Levels Of Hand Hygiene Compliance Research Articles

#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.

A cluster of Candida parapsilosis displaying fluconazole-trailing in a neonatal intensive care unit successfully contained by multiple infection-control interventions.

This study aimed to investigate and contain a cluster of invasive candidiasis cases caused by fluconazole-resistant Candida parapsilosis (FRC) in a neonatal intensive care unit. Active surveillance was initiated. Direct observations of hand-hygiene compliance (HHC) among staff were conducted before and after the implementation of hand-hygiene (HH) education. Thirty-five environmental cultures were obtained. Phylogenetic analysis of FRC was performed using Fourier-transform infrared spectroscopy and microsatellite genotyping. A total of 14 patients (mean birth weight = 860 g, gestational age = 25 weeks) infected with FRC were identified using the fully automated analyzer, including 5 with clinical infection (three with catheter-related bloodstream infection, one with cutaneous infection, and one with fatal peritonitis) and 9 with colonization. The HHC rate in nurses before performing a sterile or aseptic procedure significantly improved after the HH education (P < .05). Sinks near the patients were contaminated with FRC. All FRC strains were confirmed to be susceptible to fluconazole using the CLSI method, and the microdilution procedure indicated a trailing effect. Phylogenetic analysis showed that all the fluconazole-trailing isolates from patients were clustered together and had the same genotype. Sinks were successfully decontaminated using accelerated hydrogen peroxide and drainage pipes were replaced. Ultraviolet-C decontamination was applied in the milk preparation room. No new cases were detected after the education and disinfection interventions. Sinks are an important reservoir of C. parapsilosis. Active surveillance, environmental hygiene, and constant staff education on maintaining a high level of HHC are necessary to limit the spread of C. parapsilosis.

Isolation and Identification of Microorganisms Associated with Automated Teller Machines (ATMs) in Unizik, Awka Campus, Nigeria

Millions of individuals use automated teller machines (ATM) every single day.Anyone can use this machine, regardless of their class, age, or race. The hands, which are naturally 'vaults' of germs, serve as the contact site for all ATM machines. For a thorough evaluation of any potential microbiological contamination on the campus of UNIZIK Awka, a thorough survey was conducted. In order to evaluate, identify, and assess the level of bacterial contamination of microoganisms and their potential as reservoirs of microbes, a sample of ATMs on campus were employed as a case study. Each ATM's screen, buttons, floor, user's hand, and exposed plate all received swabs. The samples were placed in nutrient agar after being collected. The results showed the presence of increased bacterial count subsequently, most pathogens on characterization revealed the genus of the particular organisms Staphylococcus aureus, Mycobacteria, E. coli, Salmonella Shigella, and Klebsiella spp. The study showed the potential hazard inherent in ATM machine usage and draws attention to our level of hand hygiene compliance.

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.

Hand Hygiene Compliance Decreases as Workload Increases

According to this study: Hand hygiene compliance decreased significantly in the ICU setting when the number of hand hygiene opportunities exceeded 30 per hour.Adequate staffing during higher workload periods is needed to ensure that health care providers maintain a high level of hand hygiene compliance.

A nudge intervention to improve hand hygiene compliance in the hospital.

Hand hygiene among professionals plays a crucial role in preventing healthcare‐associated infections, yet poor compliance in hospital settings remains a lasting reason for concern. Nudge theory is an innovative approach to behavioral change first developed in economics and cognitive psychology, and recently spread and discussed in clinical medicine. To assess a combined nudge intervention (localized dispensers, visual reminders, and gain-framed posters) to promote hand hygiene compliance among hospital personnel. A quasi-experimental study including a pre-intervention phase and a post-intervention phase (9 + 9 consecutive months) with 117 professionals overall from three wards in a 350-bed general city hospital. Hand hygiene compliance was measured using direct observations by trained personnel and measurement of alcohol-based hand-rub consumption. Levels of hand hygiene compliance were low in the pre-intervention phase: 11.44% of hand hygiene opportunities prescribed were fulfilled overall. We observed a statistically significant effect of the nudge intervention with an increase to 18.71% (p < 0.001) in the post-intervention phase. Improvement was observed in all experimental settings (the three hospital wards). A statistical comparison across three subsequent periods of the post-intervention phase revealed no significant decay of the effect. An assessment of the collected data on alcohol-based hand-rub consumption indirectly confirms the main result in all experimental settings. Behavioral outcomes concerning hand hygiene in the hospital are indeed affected by contextual, nudging factors to a significant extent. If properly devised, nudging measures can provide a sustainable contribution to increase hand hygiene compliance in a hospital setting.

