w w w . e l s e v i e r . c o m / l o c a t e / b j i d
The
Brazilian
Journal
of
INFECTIOUS
DISEASES
Original
article
Improving
hand
hygiene
compliance
among
healthcare
workers:
an
intervention
study
in
a
Hospital
in
Guizhou
Province,
China
Xia
Mu,
Yan
Xu,
Tingxiu
Yang,
Ji
Zhang,
Chong
Wang,
Wei
Liu,
Jing
Chen,
Luyu
Tang,
Huai
Yang
∗GuizhouProvincialPeople’sHospital,DepartmentofHospital-AcquiredInfectionManagement,Guiyang,China
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received29December2015 Accepted8April2016 Availableonline25June2016
Keywords:
Handhygiene Compliance
Hospital-acquiredinfection
a
b
s
t
r
a
c
t
Objective:Handhygiene(HH)isacriticalcomponentforcontrollinghospital-acquired infec-tion(HAI).Thepresentstudywasdesignedtodevelopaninterventionapproachtoimprove compliancewithHHamonghealthcareworkersinahospitalsetting.
Methods:TheHHinterventionstudywasconductedinGuizhouProvincialPeople’sHospital, Guiyang, ChinaandorganizedbyitsDepartmentofHAIManagement.Itwasan obser-vational,prospective,quasiexperimental(before-afterintervention)study.Thestudywas dividedintotwophases:thebaselinephaseandtheinterventionphase.Theinvestigative teamincludedclinicalmonitoringstaffandinfectioncontrolpractitionerswhoreceiveda seriesofinstructionsonHHcompliance,monitoringskills,andmeasurementoftheuseof HHproducts.
Results:Basedon27,852observationsina17-monthperiod,therateofcompliancewithHH improvedfrom37.78%atbaselineto75.90%afterintervention.Significantimprovementin complianceandanincreaseinconsumptionofHHproductswasobservedafterintervention. Theperpatient-dayconsumptionofalcohol-basedhandrubproductsandhandwashagents increasedby4.75mLand4.55mL,respectively.Theconsumptionofpapertowelsincreased 3.41sheetsperpatient-day.Duringthesameperiod,theprevalencerateofHAIdecreased 0.83%.
Conclusions: Thisstudydemonstratesthatasignificantimprovementincompliancewith HHcanbeachievedthroughasystemic,multidimensionalinterventionapproachinvolving allcategoriesofhealthcareworkersinahospitalsetting,whichmayresultinadecreaseof theHAIrate.
©2016ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗ Correspondingauthor.
E-mailaddress:mumud117@163.com(H.Yang). http://dx.doi.org/10.1016/j.bjid.2016.04.009
1413-8670/©2016ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
Hospital-acquired infections (HAI) are associated with increased morbidity and mortality both in developed and developingcountries,resultinginincreasedhealthcarecosts, length of hospitalization, use of drugs, and unnecessary laboratory investigations.1,2 Several studies have reported
thathandhygiene(HH)isthemostimportant,easy,and eco-nomicalmeasuretoreduceHAI.3,4Ithasbeendemonstrated
thatenhancingHHcomplianceresultsinareductionofHAI andantimicrobialresistance.5However,adherencetoHH
rec-ommendations amonghealthcareworkers(HCWs)remains suboptimal,withcomplianceratesbeing30–75%asreported inpublishedstudies.6–8 Therehavebeenlimitedreportson
HAIandcompliancewithHHinChina.Inordertoimprove awarenessofHAI,itspreventionandcontrol,andtoincrease HHcomplianceamongHCWs,weinitiatedan intervention program,includingHHtrainingandmonitoring.Itwashoped thatthehospital-wideinterventiononHHcompliancecould beusedinotherhospitalsinordertoreduceHAIinChinaand inothercountriesaswell.
Methods
The present study was conducted in Guizhou Provincial People’sHospital, Guiyang,China, organized byits Depart-mentofHAI Managementand carriedout betweenAugust 2012 and December 2013. The hospital-wide intervention programincludedthefollowingelements:administrative sup-port,educationandtraining,improvedsupplyofHHproducts, surveillance,andfeedback.
