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1.  Effectiveness of a multimodal hand hygiene campaign and obstacles to success in Addis Ababa, Ethiopia 
Hand hygiene is the cornerstone of infection control and reduces rates of healthcare associated infection. There are limited data evaluating hand hygiene adherence and hand hygiene campaign effect in resource-limited settings, especially in Sub-Saharan Africa. This study assessed the impact of implementing a World Health Organization (WHO)-recommended multimodal hand hygiene campaign at a hospital in Ethiopia.
This study included a before-and-after assessment of health care worker (HCW) adherence with WHO hand hygiene guidelines. It was implemented in three phases: 1) baseline evaluation of hand hygiene adherence and hospital infrastructure; 2) intervention (distribution of commercial hand sanitizer and implementation of an abbreviated WHO-recommended multimodal hand hygiene campaign); and 3) post-intervention evaluation of HCW hand hygiene adherence. HCWs’ perceptions of the campaign and hand sanitizer tolerability were assessed through a survey performed in the post-intervention period.
At baseline, hand washing materials were infrequently available, with only 20% of sinks having hand-washing materials. There was a significant increase in hand hygiene adherence among HCWs following implementation of a WHO multimodal hand hygiene program. Adherence increased from 2.1% at baseline (21 hand hygiene actions/1000 opportunities for hand hygiene) to 12.7% (127 hand hygiene actions /1000 opportunities for hand hygiene) after the implementation of the hand hygiene campaign (OR = 6.8, 95% CI 4.2-10.9). Hand hygiene rates significantly increased among all HCW types except attending physicians. Independent predictors of HCW hand hygiene compliance included performing hand hygiene in the post-intervention period (aOR = 5.7, 95% CI 3.5-9.3), in the emergency department (aOR = 4.9, 95% CI 2.8-8.6), during patient care that did not involve Attending Physician Rounds (aOR = 2.4, 95% CI 1.2-4.5), and after patient contact (aOR = 2.1, 95% CI 1.4-3.3). In the perceptions survey, 64.0% of HCWs indicated preference for commercially manufactured hand sanitizer and 71.4% indicated their hand hygiene adherence would improve with commercial hand sanitizer.
There was a significant increase in hand hygiene adherence among Ethiopian HCWs following the implementation of a WHO-recommended multimodal hand hygiene campaign. Dissatisfaction with the current WHO-formulation for hand sanitizer was identified as a barrier to hand hygiene adherence in our setting.
PMCID: PMC4004416  PMID: 24636693
Hand hygiene; Ethiopia; World Health Organization; Infection control; Health personnel
2.  Effectiveness of a training programme to improve hand hygiene compliance in primary healthcare 
BMC Public Health  2009;9:469.
Hand hygiene is the most effective measure for preventing infections related to healthcare, and its impact on the reduction of these infections is estimated at 50%. Non-compliance has been highlighted in several studies in hospitals, although none have been carried out in primary healthcare.
Main objective
To evaluated the effect of a "Hand Hygiene for the reduction of healthcare-associated infections" training program for primary healthcare workers, measured by variation from correct hand hygiene compliance, according to regulatory and specific criteria, 6 months after the baseline, in the intervention group (group receiving a training program) and in the control group (a usual clinical practice).
Secondary objectives
-To describe knowledges, attitudes and behaviors as regards hand hygiene among the professionals, and their possible association with "professional burnout", stratifying the results by type of group (intervention and usual clinical practice).
-To estimate the logistic regression model that best explains hand hygiene compliance.
Experimental study of parallel groups, with a control group, and random assignment by Health Center.
Area of study.- Health centers in north-eastern Madrid (Spain).
Sample studied.- Healthcare workers (physicians, odontostomatologists, pediatricians, nurses, dental hygienists, midwife and nursing auxiliaries).
Intervention.- A hand hygiene training program, including a theoretical-practical workshop, provision of alcohol-based solutions and a reminder strategy in the workplace.
Other variables: sociodemographic and professional knowledges, attitudes, and behaviors with regard to hand hygiene.
Statistical Analysis: descriptive and inferential, using multivariate methods (covariance analysis and logistic regression).
This study will provide valuable information on the prevalence of hand hygiene non-compliance, and improve healthcare.
PMCID: PMC2806875  PMID: 20015368
3.  Improving physician hand hygiene compliance using behavioural theories: a study protocol 
Healthcare-associated infections affect 10% of patients in Canadian acute-care hospitals and are significant and preventable causes of morbidity and mortality among hospitalized patients. Hand hygiene is among the simplest and most effective preventive measures to reduce these infections. However, compliance with hand hygiene among healthcare workers, specifically among physicians, is consistently suboptimal. We aim to first identify the barriers and enablers to physician hand hygiene compliance, and then to develop and pilot a theory-based knowledge translation intervention to increase physicians’ compliance with best hand hygiene practice.
The study consists of three phases. In Phase 1, we will identify barriers and enablers to hand hygiene compliance by physicians. This will include: key informant interviews with physicians and residents using a structured interview guide, informed by the Theoretical Domains Framework; nonparticipant observation of physician/resident hand hygiene audit sessions; and focus groups with hand hygiene experts. In Phase 2, we will conduct intervention mapping to develop a theory-based knowledge translation intervention to improve physician hand hygiene compliance. Finally, in Phase 3, we will pilot the knowledge translation intervention in four patient care units.
In this study, we will use a behavioural theory approach to obtain a better understanding of the barriers and enablers to physician hand hygiene compliance. This will provide a comprehensive framework on which to develop knowledge translation interventions that may be more successful in improving hand hygiene practice. Upon completion of this study, we will refine the piloted knowledge translation intervention so it can be tested in a multi-site cluster randomized controlled trial.
PMCID: PMC3571966  PMID: 23379466
4.  Hand hygiene monitoring technology: protocol for a systematic review 
Systematic Reviews  2013;2:101.
