to assess the efficacy of daily cleaning in hospital en suite bathrooms. We applied the marker on 218 surfaces and we assigned a score according how completely the mark had been removed. We found significant statistical differences among different surfaces and wards (P < .05). Microbiologic contamination and marker removal score did not seem to be correlated. Differences in cleanliness may indicate discrepancies in cleaning procedures. Fluorescent marker proved to be a practical and effective method and it could be adopted as a first-level control system to assess hospital cleanliness.

Costs and possible benefits of a two-tier infection control management strategy consisting of active screening for multidrug-resistant organisms and tailored control measures

BACKGROUND

Multidrug-resistant organisms (MDROs) are an economic burden, and infection control (IC) measures are cost- and labour-intensive. A two-tier IC management strategy was developed, including active screening, in order to achieve effective use of limited resources. Briefly, high-risk patients were differentiated from other patients, distinguished according to type of MDRO, and IC measures were implemented accordingly.

AIM

To evaluate costs and benefits of this IC management strategy.

METHODS

The study period comprised 2.5 years. All high-risk patients underwent microbiological screening. Gram-negative bacteria (GNB) were classified as multidrug-resistant (MDR) and extensively drug-resistant (XDR). Expenses consisted of costs for staff, materials, laboratory, increased workload and occupational costs.

FINDINGS

In total, 39,551 patients were screened, accounting for 24.5% of all admissions. Of all screened patients, 7.8% (N=3,104) were MDRO positive; these patients were mainly colonized with vancomycin-resistant enterococci (37.3%), followed by meticillin-resistant Staphylococcus aureus (30.3%) and MDR-GNB (28.3%). The median length of stay (LOS) for all patients was 10 days (interquartile range 3-20); LOS was twice as long in colonized patients (P<0.001). Screening costs totalled 255,093.82€, IC measures cost 97,701.36€, and opportunity costs were 599,225.52€. The savings of this IC management strategy totalled 500,941.84€. Possible transmissions by undetected carriers would have caused additional costs of 613,648.90-4,974,939.26€ (i.e. approximately 600,000-5 million €).

CONCLUSION

Although the costs of a two-tier IC management strategy including active microbiological screening are not trivial, these data indicate that the approach is cost-effective when prevented transmissions are included in the cost estimate.

Human activities and microbial geographies. An anthropological approach to the risk of infections in West African hospitals

In hospital care, management of the risk of infection represents a crucial issue. Nevertheless, this question remains a neglected area in anthropological research, especially in African countries. To shed new light on this question, we conducted an anthropological investigation in the infectious disease department of a hospital in Niger. Daily observation of the work of the hospital staff for a total period of 6 months was spread out over 2008 and 2009. During our prolonged stay, we also collected 64 in-depth interviews of health care workers and attendants in the department. This study method made it possible to describe many of the practices and discourses related to the issues of medical and personal care and hospital hygiene and to compare the practices observed to standard principles for preventing hospital-acquired infections. Our ethnographic attention to the behavior of the actors showed the absence of formal spatial segmentations between different activities. The care provided by the untrained relatives serving as personal attendants introduced territorial enclaves governed by home hygiene standards into the interior of technical spaces. At the same time, privatizing equipment and space for their diverse activities, the medical staff disrupted technical chains and generated the recurrent crossing of microbial geographies. These results allow us to offer two principal guidelines for improving the quality of care and the management of risks of infection in hospitals in West Africa: (1) the essential role of the attendants in the care provided to hospital inpatients must be officially taken into account, especially by including them in the organization of medical hygiene procedures; (2) the different overlapping technical activities and social activities in the work space must be limited by their geographic and architectural segmentation.

Harmonizing and supporting infection control training in Europe

Healthcare-associated infection (HCAI), patient safety, and the harmonization of related policies and programmes are the focus of increasing attention and activity in Europe. Infection control training for healthcare workers (HCWs) is a cornerstone of all patient safety and HCAI prevention and control programmes. In 2009 the European Centre for Disease Prevention and Control (ECDC) commissioned an assessment of needs for training in infection control in Europe (TRICE), which showed a substantial increase in commitment to HCAI prevention. On the other hand, it also identified obstacles to the harmonization and promotion of training in infection control and hospital hygiene (IC/HH), mostly due to differences between countries in: (i) the required qualifications of HCWs, particularly nurses; (ii) the available resources; and (iii) the sustainability of IC/HH programmes. In 2013, ECDC published core competencies for infection control and hospital hygiene professionals in the European Union and a new project was launched ['Implementation of a training strategy for infection control in the European Union' (TRICE-IS)] that aimed to: define an agreed methodology and standards for the evaluation of IC/HH courses and training programmes; develop a flexible IC/HH taxonomy; and implement an easily accessible web tool in 'Wiki' format for IC/HH professionals. This paper reviews several aspects of the TRICE and the TRICE-IS projects.