Studypopulationandhospitalsetting
ThestudywascarriedoutinGuizhouProvincialPeople’s Hos-pital.Thehospitalwasfoundedin1947andearnedaranking ofAAAinChina’sgeneralhospitallicensingandaccreditation system.ThehospitalislocatedinthecityofGuiyang,Guizhou Province,China.Thehospitalhas2000beds,52clinicalunits ordepartments,and3182HCWs,coveringanareaof approx-imately45,000squaremeters.Thepresentstudywascarried outin33wardsofthehospitalfromAugust2012toDecember 2013.
Studydesign
It was an observational, prospective, quasi-experimental (before-afterintervention)study.Thestudywasdividedinto twophases:the baselinephase(from August2012to Octo-ber 2012) and the intervention phase (from October 2012 to December 2013). The primary outcome variables were compliance with HH and consumption per patient-day of alcohol-basedhandrub(ABHR)products,handwashagents, andpapertowels.Theotheroutcomevariablewastherateof HAI.
Interventionprocedures
The present intervention program included a series of
measures to improve compliance with HH among HCWs
hospital-wide.
ThefirstinterventionwasaimedatimprovingHH facili-ties.Afterthebaselinesurvey,thefollowingchangesinthe HHfacilities were accomplished:150hand twist taps were changedtonon-handtwist taps;the numberofdispensers forpapertowelsandABHRproductswasincreased;and all hand faucetswereequippedwithpapertowels, putupHH postersonHHdispensers.Inaddition,education,trainingand monitoringmeasureswereimplemented.
Thesecondpartofthecampaignwasanaggressive educa-tionprogramrelatedtoHH.Aspartoftheeducationprogram, the ICP attended all the staff meetings inall departments andprovidededucationonproperHHtechniques.Two educa-tionlecturesaboutHHtoHCWsweregivenatanauditorium; additionally, issues of HHeducation was presented to the department staff atthe health care quality meeting. Edu-cational issuesrelated toHHwere alsodiscussed withthe headnursesatthedepartmentofnursingtwotimes;forthe nurseattendantsandthemedicalprofessionalsHHeducation wascarriedonatthelocalworkplace.Thisactionhadtobe repeatedinsomewards,especiallyinICU.HHvideoplayedin thehospital’spromotionalvideo.
The final part of this campaign was to strengthen the management of HH.Every quarter, the department ofHAI managementpreparedandsentafinalreportoncompliance withHH,andontheconsumptionofHHproductstothe hospi-taldirectoranddepartmentchief.Suchreportsweretoinclude information on HH compliance inexamination ofmedical qualityandpresentationoftherateHHcompliancetothe hos-pitaldirector’scouncil.FeedbackontheobserveddataofHH waswrittenonawhiteboardattheICUwhichcouldbeseen everyday.
Datacollection
Theinvestigationteamincludedtheclinicalmonitoringstaff (physicians or nurses who had notonlytheir regular clin-ical duties, but also responsibilities associated with HH surveillance and HAI prevention) and the infection control practitioners (ICP).Duringthe baselinephase,ICPassessed HHcompliance,thenICPcompletedthefollow-upwiththe clinicalmonitoringstaffduringtheinterventionphase.The investigationteamreceivedstandardizedinstructions, includ-ingthedefinitionofHHcompliance,andmonitoring/recording recommendations. Before conducting observationsessions, the observer trainedand mustbe validated,parallel obser-vation the World Health Organization (WHO)training film. Resultswerethencomparedanddiscordantnotifications dis-cussed.Thisprocesswasrepeateduntilconsideredadequate. Theobservationperiodwasfrom08:00–18:00onaworkday, witheachobservationlastingnomorethan20minwithno shiftchangestoavoidanyimpactontheresults.
HHwasmonitoredaccordingtotheWHOHHobservation method. Basedon theWHO guidelines,“My Five Moments forHH” (5MHH), theobservers recorded the followingdata on paper questionnaires for each of their observations:
Table1–CompliancewithHHbeforeandafterintervention.