Healthcare worker hand hygiene is thought to be one of the most important strategies to prevent healthcare-associated infections, but compliance is generally poor. Hand hygiene improvement interventions must include audits of compliance (almost always with feedback), which are most often done by direct observation - a method that is expensive, subjective, and prone to bias. New technologies, including electronic and video hand hygiene monitoring systems, have the potential to provide continuous and objective monitoring of hand hygiene, regular feedback, and for some systems, real-time reminders. We propose a systematic review of the evidence supporting the effectiveness of these systems. The primary objective is to determine whether hand hygiene monitoring systems yield sustainable improvements in hand hygiene compliance when compared to usual care.
MEDLINE, EMBASE, CINAHL, and other relevant databases will be searched for randomized control studies and quasi-experimental studies evaluating a video or electronic hand hygiene monitoring system. A standard data collection form will be used to abstract relevant information from included studies. Bias will be assessed using the Cochrane Effective Practice and Organization of Care Group Risk of Bias Assessment Tool. Studies will be reviewed independently by two reviewers, with disputes resolved by a third reviewer. The primary outcome is directly observed hand hygiene compliance. Secondary outcomes include healthcare-associated infection incidence and improvements in hand hygiene compliance as measured by alternative metrics. Results will be qualitatively summarized with comparisons made between study quality, the measured outcome, and study-specific factors that may be expected to affect outcome (for example, study duration, frequency of feedback, use of real-time reminders). Meta-analysis will be performed if there is more than one study of similar systems with comparable outcome definitions.
Electronic and video monitoring systems have the potential to improve hand hygiene compliance and prevent healthcare-associated infection, but are expensive, difficult to install and maintain, and may not be accepted by all healthcare workers. This review will assess the current evidence of effectiveness of these systems before their widespread adoption.
Study registration
PROSPERO registration number: CRD42013004519
PMCID: PMC3874644  PMID: 24219817
5.  Improved Hand Hygiene Compliance is Associated with the Change of Perception toward Hand Hygiene among Medical Personnel 
Infection & Chemotherapy  2014;46(3):165-171.
Hand hygiene compliance has improved significantly through hand hygiene promotion programs that have included poster campaign, monitoring and performance feedback, and education with special attentions to perceived subjective norms. We investigated factors associated with improved hand hygiene compliance, focusing on whether the improvement of hand hygiene compliance is associated with changed perception toward hand hygiene among medical personnel.
Materials and Methods
Hand hygiene compliance and perceptions toward hand hygiene among medical personnel were compared between the second quarter of 2009 (before the start of a hand hygiene promotion program) and the second quarter of 2012. We assessed adherence to hand hygiene among medical personnel quarterly according to the WHO recommended method for direct observation. Also, we used a modified self-report questionnaire to collect perception data.
Hand hygiene compliance among physicians and nurses improved significantly from 19.0% in 2009 to 74.5% in 2012 (P < 0001), and from 52.3% to 91.2% (P < 0.001), respectively. These improvements were observed in all professional status or all medical specialties that were compared between two periods, regardless of the level of the risk for cross-transmission. Hand hygiene compliance among the medical personnel continued to improve, with a slight decline in 2013. Perceptions toward hand hygiene improved significantly between 2009 and 2012. Specifically, improvements were evident in intention to adhere to hand hygiene, knowledge about hand hygiene methods, knowledge about hand hygiene indications including care of a dirty and a clean body site on the same patient, perceived behavioral and subjective norms, positive attitude toward hand hygiene promotion campaign, perception of difficulty in adhering to hand hygiene, and motivation to improve adherence to hand hygiene.
The examined hand hygiene promotion program resulted in improved hand hygiene compliance and perception toward hand hygiene among medical personnel. The improved perception increased hand hygiene compliance. Especially, the perception of being a role model for other colleagues is very important to improve hand hygiene compliance among clinicians.
PMCID: PMC4189144  PMID: 25298905
Hand Hygiene; Health personnel; Quality Improvement
6.  Disentangling quality and safety indicator data: a longitudinal, comparative study of hand hygiene compliance and accreditation outcomes in 96 Australian hospitals 
BMJ Open  2014;4(9):e005284.
The study aims are twofold. First, to investigate the suitability of hand hygiene as an indicator of accreditation outcomes and, second, to test the hypothesis that hospitals with better accreditation outcomes achieve higher hand hygiene compliance rates.
A retrospective, longitudinal, multisite comparative survey.
Acute public hospitals in New South Wales, Australia.
96 acute hospitals with accreditation survey results from two surveys during 2009–2012 and submitted data for more than four hand hygiene audits between 2010 and 2013.
Our primary outcome comprised observational hand hygiene compliance data from eight audits during 2010–2013. The explanatory variables in our multilevel regression model included: accreditation outcomes and scores for the infection control standard; timing of the surveys; and hospital size and activity.
Average hand hygiene compliance rates increased from 67.7% to 80.3% during the study period (2010–2013), with 46.7% of hospitals achieving target compliance rates of 70% in audit 1, versus 92.3% in audit 8. Average hand hygiene rates at small hospitals were 7.8 percentage points (pp) higher than those at the largest hospitals (p<0.05). The association between hand hygiene rates, accreditation outcomes and infection control scores is less clear.
Our results indicate that accreditation outcomes and hand hygiene audit data are measuring different parts of the quality and safety spectrum. Understanding what is being measured when selecting indicators to assess the impact of accreditation is critical as focusing on accreditation results would discount successful hand hygiene implementation by smaller hospitals. Conversely, relying on hand hygiene results would discount the infection control related research and leadership investment by larger hospitals. Our hypothesis appears to be confounded by an accreditation programme that makes it more difficult for smaller hospitals to achieve high infection control scores.
PMCID: PMC4173108  PMID: 25248496
7.  Low Compliance to Handwashing Program and High Nosocomial Infection in a Brazilian Hospital 
Background. It is a fact that hand hygiene prevents nosocomial infection, but compliance with recommended instructions is commonly poor. The purpose of this study was to implement a hand hygiene program for increase compliance with hand hygiene and its relationship with nosocomial infection (NI) and MRSA infection/colonization rates. Methods. Compliance to hand hygiene was evaluated in a hospital by direct observation and measured of health care-associated infections, including methicillin resistant Staphylococcus aureus, before and after an educational intervention, using visual poster, colorful stamps, and feedback of the results. Results. Overall compliance did not increase during intervention, only handwashing before and after patient contact has improved from 40% to 76% (P = 0.01) for HCWs, but NI and MRSA rates remained high and stable. Conclusion. In a combination of high prevalence of NI and low compliance to hand hygiene, the programme of measure does not motivate the HCW hand hygiene. Future interventions should employ incremental evaluation to develop effective hand hygiene initiatives.
