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PubMed2005

Hand hygiene compliance in a hematology unit.

Transmission of pathogens from the hands of health care workers (HCWs) is the main cause of nosocomial infections, and hand hygiene is the single most important procedure to prevent it. At present, little is known about the adherence of HCWs to hand hygiene procedures in hematology units, where the patients are at high risk for acquiring hospital infections. In a prospective observational study, two observers monitored the hand hygiene compliance of HCWs in a hematology unit during 30-min observation periods distributed randomly during the daytime over 2 months. The prevalence of compliance with hand hygiene was 26% on 638 observed occasions. The noncompliance was higher among nurses [odds ratio (OR) 3.52, 95% confidence interval (CI) 1.85-6.70] and other HCWs (OR 1.72, 95% CI 0.98-3.02) compared to physicians. The compliance rate differed from 4 to 60% depending on the activity. The lowest compliance rate (4%) was observed before patient care and the highest (60%) was after insertion of invasive devices. When we classified the occasions for hand hygiene into 'before' and 'after' activities, the compliance rates were 9 and 36%, respectively (OR 5.6, 95% CI 3.4-9.0). In conclusion, noncompliance with hand hygiene was high in this hematology unit, especially among nurses and before activities. Variations with the type of HCW and activity suggest that targeted educational programs and feedback control may be useful.

Cross Infection↗

PubMed2001

Understanding adherence to hand hygiene recommendations: the theory of planned behavior.

BACKGROUND: Most health care workers (HCWs) are aware of the rationale for hand hygiene procedures, yet failure to adhere to guidelines is common. Little is known about factors that motivate HCWs to practice hand hygiene. PURPOSE: The purposes of this study were to (1) estimate adherence to hand hygiene recommendations; (2) describe relationships among motivational factors, adherence, and intensity of nursing unit activity; and (3) test an explanatory model for adherence to hand hygiene guidelines based on the theory of planned behavior (TPB). METHOD: A longitudinal, observational design was used to collect data from 120 registered nurses employed in critical care and postcritical care units. Nurses provided information about motivational factors and intentions and a self-report of the proportion of time they followed guidelines. At least 2 weeks later, the nurses' hand hygiene performance was observed while they provided patient care. Structural equation modeling was used to test the TPB-based model. RESULTS: Rate of adherence to recommendations for 1248 hand hygiene indications was 70%. The correlation between self-reported and observed adherence to handwashing recommendations was low (r = 0.21). TPB variables predicted intention to handwash, and intention was related to self-reported hand hygiene. Intensity of activity in the nursing unit, rather than TPB variables, predicted observed adherence to hand hygiene recommendations. CONCLUSIONS: The limited association between self-reported and observed hand hygiene scores remains an enigma to be explained. Actual hand hygiene behavior may be more sensitive to the intensity of work activity in the clinical setting than to internal motivational factors.

Attitude of Health Personnel↗

PubMed2006

[Hand hygiene: first measure to control nosocomial infection].

Hand hygiene prevents cross infection in hospi tals, however adherence to guidelines is commonly poor. The hand-hygiene promotion programme started on May 2004 at the University Hospital of Liège after a baseline survey of compliance. We attempted to promote hand hygiene and most par ticularly alcohol-based hand disinfection. We measured MRSA transmission rates and consumption of alcohol-based handrub solution and soap in parallel. During the campaign, consump tion of alcohol-based handrub solution and soap increased by 56% and 24% respectively and MRSA transmission rates decreased from 11,04 to 7,07 cases per 1000 admissions.

Belgium↗

PubMed2005

Attitudes and perceptions toward hand hygiene among healthcare workers caring for critically ill neonates.