Level of Hand Hygiene Compliance and Its Associated Factors Among Health Care Workers at Eka Kotebe General Hospital, Addis Ababa, Ethiopia.

Background:Poor hand hygiene is an important source of infection, but maintaining hand hygiene is the most important measure to prevent infections. Hand hygiene compliance and its associated factors are not well recognized in Ethiopia. Therefore, this study was intended to determine hand hygiene compliance and its associated factors among health care workers in Eka Kotebe General Hospital.Methods:A cross-sectional study was conducted among health care workers at Eka Kotebe General Hospital. A self-administered questionnaire supplemented by a World Health Organization Hand Hygiene Technical Reference Manual was used to collect data. Data was entered using Epi Info 7.2.0.1 and exported to SPSS 23 for analysis. The data were analyzed using descriptive and inferential statistics. Statistical significance was determined using a P-value of ⩽.05 with a 95% confidence interval.Results:Hand hygiene compliance among healthcare workers was 22.2%. Hand hygiene training (AOR = 2.9, 95% CI: 1.13-7.52), presence of hand hygiene indication poster (AOR = 3.38, 95% CI: 1.18-9.66), hand hygiene promotion by IPC team (AOR = 4.2, 95% CI: 2.53-8.58)), working experience ⩾5 years of a health care providers (AOR = 3.96, 95% CI: 1.12-13.9), being midwife (AOR = 17.1, 95% CI: 2.8-10), being nurse (AOR = 5.3, 95% CI: 2.09-7.8) by profession, and presence of water (AOR = 2.50, 95% CI: 2.20-11.78) were significantly associated factors to hand hygiene compliance.Conclusion:The level of hand hygiene compliance among health care providers was found to be low. Training about hand hygiene, the presence of hand hygiene indication posters, hand hygiene promotion by the IPC team, working experience of health care providers, being a nurse and midwife, and the presence of water were independent predictors of hand hygiene compliance. Health care workers need to be given training on hand hygiene as well as hand hygiene facilities shall be installed and supplied by the hospital in a sustained manner.

Observational Study of Hand Hygiene Compliance at a Trauma Hospital in Iraqi Kurdistan

Healthcare-associated infections, commonly caused by poor hand hygiene, represent a significant source of disease and economic burden for healthcare systems, especially those in resource-limited settings. The few existing studies on hand hygiene compliance in resource-limited hospital settings suggest that compliance is insufficient. The difference in compliance rates between units in resource-limited trauma hospitals is largely unknown. We aimed to assess hand hygiene compliance rates among healthcare workers at a trauma hospital in Iraqi Kurdistan and compare the levels of compliance between the emergency room (ER), the intensive care unit (ICU), and the acute care ward (ACW). We carried out overt observations in 2018 using the validated World Health Organization ‘five moments for hand hygiene’ observational tool. We observed a total of 622 hand hygiene opportunities performed by 149 healthcare workers. Hand hygiene compliance was defined as handwashing with soap and water or the use of alcohol-based hand rub, in accordance with the ‘five moments for hand hygiene’ concept. Overall, the hand hygiene compliance rate was found to be 6.8% (95% confidence interval 5.0–9.1). Compliance was significantly lower in the ER (1.0%), compared with the ICU (8.1%) (p = 0.0012), and the ACW (11.1%) (p &lt; 0.0001). In all three units, the availability of alcohol-based hand rub and handwashing sinks was insufficient in relation to the number of patient beds. We conclude that the overall level of hand hygiene compliance was low, with the lowest level of compliance in the ER. Our findings call for improved resource allocation and strengthened hand hygiene routines. These relatively simple measures could potentially lower the incidence of healthcare-associated infections and improve the mortality and morbidity of patients in already overburdened healthcare systems.

