Healthcare Worker Hand Hygiene Research Articles

The use of privacy-protected computer vision to measure the quality of healthcare worker hand hygiene.

(i) To demonstrate the feasibility of automated, direct observation and collection of hand hygiene data, (ii) to develop computer visual methods capable of reporting compliance with moment 1 (the performance of hand hygiene before touching a patient) and (iii) to report the diagnostic accuracy of automated, direct observation of moment 1. Observation of simulated hand hygiene encounters between a healthcare worker and a patient. Computer laboratory in a university. Healthy volunteers. Sensitivity and specificity of automatic detection of the first moment of hand hygiene. We captured video and depth images using a Kinect camera and developed computer visual methods to automatically detect the use of alcohol-based hand rub (ABHR), rubbing together of hands and subsequent contact of the patient by the healthcare worker using depth imagery. We acquired images from 18 different simulated hand hygiene encounters where the healthcare worker complied with the first moment of hand hygiene, and 8 encounters where they did not. The diagnostic accuracy of determining that ABHR was dispensed and that the patient was touched was excellent (sensitivity 100%, specificity 100%). The diagnostic accuracy of determining that the hands were rubbed together after dispensing ABHR was good (sensitivity 83%, specificity 88%). We have demonstrated that it is possible to automate the direct observation of hand hygiene performance in a simulated clinical setting. We used cheap, widely available consumer technology and depth imagery which potentially increases clinical application and decreases privacy concerns.

The Impact of Isolation on Healthcare Worker Contact and Compliance With Infection Control Practices in Nursing Homes

OBJECTIVETo directly observe healthcare workers in a nursing home setting to measure frequency and duration of resident contact and infection prevention behavior as a factor of isolation practiceDESIGNObservational studySETTING AND PARTICIPANTSHealthcare workers in 8 VA nursing homes in Florida, Maryland, Massachusetts, Michigan, Washington, and TexasMETHODSOver a 15-month period, trained research staff without clinical responsibilities on the units observed nursing home resident room activity for 15-30-minute intervals. Observers recorded time of entry and exit, isolation status, visitor type (staff, visitor, etc), hand hygiene, use of gloves and gowns, and activities performed in the room when visible.RESULTSA total of 999 hours of observation were conducted across 8 VA nursing homes during which 4,325 visits were observed. Residents in isolation received an average of 4.73 visits per hour of observation compared with 4.21 for nonisolation residents (P<.01), a 12.4% increase in visits for residents in isolation. Residents in isolation received an average of 3.53 resident care activities per hour of observation, compared with 2.46 for residents not in isolation (P<.01). For residents in isolation, compliance was 34% for gowns and 58% for gloves. Healthcare worker hand hygiene compliance was 45% versus 44% (P=.79) on entry and 66% versus 55% (P<.01) on exit for isolation and nonisolation rooms, respectively.CONCLUSIONSHealthcare workers visited residents in isolation more frequently, likely because they required greater assistance. Compliance with gowns and gloves for isolation was limited in the nursing home setting. Adherence to hand hygiene also was less than optimal, regardless of isolation status of residents.Infect Control Hosp Epidemiol 2018;39:683-687.

Patient as a Partner in Healthcare-Associated Infection Prevention.

Objectives: The objective of the study was getting to know the knowledge and attitudes towards hand hygiene (HH) among Polish patients and healthcare workers (HCWs). Methods: 459 respondents replied to the survey: 173 (37.6%) patients and 286 (62.3%) HCWs; 57 HCWs were additionally interviewed. Results: Few HCWs knew and used the “5 moments for HH” in the required situations. Both patients and HCWs rated HH of other HCWs poorly: only 75% of patients and 54% of HCWs noticed the application of HH before blood sample collection, but 1/2 of interviewed HCWs did not encounter a request for HH from a patient. According to interviews, 23 (40%) HCWs did not admonish others when they did not use HH. Seventy-five percent of patients and HCWs claimed that, in the past, in schools the toilets were poorly stocked, but the situation improved with the passage of time. Conclusions: There are barriers with resspect to treating patients as partners in HH in Polish hospitals and HCWs’ lack of compliance with the “5 moments for HH” significantly reduces patients’ safety. Practice implications: Education regarding HH should be conducted for the whole society from an early age: lack of proper supplies in school bathrooms impedes the development of positive HH habits.