BACKGROUND: Infectious complications are frequent among critically ill neonates. Hand hygiene is the leading measure to prevent healthcare-associated infections, but poor compliance has been repeatedly documented, including in the neonatal setting. Hand hygiene promotion requires a complex approach that should consider personal factors affecting healthcare workers' attitudes. OBJECTIVE: To identify beliefs and perceptions associated with intention to comply with hand hygiene among neonatal healthcare workers. METHODS: An anonymous, self-administered questionnaire (74 items) based on the theory of planned behavior was distributed to 80 neonatal healthcare workers to assess intention to comply, attitude toward hand hygiene, behavioral and subjective norm perceptions, and perception of difficulty to comply. Variables were assessed using multi-item measures and answers to 7-point bipolar scales. All multi-item scales had satisfactory internal consistency (alpha > 0.7). Multivariate logistic regression identified independent perceptions or beliefs associated with a positive intention to comply. RESULTS: The response rate was 76% (61 of 80). Of the 49 nurses and 12 physicians responding, 75% believed that they could improve their compliance with hand hygiene. Intention to comply was associated with perceived control over the difficulty to perform hand hygiene (OR, 3.12; CI95, 1.12 to 8.70; P = .030) and a positive perception of how superiors valued hand hygiene (OR, 2.89; CI95, 1.08 to 7.77; P = .035). CONCLUSION: Our data highlight the importance of the opinions of superiors and a strong perceived controllability over the difficulty to perform hand hygiene as possible internal factors that may influence hand hygiene compliance.

Adult↗

PubMed2004

Electronic monitoring and voice prompts improve hand hygiene and decrease nosocomial infections in an intermediate care unit.

OBJECTIVE: To determine whether electronic monitoring of hand hygiene and voice prompts can improve hand hygiene and decrease nosocomial infection rates in a surgical intermediate care unit. DESIGN: Three-phase quasi-experimental design. Phase I was electronic monitoring and direct observation; phase II was electronic monitoring and computerized voice prompts for failure to perform hand hygiene on room exit; and phase III was electronic monitoring only. SETTING: Nine-room, 14-bed intermediate care unit in a university, tertiary-care institution. All patient rooms, utility room, and staff lavatory were monitored electronically. PARTICIPANTS: All healthcare personnel including physicians, nurses, nursing support personnel, ancillary staff, all visitors and family members, and any other personnel interacting with patients on the intermediate care unit. All patients with an intermediate care unit length of stay >48 hrs were followed for nosocomial infection. INTERVENTIONS: Electronic monitoring during all phases, computerized voice prompts during phase II only. MEASUREMENTS AND MAIN RESULTS: We evaluated a total of 283,488 electronically monitored entries into a patient room with 251,526 exits for 420 days (10,080 hrs and 3,549 patient days). Compared with phase I, hand hygiene compliance in patient rooms improved 37% during phase II (odds ratio, 1.38; 95% confidence interval, 1.04-1.83) and 41% in phase III (odds ratio, 1.41; 95% confidence interval, 1.07-1.84). When adjusting for patient admissions during each phase, point estimates of nosocomial infections decreased by 22% during phase II and 48% during phase III; when adjusting for patient days, the number of infections decreased by 10% during phase II and 40% during phase III. Although the overall rate of nosocomial infections significantly decreased when combining phases II and III, the association between nosocomial infection and individual phase was not significant. CONCLUSIONS: Electronic monitoring provided effective ongoing feedback about hand hygiene compliance. During both the voice prompt phase and post-intervention phase, hand hygiene compliance and nosocomial infection rates improved suggesting that ongoing monitoring and feedback had both a short-term and, perhaps, a longer-term effect.

Adolescent↗

PubMed2005

A randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home.