PMCID: PMC3375026  PMID: 22719756
8.  Sequential introduction of single room isolation and hand hygiene campaign in the control of methicillin-resistant Staphylococcus aureus in intensive care unit 
BMC Infectious Diseases  2010;10:263.
After renovation of the adult intensive care unit (ICU) with installation of ten single rooms, an enhanced infection control program was conducted to control the spread of methicillin-resistant Staphylococcus aureus (MRSA) in our hospital.
Since the ICU renovation, all patients colonized or infected with MRSA were nursed in single rooms with contact precautions. The incidence of MRSA infection in the ICU was monitored during 3 different phases: the baseline period (phase 1); after ICU renovation (phase 2) and after implementation of a hand hygiene campaign with alcohol-based hand rub (phase 3). Patients infected with extended spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella species were chosen as controls because they were managed in open cubicles with standard precautions.
Without a major change in bed occupancy rate, nursing workforce, or the protocol of environmental cleansing throughout the study period, a stepwise reduction in ICU onset nonbacteraemic MRSA infection was observed: from 3.54 (phase 1) to 2.26 (phase 2, p = 0.042) and 1.02 (phase 3, p = 0.006) per 1000-patient-days. ICU onset bacteraemic MRSA infection was significantly reduced from 1.94 (phase 1) to 0.9 (phase 2, p = 0.005) and 0.28 (phase 3, p = 0.021) per 1000-patient-days. Infection due to ESBL-producing organisms did not show a corresponding reduction. The usage density of broad-spectrum antibiotics and fluoroquinolones increased from phase 1 to 3. However a significant trend improvement of ICU onset MRSA infection by segmented regression analysis can only be demonstrated when comparison was made before and after the severe acute respiratory syndrome (SARS) epidemic. This suggests that the deaths of fellow healthcare workers from an occupational acquired infection had an overwhelming effect on their compliance with infection control measures.
Provision of single room isolation facilities and promotion of hand hygiene practice are important. However compliance with infection control measures relies largely on a personal commitment, which may increase when personal safety is threatened.
PMCID: PMC2944349  PMID: 20822509
9.  The ACCOMPLISH study. A cluster randomised trial on the cost-effectiveness of a multicomponent intervention to improve hand hygiene compliance and reduce healthcare associated infections 
BMC Public Health  2011;11:721.
Public health authorities have recognized lack of hand hygiene in hospitals as one of the important causes of preventable mortality and morbidity at population level. The implementation strategy ACCOMPLISH (Actively Creating COMPLIance Saving Health) targets both individual and environmental determinants of hand hygiene. This study aims to evaluate the cost-effectiveness of a multicomponent implementation strategy aimed at the reduction of healthcare associated infections in Dutch hospital care, by promotion of hand hygiene.
The ACCOMPLISH package will be evaluated in a two-arm cluster randomised trial in 16 hospitals in the Netherlands, in one intensive care unit and one surgical ward per hospital.
A multicomponent package, including e-learning, team training, introduction of electronic alcohol based hand rub dispensers and performance feedback.
The primary outcome measure will be the observed hand hygiene compliance rate, measured at baseline and after 6, 12 and 18 months; as a secondary outcome measure the prevalence of healthcare associated infections will be measured at the same time points. Process indicators of the intervention will be collected pre and post intervention. An ex-post economic evaluation of the ACCOMPLISH package from a healthcare perspective will be performed.
Statistical analysis
Multilevel analysis, using mixed linear modelling techniques will be conducted to assess the effect of the intervention strategy on the overall compliance rate among healthcare workers and on prevalence of healthcare associated infections. Questionnaires on process indicators will be analysed with multivariable linear regression, and will include both behavioural determinants and determinants of innovation. Cost-effectiveness will be assessed by calculating the incremental cost-effectiveness ratio, defined here as the costs for the intervention divided by the difference in prevalence of healthcare associated infections between the intervention and control group.
This study is the first RCT to investigate the effects of a hand hygiene intervention programme on the number of healthcare associated infections, and the first to investigate the cost-effectiveness of such an intervention. In addition, if the ACCOMPLISH package proves successful in improving hand hygiene compliance and lowering the prevalence of healthcare associated infections, the package could be disseminated at (inter)national level.
Trial registration
PMCID: PMC3204260  PMID: 21943482
10.  A novel approach to improve hand hygiene compliance of student nurses 
The National University Hospital, Singapore routinely undertakes standardized Hand Hygiene auditing with results produced by ward and by staff type. In 2010 concern was raised over consistently low compliance by nursing students averaging 45% (95% CI 42%–48%) prompting us to explore novel approaches to educating our next generation of nurses to improve their hand hygiene practice.
We introduced an experiential learning assignment to final year student nurses on attachment to NUH inclusive of hand hygiene auditor training followed by a period of hand hygiene observation. The training was based on the World Health Organisation (WHO) “My 5 moments for hand hygiene” approach. Upon completion students completed an anonymous questionnaire to evaluate their learning experience.
By 2012, nursing students were 40% (RR: 1.4, 95% CI 1.3–1.5, p<0.001) more likely to comply with hand hygiene practices. 97.5% (359/368) of nursing students felt that the experience would enhance their own hand hygiene practice and would recommend participating in audits as a learning instrument.
With consideration of all stakeholders a sustainable, flexible, programme was implemented. Experiential learning of hand hygiene was a highly valued educational tool and in our project was directly associated with improved hand hygiene compliance. Feedback demonstrated popularity amongst participants and success in achieving its program objectives. While this does not guarantee long term behavioural change it is intuitive that instilling good habits and messages at the early stages of a career will potentially have significant long-term impact.