An educational intervention to improve hand hygiene compliance in Vietnam

BackgroundHand hygiene compliance is the basis of infection control programs. In developing countries models to improve hand hygiene compliance to reduce healthcare acquired infections are required. The aim of this study was to determine hand hygiene compliance following an educational program in an obstetric and gynecological hospital in Vietnam.MethodsHealth care workers from neonatal intensive care, delivery suite and a surgical ward from Hung Vuong Hospital, Ho Chi Minh City, Vietnam undertook a 4-h educational program targeting hand hygiene. Compliance was monitored monthly for six months following the intervention. Hand hygiene knowledge was assessed at baseline and after six months of the study.ResultsThere were 7124 opportunities over 370 hand hygiene recording sessions with 1531 opportunities at baseline and 1620 at 6 months following the intervention. Hand hygiene compliance increased significantly from baseline across all sites (43.6% [95% Confidence interval CI: 41.1–46.1] to 63% [95% CI: 60.6–65.3]; p < 0.0001). Health care worker hand hygiene compliance increased significantly after intervention (p < 0.0001). There were significant improvements in knowledge scores from baseline to 2 months post educational intervention with mean difference standard deviations (SD): 1.5 (2.5); p < 0.001).ConclusionsA simple educational model was implemented in a Vietnamese hospital that revealed good hand hygiene compliance for an extended period of time. Hand hygiene knowledge increased during the intervention. This hand hygiene model could be used in developing countries were resources are limited.

Interventions to Reduce the Incidence of Hospital-Onset Clostridium difficile Infection: An Agent-Based Modeling Approach to Evaluate Clinical Effectiveness in Adult Acute Care Hospitals.

Despite intensified efforts to reduce hospital-onset Clostridium difficile infection (HO-CDI), its clinical and economic impacts continue to worsen. Many institutions have adopted bundled interventions that vary considerably in composition, strength of evidence, and effectiveness. Considerable gaps remain in our knowledge of intervention effectiveness and disease transmission, which hinders HO-CDI prevention. We developed an agent-based model of C. difficile transmission in a 200-bed adult hospital using studies from the literature, supplemented with primary data collection. The model includes an environmental component and 4 distinct agent types: patients, visitors, nurses, and physicians. We used the model to evaluate the comparative clinical effectiveness of 9 single interventions and 8 multiple-intervention bundles at reducing HO-CDI and asymptomatic C. difficile colonization. Daily cleaning with sporicidal disinfectant and C. difficile screening at admission were the most effective single-intervention strategies, reducing HO-CDI by 68.9% and 35.7%, respectively (both P < .001). Combining these interventions into a 2-intervention bundle reduced HO-CDI by 82.3% and asymptomatic hospital-onset colonization by 90.6% (both, P < .001). Adding patient hand hygiene to healthcare worker hand hygiene reduced HO-CDI rates an additional 7.9%. Visitor hand hygiene and contact precaution interventions did not reduce HO-CDI, compared with baseline. Excluding those strategies, healthcare worker contact precautions were the least effective intervention at reducing hospital-onset colonization and infection. Identifying and managing the vast hospital reservoir of asymptomatic C. difficile by screening and daily cleaning with sporicidal disinfectant are high-yield strategies. These findings provide much-needed data regarding which interventions to prioritize for optimal C. difficile control.