Time No.ofHHopportunities Compliance,% 95%CI p-Value
Lower Upper
Bas 1266 37.78 18.68 25.86 <0.001
Int 26,586 75.90 62.64 66.92
department,timeanddate,HCWtype,5MHH,andHHtype. TheHHtypewaseitherapositiveactionbyperforming han-druborhandwash,oranegativeactionbymissinghandrubor handwash.Thesubjectstobeobservedinthepresentstudy were divided into the following categories: physiciansand interns(medicalstudentsandrefresherdoctors);nursingstaff andnursingtrainees(nursingstudentsandrefreshernurses); careworkers(nursingassistantsandotherHCW);otherstaff andfamilymembers(includingrehabilitativeand therapeu-ticservicestaff,radiologytechnicians,andfamilymembers ofpatients).Observationsforthe5MHHincludedthemoment beforetouchingthepatient(bef-pat),momentbeforeaseptic percleanprocedure(bef-asept),momentafterbodyfluid expo-surerisk(aft-b.f),momentaftertouchingthepatient(aft-pat), and moment after touching the patient surroundings (aft-p.surr).For instancesinwhichopportunitiesinvolvedmore thanoneindication,onlyonewasconsideredforthesakeof simplicityofanalysisbyapplyingthefollowingpriorityrule: bef-asept>aft-b.f>aft-pat>bef-pat>aft-p.surr.9
Theteamwasinstructedtocollectatleast20observations perinpatientdepartmentpermonth.Theclinicalmonitoring nurseregisteredHHproductsconsumptiondatamonthly.All wardstookpartinthisHHstudyandinterventionprogram.
ThedefinitionofHAIwasbasedonthecriteriasetbythe MinistryofHealthofthePeople’sRepublicofChinain2001. NewinfectionwasdefinedasanHAIdiagnosed48horlonger afteradmission, providedthat there was no evidencethat theinfectionwassub-clinicalorundiagnosedatthetimeof admission.
Statisticalanalysis
Theobservationaldatawere enteredintoaMicrosoft Excel database.AnalysiswasperformedwithExcelandIBMSPSS Statisticsversion 19.Frequencytableswere tabulated with 95%confidenceintervals.The 2testwasusedforcomparison betweengroupsandthedifferencesweredeemedstatistically significantifp<0.05.
Results
Handhygienecompliance
Therewere27,852uniqueobservationsover17months.The HH compliance rate improved from 37.78% at baseline to 75.90% after intervention (Fig. 1, Table 1). The majority of observations(33.07%)wereofnursingstaff,followedby physi-cians(27.82%),practicalnurses(17.43%),interns(13.53%),and careworkers(8.15%).Theproportionofotherstaffaccounted forless than1% (0.71%)and weretherefore ignored. Nurs-ingstaffwasthegroupwiththehighestcompliance(78.50%),
100 3.56 3.33 2.85 2.60 2.62 2.25 4 3.5 3 2.5 2 1.5 1 0.5 0
Compliance, % HAI prevalence, % Quarter HAI pre valence , % 80 60 40 Compliance , % 20 0 Bas 124th 131th 132th 133th 134th
Fig.1–HHcompliancesandprevalenceratesofHAI.
andphysicians(71.42%)hadgreatercompliancethanpractical nurses andinterns(66%and 61%,respectively).Care work-erswere the groupwiththe leastcompliance(48.17%).HH compliancewashigheraft-b.f(82.38%)thanaft-pat(73.54%). Compliancewaslower aft-p.surrandbef-asept(60.62%and 59.39%, respectively).Thelowestcompliancewasseen bef-pat(58.04%).Thecompliancerateswerestatisticallydifferent before and after intervention for all categories of HCWs (p<0.001).Regardless ofthebaselinesurveyperiodor inter-ventionperiod,thebesttwomomentsofHHcompliancewere theaft-b.fmomentandtheaft-patmoment.Gratifyingly,the bef-patmomentimprovedthemostafterintervention.
ConsumptionofHHproducts
Average ABHR consumption increased from 7.40mL per
patient-day inthe baselineperiod to12.15mLper patient-dayafterintervention(Fig.2,Table2).Thehandwashagent consumptionincreasedby38.54%from11.80mLper patient-dayatbaselineto16.35mLperpatient-dayafterintervention. Paper towelswere used morefrequently afterintervention (7.48sheetsperpatient-day)thanatthebaselineperiod(4.07 sheetsperpatient-day)(p<0.001).
30 ABHR Handwash agents Quarter Paper towels 20 10 4.07 5.44 4.81 6.03 9.99 12.98 15 12 9 6 3 0 ML per patient-da y
Sheets per patient-da
y
0
Bas 2012 4th 2013 1th 2013 2th 2013 3th 2013 4th
Fig.2–HHagentconsumptionbeforeandafter intervention.
Table2–HHagentconsumptionbeforeandafterintervention.