PMCID: PMC3679881  PMID: 23721611
Compliance; Hand hygiene; Infection control; Nursing students; Nursing education
11.  Effectiveness and Limitations of Hand Hygiene Promotion on Decreasing Healthcare–Associated Infections 
PLoS ONE  2011;6(11):e27163.
Limited data describe the sustained impact of hand hygiene programs (HHPs) implemented in teaching hospitals, where the burden of healthcare-associated infections (HAIs) is high. We use a quasi-experimental, before and after, study design with prospective hospital-wide surveillance of HAIs to assess the cost effectiveness of HHPs.
Methods and Findings
A 4-year hospital-wide HHP, with particular emphasis on using an alcohol-based hand rub, was implemented in April 2004 at a 2,200-bed teaching hospital in Taiwan. Compliance was measured by direct observation and the use of hand rub products. Poisson regression analyses were employed to evaluate the densities and trends of HAIs during the preintervention (January 1999 to March 2004) and intervention (April 2004 to December 2007) periods. The economic impact was estimated based on a case-control study in Taiwan. We observed 8,420 opportunities for hand hygiene during the study period. Compliance improved from 43.3% in April 2004 to 95.6% in 2007 (p<.001), and was closely correlated with increased consumption of the alcohol-based hand rub (r = 0.9399). The disease severity score (Charlson comorbidity index) increased (p = .002) during the intervention period. Nevertheless, we observed an 8.9% decrease in HAIs and a decline in the occurrence of bloodstream, methicillin-resistant Staphylococcus aureus, extensively drug-resistant Acinetobacter baumannii, and intensive care unit infections. The intervention had no discernable impact on HAI rates in the hematology/oncology wards. The net benefit of the HHP was US$5,289,364, and the benefit-cost ratio was 23.7 with a 3% discount rate.
Implementation of a HHP reduces preventable HAIs and is cost effective.
PMCID: PMC3217962  PMID: 22110610
12.  How does healthcare worker hand hygiene behaviour impact upon the transmission of MRSA between patients?: an analysis using a Monte Carlo model 
Good hand hygiene has for many years been considered to be the most important measure that can be applied to prevent the spread of healthcare-associated infection (HAI). Continuous emphasis on this intervention has lead to the widespread opinion that HAI rates can be greatly reduced by increased hand hygiene compliance alone. However, this assumes that the effectiveness of hand hygiene is not constrained by other factors and that improved compliance in excess of a given level, in itself, will result in a commensurate reduction in the incidence of HAI. However, there is evidence that the law of diminishing returns applies to hand hygiene, with the greatest benefits occurring in the first 20% or so of compliance. While this raises intriguing questions about the extent to which increasing compliance alone can further reduce rates of HAI, analysis of this subject has been hampered by a lack of quantifiable data relating to the risk of transmission between patients on wards.
In order to gain a greater understanding of the transmission of infection between patients via the hands of healthcare workers (HCWs), we constructed a stochastic Monte Carlo model to simulate the spread of methicillin-resistant Staphylococcus aureus (MRSA) between patients. We used the model to calculate the risk of transmission occurring, firstly between two patients in adjacent beds, and then between patients in a four-bedded bay. The aim of the study was to quantify the probability of transmission under a variety of conditions and thus to gain an understanding of the contribution made by the various factors which influence transmission.
The study revealed that on a four-bedded bay, the average probability of transmitting an infection by the handborne route is generally low (i.e. in the region 0.002 – 0.013 depending on the hand hygiene behaviour of HCWs and other factors). However, because transmission is strongly influenced by stochastic events, it is the frequency with which 'high-risk events' occur, rather than average probability, that governs whether or not transmission will take place. The study revealed that increased hand hygiene compliance has a dramatic impact on the frequency with which 'high-risk events' occur. As compliance increases, so the rate at which 'high-risk events' occur, rapidly decreases, until a point is reached, beyond which, further hand hygiene is unlikely to yield any greater benefit.
The findings of the study confirm those of other researchers and suggest that the greatest benefits derived from hand hygiene occur as a result of the first tranche of compliance, with higher levels (>50%) of hand hygiene events yielding only marginal benefits. This suggests that in most situations relatively little benefit is accrued from seeking to achieve very high levels of hand hygiene compliance.
PMCID: PMC2689235  PMID: 19445655
13.  International Nosocomial Infection Control Consortium Findings of Device-Associated Infections Rate in an Intensive Care Unit of a Lebanese University Hospital 
To determine the rates of device-associated healthcare-associated infections (DA-HAI), microbiological profile, bacterial resistance, length of stay (LOS), excess mortality and hand hygiene compliance in one intensive care unit (ICU) of a hospital member of the International Infection Control Consortium (INICC) in Beirut, Lebanon.
Materials and Methods:
An open label, prospective cohort, active DA-HAI surveillance study was conducted on adults admitted to a tertiary-care ICU in Lebanon from November 2007 to March 2010. The protocol and methodology implemented were developed by INICC. Data collection was performed in the participating ICUs. Data uploading and analyses were conducted at INICC headquarters on proprietary software. DA-HAI rates were recorded by applying the definitions of the National Healthcare Safety Network (NHSN) at the US Centers for Disease Control and Prevention (CDC). We analyzed the DA-HAI, mechanical ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLA-BSI), and catheter-associated urinary tract infection (CAUTI) rates, microorganism profile, excess LOS, excess mortality, and hand hygiene compliance.
A total of 666 patients hospitalized for 5,506 days acquired 65 DA-HAIs, an overall rate of 9.8% [(95% confidence interval (CI) 7.6–12.3], and 11.8 (95% CI 9.1–15.0) DA-HAIs per 1000 ICU-days. The CLA-BSI rate was 5.2 (95% CI 2.8–8.7) per 1000 catheter-days; the VAP rate was 8.1 (95% CI 5.5–11.7) per 1000 ventilator-days; and the CAUTI rate was 4.1 (95% CI 2.6–6.2) per 1000 catheter-days. LOS of patients was 7.3 days for those without DA-HAI, 13.8 days for those with CLA-BSI, 18.8 days for those with VAP. Excess mortality was 40.9% [relative risk (RR) 3.14; P 0.004] for CLA-BSI. Mortality of VAP and CAUTI was not significantly different from patients without DA-HAI. Escherichia coli was the most common isolated microorganism. Overall hand hygiene compliance was 84.9% (95% CI 82.3–87.3).