Patients’ Family Empowering to Increase Hand Hygiene (HH) Compliance in Health-Care Workers (HCW) from a Hematology-Oncology Ward in Mexico City

BackgroundHH is a key component to decrease infections in hospitals, but compliance in HCW remains low. We present a six-month strategy to empower patients’ caregivers on HCW HH compliance.MethodsHH compliance in HCWs was evaluated between June 1 and August 31, 2017 as recommended by WHO. Between September 1, 2016 and March 31, 2017 we undertook the empowering in the hematology-oncology ward (50 beds) from Instituto Nacional de Cancerologia, a cancer referral, teaching hospital in Mexico. To empower patients and their caregivers, a member of the team visited the patient and their relatives during the first 24h of hospital admission. Standarized information on HH and the importance of HCW compliance was given, along with a printed cartoon on HH opportunities (5 moments from WHO). Patients and their caregivers were trained to observe and record HH opportunties, an were invited to remind HCWs if HH omissions were observed. Data on HH compliance was collected monthly during the empowerment and 1 month after. Data was compared with the HH compliance from the 6 previous. We compared overall compliance and for each 5 HH moments before and after the empowering (chi 2 test).ResultsWe empowered 82 caregivers (M: 25.6%) and F: 74.4%), mean age 44 years. 24.4% had completed primary education, and 13.1% had higher education. Mothers and spouses were the primary caregivers (28.1% and 36.6%). HH compliance increased in all 5 moments: Before touching a patient (M1) (B: 9.5%, A: 57.6%, P = 0.005); before a clean or aseptic procedure (M2) (B: 7.9%, A: 48%, P = 0.002); after body fluid exposure (M3) (B: 10%, A: 59%, P = 0.0005), after touching a patient (M4) (B: 7.4%, A: 57.9%, P = 0.0005), and after touching patient surroundings (M5) (B: 2.4%, A: 77.4%, P = 0.0008). Nurses achieved a higher increase on compliance compared with physicians. Caregivers recognition on HH increased for each opporunity, being more notorious for M2 (B:31.7%, A: 61.5%); M3 (B: 7.3%, A: 31.5%), and M4, (B: 36.5%, A: 68.7%). Perception on the importance of preventing health-care-related infections increased from 80.5% to 90.3%.ConclusionEmpowering patients’ primary caregivers was an effective intervention to increase HCWs HH compliance at a hematology-oncology ward. The effect of this intervention remains to be evaluated on the long-term basis, but demonstrate the importance of involving patients and their relatives on health-care delivery.Disclosures All authors: No reported disclosures.

Impact of a Successful Speaking Up Program on Health-Care Worker Hand Hygiene Behavior.

Background:Health-care worker (HCW) hand hygiene (HH) is the cornerstone of efforts to reduce hospital infections but remains low. Real-time mitigation of failures can increase process reliability to > 95% but has been challenging to implement for HH.Objective:To sustainably improve HCW HH to > 95%.Methods:A hospital-wide quality improvement initiative to improve HH was initiated in February 2012. HCW HH behavior was measured by covert direct observation utilizing multiple-trained HCW volunteers. HH compliance was defined as correct HH performed before and after contact with the patient or the patient’s care area. Interventions focusing on leadership support, HCW knowledge, supply availability, and culture change were implemented using quality improvement science methodology. In February 2014, the hospital began the Speaking Up for Safety Program, which trained all HCWs to identify and mitigate HH failures at the moment of occurrence and addressed known barriers to speaking up.Results:Between January 1, 2012, and January 31, 2016, there were 30,514 HH observations, averaging 627 observations per month (9% attending physicians, 12% resident physicians, 46% nurses, 33% other HCW types). HCW HH gradually increased from 75% to > 90% by December 2014. After the Speaking Up for Safety Program, HCW HH has been > 95% for 20 months. Physician HH compliance has been above 90% for over a year.Conclusion:Creating a specific process for staff to speak up and prevent HH failures, as part of a multimodal improvement effort, can sustainably increase HCW HH above 95%.