OBJECTIVE: Good hand hygiene may reduce the spread of infections in families with children who are in out-of-home child care. Alcohol-based hand sanitizers rapidly kill viruses that are commonly associated with respiratory and gastrointestinal (GI) infections. The objective of this study was to determine whether a multifactorial campaign centered on increasing alcohol-based hand sanitizer use and hand-hygiene education reduces illness transmission in the home. METHODS: A cluster randomized, controlled trial was conducted of homes of 292 families with children who were enrolled in out-of-home child care in 26 child care centers. Eligible families had > or =1 child who was 6 months to 5 years of age and in child care for > or =10 hours/week. Intervention families received a supply of hand sanitizer and biweekly hand-hygiene educational materials for 5 months; control families received only materials promoting good nutrition. Primary caregivers were phoned biweekly and reported respiratory and GI illnesses in family members. Respiratory and GI-illness-transmission rates (measured as secondary illnesses per susceptible person-month) were compared between groups, adjusting for demographic variables, hand-hygiene practices, and previous experience using hand sanitizers. RESULTS: Baseline demographics were similar in the 2 groups. A total of 1802 respiratory illnesses occurred during the study; 443 (25%) were secondary illnesses. A total of 252 GI illnesses occurred during the study; 28 (11%) were secondary illnesses. The secondary GI-illness rate was significantly lower in intervention families compared with control families (incidence rate ratio [IRR]: 0.41; 95% confidence interval [CI]: 0.19-0.90). The overall rate of secondary respiratory illness was not significantly different between groups (IRR: 0.97; 95% CI: 0.72-1.30). However, families with higher sanitizer usage had a marginally lower secondary respiratory illness rate than those with less usage (IRR: 0.81; 95% CI: 0.65-1.09). CONCLUSIONS: A multifactorial intervention emphasizing alcohol-based hand sanitizer use in the home reduced transmission of GI illnesses within families with children in child care. Hand sanitizers and multifaceted educational messages may have a role in improving hand-hygiene practices within the home setting.

Anti-Infective Agents, Local↗

PubMed2006

Hand hygiene compliance in healthcare workers.

The 'clean-your-hands' campaign has now been introduced into hospitals in England but it was initially piloted in six acute trusts. The campaign was multi-modal and aimed to improve hand hygiene compliance. This review reports the findings from one of the trusts involved in the pilot. The campaign consisted of a toolkit that included placing alcohol hand rub beside patients, along with posters and supporting marketing materials. A guide to implementation and a strategy aimed at increasing patient information and empowerment was also initiated. In order to assess the success of the campaign, audits of hand hygiene in healthcare workers were conducted over a six-month period. Additionally, data were obtained from staff surveys, patient surveys, usage levels of alcohol hand rub and interviews with the on-site lead. The local campaign indicated that a multi-modal campaign induced a marked increase in hand hygiene compliance (from 32% to 63%), with 74% of staff reporting increased compliance throughout the campaign. Usage of alcohol hand rub increased by 184%. The majority of patients indicated that the public should be actively involved in helping healthcare staff to improve their hand hygiene.

Cross Infection↗

PubMed2006

Hand rub consumption and hand hygiene compliance are not indicators of pathogen transmission in intensive care units.

The objective of this study was to investigate whether nosocomial infection (NI) rates, hand hygiene compliance rates and the amount of alcohol-based hand rub used for hand disinfection are useful indicators of pathogen transmission in intensive care units (ICUs), and whether they could be helpful in identifying infection control problems. All isolates of 10 of the most frequent pathogens from patients who were hospitalized in an ICU for >48 h were genotyped to identify transmission episodes in five ICUs. The incidence of transmission was correlated with hand hygiene compliance, hand rub consumption and NI rates. The incidence of transmission episodes varied between 2.8 and 6.8 in the five ICUs. The NI rate was 8.6-22.5 per 1000 patient-days, hand hygiene compliance was 30-47% and hand rub consumption was 57-102 L per 1000 patient-days. There was no correlation between the incidence of transmission episodes and hand rub consumption or hand hygiene compliance. The correlation between transmission rates and NI rates was 0.4 (P = 0.5), and with the exclusion of one ICU, it was 1 (P < 0.01). The incidence of NI is a relatively good indicator for the identification of pathogen transmissions, but hand rub consumption and hand hygiene compliance, at least with the relatively low level of compliance found in this study, are not indicators of pathogen transmission.

Anti-Infective Agents, Local↗

PubMed2004

Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection.