DA-HAI rates, bacterial resistance, LOS and mortality were moderately high, below INICC overall data and above CDC-NHSN data. Infection control programs including surveillance and antibiotic policies are essential and continue to be a priority in Lebanon.
PMCID: PMC3326952  PMID: 22529622
Catheter associated urinary tract infection; Central line associated bloodstream infection; Ventilator associated pneumonia; Intensive care unit; Lebanon; International Nosocomial Infection Control Consortium
14.  Hand hygiene compliance and associated factors among health care providers in Gondar University Hospital, Gondar, North West Ethiopia 
BMC Public Health  2014;14:96.
Health care associated infections are more predominant in developing countries where Hand hygiene compliance is associated with so many factors. However, these factors have not been studied so far in the study area. This study sought to determine Hand hygiene compliance and associated factors among health care providers.
Institution based cross-sectional study was conducted from April to May, 2013 in Gondar University Hospital. Stratified sampling technique was used to select 405 health care providers. Standardized questionnaire and world health organization observational checklist was used to collect the data. Data was entered and analyzed by using SPSS version 20. Descriptive statistics and binary logistic regression model was used to summarize the result.
A total of 405 study participants were interviewed and observed with a response rate of 96.4%. Good Hand hygiene compliance of healthcare providers was found to be 16.5%. Having knowledge about hand hygiene compliance, (AOR = 3.80, 95% CI 1.60, 8.97), getting training (AOR = 2.60, 95% Cl 1.21, 5.62), the presence of individual towel/tissue paper (AOR = 1.91, 95% CI 1.03, 3.56) presence of alcohol based hand rub for Hand hygiene compliance (AOR = 6.58, 95% CI 2.67, 16.22) and knew the presence of infection prevention committees (AOR = 2.6, 95% CI 1.23, 5.37) were significantly associated with hand hygiene compliance.
Hand hygiene compliance among health care providers in Gondar University Hospital was found to be low. It is better to give training on Hand hygiene compliance and provide Alcohol based hand rub and individual towel or tissue paper for hand hygiene compliance.
PMCID: PMC3912925  PMID: 24479696
Hand hygiene compliance; Health care provider; Gondar University Hospital
15.  Medical and health economic evaluation of prevention- and control measures related to MRSA infections or -colonisations at hospitals 
Methicillin-resistant Staphylococcus aureus (MRSA) are dangerous agents of nosocomial infections. In 2007 the prevalence of MRSA is 20.3% in Germany (Oxacilline-resistance according to EUCAST-criteria [EUCAST = European Committee on Antimicrobial Susceptibility Testing]).
Which measurements are effective in the prevention and control of MRSA-infections in the hospital?How effective are contact precautions, screening, decolonisation, education and surveillance?Which recommendations can be given to health care politics on the basis of cost-effectiveness studies?Have there been any adverse effects on patients and clinical staff?What kind of liability problems exist?
Based on a systematic review of the literature studies are included which have been published in German or English language since 2004.
1,508 articles have been found. After having surveyed the full text, 33 medical, eight economic and four ethical/juridical studies are included for the Health Technology Assessment (HTA) report.
The key result of the HTA report is that different measurements are effective in the prevention and control of MRSA-infections in hospitals, though the majority of the studies has a low quality. Effective are the conduction of differentiated screening measurements if they take into account the specific endemic situation, the use of antibiotic-control programs and the introduction and control of hygienic measurements. The break even point of preventive and control measurements cannot be defined because the study results differ too much. In the future it has to be more considered that MRSA-infections and contact precautions lead to a psycho-social strain for patients.
It is hardly possible to describe causal efficacies because in the majority of the studies confounders are not sufficiently considered. In many cases bundles of measurements have been established but not analyzed individually. The internal and external validity of the studies is too weak to evaluate single interventions. Hygienic measurements prove to be effective in combination with other measurements. But it cannot be said which of the single measurements (gloves, washing hands, wearing gowns or masks) has the strongest effect on the reduction of MRSA. It is irritating that there are high differences in the compliance concerning hand hygiene between different studies. A general decolonisation is questionable for different reasons: first because of the side-effects for patients, second because of the high rate of spontaneous remissions in the untreated control group, third because of the differentiated process from colonisation to infection. Severalfold Hawthorne effects have been reported. One of them is that the competition between hospitals to reduce MRSA-rates leads already to a reduction.
It is evident that selective screening programs of risk patients considering the particular MRSA-prevalence are of use. The application of rapid tests seems to be only recommendable for risk patients and a high MRSA-prevalence. The improvement of the compliance of hand hygiene should be the basis of any prevention strategy. Training of staff members (with feedback mechanisms) is effective to improve compliance and to optimise the use of antibiotics. Antibiotic management programs are effective as well. Obviously multimodal approaches can lead to overadditive effects. Therefore the catalogue of preventive and control measurements has to be further evaluated. Good cost-efficacy studies are missing in Germany. The psychosocial effects of MRSA-infections are not researched in Germany. There is only punctual information on the risk management of hospitals.
PMCID: PMC3010887  PMID: 21289877
MRSA; Methicillin resistant Staphylococcus aureus; Staphylococcus aureus; Staphylococcus; MRSA infection; MRSA colonization/colonisation; healthcare-associated MRSA; hospital-acquired MRSA; HaMRSA; Methicillin resistance; Oxacillin resistant Staphylococcus aureus; ORSA; nosocomial infection; prevention; control; infection-control; preventive measures; treatment; precautions; screening; surveillance; isolation; training; education; hand hygiene; handwashing; decolonisation; eradication; decontamination; antibiotic; hospital; staff; patient; cost; cost-benefit-analysis; cost effectiveness; cost analysis; economics
16.  Healthcare workers' and parents' perceptions of measures for improving adherence to hand-hygiene 
BMC Public Health  2011;11:466.