Challenges to sustainability of hand hygiene at a rural hospital in Rwanda

Many hand hygiene (HH) programs have been implemented across Sub-Saharan Africa (SSA); however, most of these have been in large, referral hospitals. Our objective was to assess the impact of HH programs aimed at improving compliance at a rural hospital, and to identify unique challenges to HH sustainability. Interventions to improve HH through providing handwashing stations, health care worker (HCW) training, and alcohol handrub were completed in 2014 and 2015. HH infrastructure, compliance, and glove use were assessed among HCWs after the intervention in 2015 and 2016. HCWs were interviewed about challenges to sustainability of HH compliance. Total HH compliance decreased 32.1% between 2015 and 2016 (P < .001). HH for patient protection was completed significantly less than HH for HCW protection in 2016, and HCWs appeared to substitute HH for patient protection with glove use. A high rate of physician turnover was associated with a larger decrease in HH compliance compared with nurses, and interviews suggested recruiting and retention of key personnel might play a role in HH sustainability. Availability of alcohol-based handrub in patient rooms decreased from 100% in 2015 to 79.5% in 2016 (P < .01). Many challenges exist to sustaining HH compliance in SSA. In rural settings, difficulty recruiting and retaining trained personnel, inconsistent availability in HH infrastructure, and variability in HCW HH training may be contributing factors.

Speaking Up: The Next Step to Improving Health Care Worker Hand Hygiene.

Since Ignaz Semmelweis recognized hand hygiene as a key behavior to prevent health care–associated infections, health care workers (HCWs) have struggled to listen to and act on this seemingly simple advice. Despite this knowledge, HCW hand hygiene remains poor, ∼40% nationally.1 The hand hygiene behavior of HCWs is significantly influenced by long-standing habits, which are often difficult to change. This difficulty contributes to the challenges hospitals have faced trying to sustainably improve HCW hand hygiene. Multiple studies reinforce the need for a multimodal approach to improve hand hygiene.1–3 The World Health Organization recommends a combination of interventions: an institutional focus on hand hygiene, education and training, supply availability, workplace reminders, and feedback of compliance data.1 Hospitals that have implemented a similar bundle of interventions have seen HCW hand hygiene improve, but compliance usually plateaus at 90%.4 In the recent quality improvement (QI) initiative by McLean et al,5 the goal was to improve HCW hand hygiene to ≥95% by using high-reliability concepts. This was a time series QI study implemented on 2 pediatric medical surgical units within a large academic medical center. Hand hygiene compliance was defined as correct hand hygiene before and …

Knowledge of Hand Hygiene Practices among Healthcare workers in Neonatal and Paediatric Intensive Care Unit of a tertiary care hospital of Odisha

BackgroundThe objective of this study was to assess the knowledge of hand hygiene of healthcare workers in the neonatal and paediatric intensive care unit in a tertiary care hospital.Methods : Study was conducted to assess the knowledge of hand hygiene for the five moments of hand hygiene of WHO. Healthcare workers were given a questionnaire during routine patient care on random basis and the data was collected. Data analysis was performed using SPSS software version 13.Results : A total of 50 health care workers were questioned during the observation period. Answers differed by role: nurses (25) and doctors (10).15 nurses have no knowledge of moments of hand hygiene and were excluded from study. Nurses were more likely to use soap and water compared to waterless-alcohol-based hand hygiene practices. Doctors were most likely to use alcoholic hand rub.Conclusion : Though knowledge of hand hygiene practice is high ,use of alcohol-based disinfectant was found to be very low compared to soap and water. Keywords: Hand hygiene, Health care, Soap and water, Alcohol hand rub.

Good to Great: Quality-Improvement Initiative Increases and Sustains Pediatric Health Care Worker Hand Hygiene Compliance.