Isolation and identification of microorganisms associated with automated teller machines on Federal Polytechnic Ede campus.

Automated Teller Machines (ATM) are visited everyday by millions of people. This machine is accessible to the general public irrespective of class, age or race. The contact point of all ATM machines is the hand which on their own are 'vaults' of microorganisms. An elaborate survey was taken for complete assessment of possible microbial contamination in the Federal Polytechnic Ede campus. Selected ATM machines on campus were used as case study to characterize, identify and determine the degree of bacterial contamination of microorganisms and their potential as reservoir of microbes. Swabs were collected from each ATM screen, buttons, floor, user's hand, and exposure of plates. After collection of the samples, they were plated in nutrient agar. The results showed the presence of increased bacterial count subsequently, most pathogens on characterization revealed the genus of the particular organisms E. coli, Pseudomonas, Staphylococcus aureus, Klebsiella, Micrococcus, Salmonella and Serratia. The study showed the potential hazard inherent in ATM machine usage and draws attention to our level of hand hygiene compliance.

An Evaluation of the Hand Hygiene Behaviour and Compliance of the General Public When Using Public Restrooms in Northern Ireland (NI) during the Initial Weeks of the Novel Coronavirus (COVID-19) Pandemic.

Background: The ongoing novel coronavirus (COVID-19) global pandemic has resulted in significant levels of morbidity and mortality worldwide, particularly among the elderly and immuno-suppressed groups. Although adequate hand hygiene (HH) behaviour and compliance is widely accepted as being the most effective self-protective measure in preventing the spread of diseases like COVID-19, previous research suggests that normal hand hygiene compliance is poor, but generally improves during a disease pandemic. This research aimed to evaluate the hand hygiene behaviour and compliance of the general public in the initial weeks of the COVID-19 pandemic in Northern Ireland (NI). Methods: This cross-sectional study involved the use of infrared-imaging cameras to observe the hand hygiene behaviour and compliance of the general public when using one set of male and female public restrooms. Results: The findings of this study indicated that the level of hand hygiene compliance of the general public was poor in the initial weeks, with 82.93% overall not washing their hands adequately. Conclusions: Inadequate HH behaviour and compliance may have added significantly to the rapid rate of spread of COVID-19 in the initial weeks of the pandemic in NI. Current public health campaigns do not appear, based on this study, to have the desired impact and may need to be reviewed or re-enforced in order to achieve the levels of hand hygiene compliance required to slow the spread of COVID-19 and other communicable diseases in the future.

Production of Disinfectants (Hand Sanitizers)

Hand sanitizer is a supplement or alternative to hand washing with soap and water. The production of hand sanitizers from locally grown medicinal plants namely; wild spinach, turmeric, garlic) and camphor was achieved by obtaining the plants, grinding and performing ethanolic extraction for 72hrs on them. This ethanolic extract in combination with glycerin and absolute ethanol were used for the final preparation. Turmeric and garlic failed the hand sanitizer ‘s approval test based on their colour and pungent smell, but wild spinach and camphor were found to be good candidates for hand sanitizers production here in Nigeria and inclusion of such products here could increase hand hygiene compliance levels.

A spatiotemporal simulation study on the transmission of harmful microorganisms through connected healthcare workers in a hospital ward setting