This study was conducted to evaluate perceptions of healthcare workers (HCW) and parents regarding hand-hygiene and effectiveness of measures for increasing hand-hygiene adherence, in a children's hospital in Italy.
A cross-sectional study was performed from 5 to 13 July 2010, using two self-administered anonymous questionnaires (one for HCWs and one for parents/caregivers). The questionnaires included information regarding individual perceptions associated with hand hygiene.
We collected 139 questionnaires from HCWs and 236 questionnaires from parents. Alcohol-based handrub was reported to be available at the point of care by 95.0% of the HCWs and in the child's room by 97.0% of the parents. For both HCWs and parents, availability of alcohol-based handrub was perceived as the most useful action for improving adherence to hand hygiene (scores ≥ 6 on a 7-point Likert-type scale: 84.8% [CI95%78.0-90.1] for HCWs and 87.9% [CI95% 83.3-91.7] for parents). Parents' reminding HCWs to perform hand hygiene was perceived as the least useful action (scores ≥ 6: 48.9% [CI95% 40.5-57.3] for HCWs and 55.7% [CI95% 49.2-62.1] for parents). Factors that affected HCWs' perceptions of the effectiveness of actions for improving adherence to hand hygiene included years of practice, type of ward and previous formal training on hand hygiene. For parents, factors affecting perceptions included previous information on hand hygiene and previous hospitalizations for their child.
Investigating HCWs' and parents' perceptions of measures for improving adherence can provide useful information for implementing actions for hand-hygiene promotion in children's hospitals. In this study, HCWs' and parents' perceptions were similar; alcohol-based hand-rub availability was perceived as the most useful tool, confirming its crucial role in multimodal interventions. Poor perception of inviting parents to remind HCWs to perform hand-hygiene has been previously observed, and deserves further investigation. Information and education activities were associated with more positive perceptions regarding various improvement measures. Though the relationship between perceptions and behaviours remains to be fully determined, HCWs should participate in formal training and families should be properly informed, not only to increase knowledge but also to improve perceptions on effectiveness of actions to be implemented.
PMCID: PMC3141450  PMID: 21668982
17.  A qualitative study of senior hospital managers’ views on current and innovative strategies to improve hand hygiene 
BMC Infectious Diseases  2014;14(1):611.
Despite universal recognition of the importance of hand hygiene in reducing the incidence of healthcare associated infections, health care workers’ compliance with best practice has been sub-optimal. Senior hospital managers have responsibilities for implementing patient safety initiatives and are therefore ideally placed to provide suggestions for improving strategies to increase hand hygiene compliance. This is an under-researched area, accordingly the aim of this study was to identify senior hospital managers’ views on current and innovative strategies to improve hand hygiene compliance.
Qualitative design comprising face-to-face interviews with thirteen purposively sampled senior managers at a major teaching and referral hospital in Sydney, Australia. Data were analysed thematically.
Seven themes emerged: culture change starts with leaders, refresh and renew the message, connect the five moments to the whole patient journey, actionable audit results, empower patients, reconceptualising non-compliance and start using the hammer.
To strengthen hand hygiene programmes, strategies based on the five moments of hand hygiene should be tailored to specific roles and settings and take into account the whole patient journey including patient interactions with clinical and non-clinical staff. Senior clinical and non-clinical leaders should visibly champion and mandate best practice initiatives and articulate that hand hygiene non-compliance is culturally and professionally unacceptable to the organization. Strategies that included a disciplinary component and which conceptualise hand hygiene non-compliance as a patient safety error may be worth evaluating in terms of staff acceptability and effectiveness.
PMCID: PMC4237732  PMID: 25407783
Hand hygiene; Qualitative interviews; Compliance; Hospital managers; Patient safety; Innovative strategies
18.  Efficacy of a multimodal intervention strategy in improving hand hygiene compliance in a tertiary level intensive care unit 
The role of hand hygiene in preventing health care associated infections (HCAIs) has been clearly established. However, compliance rates remain poor among health care personnel.
a) To investigate the health care workers’ hand hygiene compliance rates in the intensive care unit (ICU), b) to assess reasons for non-compliance and c) to study the efficacy of a multimodal intervention strategy at improving compliance.
A mixed medical–surgical ICU of a tertiary level hospital.
A before–after prospective, observational, intervention study.
Materials and Methods:
All health care personnel who came in contact with patients in the ICU were observed for their hand hygiene compliance before and after a multimodal intervention strategy (education, posters, verbal reminders and easy availability of products). A self-report questionnaire was also circulated to assess perceptions regarding compliance. Statistical analysis was done using χ2 test or Fisher exact test (Epi info software).
Hand hygiene compliance among medical personnel working in the ICU was 26% and the most common reason cited for non-compliance was lack of time (37%). The overall compliance improved significantly following the intervention to 57.36% (P<0.000). All health care worker groups showed significant improvements: staff nurses (21.48–61.59%, P<0.0000), nursing students (9.86–33.33%, P<0.0000), resident trainees (21.62–60.71%, P<0.0000), visiting consultants (22–57.14%, P=0.0001), physiotherapists (70–75.95%, P=0.413) and paramedical staff (10.71–55.45%, P< 0.0000).
Hand hygiene compliance among health care workers in the ICU is poor; however, intervention strategies, such as the one used, can be useful in improving the compliance rates significantly.
PMCID: PMC3097548  PMID: 21633540
Hand hygiene compliance; intensive care unit; multimodal intervention
19.  Dissemination of the CDC's Hand Hygiene Guideline and impact on infection rates 
The diffusion of national evidence-based practice guidelines and their impact on patient outcomes often go unmeasured.
Our objectives were to (1) evaluate implementation and compliance with clinical practices recommended in the new Centers for Disease Control and Prevention (CDC) Hand Hygiene Guideline, (2) compare rates of health care-associated infections (HAI) before and after implementation of the Guideline recommendations, and (3) examine the patterns and correlates of changes in rates of HAI. We used pre- and post-Guideline implementation site visits and surveys in the setting of 40 US hospitals—members of the National Nosocomial Infections Surveillance System—and measured HAI rates 1 year before and after publication of the CDC Guideline and used direct observation of hand hygiene compliance and Guideline implementation scores.