The Joint Commission, the Centers for Disease Control and Prevention, and the World Health Organization challenge hospitals to achieve and sustain compliance with effective hand hygiene (HH) practice; however, many inpatient units fail to achieve a high level of reliability. The aim of the project was to increase and sustain health care worker (HCW) compliance with HH protocols from 87% (level of reliability [LOR] 1) to ≥95% (LOR 2) within 9 months on 2 pediatric inpatient units in an academic children's hospital. This study was a time-series, quality-improvement project. Interventions were tested through multiple plan-do-study-act cycles on 2 pediatric inpatient units. HH compliance audits of HCWs on these units were performed randomly each week by the hospital infection prevention program. Control charts of percentages of HCW HH compliance were constructed with 3-σ (data within 3 SDs from a mean) control limits. These control limits were adjusted after achieving significant improvements in performance over time. Charts were annotated with interventions including (1) increasing awareness, (2) providing timely feedback, (3) empowering patients and families to participate in mitigation, (4) providing focused education, and (5) developing interdisciplinary HH champions. HH compliance rates improved from an average of 87% (LOR 1) to ≥95% (LOR 2) within 9 months, and this improvement has been sustained for >2 years on both pediatric inpatient units. Significant and sustained gains in HH compliance rates of ≥95% (LOR 2) can be achieved by applying high-reliability human-factor interventions.

The effect of merging two infectious disease units on hand hygiene adherence in Italy.

Healthcare-associated infections (HAIs) are common and harmful to patients. Effective hand hygiene can help prevent HAIs, however, suboptimal healthcare worker hand hygiene remains problematic across the globe. This study analyses the impact of organisational changes on hand hygiene. This observational study assessed hand hygiene by different professions before and after a merger of a recently combined infectious diseases (ID) unit coupled with a qualitative study about barriers to optimal hand hygiene. Direct observations were compared with previous data collected on both units before they merged. We also conducted focus groups with the doctors and nurses about hand hygiene. After two ID units merged in 2013, we observed 681 provider-patient interactions. We compared these with a previous observation period in 2012. Hand hygiene adherence among nurses significantly declined after the merger (from 36% to 24%, P <0.001). However, adherence among doctors increased from 51% to 63% after the merger (P = 0.004). Data from the focus groups revealed a gap between doctor and nurses perceptions of education and goal adherence rates. Our findings underscore the important role played by effective unit leaders to prevent infection. We found long-term sustainability of hand hygiene practices among doctors. However, adherence among nurses was substantially lower.

A Cluster of Fluconazole-Resistant Malassezia pachydermatis in a Neonatal Intensive Care Unit — California, 2015–2016

Background Malassezia pachydermatis, a common veterinary yeast, rarely causes outbreaks in neonatal intensive care units (NICUs). One outbreak was associated with healthcare worker (HCW) colonization with strains shared by pet dogs. Prevention relies on good hand hygiene, but data HCW pet ownership and interaction are lacking. We report a cluster of 5 cases of M. pachydermatis infection or colonization during December 2015–September 2016 in a Level 3, 84-bed NICU and results of a HCW survey on hand and pet-related hygiene.Methods A case was defined as a culture yielding M. pachydermatis from sterile sites or skin of a NICU patient. We used whole-genome sequencing (WGS) to examine genetic relatedness among the 5 M. pachydermatis isolates compared with 9 isolates in CDC’s historical collection. As part of a series of NICU hand hygiene improvement campaigns, we administered a web-based survey of hand hygiene practice, pet ownership, and pet health to 290 NICU HCWs employed while case-patients were admitted.ResultsWe identified 5 cases (3 fungemias, 1 infected urinoma, 1 colonization) during the 9-month period (Figure 1), and a hospital lookback revealed no M. pachydermatis infections before the first case. All patients had low birth weight, central venous or peripheral arterial catheters, prior broad-spectrum antibiotics, and antifungal prophylaxis. All isolates were resistant to fluconazole and were highly related by WGS (<14 single-nucleotide polymorphisms [SNPs]) but unrelated to historical isolates (>40,000 SNPs). Survey respondents (N = 151[52%]; Figure 2) reported perceived peer HCW hand hygiene lower than their own, and 69% reported daily contact with dogs or cats. Survey results did not differ among staff who did (n = 15) and did not (n = 136) care for all case patients. No cases were reported in the 7 months following the fifth case.Conclusion We report a NICU cluster of fluconazole-resistant M. pachydermatis cases nearly identical by WGS, suggesting a common source of infection, possibly related to HCW carriage following contact with household pets. A hygiene improvement campaign may have mitigated further transmission. M. pachydermatis is a potential cause of fungemia among neonates on fluconazole prophylaxis.Disclosures All authors: No reported disclosures.

