Hygiene Monitoring System Research Articles

Evaluation of Electronic Hand Hygiene Monitoring Systems in UAE Hospitals

Abstract Introduction/Objective Introduction: Hand hygiene (HH) compliance is pivotal in preventing infections in healthcare settings, necessitating robust monitoring systems. This abstract outlines the assessment of three electronic HH monitoring systems across four United Arab Emirates (UAE) hospitals. Methods/Case Report Methods: A prospective observational study was conducted in four UAE governmental hospitals, evaluating three HH monitoring systems. Sensors were strategically positioned on alcohol-based dispensers, healthcare workers’ ID badges, and patients’ beds in these systems. Additionally, a comparative analysis was performed between direct observation data and automated system data. Results (if a Case Study enter NA) Results: System 1 was evaluated at Hospitals A and B, revealing HH compliance rates of 65% and 46%, respectively, contrasting with direct observation rates of 88% and 80%. Hospital C assessed System 2, reporting a compliance rate of 70%, compared to direct observation’s 94%. System 3, evaluated at Hospital D, showed a compliance rate of 39%, in contrast to the 88% observed directly. Conclusion Conclusion: While electronic monitoring systems offer continuous surveillance and data analysis benefits, they also present limitations. These include challenges in accurately distinguishing HH indications and opportunities, identifying all required HH moments, and capturing technique nuances. Understanding these strengths and limitations is vital for healthcare institutions aiming to implement effective HH monitoring strategies to enhance patient safety and reduce healthcare-associated infections (HAI

The state of hand rub dispensers in healthcare settings – a multicenter assessment in 19 German healthcare facilities

BackgroundHand hygiene is one of the most important hygiene measures to prevent healthcare-associated infections. Well-functioning hand rub dispensers are the foundation of hand hygiene but are often overlooked in research. As the point of origin for hand hygiene, dispensers not only promote compliance through ease of use, but also strongly influence the amount of hand rub used per disinfection. This work investigates how dispenser types and conditions affect dispensed volumes and usability.MethodsData from 5,014 wall-mounted or point-of-care dispensers was collected from 19 German healthcare facilities during installation of an electronic hand hygiene monitoring system, including dispenser type and dispensed hand rub volumes. Of these dispensers, 56.2% were metal dispensers, and the majority (89.5%) were wall-mounted. For one hospital, 946 wall-mounted dispensers were analyzed in detail regarding pump material, damages, functionality, cleanliness, and filling levels.ResultsDispensed volumes varied across and within dispenser types, ranging from 0.4 mL to 4.4 mL per full actuation, with the largest volumes generally dispensed by plastic dispensers with a preset of 1.0 to 3.0 mL per actuation. In general, most dispensers dispense more hand rub per full actuation than specified by the manufacturer. When different types of dispensers are used within a healthcare facility, vastly different volumes can be dispensed, making reliable and reproducible disinfection difficult for healthcare workers. In the detailed analysis of 946 dispensers, 27.1% had cosmetic defects, reduced performance, or were unusable, with empty disinfectant being the most common reason. Only 19.7% of working dispensers delivered their maximum volume on the first full actuation.ConclusionEven though several studies addressed the variability in dispensed volumes of hand hygiene dispensers, studies dealing with dispenser types and functionality are lacking, promoting the common but false assumption that different dispensers may be equivalent and interchangeable. Variability in dispensed volumes, coupled with frequent dispenser defects and maintenance issues, can be a major barrier to hand hygiene compliance. To support healthcare workers, more attention should be paid to ‘dispenser compliance’, selecting dispensers with similar volume ranges and proper maintenance.

Relationship between Hand Hygiene and MDRO Acquisition after Implementation of an Electronic Hand Hygiene Monitoring System