All study hospitals had changed their policies and procedures and provided products in compliance with Guideline recommendations; 89.8% of 1359 staff members surveyed anonymously reported that they were familiar with the Guideline. However, in 44.2% of the hospitals (19/40), there was no evidence of a multidisciplinary program to improve compliance. Hand hygiene rates remained low (mean, 56.6%). Rates of central line-associated bloodstream infections were significantly lower in hospitals with higher rates of hand hygiene (P < .001). No impact of Guideline implementation or hand hygiene compliance on other HAI rates was identified. Other factors occurring over time could affect rates of HAI. Observed hand hygiene compliance rates were likely to overestimate rates in actual practice. The study may have been of too short duration to detect the impact of a practice guideline.
Wide dissemination of this Guideline was not sufficient to change practice. Only some hospitals had initiated multidisciplinary programs; practice change is unlikely without such multidisciplinary efforts and explicit administrative support.
PMCID: PMC2137889  PMID: 18063132
20.  Successful control of a Methicillin-resistant Staphylococcus aureus outbreak in a neonatal intensive care unit: a retrospective, before-after study 
BMC Infectious Diseases  2013;13:440.
Aim of this study was to provide a detailed description of a Methicillin-resistant Staphylococcus aureus (MRSA) outbreak management strategy in the neonatal intensive care unit of a university hospital.
This was a retrospective, “before-after” study, over two consecutive 18-month periods. The outbreak management strategy was performed by a multidisciplinary team and included: extensive healthcare workers (HCW) involvement, education, continuous hand-hygiene training and active MRSA colonization surveillance. The actions implemented were identified based on an anonymous, voluntary, reporting system, carried out among all the HCW, and regular audit and feedback were provided to the nursing staff.
The main measured outcome was the rate of MRSA infections before and after the implementation of the outbreak management strategy. Piecewise linear Poisson regression was performed and the model adjusted for confounding variables. The secondary outcome was the rate of laboratory-confirmed bloodstream infections before and after the outbreak management strategy. The rates of MRSA colonization, implementation of proposed actions, observed compliance for hand-hygiene and insertion/care of central lines were also recorded during the second period.
1015 newborns were included. The rate of MRSA infections throughout the two periods fell from 3.5 to 0.7 cases per 1000 patient-days (p=0.0005). The piecewise Poisson regression analysis adjusted for confounding variables showed a significant decrease in the MRSA infection rate after the outbreak management strategy (p=0.046). A significant decrease in positive laboratory confirmed blood cultures was observed over the two periods (160 vs 83; p<0.0001). A significant decline in the MRSA colonization rate occurred over the second period (p=0.001); 93% of the proposed actions were implemented. The compliance rate for hand-hygiene and insertion/care of central lines was respectively 95.9% and 62%.
The implementation of multiple, simultaneous, evidence-based management strategies is effective for controlling nosocomial infections. Outbreak management strategies may benefit from tools improving the communication between the institutional and scientific leadership and the ground-level staff. These measures can help to identify individualized solutions addressing specific unit needs.
PMCID: PMC3849690  PMID: 24053628
Quality-improvement; Practices; Newborn; Hospital-acquired infection; Community; Endemic; Voice, Bundle
21.  Video observation of hand hygiene practices during routine companion animal appointments and the effect of a poster intervention on hand hygiene compliance 
BMC Veterinary Research  2014;10:106.
Hand hygiene is considered one of the most important infection control measures in human healthcare settings, but there is little information available regarding hand hygiene frequency and technique used in veterinary clinics. The objectives of this study were to describe hand hygiene practices associated with routine appointments in companion animal clinics in Ontario, and the effectiveness of a poster campaign to improve hand hygiene compliance.
Observation of hand hygiene practices was performed in 51 clinics for approximately 3 weeks each using 2 small wireless surveillance cameras: one in an exam room, and one in the most likely location for hand hygiene to be performed outside the exam room following an appointment. Data from 38 clinics were included in the final analysis, including 449 individuals, 1139 appointments before and after the poster intervention, and 10894 hand hygiene opportunities. Overall hand hygiene compliance was 14% (1473/10894), while before and after patient contact compliance was 3% (123/4377) and 26% (1145/4377), respectively. Soap and water was used for 87% (1182/1353) of observed hand hygiene attempts with a mean contact time of 4 s (median 2 s, range 1-49 s), while alcohol-based hand rub (ABHR) was used for 7% (98/1353) of attempts with a mean contact time of 8 s (median 7 s, range 1-30 s). The presence of the posters had no significant effect on compliance, although some staff reported that they felt the posters did increase their personal awareness of the need to perform hand hygiene, and the posters had some effect on product contact times.
Overall hand hygiene compliance in veterinary clinics in this study was low, and contact time with hand hygiene products was frequently below current recommendations. Use of ABHR was low despite its advantages over hand washing and availability in the majority of clinics. The poster campaign had a limited effect on its own, but could still be used as a component of a multimodal hand hygiene campaign. Improving the infection control culture in veterinary medicine would facilitate future campaigns and studies in this area, as well as overall patient and staff safety.
PMCID: PMC4108058  PMID: 24885304
Veterinary; Companion animal; Hand hygiene; Infection control; Video observation; Intervention
22.  Systemic mistakes in hand hygiene practice in Ukraine: detection, consequences and ways of elimination 
Aim: Every year, millions of people around the world suffer from different infectious diseases, considerable part of which are hospital-acquired infections. WHO considers hand hygiene as a priority measure aimed to reduce the level of infection. We evaluated various aspects related to the situational behavior and prioritization regarding hand hygiene measures among the healthcare workers of Ukraine.
Method: Identification of system mistakes in hand hygiene was carried out first of all by direct and indirect observation of the activities of medical and pharmaceutical personnel in their everyday practice as well as during their participation in trainings on routine hand hygiene. Questionnaires also were used to estimate the level of hand hygiene compliance of participants of the study. During this period 112 training courses, 315 master-classes and presentations on proper hand hygiene were realized. The target audience included health care workers of medical centers, clinics, maternity hospitals, health care organizations and staff of pharmacies and pharmaceutical manufacturing enterprises in all regions of Ukraine. 638 respondents took part in anonymous survey on hand hygiene practice.