Improving Healthcare Worker Hand Hygiene Compliance: The Role of Behavior Change Theories

Improving Healthcare Worker Hand Hygiene Compliance: The Role of Behavior Change Theories

Healthcare worker and family caregiver hand hygiene in Bangladeshi healthcare facilities: results from the Bangladesh National Hygiene Baseline Survey

SUMMARYBackgroundHealthcare facility hand hygiene impacts patient care, healthcare worker safety, and infection control, but low-income countries have few data to guide interventions.AimTo conduct a nationally representative survey of hand hygiene infrastructure and behaviour in Bangladeshi healthcare facilities to establish baseline data to aid policy.MethodsThe 2013 Bangladesh National Hygiene Baseline Survey examined water, sanitation, and hand hygiene across households, schools, restaurants and food vendors, traditional birth attendants, and healthcare facilities. We used probability proportional to size sampling to select 100 rural and urban population clusters, and then surveyed hand hygiene infrastructure in 875 inpatient healthcare facilities, observing behaviour in 100 facilities.FindingsMore than 96% of facilities had ‘improved’ water sources, but environmental contamination occurred frequently around water sources. Soap was available at 78–92% of handwashing locations for doctors and nurses, but just 4–30% for patients and family. Only 2% of 4676 hand hygiene opportunities resulted in recommended actions: using alcohol sanitizer or washing both hands with soap, then drying by air or clean cloth. Healthcare workers performed recommended hand hygiene in 9% of 919 opportunities: more after patient contact (26%) than before (11%). Family caregivers frequently washed hands with only water (48% of 2751 opportunities), but with little soap (3%).ConclusionHealthcare workers had more access to hand hygiene materials and performed better hand hygiene than family, but still had low adherence. Increasing hand hygiene materials and behaviour could improve infection control in Bangladeshi health-care facilities.

Irritant Contact Dermatitis on Hands.

Hand hygiene (HH) is the single most important procedure health care workers (HCWs) can follow to reduce the risk of spreading health care-associated infections, yet compliance with this simple task remains at less than 50%. One of the reasons often cited for noncompliance is irritant contact dermatitis (ICD) resulting from repeated exposure to HH products and procedure. This literature review used the World Health Organization's components of empowerment as a guideline for the search and development of a clinical model to address HCW HH and ICD.

Impact of sink location on hand hygiene compliance after care of patients with Clostridium difficile infection: a cross-sectional study.

BackgroundThe impact of sink location on hand washing compliance after contact with patients with Clostridium difficile infection (CDI) is poorly understood. The aim of this study is to determine the location of hand wash sinks available to healthcare workers (HCWs) after caring for patients with CDI and to assess the impact on hand washing compliance.MethodsWe performed a cross-sectional study in a 637-bed tertiary care hospital, Canada. HCW hand hygiene compliance after contact with CDI patients was measured through direct unobtrusive observations. Location of sinks in relation with the patients’ rooms was assessed on the day of diagnosis. Predictors of compliance were assessed through univariate and multivariate logistic regression.Results247 hand hygiene opportunities following care of a CDI patient were observed. Glove use compliance was 85.4 % (211/247), but hand washing compliance after care of CDI patients was only 14.2 % (35/247). Hand rubbing was performed instead of hand washing in 33.2 % of opportunities (82/247). The median distance between the patient zone of CDI patients and the nearest sink was 13.1 m (interquartile range, 7.6-23.2). Sinks were directly visible upon exiting the patient’s room on only 33.2 % (82/247) occasions. By multivariate analysis, an increasing distance between the patient zone and the nearest sink was inversely associated with hand washing compliance (adjusted OR, 0.90, 95 % CI, 0.84-0.97; P = 0.008), while proper timing of glove removal upon leaving the patient zone was directly associated with hand washing compliance (adjusted OR, 14.87; 95 % CI, 1.93-114.43; P = 0.01).ConclusionsHand washing compliance following contact with patients with C. difficile infections was low. Poor access to sinks is associated with decreased hand washing compliance. Improvement strategies are urgently needed.