OBJECTIVE: Health care-associated infections persist as a major problem in most neonatal intensive care units. Hand hygiene has been singled out as the most important measure in preventing hospital-acquired infection. However, hand hygiene compliance among health care workers (HCWs) remains low. The objective of this study was to assess the frequency and nature of patient contacts in neonatal intensive care units and observe the compliance and technique of hand hygiene among HCWs before and after the implementation of a multimodal intervention program. METHODS: The nature and frequency of patient contacts, the hand hygiene compliance, and hand-washing techniques of HCWs were observed unobtrusively to reflect the baseline compliance and to investigate factors for noncompliance. The intervention consisted of problem-based and task-orientated hand hygiene education, enhancement of minimal handling protocol and clustering of nursing care, liberal provision of alcohol-based hand antiseptic, improvement in hand hygiene facilities, ongoing regular hand hygiene audit, and implementation of health care-associated infection surveillance. The observational study was repeated 6 months after the completion of the intervention program, which extended over 1-year period. RESULTS: Overall hand hygiene compliance increased from 40% to 53% before patient contact and 39% to 59% after patient contact. More marked improvement was observed for high-risk procedures (35%-60%). The average number of patient contacts also decreased from 2.8 to 1.8 per patient per hour. There was improvement in most aspects of hand-washing technique in the postintervention stage. The health care-associated infection rate decreased from 11.3 to 6.2 per 1000 patient-days. CONCLUSION: A problem-based and task-orientated education program can improve hand hygiene compliance. Enhancement of minimal handling and clustering of nursing procedures reduced the total patient contact episodes, which could help to overcome the major barrier of time constraints. A concurrent decrease in health care-associated infection rate and increase in hand hygiene compliance was observed in this study. The observational study could form part of an ongoing audit to provide regular feedback to HCWs to sustain the compliance.

Anti-Infective Agents, Local↗

PubMed2006

Using the six sigma process to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health Care Settings was issued in 2002. In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established complying with the CDC Guideline as a National Patient Safety Goal for 2004. This goal has been maintained through 2006. The CDC's emphasis on the use of alcohol-based hand rubs (ABHRs) rather than soap and water was an opportunity to improve compliance, but the Guideline contained over 40 specific recommendations to implement. OBJECTIVE: To use the Six Sigma process to examine hand hygiene practices and increase compliance with the CDC hand hygiene recommendations required by JCAHO. DESIGN: Six Sigma Project with pre-post design. PARTICIPANTS: Physicians, nurses, and other staff working in 4 intensive care units at 3 hospitals. MEASUREMENTS: Observed compliance with 10 required hand hygiene practices, mass of ABHR used per month per 100 patient-days, and staff attitudes and perceptions regarding hand hygiene reported by questionnaire. RESULTS: Observed compliance increased from 47% to 80%, based on over 4,000 total observations. The mass of ABHR used per 100 patient-days in 3 intensive care units (ICUs) increased by 97%, 94%, and 70%; increases were sustained for 9 months. Self-reported compliance using the questionnaire did not change. Staff reported increased use of ABHR and increased satisfaction with hand hygiene practices and products. CONCLUSIONS: The Six Sigma process was effective for organizing the knowledge, opinions, and actions of a group of professionals to implement the CDC's evidence-based hand hygiene practices in 4 ICUs. Several tools were developed for widespread use.

Centers for Disease Control and Prevention, U.S.↗

PubMedDate not supplied

Outcomes of an infection prevention project focusing on hand hygiene and isolation practices.

Nosocomial infections are a major health problem for hospitalized patients and their families. Since the 1800s, hand hygiene has been recognized as the single best method to prevent the spread of pathogens and nosocomial infections. Despite this fact, many healthcare workers do not adhere to hand hygiene policies. The Centers for Disease Control and Prevention issued a guideline for hand hygiene practices in 2002. Multifaceted approaches to improve hand hygiene have been shown to increase compliance among healthcare workers and subsequently reduce infections. A performance improvement project was initiated to implement this guideline and other strategies to prevent nosocomial infection. This article summarizes the performance improvement processes and the preliminary outcomes on adherence to infection prevention policies related to hand hygiene and isolation practices. Clinically and statistically significant increases were noted for hand hygiene prior to patient care and in wearing masks when indicated. Nurses and patient care technicians had the greatest increases in compliance. Increases in hand hygiene after patient contact and wearing of gown and gloves were also noted, but results were not statistically significant. Nosocomial infection rates from antibiotic-resistant organisms decreased in the first surveillance, but rates increased during the 1-year surveillance. Consumption of alcohol-based foam disinfectant doubled from baseline. Findings are consistent with other published studies. The project will continue with further reinforcement and education over the second year.