Variable Time Consumption 95%CI p-Value
Lower Upper
ABHR(mLperpatient-day) Bas 7.40 5.69 9.12 0.004
Int 12.15 10.95 13.36
Handwashingagents(Lperpatient-day) Bas 11.80 9.09 14.52 0.009
Int 16.35 14.27 18.43
Papertowels(sheetsperpatient-day) Bas 4.07 3.30 4.85 <0.001
Int 7.48 6.58 8.39
Table3–PrevalenceratesofHAIbeforeandafterHHintervention.
Time No.ofHAIcases HAIprevalence(%) 95%CI p-Value
Lower Upper
Bas 613 3.56 2.33 4.79 <0.001
Int 2699 2.73 2.30 3.16
HAIrates
TherewasasignificantdifferenceinHAIratesbetween base-line and intervention periods (3.56%; 95% CI: 2.33–4.79vs. 2.73%,95%CI:2.30–3.16,respectively;p=0.002;Fig.1,Table3). The fourth quarterof 2013 was the period that registered themostsharpreductionofnosocomialinfectionsduringthe studyperiod.
Discussion
There are increasing efforts in developing effective meas-urestoimprovehygieneandtoreduceinfectionsinhospital settingsinChina.China’sMinistryofHealthformally promul-gatedthe“StandardforHHforHCWsinHealthcareSettings” in2009.10TomeettherequirementsoftheMinistryofHealth
forhospitalaccreditationin2011,11themajorityofhospitals
inChinabegantopayattention toHHin2012.Inthepast, HHhasnotreceivedcloseattentionandtheHHfacilitieswere essentiallylackinginourhospital;someHCWswerenotaware ofHHrequirementsandregulations.Tothebestofour knowl-edge,thepresentstudyrepresentsthefirstattemptinGuizhou Provincetodevelopan interventionalapproachtoimprove compliancewithHHinahospitalsetting.Inthepresentstudy, themeanoverallHHcompliancerateimprovedfrom37.78% inthe baselinephase to75.90% inthe interventionphase. Theconsumption ofABHR productsand handwash agents increased by 64.19% and 38.56% per patient-day, respec-tively.Theconsumptionofpapertowelsincreasedby83.78% per patient-day. As a result of the intervention, the inci-denceofHAIdecreasedfrom3.56%atbaselineto2.73%after intervention.
ThedepartmentofHAImanagementdevelopedaseries of actions to improve the medical staff’s HH compliance, including improvementsinHHfacilities, awarenessof HH, training, education, assessment, and establishment of a qualityevaluationsystemthroughmonitoringandfeedback. InordertoimprovetheHHfacilitiesandmakeeasytheaccess toHHinstruments,ourhospitalchanged150handtwisttaps
tonon-handtwisttaps,increasedthenumberofpapertowel and ABHRdispensers,and equippedall handsfaucetswith papertowels.ABHRwasmadeeasilyavailable,andadditional dispenserswereinstalledonthewallsinpatients’rooms,on theclinicaltrolleyingeneralwardareas,andateverybedside in the intensive care unit, infectious disease wards and patientwardswithotherinvasiveoperations.InallwardsHH posterswereaffixedonHHdispenser.DuringDecember2012, mandatoryHHtraining washeldforallHCWsaccordingto WHOrecommendations.12,13Allstaffparticipatedintraining
of“howtodo”and“whentodo”accordingtoWHOguidelines on HHinhealthcarehygiene practices.9 TheICP attended
allstaffmeetingsofalldepartmentsandprovidededucation on proper hand hygiene techniques. Educationsessions of HH to different professionals were conducted in different places. After some training to enhance HH consciousness of themedical staff therewas agradual perception ofthe importanceofsuchpracticetopatienthealth.
The most frequently reported methods of measuring compliance withHHare directobservation ofthe practice, measurementoftheconsumptionofproductsusedforHH, and electronic counters fordispensers ofABHR.11,12 In the
presentstudy,thefirsttwomethodswerechosen.Itwasuseful tostratifyadherencebyinstitutionalsector,professionaltype, andmomentofHHusingthe“5MHH”.Feedbacktotheclinical departmentsandhospitalwereprovidedquarterly.Ourstudy showedanincreaseincompliancewithHHandconsumption ofproductsusedinHHafterintervention.