Relationship between healthcare worker surface contacts, care type and hand hygiene: an observational study in a single-bed hospital ward

This study quantifies the relationship between hand hygiene and the frequency with which healthcare workers (HCWs) touch surfaces in patient rooms. Surface contacts and hand hygiene were recorded in a single-bed UK hospital ward for six care types. Surface contacts often formed non-random patterns, but hygiene before or after patient contact depends significantly on care type (P=0.001). The likelihood of hygiene correlated with the number of surface contacts (95% confidence interval 1.1-5.8, P=0.002), but not with time spent in the room. This highlights that a potential subconscious need for hand hygiene may have developed in HCWs, which may support and help focus future hygiene education programmes.

Successful development of a direct observation program to measure health care worker hand hygiene using multiple trained volunteers

Direct observation of health care worker (HCW) hand hygiene (HH) remains the gold standard, but implementation is challenging. Our objective was to develop an accurate HH observation program using multiple HCW volunteers. HH compliance was defined as correct HH performed before and after contact with a patient or a patient's environment. HCW volunteers from each unit at our children's hospital were trained by infection preventionists to covertly collect HH observations during routine care using an electronic tool. Questionnaires sent to observers in February and December 2014 recorded demographic characteristics, observation time, and scenarios assessing accuracy. HCWs were surveyed regarding their awareness that their HH behavior was being recorded. There were 146 HH observers. The majority of observers reported making 1-2 observations per shift (65%) and taking ≤10 minutes recording an observation (85%). Between January 2012 and December 2014 there were 22,484 HH observations (average, 622 per month), including nurses (46%), physicians (21%), and other HCWs (33%). Observers correctly recorded HH behavior more than 90% of the time in 5 of the 6 scenarios. Most HCWs (86%) were unaware they were being observed. A direct observation program staffed by multiple HCW volunteers can inexpensively and accurately collect HCW HH data.

Assessment of Fidelity in Interventions to Improve Hand Hygiene of Healthcare Workers: A Systematic Review.

Compliance with hand hygiene in healthcare workers is fundamental to infection prevention yet remains a challenge to sustain. We examined fidelity reporting in interventions to improve hand hygiene compliance, and we assessed 5 measures of intervention fidelity: (1) adherence, (2) exposure or dose, (3) quality of intervention delivery, (4) participant responsiveness, and (5) program differentiation. Systematic review A librarian performed searches of the literature in PubMed, Cumulative Index to Nursing and Allied Health (CINAHL), Cochrane Library, and Web of Science of material published prior to June 19, 2015. The review protocol was registered in PROSPERO International Prospective Register of Systematic Reviews, and assessment of study quality was conducted for each study reviewed. A total of 100 studies met the inclusion criteria. Only 8 of these 100 studies reported all 5 measures of intervention fidelity. In addition, 39 of 100 (39%) failed to include at least 3 fidelity measures; 20 of 100 (20%) failed to include 4 measures; 17 of 100 (17%) failed to include 2 measures, while 16 of 100 (16%) of the studies failed to include at least 1 measure of fidelity. Participant responsiveness and adherence to the intervention were the most frequently unreported fidelity measures, while quality of the delivery was the most frequently reported measure. Almost all hand hygiene intervention studies failed to report at least 1 fidelity measurement. To facilitate replication and effective implementation, reporting fidelity should be standard practice when describing results of complex behavioral interventions such as hand hygiene.