Centers for Disease Control and Prevention, U.S.↗

PubMed2007

Multicenter intervention program to increase adherence to hand hygiene recommendations and glove use and to reduce the incidence of antimicrobial resistance.

OBJECTIVE: To determine whether a multimodal intervention could improve adherence to hand hygiene and glove use recommendations and decrease the incidence of antimicrobial resistance in different types of healthcare facilities. DESIGN: Prospective, observational study performed from October 1, 1999, through December 31, 2002. We monitored adherence to hand hygiene and glove use recommendations and the incidence of antimicrobial-resistant bacteria among isolates from clinical cultures. We evaluated trends in and predictors for adherence and preferential use of alcohol-based hand rubs, using multivariable analyses. SETTING: Three intervention hospitals (a 660-bed acute and long-term care hospital, a 120-bed community hospital, and a 600-bed public teaching hospital) and a control hospital (a 700-bed university teaching hospital).Intervention. At the intervention hospitals, we introduced or increased the availability of alcohol-based hand rub, initiated an interactive education program, and developed a poster campaign; at the control hospital, we only increased the availability of alcohol-based hand rub. RESULTS: We observed 6,948 hand hygiene opportunities. The frequency of hand hygiene performance or glove use significantly increased during the study period at the intervention hospitals but not at the control hospital; the maximum quarterly frequency of hand hygiene performance or glove use at intervention hospitals (74%, 80%, and 77%) was higher than that at the control hospital (59%). By multivariable analysis, preferential use of alcohol-based hand rubs rather than soap and water for hand hygiene was more likely among workers at intervention hospitals compared with nonintervention hospitals (adjusted odds ratio, 4.6 [95% confidence interval, 3.3-6.4]) and more likely among physicians (adjusted odds ratio, 1.4 [95% confidence interval, 1.2-1.8]) than among nurses at intervention hospitals. A significantly reduced incidence of antimicrobial-resistant bacteria among isolates from clinical culture was found at a single intervention hospital, which had the greatest increase in the frequency of hand hygiene performance. CONCLUSIONS: During a 3-year period, a multimodal intervention program increased adherence to hand hygiene recommendations, especially to the use of alcohol-based hand rubs. In one hospital, a concomitant reduction was found in the incidence of antimicrobial-resistant bacteria among isolates from clinical cultures.

Alcohols↗

PubMedDate not supplied

Can alcohol hand rubs increase compliance with hand hygiene?

A review of the literature indicates that alcohol hand rubs reduce microbial load, are less irritant to the skin of healthcare workers, and are more easily accessible than conventional methods of hand hygiene. The review also indicates that using alcohol hand rub increases compliance to hand hygiene guideline rates by 25%. This study examines whether making alcohol hand rubs readily available to healthcare workers will increase and maintain compliance with hand hygiene protocols and guidelines, thereby reducing nosocomial infection, or whether the methods of staff education on the use and benefits of products and other interventions need to be examined.

Alcohols↗

PubMed2006

Comparison of a waterless hand-hygiene preparation and soap-and-water hand washing to reduce coliforms on hands in animal exhibit settings.

Outbreaks of enteric disease associated with exposure to live animals on exhibit have occurred with increasing frequency in recent years. Possibly the most important pathogen causing such outbreaks is Escherichia coli O157:H7, because of the serious illness it can cause. Hand hygiene is consistently protective against disease among persons exposed to animals implicated in these outbreaks. Livestock barns have limited hand-washing facilities, therefore a waterless hand-sanitizing gel would be a potentially preventive measure readily available to visitors and animal exhibitors. This study compared the reduction of bacterial counts on hands of animal exhibitors when soap and water was used or when an ethanol-based hand gel was used after animal handling. Participants were youth and adults involved with showing livestock. The sanitation methods were similar in reducing the total bacteria and coliform counts on the hands of the participants (Wilcoxon rank sum test P values 0.12 and 0.69 respectively).

Animals↗

PubMedDate not supplied

Assessing nurses' hand hygiene practices by direct observation or self-report.