Results: The most common mistakes were to regard hand washing and hand disinfection equally, to wash hands before doing a hand disinfection, to neglect the five moments for hand hygiene and to ignore hand hygiene before and after wearing protective gloves. Practitioners, medical attendants, pharmacy and pharmaceutical industry workers highlighted the need for practical and understandable instructions of various hand hygiene procedures, including the clarification of the possible technical mistakes. This became a ground for us to create individual master classes on hand hygiene for each cluster of healthcare workers.
Conclusions: Changing hand hygiene behavior and attitude is possible by beginning to observe clinical practice and by involving healthcare workers in teaching and training.
PMCID: PMC4332274
hand hygiene; hand disinfection; hand washing; hand care; compliance; healthcare settings; medical staff; Ukraine
23.  The relationship between hand hygiene and health care-associated infection: it’s complicated 
The reasoning that improved hand hygiene compliance contributes to the prevention of health care-associated infections is widely accepted. It is also accepted that high hand hygiene alone cannot impact formidable risk factors, such as older age, immunosuppression, admission to the intensive care unit, longer length of stay, and indwelling devices. When hand hygiene interventions are concurrently undertaken with other routine or special preventive strategies, there is a potential for these concurrent strategies to confound the effect of the hand hygiene program. The result may be an overestimation of the hand hygiene intervention unless the design of the intervention or analysis controls the effect of the potential confounders. Other epidemiologic principles that may also impact the result of a hand hygiene program include failure to consider measurement error of the content of the hand hygiene program and the measurement error of compliance. Some epidemiological errors in hand hygiene programs aimed at reducing health care-associated infections are inherent and not easily controlled. Nevertheless, the inadvertent omission by authors to report these common epidemiological errors, including concurrent infection prevention strategies, suggests to readers that the effect of hand hygiene is greater than the sum of all infection prevention strategies. Worse still, this omission does not assist evidence-based practice.
PMCID: PMC4319644
compliance; epidemiological principles; study design; bacteria; control; multiple drug resistance
24.  Increasing the frequency of hand washing by healthcare workers does not lead to commensurate reductions in staphylococcal infection in a hospital ward 
Hand hygiene is generally considered to be the most important measure that can be applied to prevent the spread of healthcare-associated infection (HAI). Continuous emphasis on this intervention has lead to the widespread opinion that HAI rates can be greatly reduced by increased hand hygiene compliance alone. However, this assumes that the effectiveness of hand hygiene is not constrained by other factors and that improved compliance in excess of a given level, in itself, will result in a commensurate reduction in the incidence of HAI. However, several researchers have found the law of diminishing returns to apply to hand hygiene, with the greatest benefits occurring in the first 20% or so of compliance, and others have demonstrated that poor cohorting of nursing staff profoundly influences the effectiveness of hand hygiene measures. Collectively, these findings raise intriguing questions about the extent to which increasing compliance alone can further reduce rates of HAI.
In order to investigate these issues further, we constructed a deterministic Ross-Macdonald model and applied it to a hypothetical general medical ward. In this model the transmission of staphylococcal infection was assumed to occur after contact with the transiently colonized hands of HCWs, who, in turn, acquire contamination only by touching colonized patients. The aim of the study was to evaluate the impact of imperfect hand cleansing on the transmission of staphylococcal infection and to identify, whether there is a limit, above which further hand hygiene compliance is unlikely to be of benefit.
The model demonstrated that if transmission is solely via the hands of HCWs, it should, under most circumstances, be possible to prevent outbreaks of staphylococcal infection from occurring at a hand cleansing frequencies < 50%, even with imperfect hand hygiene. The analysis also indicated that the relationship between hand cleansing efficacy and frequency is not linear – as efficacy decreases, so the hand cleansing frequency required to ensure R0 < 1 increases disproportionately.
Although our study confirmed hand hygiene to be an effective control measure, it demonstrated that the law of diminishing returns applies, with the greatest benefit derived from the first 20% or so of compliance. Indeed, our analysis suggests that there is little benefit to be accrued from very high levels of hand cleansing and that in most situations compliance > 40% should be enough to prevent outbreaks of staphylococcal infection occurring, if transmission is solely via the hands of HCWs. Furthermore we identified a non-linear relationship between hand cleansing efficacy and frequency, suggesting that it is important to maximise the efficacy of the hand cleansing process.
PMCID: PMC2553083  PMID: 18764942
25.  Contact lens use and its compliance for care among healthcare workers in Pakistan 
Indian Journal of Ophthalmology  2013;61(7):334-337.
Poor care and hygiene of contact lens (CL) results in eye problems and infections. Healthcare workers have an important role in advocating correct lens care.
To determine the practices of CL care and the adverse consequences of poor CL care among healthcare workers.
Setting and Design:
A cross-sectional study in one public and three private sector hospitals in Karachi, Pakistan, in 2009–2010.
Materials and Methods:
We questioned 500 healthcare workers of all ages and both sexes, who wore CL, about compliance with advice on care and any complications due to improper hygiene practices. Ethical approval was obtained. Chi-square tests were used to determine significance and p-value less than 0.05 was considered statistically significant.
Of the total CL users, 385 (77%) were females. Most (75%) respondents wore CL to correct myopia, whereas 54% wore CL only occasionally. Surprisingly, only 24% knew the CL cleaning protocol. Lens solution was changed daily by 33% of users and after more than 2 weeks by 42%. Although 412 (82%) participants practised reasonable hand hygiene before inserting CL, 88 (18%) did not. Infection and eye dryness were statistically significantly (P < 0.01) associated with sex, hand-washing, and frequency of CL use.
Noncompliance with the CL protocol was common among healthcare workers in our society. This behavior calls for targeted health education and awareness programs for healthcare workers.
PMCID: PMC3759103  PMID: 23552347
Contact lens; healthcare workers; health professionals

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