Background: Hand hygiene (HH) is fundamental to preventing the transmission of pathogens between patients. Unfortunately, adherence to HH is suboptimal and monitoring adherence is challenging. Electronic HH monitoring systems (EHHMS) are emerging potential solutions to increase the number of HH observations and eliminate the potential for observation bias. This aim of this study is to assess the impact of improved HH adherence after the introduction of an EHHMS on the rates of healthcare facility-onset multidrug-resistant organisms and Clostridioides difficile (HO-MDRO). Methods: We performed a retrospective, quasi-experimental study to evaluate the impact of HH on HO-MDROs across 4 acute care facilities (59 hospital units, 14 of which were ICUs) from January 2021 - September 2022 after implementing an EHHMS in a large academic healthcare system. Clinical cultures from all sources were included; routine surveillance cultures were not collected during this period. HO determination was made using National Healthcare Safety Network (NHSN) definitions. The association between monthly unit-level HH adherence (%) and HO-MDRO rate per 1000 patient-days was assessed using mixed-effects Poisson regression using rate ratios (RR), which accounts for unobserved heterogeneity between units while controlling for number of tests ordered per month per hospital unit. HH adherence was stratified in quartiles (Q1: 24-43%, Q2: 43-51%, Q3: 52-61%, Q4: 61-84%). Results: During the study period, there were 23 million HH opportunities and 1875 MDROs in 772,930 patient-days. HH adherence increased from 41% January 2021 to 57% September 2022. ESBL, MSSA, and CDIFF accounted for most MDROs (Figure 1). The mean monthly HH adherence rate was 52% per unit, with a median of 1.66 (IQR: 0-3.5) MDROs/1000 patient-days. Mixed-effects Poisson regression suggested no significant overall relationship between HH adherence and MDRO rate (Figure 2). A close to null association was observed when comparing quartile two to quartile one (RR: 0.97, 95% CI: 0.82, 1.15), quartile three to quartile one (RR: 0.96, 95% CI: 0.79, 1.17), and quartile four to quartile one (RR: 1.05, 95% CI: 0.86, 1.28). Results were similar across hospitals (Figure 3). Conclusions: Although implementing an EHHMS led to an improvement in HH adherence, we were not able to demonstrate a resultant decrease in HO-MDROs. Potential explanations include the relatively rare outcomes of interest, unrecognized confounders, and the complex interaction between HH and HO-MDROs, since poor HH adherence on a unit may lead to increased attention from infection prevention and therefore increased focus on other MDRO prevention measures.

#1817 Decrease in hospital-acquired blood stream infection by using automated sensor technology to improve and keep a high level of hand hygiene compliance

Abstract Background and Aims Hospital-acquired infection (HAIs) is a problem for 6-8% of hospitalized patients. HAIs has personal costs, prolongs the hospital stay, increasing the risk of morbidity, mortality, time and staff consuming. Hand hygiene (HH) is essential for preventing infections. World Health Organization (WHO) recommends hand hygiene compliance (HHC) as a key performance indicator. Manual observations of HHC are time consuming and may affect compliance by the physical presence of the observers (Hawthorne effect). There is a need to identify the most effective long-term intervention to improve HHC and reduce HAI. The Danish Ministry of Health have chosen blood stream infections (HA-BSI) as a national indicator for the overall risk of HAIs expecting an incidence of no more than 8 cases per 10,000 patient days. The aim of the present study was to examine the use of an automated sensor technology to improve HHC and prevent HAIs in an inpatient department for nephrology and intern medicine. Nephrology patients have a high number of invasive catheters, which may increases the risk of HAI. Method The study comprised a 2 year cohort with no specific HHC interventions (July 2018-June 2020), a baseline period (February 2020-June 2020) to investigate HHC level by an electronic hand hygiene measuring system (EHHMS) without ongoing HHC interventions followed by a 3 year cohort period (July 2020-June 2023) with various EHHMS-based feedback interventions to staff. Intervention consisted primarily of group feedback and later individual feedback. All caregivers and doctors carried an anonymous Sani ID tag (Sani Nudge, DK) fixed to their nametag throughout the study period. EHHMS-based Sani Sensors were located in designated locations in the clinical department with the purpose of continuously capturing the caregiver patient contact including staff use of liquid alcohol based hand rub (ABHR). In Denmark, the national hygiene guidelines also require that ABHR follow hand wash. Local hygiene mentors regularly presented anonymous group data on boards and in letters to the staff. Soon after there was a demand on individual data, which was then added by individual results forwarded in a personal email every week. HA-BSI was defined as the presence of a pathogen in the blood and the prescription of an appropriate concomitant antimicrobial treatment and classified as hospital-acquired if the patient has been hospitalized for >48 hours. Data were obtained from various electronic health care systems in the hospital. Results We collected HHC data by monitoring 203 caregivers and 50 doctors for a period of 40 months. Caregivers HHC improved after implementation of an electronic hand hygiene measuring system from baseline to group feedback and finally individual feedback (39% vs 50% vs 71%). For doctors, the improvement from baseline to group feedback and finally individual feedback was 30% vs. 32% vs 52%. The overall improvement curve reached a stable plateau after 20 months. An incidence rate of 14 HA-BSI cases per 10,000 patient days during a previous two years control period (95% CI 8.8-21.2) was during the intervention period markedly reduced to 5 HA-BSI cases per 10,000 patient days (95% CI 2.3-9.0). This difference was statistically significant, P = 0.004. Conclusion The use and feedback of the electronic hand hygiene monitoring system improved successfully hand hygiene compliance in the groups of both caregivers, doctors, and furthermore reduced the rate of HA-BSI significantly. We observed a significant stepwise increase in compliance after group feedback data and later after reporting individual data. There continue to be a need to find effective long-term interventions to improve and keep a high level of hand hygiene compliance and a sustained reduction in hospital-acquired bloodstream infection.