BackgroundHand transmission of harmful microorganisms may lead to infections and poses a major threat to patients and healthcare workers in healthcare settings. The most effective countermeasure against these transmissions is the adherence to spatiotemporal hand hygiene policies, but adherence rates are relatively low and vary over space and time. The spatiotemporal effects on hand transmission and spread of these microorganisms for varying hand hygiene compliance levels are unknown. This study aims to (1) identify a healthcare worker occupancy group of potential super-spreaders and (2) quantify spatiotemporal effects on the hand transmission and spread of harmful microorganisms for varying levels of hand hygiene compliance caused by this group.MethodsSpatiotemporal data were collected in a hospital ward of an academic hospital using radio frequency identification technology for 7 days. A potential super-spreader healthcare worker occupation group was identified using the frequency identification sensors’ contact data. The effects of five probability distributions of hand hygiene compliance and three harmful microorganism transmission rates were simulated using a dynamic agent-based simulation model. The effects of initial simulation assumptions on the simulation results were quantified using five risk outcomes.ResultsNurses, doctors and patients are together responsible for 81.13% of all contacts. Nurses made up 70.68% of all contacts, which is more than five times that of doctors (10.44%). This identifies nurses as the potential super-spreader healthcare worker occupation group. For initial simulation conditions of extreme lack of hand hygiene compliance (5%) and high transmission rates (5% per contact moment), a colonised nurse can transfer microbes to three of the 17 healthcare worker or patients encountered during the 98.4 min of visiting 23 rooms while colonised. The harmful microorganism transmission potential for nurses is higher during weeknights (5 pm – 7 am) and weekends as compared to weekdays (7 am – 5 pm).ConclusionSpatiotemporal behaviour and social mixing patterns of healthcare can change the expected number of hand transmissions and spread of harmful microorganisms by super-spreaders in a closed healthcare setting. These insights can be used to evaluate spatiotemporal safety behaviours and develop infection prevention and control strategies.

An agent-based model to simulate the transmission of vancomycin-resistant enterococci according different prevention and control measures.

Despite the existence of various levels of infection prevention and control (IPC) measures aimed at limiting the transmission of vancomycin-resistant enterococci (VRE) in hospitals, these measures are sometimes difficult to implement. Using an agent-based model (ABM), we simulated the transmission of VRE within and between 3 care units according to different IPC measures. The ABM was modelled on short-stay medical wards, represented by 2 conventional care units and 1 intensive care unit. The scenarios consisted of the simulation of various compliance rates of caregivers with regard to hand hygiene (HH) in different contexts of IPC measures: (1) standard precautions for all patients, (2) additional contact precautions for VRE-carrier patients, (3) geographical cohorting of carrier patients, and (4) creation of an isolation unit with dedicated staff. With <50% HH compliance, the dissemination of VRE was not adequately controlled. With 80% compliance for all patients (ie, standard precautions scenario), there were no secondary VRE cases in 50% of the simulations, which represented the best scenario. A more realistic rate, 60% HH compliance for all patients, revealed interesting results. Implementing an isolation unit was effective only if the level of HH compliance was low. Patient cohorting was less effective. The present ABM showed that while contact precautions, geographic cohorting, and an isolation unit may represent good complements to standard precautions, they may theoretically not be necessary if HH is followed at a high level of compliance.

The impact of COVID-19 pandemic on hand hygiene performance in hospitals

BackgroundAchieving high levels of hand hygiene compliance of health care personnel has been an ongoing challenge. The objective of this study was to examine the impact of the COVID-19 pandemic on hand hygiene performance (HHP) rates in acute care hospitals.MethodsHHP rates were estimated using an automated hand hygiene monitoring system installed in 74 adult inpatient units in 7 hospitals and 10 pediatric inpatient units in 2 children's hospitals. A segmented regression model was used to estimate the trajectory of HHP rates in the 10 weeks leading up to a COVID-19-related milestone event (eg, school closures) and for 10 weeks after.ResultsThree effects emerged, all of which were significant at P < .01. Average HHP rates increased from 46% to 56% in the months preceding pandemic-related school closures. This was followed by a 6% upward shift at the time school closures occurred. HHP rates remained over 60% for 4 weeks before declining to 54% at the end of the study period.ConclusionsData from an automated hand hygiene monitoring system indicated that HHP shifted in multiple directions during the early stages of the pandemic. We discuss possible reasons why HHP first increased as the pandemic began and then decreased as it progressed.

