Status of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities

doi:10.1016/j.ajic.2013.11.015

American Journal of Infection Control

Volume 42, Issue 3, March 2014, Pages 224-230

https://doi.org/10.1016/j.ajic.2013.11.015 Get rights and content

Background

The World Health Organization (WHO) launched a multimodal strategy and campaign in 2009 to improve hand hygiene practices worldwide. Our objective was to evaluate the implementation of the strategy in United States health care facilities.

Methods

From July through December 2011, US facilities participating in the WHO global campaign were invited to complete the Hand Hygiene Self-Assessment Framework online, a validated tool based on the WHO multimodal strategy.

Results

Of 2,238 invited facilities, 168 participated in the survey (7.5%). A detailed analysis of 129, mainly nonteaching public facilities (80.6%), showed that most had an advanced or intermediate level of hand hygiene implementation progress (48.9% and 45.0%, respectively). The total Hand Hygiene Self-Assessment Framework score was 36 points higher for facilities with staffing levels of infection preventionists > 0.75/100 beds than for those with lower ratios (P = .01) and 41 points higher for facilities participating in hand hygiene campaigns (P = .002).

Conclusion

Despite the low response rate, the survey results are unique and allow interesting reflections. Whereas the level of progress of most participating facilities was encouraging, this may reflect reporting bias, ie, better hospitals more likely to report. However, even in respondents, further improvement can be achieved, in particular by embedding hand hygiene in a stronger institutional safety climate and optimizing staffing levels dedicated to infection prevention. These results should encourage the launch of a coordinated national campaign and higher participation in the WHO global campaign.

Section snippets

Study sample

From July through December 2011, US health care facilities registered for the WHO “SAVE LIVES: Clean Your Hands” global initiative (N = 2,238) were invited by e-mail to participate in a WHO global survey¹³ by completing the WHO HHSAF (Appendix) and submitting their results confidentially through a dedicated Web site. Participation in the survey was also promoted on the CDC Hand Hygiene in Health care Settings Web site and through the electronic newsletter of the Association for Professionals in

Results

Of 2,238 invited facilities, 168 participated in the survey (response rate, 7.5%). Thirty- nine responses were excluded from the analysis because the HHSAF was incomplete. Characteristics of the 129 participating facilities from 42 states and Puerto Rico (Fig 1) are shown in Table 1. Facilities ranged in size from 5 to 671 inpatient beds. Most were nonteaching (80.6%), acute care (65.9%) facilities belonging to the public sector (56.6%). Median infection preventionist staffing was 0.76 per 100

Discussion

The United States has been a pioneer in hand hygiene best practices promotion since the issue of the CDC evidence-based recommendations in 2002, which formed the basis for global guidelines subsequently developed by the WHO. However, a study conducted in the following years showed that there was no evidence of either multidisciplinary programs to improve hand hygiene compliance or any impact of hand hygiene promotion on HAI rates in many US hospitals.¹⁴ In addition, lack of staff time and

Acknowledgments

The authors thank all the participating facilities for their collaboration, in particular, Katherine Ellingson, PhD, Centers for Disease Control and Prevention, Atlanta, GA, for her important participative role in study design, promotion of the survey dissemination, and contribution to the manuscript; Liliana Pievaroli, WHO, and Janet Pasricha, The Jenner Institute, Oxford University, Oxford, UK, for their technical support to the survey; and Rosemary Sudan, University of Geneva Hospitals and

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Cited by (51)