Hand hygiene compliance in nursing home wards: the effect of increased accessibility of alcohol-based hand rub

Elderly nursing home residents are vulnerable to infection from micro-organisms. Hand hygiene is considered one of the most important measures to prevent transmission. To determine the effect of increased accessibility to alcohol-based hand rub (ABHR) in nursing home wards by monitoring hand hygiene compliance (HHC) among healthcare workers (HCWs). An 11-month intervention study was conducted in a Danish six-ward nursing home. Data were collected using an automatic hand hygiene monitoring system (AHHMS). After a baseline period, one extra ABHR dispenser was placed in each of the 150 apartments. Baseline HHC was compared with the HHC during an immediate intervention period and a long-term intervention period. A total of 159 HCWs were included. The AHHMS registered 341,078 hand hygiene opportunities. Overall baseline HHC was 31% (95% confidence interval: 30-32). A significant+18% absolute immediate effect (first five months) (95% CI: 17-19; P < 0.0001) and+13 percentage points (95% CI: 11-14; P < 0.0001) long-term effect (another four months) were recorded. HCWs working day shifts and short-term employees had a higher baseline HHC than HCWs working evening/night shifts. However, HCWs working night shifts achieved the greatest long-term effect with a mean+27 percentage point difference (P < 0.0001). Placing an additional ABHR dispenser strategically within staff workflow significantly increased HHC among HCWs, demonstrating a noteworthy effect. The study is the first to report the effect on nursing home dispenser accessibility as a single intervention and to show a significant unmet potential.

Epidemiological investigation of a foodborne collective infection (FBCI) episode at the Institute for Renewable Energy and Energy Efficiency Trade (IFMEREE-Oujda)

Foodborne outbreaks (FBOs) are common and sometimes severe, posing a public health emergency, especially in closed communities (cafeterias, hostels, schools), requiring prompt investigation and mandatory reporting. This retrospective cohort study involving 80 students was conducted in February 2017 following an FBO episode at IFMEREE in Oujda. A clinical and epidemiological definition of cases was developed. A questionnaire was designed to collect information on the implicated foods. Descriptive, univariate, and multivariate analyses were performed to study the food-related factors associated with this epidemic. In total, 57 respondents, aged 17 to 29 years, with an average of 20 years and a mode of 18 years, participated. The male sex predominated, with a sex ratio (M/F) of 2.16. There were 30 cases, resulting in an attack rate of 52.6%, with a female predominance (72.2% female vs. 43.4% male), and no deaths were reported. Among the foods served during lunch, buttermilk (LBEN) was the only food significantly associated with FBO, with a relative risk (RR) of 2.45, a confidence interval (CI95%: [1.61-3.74], p 0.0012), and an adjusted odds ratio (OR) of 17.05 (CI95%: [2.0-145.1], p 0.0096). Following our investigation of the FBO, a new hygiene control and monitoring system involving a new subcontracting company was implemented. This system aims to ensure compliance with the cold chain and update the medical records of kitchen and service staff. It also ensures improved traceability of foods, especially implicated dairy products (LBEN), from production to consumption, encompassing the entire distribution chain, including the requirement for a control meal.