Significantly Improved Hand Hygiene Compliance Using Nudging and Performance Feedback Based on Data from an Automated Monitoring System

<h3>Background</h3> Hand hygiene compliance (HHC) plays an important role in infection prevention but is often suboptimal. Evidence-based practices to increase and sustain HHC is needed. We aimed to test the effect of nudging and performance feedback on healthcare workers' HHC using anonymized data from an automated monitoring system. <h3>Methods</h3> This prospective, quality-improvement project was conducted between February 2018 and April 2019. The automated monitoring system was installed at an Orthopedic Surgery Department (29-beds unit) and measured hand hygiene opportunities and alcohol-based hand sanitations in all rooms of the ward. Staff were nudged by discrete symbols and lights from the sensors placed on existing alcohol gel dispensers. The study period was divided into four phases where the healthcare workers received different types of feedback: 1) Baseline (2 months), 2) Nudging (2.5 months), 3) Team feedback (5.5 months) and 4) Individual feedback (4 months). Continuous variables are presented as means. Student's t-test test was used for comparisons between the groups. Analyses were performed using the Microsoft® Power BI software. A 2-sided value of p < 0.05 was considered statistically significant. <h3>Results</h3> In total, 14 and 74 Sani IDs were handed out to doctors and nurses, respectively. HHC significantly increased from baseline for both doctors (30% vs. 55%, p=0.0005) and nurses (42% vs. 61%, p < 0.0001) when they were visually nudged. The doctors further improved (76%, p=0.002) when they received team performance feedback compared with nudging only, while the nurses kept a steady HHC level. The staff who received individual performance feedback increased HHC level even further compared to the period when they only received team performance feedback (61% vs. 77%, p < 0.0001). <h3>Conclusions</h3> Using nudging and performance feedback significantly improves HHC for both doctors and nurses. The highest HHC level was achieved when using individual performance feedback.

Hand hygiene compliance: bridging the awareness-practice gap in sub-Saharan Africa.

This review provides an exploratory overview of hand hygiene compliance in sub-Saharan Africa and examines strategies to bridge the compliance gap.While there is increasing awareness on hand hygiene, empirical evidence suggests that there is no concurrent increase in correct hand hygiene practice among key populations in sub-Saharan Africa. Children, adolescents and even healthcare providers (HCPs) in sub-Saharan Africa consistently assume poor hand hygiene compliance levels resulting in negative health consequences. Faecal-oral diseases remain common among schoolchildren, leading to school absenteeism and disease-specific morbidity. Additionally, the incidence of nosocomial infections in health facilities in sub-Saharan Africa remains high, as many HCPs do not adopt good hand hygiene practice. Increased disease burden, high healthcare costs and eroding public confidence in the healthcare system are a few implications of HCPs’ poor compliance with hand hygiene. These trends underscore the inadequacies of educational approaches (cognition model) to hand hygiene promotion commonly adopted in sub-Saharan Africa.It was therefore recommended that the governments of sub-Saharan Africa should focus on promoting skill-based hygiene education which will help schoolchildren develop good hand hygiene practice as a lifelong skill. In addition, efforts should be made to implement a multimodal hand hygiene strategy in healthcare facilities in order to increase compliance by healthcare providers.

Hand hygiene initiative: comparative study of pre- and postintervention outcomes.

Adequate hand hygiene is considered the most effective measure to reduce transmission of nosocomial pathogens. To determine the effectiveness of infection control intervention to improve compliance with hand hygiene in the Emergency Department, Al-Leith General Hospital, Saudi Arabia, and evaluate bacterial load on hands as a possible indicator of improvement. The study consisted of 3 phases: Phase I, measurement of basal hand hygiene compliance level; Phase II, multimodal hand hygiene educational programme was initiated; and Phase III, hand hygiene compliance level was measured again. Data were collected by direct observation of healthcare workers in the emergency department between October 2016 and March 2017, using the standardized World Health Organization method for direct observation, "Five Moments for Hand Hygiene". The intervention comprised health education sessions using direct personal contact. Hands of healthcare workers were sampled during Phases I and III by sterile bag method, and bacterial load was determined. A total of 1374 opportunities for hand hygiene were observed during the triphase study. Implementation of the interventional hand hygiene educational programme significantly improved compliance with hand hygiene guidelines from 30.7% to 45.5% (P < 0.01). Log10 bacterial load per hand dropped from 4.97 (standard deviation = 0.32) to 4.57 (0.47) (P < 0.05). Hand hygiene educational programmes were effective in improving compliance in the emergency department, and bacterial load on hands of healthcare workers could be used as an indicator of improvement in hand hygiene compliance.