Lifting the curtains of silence: Patient perceptions towards needs and responsibilities in contributing to the prevention of healthcare-associated infections and antimicrobial resistance
2023, American Journal of Infection Control
Beyond the use of policy and system-focused approaches, it has been established globally that patients can play a role in enhancing the health care landscape. However, efforts to meaningfully translate patient engagement strategies that promote participation by hospitalized patients in relevant infection prevention and antimicrobial stewardship activities have not yet been realized. This study mapped the key factors acting as barriers and facilitators of patient engagement using a theoretical framework to identify potential new approaches to promote engagement.
Semistructured interviews were conducted with 36 patients from 3 major hospitals in Sydney, Australia, in 2019. Transcripts were inductively analyzed, with the resulting themes categorized into the components of the Capability-Opportunity-Motivation-Behavior model.
The themes regarding barriers to patient engagement with relevant infection prevention and antimicrobial stewardship activities were: (1) Capability: misunderstanding and knowledge gaps about antimicrobial resistance; (2) Opportunity: strong family/patient support networks and good relationships with nursing staff provide an opportunity to support engagement; (3) Motivation: those who have some level of understanding or experience see the benefit and are most likely to engage actively.
Assuming patients are inclined to participate in efforts, a logical starting point would be to build awareness amongst patients and providers; however, education will not suffice. There needs to be a system and policy shift to ensure that patient engagement is recognized as a worthy endeavor.
Comparison of hand hygiene compliance self-assessment and microbiological hand contamination among healthcare workers in Mwanza region, Tanzania
2021, Infection Prevention in Practice
Citation Excerpt :
For example, a study conducted in Italy among healthcare facilities showed that, among 50 healthcare facilities 70.4%, 19% and 11% had an intermediate level, advanced level and basic level of hand hygiene, respectively [28]. An observational study conducted among healthcare facilities in United States of America showed that out 129 healthcare facilities evaluated in the study, 48.9%, 45% and 6.2% had an advanced, intermediate and basic level of HH respectively [7]. The differences compared with our study could be due to the economic differences between the countries and the different levels of IPC resources and different IPC strategies.
Compliance with hand hygiene (HH) practices remains a major challenge in preventing healthcare-associated infections (HCAI). Little is known whether self-reported HH compliance reflects the level of hand contamination microbiologically as a guide for specific infection prevention and control (IPC) measures.
A cross-sectional study was conducted between July and September 2019 involving 18 healthcare facilities (HCF) in Mwanza region, Tanzania. It assessed HH using astructured questionnaire and microbiological analysis of hand samples for culture (n=212), and the WHO Hand Hygiene Self-Assessment Framework (2010) (n=74).
The overall median HH score (interquartile range) was 212.5 (190–245) and designated at basic level in the WHO framework. The scores progressively increased from basic level in health centres to intermediate level in a tertiary hospital. Self-reported HH compliance using the WHO recommended cut-off value of ≥81.0% was 10.8% (8/74). A total of 56 (26.4%) healthcare workers (HCWs) hands had bacterial contamination; 17.9% (n=38) by Gram negative bacteria (including coliforms, Acinetobacter spp and Pseudomonas aeruginosa), 8.0% (n=17) by meticillin-resistant Staphylococcus aureus (MRSA) and 0.5% (n=1) by both. Hand contamination was significantly higher in district hospitals (P-value=0.0437), and among HCWs residing in the rural areas (P-value=0.017).
The median HH score amongst HCF in Mwanza region was at basic level. A quarter of HCWs hands were contaminated by bacteria which mismatched self-reported HH. A need to incorporate HH microbiological paramaters to the WHO HH assessment tool is needed, and future IPC interventional measures should be tailored to the HCF tier and in rural areas.
Bacteriological profile and antimicrobial efficacy of alcohol-based hand rubs among health care workers and family caregivers at the children's university teaching hospital in Lusaka, Zambia
2021, Scientific African
Hands of healthcare workers (HCWs) and family caregivers are a potential source of bacterial pathogens that may be transferred to susceptible individuals. However, there is a paucity of data regarding the effect of hand rubs used in Zambian hospitals. Therefore, we determined the effect of locally made alcohol-based hand rubs in three selected wards of the Children Hospital at the University Teaching Hospital in Zambia.
This was a cross-sectional study involving 31 participants (12 family caregivers, 5 doctors and 14 nurses). The samples were collected before and after the use of the alcohol-based hand rub by direct fingerprints. They were then cultured and identified using conventional microbiological methods. The Kirby-Bauer Disc Diffusion method was used for antimicrobial susceptibility testing.
All samples collected from the participants yielded bacterial growth with a total of 7 species isolated. These included coagulase-negative staphylococcus (33.3%), Bacillus species (28.9%), Staphylococcus aureus (22.2%), Enterobacter agglomerans (6.7%), Corynebacterium species (4.4%), Escherichia coli (2.2%) and Burkholderia pseudomallei (2.2%). Notably, all study participants hands were not only contaminated but with drug-resistant organisms as most of the bacterial isolates were resistant to routine antibiotics used at the hospital including ciprofloxacin. S. aureus was also resistant to oxacillin thus suggesting the presence of Methicillin-Resistant S. aureus. The use of alcohol-based hand rubs reduced the bacterial load by 92.6% on doctors and nurses’ hands and by 84.5% on the hands of family caregivers.