WashRing: An Energy-Efficient and Highly Accurate Handwashing Monitoring System via Smart Ring

The outbreak of COVID-19 has greatly changed everyone's lifestyle all over the world. One of the best ways to prevent the spread of infections is by washing hands properly. Although a number of hand hygiene monitoring systems have been proposed, they either cannot achieve high accuracy in practice or work only in limited environments such as hospitals. Therefore, a ubiquitous, energy-efficient and highly accurate hand hygiene monitoring system is still lacking. In this paper, we present <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">WashRing</i> —the first smart ring-based handwashing monitoring system. In WashRing, we design a Partially Observable Markov Decision Process (POMDP) based adaptive sampling approach to achieve high energy efficiency. Then, we design an automatic feature extraction scheme based on wavelet scattering and a CNN-LSTM neural network to achieve fine-grained gesture recognition. Finally, we model the handwashing gesture classification as a few-shot learning problem to mitigate the burden of collecting extensive data from five fingers. We collect data from 25 subjects over 2 months and evaluate the system performance on both commercial OURA ring and customized ring. Evaluation results show that WashRing achieves 97.8% accuracy which is 10.2%–15.9% higher than state-of-the-arts. Our adaptive sampling approach reduces energy consumption by 64.2% compared to fixed duty cycle sampling strategies.

Healthcare staff perceptions of an electronic hand hygiene monitoring system within a large university system

Healthcare staff perceptions of an electronic hand hygiene monitoring system within a large university system

Development of Hand Hygiene Monitoring System Based on Android Mobile Application and User Perspective

Hand hygiene plays a crucial role in promoting overall health and preventing the spread of diseases. The World Health Organization reported that the prevalence of healthcare-associated infections (HAIs) ranges from 3-12% in high-income countries and 5-19% in low-and middle-income countries. Improved hand hygiene compliance can substantially reduce HAI rates. In Indonesia, the Ministry of Health has designated handwashing compliance as a compulsory quality indicator for hospitals. Introducing a mobile app can improve hand hygiene practices. This study aims to develop and design an Android mobile application that serves as an easy-to-operate hand hygiene monitoring system and to understand user perspectives. The study used Agile Methods for app development and a qualitative approach to know users' perspectives. Respondents (n=10) from AMC Muhammadiyah Hospital, including the IPC team, department heads, and administrators, were interviewed. The result revealed that mobile application is easy to use and have an attractive user interface. Users expressed the application's user-friendliness and utility in conducting observations. Nonetheless, they identified some drawbacks, such as lagging issues and a complicated manual installation process due to the app's unavailability on Playstore. Users expect the app's future inclusion on Play Store for simplified installation and request its development for iOS to cater to hospital staff using iPhones.

Sample sizes for estimating the sensitivity of a monitoring system that generates repeated binary outcomes with autocorrelation.

Sample size formulas are provided to determine how many events and how many patient care units are needed to estimate the sensitivity of a monitoring system. The monitoring systems we consider generate time series binary data that are autocorrelated and clustered by patient care units. Our application of interest is an automated hand hygiene monitoring system that assesses whether healthcare workers perform hand hygiene when they should. We apply an autoregressive order 1 mixed effects logistic regression model to determine sample sizes that allow the sensitivity of the monitoring system to be estimated at a specified confidence level and margin of error. This model overcomes a major limitation of simpler approaches that fail to provide confidence intervals with the specified levels of confidence when the sensitivity of the monitoring system is above 90%.

Effects of data-driven feedback on nurses' and physicians' hand hygiene in hospitals – a non-resource-intensive intervention in real-life clinical practice

Hand hygiene (HH) by healthcare workers (HCWs) is one of the most important measures to prevent hospital-acquired infections. However, HCWs struggle to adhere to HH guidelines. We aimed to investigate the effect of a non-resource intensive intervention with group and individual feedback on HCWs HH in a real-life clinical practice during the COVID-19 pandemic. In 2021, an 11-month prospective, interventional study was conducted in two inpatient departments at a Danish university hospital. An automated hand hygiene monitoring system (Sani Nudge™) was used to collect data. HH opportunities and alcohol-based hand rub events were measured. Data were provided as HH compliance (HHC) rates. We compared HHC across 1) a baseline period, 2) an intervention period with weekly feedback in groups, followed by 3) an intervention period with weekly individual feedback on emails, and 4) a follow-up period. We analyzed data from physicians (N=65) and nurses (N=109). In total, 231,022 hygiene opportunities were analyzed. Overall, we observed no significant effect of feedback, regardless of whether it was provided to the group or individuals. We found a trend toward a higher HHC in staff restrooms than in medication rooms and patient rooms. The lowest HHC was found in patient rooms. The automated hand hygiene monitoring system enabled assessment of the interventions. We found no significant effect of group or individual feedback at the two departments. However, other factors may have influenced the results during the pandemic, such as time constraints, workplace culture, and the degree of leadership support.