Methods of obtaining data on hand hygiene practices have not been well validated. The purpose of this study was to compare two methods of assessment of hand hygiene practices--direct observation and self-report using diaries. For 22 months, nursing staff (n = 119) from two neonatal ICUs recorded their hand hygiene practices on a diary card one shift/month (n = 1,071 diary cards). The same data were collected in monthly 1-hour direct observation sessions (n = 206 hours). Amount of time in gloves and total hand hygiene episodes/hour did not differ significantly by diary or observation, but four other specific parameters were significantly different. If hand hygiene practices are to be assessed over time, the same method must be used. Given these measurement limitations, more valid, practical, and less costly methods are needed.

Data Collection↗

PubMed2002

Alcohol-based handrub improves compliance with hand hygiene in intensive care units.

BACKGROUND: Nosocomial infection is a leading complication in intensive care units. Although hand hygiene is the single most efficient preventive measure, compliance with this simple action remains low. OBJECTIVES: To assess the effect of an intervention to promote hand hygiene and to investigate risk factors for noncompliance in intensive care units. METHODS: We performed 7 observational surveys and implemented a promotional campaign after baseline in medical, surgical, and pediatric intensive care units of a teaching hospital. Health care workers were observed during routine patient care. The intervention consisted of a hospitalwide promotional campaign, including observation and performance feedback, posters display, and distribution of individual bottles of alcohol-based handrub. The main outcome measure was compliance with hand hygiene through handwashing or handrubbing. RESULTS: We observed 2743 opportunities for hand hygiene distributed over 248 periods. Overall compliance increased from 38.4% to 54.5% during the study (P<.001). Although recourse to handwashing remained stable at around 30%, handrubbing increased from 5.4% at baseline to 21.7% at the last survey (P<.001). Compliance increased among nurses and nursing assistants, but remained stable among physicians. Handwashing compliance decreased, on average, by 4.7% for an increase of 10 opportunities for hand hygiene per hour of patient care (P<.001), whereas no such association existed for handrubbing. CONCLUSIONS: Our intervention induced a marked and sustained increase in compliance with hand hygiene. In intensive care units, less time-consuming handrubbing might replace standard handwashing and overcome the barrier of time constraints.

Critical Care↗

PubMed2005

Alcohol-based hand disinfection: a more robust hand-hygiene method in an intensive care unit.

This study involved observation of hand-hygiene behaviour and evaluation of the effect of alcohol-based hand disinfection and handwashing with plain liquid soap on microbial flora. The study was performed in a combined medical and surgical intensive care unit. We demonstrated a crude compliance of hand hygiene of 50.4%, which was only performed adequately in 20.8% of cases. Of this group, handwashing and hand-disinfection procedures were performed properly 34.0% and 71.6% of the time, respectively. Hand samples for bacteriological examinations with the glove juice method demonstrated that whilst handwashing was sensitive to the way in which hand hygiene was performed, alcohol-based hand disinfection was less sensitive to such performance. Our study demonstrated that alcohol-based hand disinfection is a robust hand-hygiene method with many advantages in a practical setting. It is very feasible for use in hospital wards.

Adult↗

PubMed2005

Compliance with hand hygiene and glove use in a university-affiliated hospital.

OBJECTIVE: The hands of healthcare workers often transmit pathogens causing nosocomial infections. This study examined compliance with handwashing and glove use. SETTING: A university-affiliated hospital. DESIGN: Compliance was observed covertly. Healthcare workers' demographics, hand hygiene facilities, indications for hand hygiene, compliance with handwashing and glove use in each procedure, and duration of handwashing were recorded. RESULTS: Nine nurses and 33 assistant physicians were monitored during the study. One researcher recorded 1400 potential opportunities for handwashing during 15-minute observation periods. The mean duration of handwashing was 10 +/- 2 seconds. Most healthcare workers (99.3%) used liquid soap during handwashing, but 79.8% did not dry their hands. For all indications, compliance with handwashing was 31.9% and compliance with glove use was 58.8%. Compliance with handwashing varied inversely with both the number of indications for hand hygiene and the number of patient beds in the hospital room. Compliance with handwashing was better in dirty high-risk situations. CONCLUSION: Compliance with handwashing was low, suggesting the need for new motivational strategies such as supplying feedback regarding compliance rates

Adult↗