Clinical experiences with a new system for automated hand hygiene monitoring: A prospective observational study

Hand hygiene compliance (HHC) among health care workers remains suboptimal, and good monitoring systems are lacking. We aimed to evaluate HHC using an automated monitoring system. A prospective, observational study was conducted at 2 Danish university hospitals employing a new monitoring system (Sani nudge). Sensors were located on alcohol-based sanitizers, health care worker name tags, and patient beds measuring hand hygiene opportunities and sanitations. In total, 42 nurses were included with an average HHC of 52% and 36% in hospitals A and B, respectively. HHC was lowest in patient rooms (hospital A: 45%; hospital B: 29%) and highest in staff toilets (hospital A: 72%; hospital B: 91%). Nurses sanitized after patient contact more often than before, and sanitizers located closest to room exits and in hallways were used most frequently. There was no association found between HHC level and the number of beds in patient rooms. The HHC level of each nurse was consistent over time, and showed a positive correlation between the number of sanitations and HHC levels (hospital A: r = 0.69; hospital B: r = 0.58). The Sani nudge system can be used to monitor HHC at individual and group levels, which increases the understanding of compliance behavior.

Current hand hygiene education is suboptimal.

To address the low levels of hand hygiene compliance (HHC) at our academic medical centre, we developed an annual patient safety course required for all incoming third-year medical students. Based on previous observations of medical students, it was determined that hand hygiene (HH) would be a central component of the course. Over a 1-year period (2015/16), we observed third- and fourth-year medical students who had participated in the annual patient safety course entering three intensive care units (ICUs) at two teaching hospitals. A total of 150 medical students failed to perform HH on entry and were subsequently asked why they did not comply. Of the 150 medical students observed entering an ICU without performing HH, 74.7% were male and 25.3% were female. Males cited inadequate time (21.4%), lack of role models (10.7%) and provided incorrect information regarding HH requirements (58.9%). Females cited concerns about dry or cracked skin (34.2%) and forgetting (23.7%). Our study demonstrates that even when medical students receive intensive HH education, compliance remains low. Of note, males and females offered different reasons for why they failed to perform HH. To address the suboptimal HHC, we developed an annual patient safety course required for all third-year medical students immediately prior to beginning clinical rotations. In this study, we sought to understand why medical students' HH remains suboptimal even after an intensive course.

Testing a novel audit and feedback method for hand hygiene compliance: A multicenter quality improvement study.

Although most hospitals report very high levels of hand hygiene compliance (HHC), the accuracy of these overtly observed rates is questionable due to the Hawthorne effect and other sources of bias. In the study, we aimed (1) to compare HHC rates estimated using the standard audit method of overt observation by a known observer and a new audit method that employed a rapid (&lt;15 minutes) "secret shopper" method and (2) to pilot test a novel feedback tool. Quality improvement project using a quasi-experimental stepped-wedge design. This study was conducted in 5 acute-care hospitals (17 wards, 5 intensive care units) in the Midwestern United States. Sites recruited a hand hygiene observer from outside the acute-care units to rapidly and covertly observe entry and exit HHC during the study period, October 2016-September 2017. After 3 months of observations, sites received a monthly feedback tool that communicated HHC information from the new audit method. The absolute difference in HHC estimates between the standard and new audit methods was ~30%. No significant differences in HHC were detected between the baseline and feedback phases (OR, 0.92; 95% CI, 0.84-1.01), but the standard audit method had significantly higher estimates than the new audit method (OR, 9.83; 95% CI, 8.82-10.95). HHC estimates obtained using the new audit method were substantially lower than estimates obtained using the standard audit method, suggesting that the rapid, secret-shopper method is less subject to bias. Providing feedback using HHC from the new audit method did not seem to impact HHC behaviors.