Current issues in hand hygiene

Multiple aspects of hand hygiene have changed in recent years. A PubMed search was conducted to identify recent articles about hand hygiene. The COVID-19 pandemic caused temporary changes in hand hygiene compliance rates and shortages of alcohol-based hand sanitizers (ABHSs), and in marketing of some products that were ineffective or unsafe. Fortunately, ABHSs are effective against SARS-CoV-2 and other emerging pathogens including Candida auris and mpox. Proper placement, maintenance, and design of ABHS dispensers have gained additional attention. Current evidence suggests that if an adequate volume of ABHS has been applied to hands, personnel must rub their hands together for at least 15 seconds before hands feel dry (dry time), which is the primary driver of antimicrobial efficacy. Accordingly, practical methods of monitoring hand hygiene technique are needed. Direct observation of hand hygiene compliance remains a challenge in many healthcare facilities, generating increased interest in automated hand hygiene monitoring systems (AHHMSs). However, several barriers have hindered widespread adoption of AHHMSs. AHHMSs must be implemented as part of a multimodal improvement program to successfully improve hand hygiene performance rates. Remaining gaps in our understanding of hand hygiene warrant continued research into factors impacting hand hygiene practices.

Tailored positioning and number of hand rub dispensers: the fundamentals for optimized hand hygiene compliance

Availability of alcohol-based hand rub (ABHR) dispensers at positions adapted to the work flow of healthcare workers (HCWs) is decisive in order to carry out indication-based hand rubbing. Although requirements and guidelines regarding the positioning of ABHR dispensers are in place, scientific evidence is often lacking. In order to analyse the impact of the location and number of ABHR dispensers on hand hygiene performance, additional dispensers were systematically placed in patient rooms in a surgical 38-bed ward at Marburg University Hospital, Germany to complement the existing dispenser locations. ABHR use was monitored continuously before and after complementation using the NosoEx hand hygiene monitoring system. The ward had 53 dispensers before the intervention and 82 dispensers after the intervention. The addition of dispensers increased ABHR consumption across the entire ward. Before the intervention, mean consumption was 20.6 mL/patient-day, whereas mean consumption after the intervention was 25.3 mL/patient-day. Depending on the combination of dispenser locations, consumption increased through targeted supplementation in patient rooms. The presence of two or three dispensers per patient room resulted in significantly greater ABHR consumption compared with one dispenser per patient room. The preferred location combinations were entrance-front bed-back bed and entrance-foot end. ABHR consumption can be increased significantly by optimizing the position and number of dispensers. The outstanding factors are visibility and integrability of dispenser use into the work flow; in particular, a dispenser should be positioned in the entrance area. Recommendations should be optimized with regard to the required number and location of dispensers in patient rooms.

Investigating Individual Hand Hygiene Improvements and Effect on Hospital-acquired Infections Using an Electronic Hand Hygiene Monitoring System: A Long-term Follow-up Study

Investigating Individual Hand Hygiene Improvements and Effect on Hospital-acquired Infections Using an Electronic Hand Hygiene Monitoring System: A Long-term Follow-up Study

Utilization of an Electronic Hand Hygiene Monitoring System in Investigating an Increase in Clostridioides Infections

Utilization of an Electronic Hand Hygiene Monitoring System in Investigating an Increase in Clostridioides Infections

Healthcare Personnel Hand Hygiene Compliance: Are We There Yet?

Poor hand hygiene is well documented as a factor in healthcare-associated infections and excellent rates of hand hygiene remains elusive. There is increased use of universal or increased gloving to minimize hand contamination, but its use does not replace hand hygiene opportunities. There is significant interest in electronic hand hygiene monitoring systems, but they are not without their unique issues. Behavioral psychology remains a significant factor in motivating hand hygiene behaviors; even in COVID-19, hand hygiene rates initially improved but trended down back to baseline while still dealing with the pandemic. More emphasis should be placed on the how to properly perform hand hygiene and why it is so important, as well as the role of gloves, is needed. Continued investment and awareness of their status as role models from both system leadership and senior healthcare providers are needed.

Provider Satisfaction With Artificial Intelligence–Based Hand Hygiene Monitoring System During the COVID-19 Pandemic: Study of a Rural Medical Center

ObjectiveThe objectives of this study were to investigate providers’ attitudes toward an artificial intelligence (AI)–based hand hygiene monitoring system and to examine the relationship between provider well-being and satisfaction with the usage of that system. MethodsA self-administered questionnaire was mailed to 48 health care providers (ie, physicians, registered nurses, and other providers) at a rural medical center in north Texas between September and October 2022. In addition to descriptive statistics, Spearman's correlation test was conducted to discern the relationship between provider satisfaction with the usage of the AI-based hygiene monitoring system and their well-being. A Kendall's tau correlation coefficient test was utilized to assess the correlation between subgroup demographics and survey questions. ResultsWith a 75% response rate (n = 36), the providers reported sufficient satisfaction with monitoring system usage and that AI directly affects provider well-being. Providers with more years of experience and younger than 40 years of age reported significantly higher satisfaction with AI technology in general and considered the amount of time that they spent on AI-related tasks as interesting compared with their counterpart providers. ConclusionThe findings suggest that higher satisfaction with the AI-based hygiene monitoring system was related to greater provider well-being. Providers sought successful implementation of an AI-based tool that met their expectations, but such implementation required marked levels of consolidation to ensure that it fits within the existing workflows and was accepted by users.

Individual hand hygiene improvements and effects on healthcare-associated infections: a long-term follow-up study using an electronic hand hygiene monitoring system

Obtaining detailed insights into people's unique hand hygiene behaviour could play an important role in developing the most effective long-term hand hygiene compliance (HHC) interventions. To investigate the effect of two feedback interventions provided by an electronic hand hygiene monitoring system (EHHMS) on sustained HHC improvement, individual responsiveness, and prevention of hospital-acquired bloodstream infections (HABSIs) and urinary tract infections (HAUTIs). The study included two 2-year cohorts (exposed and unexposed to EHHMS) observed over 4 years in an internal medicine department with 142 caregivers and 39 doctors. Healthcare workers (HCWs) were stratified into four groups based on their baseline performance to assess predicted responsiveness to the interventions. All HCWs increased their HHC independently from their performance at baseline, except for a few in the low-performance groups with constantly low HHC. The two low-performance groups at baseline were most responsive to group feedback (weekly change in HHC of 4.4% and 3.1%) compared with individual feedback (weekly change in HHC of 1.0% and 2.2%). The number of cases of HABSI reduced significantly during the intervention period (P=0.01), with the greatest effect on Staphylococcus aureus. No significant change in HAUTIs was observed. The EHHMS interventions sustained the HHC improvements successfully and reduced the number of cases of HABSI. Nearly all HCWs responded to the interventions. The two low-performance groups at baseline never reached the same HHC levels as those in the high-performance groups, indicating the potential for further improvement and the need for intensified individualized interventions.

659 - Implementing an electronic hand hygiene monitoring system across a large healthcare system during the COVID-19 pandemic

659 - Implementing an electronic hand hygiene monitoring system across a large healthcare system during the COVID-19 pandemic

Implementation of an electronic hand hygiene monitoring system: Learnings on how to maximize the investment

Electronic monitoring systems (EMS) for measuring hand hygiene performance have many advantages. Previous studies have shared results of EMS in individual units or single institutions, without many details of implementation. The implementation steps for house wide use of an EMS in 12 hospitals are described. Hospital resources used in this 3-year implementation included those for installation activities, initial education about the components and function of the EMS, evaluation of healthcare professionals' processes related to hand hygiene, routine data feedback in a variety of methods, continuous coaching and training on the EMS, incentive programs and strong leadership support. Continual process improvement activities resulted in a 23% increase in hand hygiene performance, from 53% at baseline, to 76%. Implementation of an EMS required many resources beyond those for the technology, but resulted in measurable improvement in hand hygiene performance.