Following the intervention, there has been an overall improvementofcompliancewithHHofallHCWs.However, itshouldbepointedoutthatthebuildingupofHH conscious-nesstakestime,requiresrepeatedtraining,andreminding. Timelyandregularfeedbackmightbeakeyfactorinimproving andmaintainingthecompliancerate.IncorporatingHHinto themedicalqualityevaluation,and feedbacktothe depart-ment chiefattractedattention.Part ofthe departmentwill formulateapunitivepolicytopenalizeHCWswhodonot per-formHH,thusattractingmoreattentionfromHCWs.Feedback ontheobserveddataofHHwrittenonawhiteboardatthe ICU canbe seenevery day. TheHHcompliancerates were
analyzedaccordingtoprofessionalcategoryandmoment cat-egory.There were far moreopportunitiesofHHfornurses inmostdepartments thanforphysicians;nurses’HH com-pliancerate was higher than that ofphysicians and other staff.Ourobservationsweresimilartopreviousreports.14,15
Careworkersweremostlyilliterateandthemajoritywasnot awareofthebenefitsofHHbeforetheintervention.Through the intervention, their compliance with HH improved sig-nificantly,but their compliance rates were still lower than thatof other professionals. Althoughthe methodof direct observationofHHhasseveraladvantages,ithasamajor dis-advantage,whichisthatonlyaverysmallportionofallHH opportunitiesarecapturedbesidesbeinglabor-intensiveand time-consuming.Additionally, the presenceofan observer mayproducetheHawthorneeffect.16,17Inthefuture,wemay
usetrainedmedicalstudentstoobservetheHHcomplianceof medicalstafftodecreasetheobservationbiasorHawthorne effect.
Inthepresent study,the consumptionofproductsused forHHwas monitoredand oughttobeinaccordance with theobservedHHcompliance.TheconsumptionofHH prod-uctscanbeaffectedbyvariousfactors,includingthepatient’s condition,treatmentbehaviorofdifferenthospitalsor depart-ments,andnumberandtypesofHCWs.Boyceetal.18found
that the amount of ABHR used increased from 3L/1000 patient-daysto30L/1000patient-dayswhentheoverall HH compliancerateamongHCWsincreasedfromabaselinelevel of38%to63%afterintervention.Pittetetal.19reportedthat
compliance was improved progressively from 48% in 1994 to66%in1997andthat, duringthe sameperiod,the over-allnosocomialinfection ratedecreased from16.9% in1994 to9.9%in1998.Thegroupalsofoundthatthe methicillin-resistant Staphylococcus aureus transmission rate decreased andthehospital-wideconsumptionofABHRincreasedfrom 3.5to15.4Lper1000patient-days.
HAI is an important cause of morbidity and mortality among hospitalized patients worldwide. The transmission of healthcare-associated pathogens often occurs via the contaminated hands of HCWs.HH isconsidered the most effective and simple measure in preventing the spread of infectionandmultiresistantorganisms.CompliancewithHH increasedcontinuously,followed byimprovedHCW aware-ness of infection control, to achieve the original goal of infectioncontrolforreducingtheincidenceofHAIandthe spreadofpathogens.20,21
Ofnote,duringourmonitoringinthepresent study,the directobservationwasfocusedontherighttimetoperform HH,notthecorrectnessoftheoperator,thedurationandsteps, orappropriatenessofrubbing.ThequalityofHHreliesonthe correctoperationofall procedures attheright time.If not performedcorrectly,theremovaloftransientmicroorganism fromHCWs’handscannotbeachieved.22 Infuturestudies,
thecorrectnessofeachHHprocedureshouldbeemphasized inobservationandanalysis.
Inconclusion,ourinterventionprogramresultedin signifi-cantlyincreasedcompliancewithHHinallcategoriesofHCWs inourhospital.HHseemstobesimple,butpersistenceofHH isdifficult23,24andrequireslong-termcommitmenttochange
fromthepartofhospitaladministrationandall HCWsand patients.
Ethical
approval
Thestudyprotocolwasreviewedandapprovedbythe Institu-tionalReviewBoardofGuizhouProvincialPeople’sHospital.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgements
This work was supported by the Science Foundation of GuizhouProvinceofChina(Nos.LS[2011]026andJ[2012]2242). Wewould liketothankother colleagues (GuizhouProvincial People’s Hospital,Guizhou,China)forthecontributiontodata acquisition.
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