This study confirms that the hands of HCWs and family caregivers may play a role in the transmission of drug-resistant bacteria and that alcohol-based hand rubs can be an effective way of reducing bacterial hand contamination among healthcare workers and family caregivers. Therefore, we recommend that measures be put in place by the hospital to ensure the availability of hand rubs to HCWs as well as caregivers.
Patient education on infection control: A systematic review
2020, American Journal of Infection Control
Citation Excerpt :
This better level of education can be explained since patients with central lines and those undergoing surgeries are at a higher risk of acquiring an HAI and thus are given more attention by the HCW. A low percentage of education was also recognized when educating on HH, except the study by Barker et al19 (74.2%) although HH is suggested to be the most effective approach to prevent the transmission of HAIs.43-46 At the same time, asking patients to remind their health care professionals to perform HH is considered as 1 of the pioneering strategies to promote patient empowerment.46-51
Lately, suggestions have been emphasizing the importance of engaging patients and family members in infection control (IC) through participation and education after showing that patients and family members can aid in preventing the transmission of health care-associated infections. However, assessing patient education on IC measures in hospitals is poorly investigated.
To identify all available studies in the literature that assessed hospitalized patients’ education on IC measures.
PubMed, Embase, and CINAHL were searched from inception till May 6, 2020 without restrictions. We used Strengthening the Reporting of Observational Studies in Epidemiology tool for assessing the reporting quality of each eligible study.
Of the 6,740 identified papers, 25 were eligible for inclusion. Education on health care-associated infections was investigated in 8 studies, education on central line-associated bloodstream infections in 1, education on surgical site infections in 2, education on hand hygiene in 12, education on isolation rationale, precautions, usage of personal protective equipment in 3, and education on respiratory hygiene in 1. In general, a low percentage of patient education on IC was found in most of the included papers.
The low percentage of patient education on IC in hospitals highlights the need for additional emphasis on patient involvement in IC. Further studies are needed to assess patient education on several IC measures and to explore the education of family members as well.
The difference in hand hygiene compliance rate between unit-based observers and trained observers for World Health Organization checklist and optimal hand hygiene
2020, International Journal of Infectious Diseases
Hand hygiene (HH) is crucial to prevent healthcare-associated infections and the spread of multidrug-resistant organisms. The monitoring of HH compliance may be affected by observer expertise. A sufficient duration of HH is necessary to remove microorganisms. The aim of this study was to measure compliance with both the World Health Organization (WHO) checklist and optimal HH as reported by unit-based observers and infection control nurses (ICN).
Optimal HH was defined as adhering to the exact duration and following a six-step procedure. The disparity in compliance with the WHO checklist and optimal HH was analyzed among each profession, unit, and indication, covering a period of 3 years.
There was a statistically significant difference in WHO checklist compliance (94.4% vs. 87.0%, p < 0.01) and optimal HH rate (86.3% vs. 42.4%, p < 0.01) between unit-based observers and ICN. The optimal HH rate was especially lower for doctors (30.1%), in the intensive care units (39.4%), and before clean and aseptic procedures (37.0%) as observed by ICN.
Although the overall WHO checklist HH rate was reported to be higher than 90%, optimal HH was only half this rate. More education and awareness of the significance of HH, as well as adherence to the optimal HH procedures, are needed to prevent hospital-acquired infections.
Assessing sustainability of hand hygiene adherence 5 years after a contest-based intervention in 3 Japanese hospitals
2020, American Journal of Infection Control
Our goal was to evaluate the 5-year sustainability of a multimodal intervention that included a prize to the hospital with the highest overall hand hygiene adherence rates among health care workers.
We conducted an observational study in 3 Japanese tertiary care hospitals using unobtrusive direct observation of physician and nurse hand hygiene adherence. Observations were performed by a trained observer on inpatient medical, surgical, intensive care, and emergency units. The primary outcome was hand hygiene adherence rates before patient contact. Secondary outcomes were health care worker survey responses to a World Health Organization (WHO) questionnaire on hand hygiene practices.
Hand hygiene adherence rates had improved significantly after the introduction of a multimodal intervention (based on principles recommend by the WHO) in 2012 and 2013 (from 18.0% pre-intervention to 32.7% 6 months post-intervention; P < .001). No significant changes were found in hand hygiene adherence in these hospitals 5 years after the original intervention (31.9% 5 years after intervention; P = .53); however, substantial variability in hand hygiene adherence by unit and health care worker type was noted.
A multimodal hand hygiene initiative achieved sustained improvement in hand hygiene adherence in 3 Japanese hospitals 5 years after the original intervention.

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: B. Allegranzi and L. Conway contributed equally to this article.

: Conflicts of interest: None to report.

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Major articleStatus of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities

Background

Methods

Results

Conclusion

Section snippets

Study sample

Results

Discussion

Acknowledgments

Lancet

J Hosp Infect

Am J Infect Control

Am J Infect Control

J Hosp Infect

Lancet

Am J Infect Control

J Hosp Infect

Lancet

J Hosp Infect

Estimating health care-associated infections and deaths in US hospitals, 2002

Public Health Rep

MMWR Recomm Rep

Systematic review of studies on compliance with hand hygiene guidelines in hospital care

Infect Control Hosp Epidemiol

Achievable benchmarks of care: the ABCs of benchmarking

J Eval Clin Pract

Major article
Status of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities