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BACKGROUND Hand Hygiene (HH) is the most important method to prevent spread of healthcare associated infections. Parents, family and visitors (PFV) are integral partners with the healthcare team for optimal patient outcomes. We aim at improving HH compliance by PFV upon entering a pediatric oncology inpatient unit. METHODS A performance improvement project implemented several interventions between July and November 2018 in Plan-Do-Study-Act (PDSA) cycles that included baseline data collection phase where a wall-mounted alcohol-based hand gel dispenser was available next to the unit entrance, Cycle1 (HH station and poster just facing the entrance as a visual cue), Cycle2 (visual cue + PFV symptom screen as verbal reminder of infections, without HH instructions), and Cycle3 (visual cue + verbal PFV symptom screen + HH verbal instructions). Pre-defined paper observation tool and scripts for symptom screening and HH, in English and Spanish, were used by patient care associates (PCA) who were positioned at the unit entrance reception desk between 07:00 and 23:00. Percent HH compliance was calculated for each cycle. Only observations with complete documentation were included in the analysis. A goal of 90% compliance by December 31, 2018 was set. The participating PCAs were surveyed regarding process feasibility and sustainability. RESULTS Of 1272 observed visitors, 76% were adults, 14% children, and 7% adolescents. Of 955 (75%) observations with complete documentation, 204 were baseline, 293 Cycle1, 330 Cycle2, but it decreased to 128 observations for Cycle3. The percent HH compliance increased from 5% at baseline, to 16% in Cycle1, 21% Cycle2, and 65% Cycle3. CONCLUSIONS A multimodal performance improvement project improved PFV HH compliance. Direct verbal instructions for HH?was the most effective, but less efficient as suggested by?the?decreased number of Cycle3 complete observations. The PCA survey results will help develop a plan for process sustainability.

Strategies to improve adherence to standard and transmission-based precautions are essential to reduce the risk of health care-associated infections. This study aims to evaluate the effectiveness of an educational strategy on precautions among nursing staff in primary health care settings.A randomized nonblinded controlled trial was conducted with 100 nursing staff working in 28 primary health care units. Groups were allocated randomly. The intervention group received a WebQuest educational strategy: a guided, creative method designed to engage participants in developing learning tasks, organized in 5 dimensions. The control group did not receive any training. Knowledge and self-reported adherence were assessed at 3 time points in the intervention group and at 2 time points in the control group. Data analyses were performed using Pearson's chi-square or Fisher's exact for categorical data, and Mann-Whitney and Repeated Measures analysis of variance for quantitative data.A higher level of knowledge was identified in the postintervention for the dimensions of risk assessment, hand hygiene, and mask use and cough etiquette (all P values P.05). The self-reported adherence increased in intervention (P = .008) and control groups (P = .005). The differences decreased after 6 months.The educational intervention increased the knowledge and self-reported adherence to standard and transmission-based precautions.

Background: Scientific evidence suggest that hand hygiene as one of the most effective measures to control infection. To promote good hand hygiene practices, the World Health Organization introduced May 5 as World Hand Hygiene Day (WHHD), and international stakeholders established Global Handwashing Day (GHD) on October 15. However, its contributions to raising public awareness of hand hygiene is unclear. Methods: This study evaluates the impact of the WHHD and GHD on the public awareness of hand hygiene in Japan, the United Kingdom, the United States, and worldwide from 2016 to 2020, using the relative search volume of "Hand hygiene" in Google Trends as a surrogate. To identify a statistically significant timepoint of a trend change, we performed Joinpoint regression analysis. Results: Upticks of the relative search volumes as well as joinpoints were noted worldwide around the WHHD and GHD from 2016 to 2019, but no joinpoints were identified around the WHHD and GHD in 2020. No such changes were observed in Japan, the United Kingdom, and the United States during these periods. Conclusions: While the WHHD was originally established to raise awareness of hand hygiene in healthcare facilities, our result suggests that the WHHD and GHD may not have effectively disseminated the importance of hand hygiene to the general public at a country level. Additional policy measures to advocate hand hygiene to the public are necessary to communicate its benefits. (c) 2021 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Background Direct observation is the gold standard method for measuring hand hygiene compliance but its utility is increasingly being questioned. Various alternative electronic methods have been proposed, yet there is a paucity of research examining the use of these according to the World Health Organization's (WHO) ‘5 Moments for Hand Hygiene’. As a part of the process of developing a video-based monitoring system (VMS) capable of measuring hand hygiene compliance against the 5 moments criteria this paper reports methodological and technical issues that might arise from the use of a VMS for auditing in clinical practice. Methods In-depth semi-structured interviews were conducted with 27 Australian content experts in hand hygiene auditing and infection prevention to explore their responses to proposed VMS auditing approaches. Transcripts were analyzed using thematic and content analysis. Results Technical and methodological considerations for the use of VMS were interrelated and included concerns surrounding privacy, footage security, fears of surveillance and the potential for medico-legal consequences. Additionally, possible detrimental impacts on healthcare worker (HCW) -patient relationships, issues of cost versus benefits, HCW and patient safety and changes to feedback were also identified. Conclusions The primary methodological and technical issues to overcome in order to implement VMS for hand hygiene auditing in clinical practice, centered upon issues of acceptability to patients and health professionals, privacy, consent and liability. Checklist COREQ

Background Patient, family, and visitor hand hygiene can prevent health care-associated infections, but little is known about their hand hygiene knowledge, attitudes, and practices. We aimed to assess patient, family, and visitor hand hygiene knowledge, attitudes, and practices at a pediatric and maternity hospital in Vancouver, British Columbia, Canada. Methods Surveys based on the Theoretical Domains Framework were distributed to patients, families, and visitors to provide cross-sectional qualitative and quantitative data. This was supplemented with covert observations by trained medical students to determine patient, family, and visitor hand hygiene rates. Results Of 348 survey respondents, there was a clear preference for hand washing with soap and water over use of alcohol-based hand rub. Beliefs about consequences were the main driver for hand hygiene. Self-reported hand hygiene rates were higher than observed rates. The overall hand hygiene rate was observed to be 10.3% (72/701), with soap and water used for 75% of hand hygiene events. Conclusion There are misconceptions regarding hand hygiene practices and low hand hygiene rates among patients, families, and visitors. Development of interventions to improve hand hygiene should focus on correcting misconceptions and emphasizing consequences of failing to perform hand hygiene in the health care setting.

Background Health care-acquired infections are one of the top causes of mortality in the United States (Stone, 2009; Scott, 2009). Hand hygiene (HH) can reduce the incidence of such infections. Adherence to HH practices remains challenging for health care workers (World Health Organization, 2014). This investigation compared results of private and public HH feedback at the team and individual level. Methods A quality improvement study was conducted in 2 units utilizing HH radiofrequency identification (RFID) technology. Each unit was assigned either private or public feedback mechanisms. The study was divided into 3 phases; baseline, team, and individual. Time series analysis compared HH compliance by health care workers' role and feedback mechanisms. Results Individual HH compliance were the highest in both groups. The private group compliance was 63.3% (P ≤ .0001) and the public group compliance was 55.4% (P = .0001). During the team feedback phase, HH compliance decreased in the private group to 42.79% (P = .006); however, compliance increased in the public feedback group to 42.5% (P = .2661). The physician role in the private group decreased by 12% (P = .1804) during the individual phase. Conclusions HH data provided at the individual level and posted publicly could improve HH compliance. Use of RFID measurement technology can provide organizations with tools to measure HH compliance.

Background Daily use of chlorhexidine gluconate (CHG) has been shown to reduce risk of healthcare-associated infections. We aimed to assess moving CHG bathing into routine practice using a human factors approach. We evaluated implementation in non-intensive care unit (ICU) settings in the Veterans Health Administration. Methods Our multiple case study approach included non-ICU units from 4 Veterans Health Administration settings. Guided by the Systems Engineering Initiative for Patient Safety, we conducted focus groups and interviews to capture barriers and facilitators to daily CHG bathing. We measured compliance using observations and skin CHG concentrations. Results Barriers to daily CHG include time, concern of increasing antibiotic resistance, workflow and product concerns. Facilitators include engagement of champions and unit shared responsibility. We found shortfalls in patient education, hand hygiene and CHG use on tubes and drains. CHG skin concentration levels were highest among patients from spinal cord injury units. These units applied antiseptic using 2% CHG impregnated wipes vs 4% CHG solution/soap. Discussion Non-ICUs implementing CHG bathing must consider human factors and work system barriers to ensure uptake and sustained practice change. Conclusions Well-planned rollouts and a unit culture promoting shared responsibility are key to compliance with daily CHG bathing. Successful implementation requires attention to staff education and measurement of compliance.

Highlights • The impact of a multimodal infection control strategy originally designed for containment of COVID-19 on the rates of other hospital-acquired-infections (HAIs) was evaluated over a 7-month period across the largest healthcare system in Singapore. • During the COVID-19 pandemic, methicillin-resistant Staphylococcus aureus acquisition rates declined significantly, together with central-line-associated-bloodstream infection rates; likely due to increased compliance with standard precautions. • Enhanced infection control measures resulted in the unintended positive consequences of containing health care-associated respiratory viral infections, with a significant and sustained decline for both enveloped and nonenveloped respiratory viruses. • The ongoing COVID-19 pandemic provided the impetus to demonstrate the potential benefit of heightened infection control measures in controlling HAIs and acquisition of multidrug-resistant-organisms., Background In the current COVID-19 pandemic, aggressive Infection Prevention and Control (IPC) measures have been adopted to prevent health care-associated transmission of COVID-19. We evaluated the impact of a multimodal IPC strategy originally designed for the containment of COVID-19 on the rates of other hospital-acquired-infections (HAIs). Methodology From February-August 2020, a multimodal IPC strategy was implemented across a large health care campus in Singapore, comprising improved segregation of patients with respiratory symptoms, universal masking and heightened adherence to Standard Precautions. The following rates of HAI were compared pre- and postpandemic: health care-associated respiratory-viral-infection (HA-RVI), methicillin-resistant Staphylococcus aureus, and CP-CRE acquisition rates, health care-facility-associated C difficile infections and device-associated HAIs. Results Enhanced IPC measures introduced to contain COVID-19 had the unintended positive consequence of containing HA-RVI. The cumulative incidence of HA-RVI decreased from 9.69 cases per 10,000 patient-days to 0.83 cases per 10,000 patient-days (incidence-rate-ratio = 0.08; 95% confidence interval [CI] = 0.05-0.13, P< .05). Hospital-wide MRSA acquisition rates declined significantly during the pandemic (incidence-rate-ratio = 0.54, 95% CI = 0.46-0.64, P< .05), together with central-line-associated-bloodstream infection rates (incidence-rate-ratio = 0.24, 95% CI = 0.07-0.57, P< .05); likely due to increased compliance with Standard Precautions. Despite the disruption caused by the pandemic, there was no increase in CP-CRE acquisition, and rates of other HAIs remained stable. Conclusions Multimodal IPC strategies can be implemented at scale to successfully mitigate health care-associated transmission of RVIs. Good adherence to personal-protective-equipment and hand hygiene kept other HAI rates stable even during an ongoing pandemic where respiratory infections were prioritized for interventions.

Through survey-led interviews, health care staff recognizes that patients have different bathing techniques and need more education on chlorhexidine gluconate cleansing. Preliminary findings gathered will be used to develop and test electronic competency-based tools to ensure patients are provided with the same comprehensive instructions before using chlorhexidine gluconate bathing products.

Background 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. Purpose To identify all available studies in the literature that assessed hospitalized patients’ education on IC measures. Methods 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. Main Findings 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. Conclusions 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.

Antimicrobial resistance (AMR) continues to threaten global health. Although global and national AMR action plans are in place, infection prevention and control is primarily discussed in the context of healthcare facilities with home and everyday life settings barely addressed.\ud \ud As seen with the recent global SARS-CoV-2 pandemic, everyday hygiene measures can play an important role in containing the threat from infectious microorganisms.\ud \ud This position paper has been developed following a meeting of global experts in London, 2019. It presents evidence that home and community settings are important for infection transmission and also the acquisition and spread of AMR. It also demonstrates that the targeted hygiene approach offers a framework for maximizing protection against colonization and infections, thereby reducing antibiotic prescribing and minimizing selection pressure for the development of antibiotic resistance. If combined with the provision of clean water and sanitation, targeted hygiene can reduce the circulation of resistant bacteria in homes and communities, regardless of a country's Human Development Index (overall social and economic development). Achieving a reduction of AMR strains in healthcare settings requires a mirrored reduction in the community.\ud \ud The authors call upon national and international policy makers, health agencies and healthcare professionals to further recognize the importance of targeted hygiene in the home and everyday life settings for preventing and controlling infection, in a unified quest to tackle AMR.

Background Coronavirus disease 2019 (COVID-19) is characterized by risk of nosocomial transmission; however, the extent of environmental contamination and its potential contribution of environmental contamination to SARS-CoV-2 transmission are poorly understood. This study aimed to investigate whether environmental contamination may play a role in SARS-CoV-2 transmission. Methods Air samples were collected by natural precipitation, and environmental surface samples were collected by conventional surface swabbing. SARS-CoV-2 RNA detection was performed using reverse transcription polymerase chain reaction. Results Viral RNA was not detected in the 44 air samples. The positive rates in 200 environmental surface samples in medical areas (24.83%) was higher than that in living quarters (3.64%), with a significant difference (P Conclusions Most of the touchable surfaces in the designated hospital for COVID-19 were heavily contaminated, suggesting that the environment is a potential medium of disease transmission. These results emphasize the need for strict environmental surface hygiene practices and enhanced hand hygiene to prevent the spread of the virus.

Background Clostridioides difficile infection (CDI) causes significant morbidity in nursing home residents. Our aim was to describe adherence to a bundled CDI prevention initiative, which had previously been deployed nationwide in Veterans Health Administration (VA) long-term care facilities (LTCFs), and to improve compliance with reinforcement. Methods A multicenter pre- and post-reinforcement of the VA bundle consisting of environmental management, hand hygiene, and contact precautions was conducted in 6 VA LTCFs. A campaign to reinforce VA bundle components, as well as to promote select antimicrobial stewardship recommendations and contact precautions for 30 days, was employed. Hand hygiene, antimicrobial usage, and environmental contamination, before and after bundle reinforcement, were assessed. Results All LTCFs reported following the guidelines for cleaning and contact precautions until diarrhea resolution pre-reinforcement. Environmental specimens rarely yielded C difficile pre- or post-reinforcement. Proper hand hygiene across all facilities did not change with reinforcement (pre 52.51%, post 52.18%), nor did antimicrobial use (pre 87–197 vs. post 84–245 antibiotic days per 1,000 resident-days). LTCFs found it challenging to maintain prolonged contact precautions. Discussion Variation in infection prevention and antimicrobial prescribing practices across LTCFs were identified and lessons learned. Conclusions Introducing bundled interventions in LTCFs is challenging, given the available resources, and may be more successful with fewer components and more intensive execution with feedback.

Background Alcohol based hand rubs (ABHR) are extremely effective at reducing microbial contamination and have an essential role in best practice hand hygiene described by the World Health Organization. Methods We determined ABHR drying time when performing hand hygiene in a laboratory setting. Which was followed by identifying the amount of ABHR needed for complete hand coverage. When the aforementioned was analyzed real-time data were gathered to examine the amount used for hand hygiene in a hospital setting. In parallel hands of healthcare workers (HCWs) were monitored for drying time and perception on ABHR use. Results In 86% (24,446,397/28,280,383) of the events a single dose of ABHR was used on clinical wards. Twenty-four HCWs expected hand hygiene to take 7.5 seconds (median; range 3-30 seconds). Forty-three HCWs show that 1.5 mL ABHR dose achieves the desired drying time according to World Health Organization guidelines (av. median 26 seconds), but is consistently perceived to have a longer drying time than expected (av. median 18 seconds). In-vivo results (n = 10) indicate that 2.25 mL ABHR is required for adequate coverage (82%-90%) of both sides of the hand. Conclusions Results indicate that set standards for the use of ABHR do not match “in-vivo” behaviour of HCWs. Perceived drying times are shorter than actual drying time. The needed drying time to reach acceptable antimicrobial efficacy of ABHRs should be revisited.

Monitoring healthcare workers' (HCWs) hand hygiene (HH) performance is recommended for improving compliance. Observer biases challenge data validity, thus supplemental approaches such as video observation are needed to complement monitoring.We investigate first-person view (FPV) video observation during simulated standardized patient care handling a catheter in a study with 71 HCWs. HH performance was evaluated for (1) all HH opportunities and (2) a subset of opportunities required in an ideal work sequence, hereafter core opportunities. HCWs' acceptance of FPV video observation and usability judgments were assessed.Compliance level for core HH opportunities (M = 43.5%) was significantly higher than compliance considering all opportunities (M = 30.4%, t(70) = 8.493, P.001). Reducing HH opportunities to core opportunities would significantly increase compliance levels from the observed average of 30.4% to 44.9% (t(70) = 12.822, P.001). Overall, both usability ratings and acceptance of the body camera were promising.FPV video observation in simulated standardized patient care provides new instruments to evaluate HH performance beyond mere compliance rates. Our results emphasize the role of optimizing workflow in order to improve HCW's HH compliance.FPV video observation in a standardized patient care simulation is feasible and offers information for HH interventions that target actual deficiencies.

Background Some electronic hand hygiene (HH) monitoring systems require a benchmark of HH opportunities. To establish a benchmark, we measured rates of HH opportunities among general surgery patients at a tertiary care hospital. Methods Trained observers recorded HH opportunities for newly admitted patients daily for up to 5 days. We used multivariable logistic regression to assess the relationship between patient variables and the HH opportunity rate. A subset of observed HH events was compared to event data from an electronic HH monitoring system. Results We observed 2,404 HH opportunities over 677.4 care-hours for 23 patients (median 3.25 per hour; IQR 2.2-4.7, range 0-13). Rates of HH opportunities were significantly higher on admission day 1, for sessions starting before 9 AM, and for patients without roommates. HH was performed using alcohol-based hand rub from dispensers at the door to a patient's room more often than bedside or pocket dispensers (72.7% vs 20.8% or 5.1%). Electronic dispenser event counts did not match observed event counts. Conclusions Our results provide a benchmark HH opportunity rate for general surgery patients, and highlight the importance of validating electronic HH event counts. Further research is needed to determine which patient factors affect HH opportunity rates.

Stethoscope hygiene is rarely done despite guideline recommendations. We wanted to determine whether demonstrating what is growing on the stethoscopes of providers via culture or bioluminescence technology alters perceptions and improves compliance.Providers were given the opportunity to (1) culture their stethoscopes before and after disinfection with alcohol pads, alcohol-based hand rub, or hydrogen peroxide disinfectant wipes and (2) swab stethoscopes for bioluminescence-based adenosine triphosphate testing before and after disinfection. Outcomes were observed for hand and stethoscope hygiene rates and before and after intervention survey responses. The bacteria that were isolated, colony-forming units (CFU), and bioluminescence scores were tracked.A total of 1,245 observed hand hygiene opportunities showed that compliance improved from 72.5%-82.3% (P.001). In addition, 590 observed patient-provider encounters revealed no significant change in stethoscope hygiene rates of 10% initially and 5% afterward (P = .08), although self-reported rates trended from 56%- 67% postintervention (P = .06). Perceptions regarding stethoscope hygiene importance improved (8.5/10 to 9.3/10; P = .04). Disinfection with alcohol pads, alcohol-based hand rub, and hydrogen peroxide disinfectant wipes were equivalent in CFU reduction (P = .21).Showing providers what is growing on their stethoscopes via cultures and bioluminescence technology before and after disinfection improved "buy in" regarding stethoscope hygiene importance. Both methods were rated as having an equal impact, however, objective observations failed to show improvement.

Although educational programs could enhance knowledge, practices, and compliance with hand hygiene (HH) for health care workers, the researches focusing on effective methods for educating and increasing the compliance with HH practices are scanty. Consequently, the researchers conducted the present study to assess HH-related knowledge, attitude, and compliance rate after the implementation of a modified version of the World Health Organization (WHO) multimodal strategy was written in the background.A pretest-posttest quasiexperimental study was conducted in a university hospital in Cairo among 84 nurses. The study consisted of 4 phases: baseline assessment, intervention, postintervention assessment, and follow-up phase. The intervention (HH-campaign) consisted of 4 components: infrastructure change, training/education of health care workers, posting visual reminders, and development of institutional safety climate "hand hygiene champions."HH compliance rate significantly increased from 28% before the intervention to 50% after the intervention and 58% after the follow-up period (P.001). The knowledge score and the attitude score significantly improved before and after the intervention (P.001). The use of alcohol handrub significantly increased from 9.5% before the intervention to 65% after the intervention and 76% after the follow-up period.Implementation of a modified version of the World Health Organization multimodal strategy successfully doubled HH compliance rates. Tackling a social way of thinking together with regular frequent training and follow-up are essential to sustain adherence to safe HH practices.

Background Studies that examine the perceptions and behaviors of patients regarding patient hand hygiene rarely examine the viewpoint of patients about their hand hygiene behavior relative to current resources provided in the hospital. Methods Voluntary interviews that employed a 16-item survey tool were used among patients (N = 107) in outpatient clinics at post-admission visits. The survey was created using the Behavior Change Wheel, Capability, Opportunity, Motivation Behavior model. Patients were asked whether they brought hand sanitizer to the hospital, used hospital resources to clean their hands, and their perspective on patient hand hygiene importance compared with hospital staff, as well as their satisfaction or lack of satisfaction with hand hygiene independence. Results Most of the participants (65, 60.7%) reported that prior to being admitted to the hospital, they were able to maintain cleaning their hands with little or no difficulty. During their admission, only 21 (19.6%) of the participants reported needing little or no assistance. More than one-half of the participants, 34 (31.8%) and 23 (21.5%), respectively, reported, mostly or completely agreeing that the hand hygiene of the health care staff was more important than their own. Close to one-half of the participants (50, 46.7%) reported not being satisfied at all with their ability to maintain their hand hygiene in the hospital, whereas only 10 (9.3%) were very satisfied with their ability to maintain hand hygiene. Conclusions Findings from this study will enhance our understanding of how to incorporate inpatient hand hygiene into existing infection control programs in inpatient settings.

Highlights • COVID safe behavior includes mask use • Face touching is 1.5 more likely in non-mask wearers, Background Iranian were advice to wear a mask and not touch their face during COVID-19 restrictions in Iran. Methods 1000 people were observed for 15-30 minutes in public places between 22 April and 9 May 2020. The average number of touches to the mucosal zone was calculated per hour and mask wearers (N=568) were compared with those not wearing a mask (N=432). Findings 92% were observed touching their face at least once an hour and averaged 10 (SD 6) touches per hour. Non-mask wearers touched their face significantly more often than mask wearers (11 vs 8 times per hour, P

Few studies have examined the use of hand hygiene interventions among health care personnel and employee absenteeism. To improve the hand hygiene practices of emergency room nurses and technicians, we implemented mandatory use of an automated hand hygiene compliance system. After implementation, we found reductions in employee absenteeism and the number of overtime hours worked by substitute staff. These unanticipated results demonstrate a return on investment that benefits the health of employees.

Background Proper handwashing technique can reduce the mortality of a child. This study aimed to evaluate the impact of a school-based hand hygiene program on the handwashing compliance of children and school absenteeism in Southern Africa. Methods We conducted a 2-arm cluster randomized trial in which 6 private primary schools were allocated randomly to either intervention (3 schools) or control (3 schools) groups. The intervention group consisted of implementing a series of planned activities and measures of hand hygiene program over 9 months. Parameters of primary and secondary outcomes were estimated with generalized estimating equations. Results There were no significant between-group differences in demographic characteristics. The knowledge scores in the intervention group were significantly higher than the scores in the control group, and the technique scores in the intervention group were significantly higher than the scores in the control group after baseline. Further, after the third month, the cleanliness scores in the intervention group were significantly higher than the scores in the control group. In addition, the number of sick leave days decreased in the intervention group. Conclusions The impact of the school-based hand hygiene program was positive. It can be used in both the planning and development of a hand hygiene protocol to increase the handwashing compliance rate of schoolchildren and to reduce school absenteeism in developing countries.

Using an innovative, covert, in-room observer method to evaluate infection control practices for patients with Clostridioides difficile infection, we found no difference between physician and nursing hand hygiene compliance and contact precaution usage. There was also no diurnal variation in hand hygiene practices, but decreased contact precaution usage at night. Conversely, hospital-wide data from overt observations collected over the same time period showed significantly higher hand hygiene compliance among nurses than physicians.

Background Caring for patients in contact precautions can be challenging. In this pilot study, we sought to understand, using qualitative and visual methods, how nurses provide care for patients in contact precaution rooms and to identify potential breakdowns in practice that could increase risk of disease transmission. Methods Qualitative data were collected while shadowing 4 nurses on 2 medical/surgical units at a university medical center between September and October 2016. Observers documented nurses' movements in handwritten fieldnotes. Fieldnote data were analyzed using a descriptive approach with visual depiction to map care delivery in precaution and non-precaution rooms. Results Nurses moved between non-precaution rooms, completing 1-4 tasks per room entry, over the course of several brief room entries and exits. In contrast, nurses rarely entered contact precaution rooms to complete only a few tasks, generally completing ≥10 tasks per room entry. Although hand hygiene on room entry/exit was consistently performed, a breakdown in practice occurred in precaution rooms as nurses tended to move between tasks and contact with the environment without performing hand hygiene. Conclusions Differences in how nurses structure their work in contact precaution rooms may contribute to risk of infectious disease transmission. Understanding and addressing the challenges specific to how nurses work is a critical part of infection prevention in today's hospital environment.

Background Health service hand hygiene programs have seen widespread use of chlorhexidine solutions. Reports of both immediate and delayed hypersensitivity to chlorhexidine are increasing among health care workers. This study examined the prevalence of self-reported symptoms of sensitivity to chlorhexidine solutions among health care workers. Methods This study was a cross-sectional online anonymous survey of all workers at a single health service. Results Of the 1,050 completed responses, 76.3% were female, 35.3% were nurses and midwives, 28% were medical staff, and 8.7% were working in nonclinical areas. Over 95% used chlorhexidine-based hand hygiene products in their workplace. Nurses and midwives most frequently reported asthma (13.7%), contact dermatitis (27.8%), and previous testing for allergy to chlorhexidine (4.9%). There was a correlation between both the presence of atopy, eczema, or dermatitis and the self-reporting of dry skin, eczema, or dermatitis attributed to chlorhexidine use. Discussion Occupational chlorhexidine allergy is an important risk to health care workers. Self-reported symptoms of sensitivity to chlorhexidine solutions revealed high reported use and presence of skin symptoms among health care workers. Conclusions Screening programs need to identify nurses who develop chlorhexidine sensitivity due to occupational exposure. Strategies to mitigate risk should provide alternatives for those with sensitization.

Background Hospital-acquired infections caused by multidrug-resistant organisms (MDROs) are a threat to patient safety and hospital economy. Training in hygiene precautions is known to limit MDRO spread and patient morbidity. As infection prevention is a collaborative task, we developed an interprofessional educational intervention, including a reflective unit about MDRO. This article reports on the perceptions of professionals for MDRO management. Methods In 2017, we conducted 8 trainings, including facilitated group discussions focusing on the question how participants think others experience MDRO. Results were analyzed using a socio-constructivist qualitative approach. Results A total of 51 health care workers from 13 professions and 5 hospitals participated, generating 366 items for coding. Three main themes could be identified: (1) significant barriers in educating clinicians and informing lay persons, (2) emotional reactions–especially anxiety and anger–from the perspective of lay persons and professionals evoked by MDRO, and (3) perceived economic burden. Conclusions MDROs generate psychosocial side effects with an impact on health care management and on professional-patient relationships and interprofessional relationships. Specifically, emotions evoked by insufficient information and transparency play a major role. Therefore, hygiene trainings must not be limited to basic skills. In addition, they should be comprised of communication and educational techniques and evoke attentiveness for emotional stress.

Background Bed bath in daily nursing care is crucial for cleaning and moisturizing patients’ skin. The purpose of this study was to compare the effectiveness of cleaning and level of comfort of towel and disposable baths. The 2 methods were evaluated based on measurements of the transition of resident skin bacteria, stratum corneum water content, transepidermal water loss, and perceived relaxation levels. Methods Twenty-six healthy women aged 65-90 years participated in this study and received disposable and towel baths. We measured 4 indicators before and after bathing. The participants’ relaxation levels were measured by the Japanese adult version of the Profile of Mood States Second Edition short form. Results Both disposable and towel baths significantly decreased resident skin bacteria. Disposable bath also significantly reduced Staphylococcus aureus and effectively maintained the water content of the stratum corneum. Furthermore, disposable bath was as effective as towel bath at contributing to participants’ relaxation levels. Conclusions This study suggested that using a disposable bath for daily cleaning of patients’ skin is more comfortable and effective than using a towel bath.

Background: Good infection prevention is an important aspect of quality of medical care. The aim was to evaluate infection prevention and control (IPC) performance among Dutch general practitioners (GPs).Methods: Based on the current national IPC guidelines for GPs, a self-administered anonymous online questionnaire was developed and sent to GPs in the Nijmegen region of the Netherlands. Thirty-two questions were constructed to survey characteristics of GPs' offices and assess current performance of IPC measures.Results: One hundred questionnaires were included in our analysis. The preferred method of hand hygiene was soap and water (56%) versus alcohol-based handrub (44%). The cleaning of nondisposable, noncritical, semicritical, and critical instruments was consistent with national guideline recommendations or superior to them in 100%, 49%, and 97% of cases, respectively. An average of 57% of GPs reported environmental cleaning frequencies that were compliant with the national guidelines or superior to them. Personal protective equipment was available in 62% of GPs' practices but used in only 25% of home visits to patients.Conclusions: Not all national IPC guidelines seem to be followed to the fullest extent. The current situation indicates there is room for potential improvement regarding implementation of IPC measures in GPs' offices. Area-specific guidelines and continuous medical education regarding IPC may help improve the situation. (C) 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Application of antiseptic products to the skin plays an important role in prevention of a variety of health care-associated infections. Preoperative bathing or showering is widely recommended to reduce the risk of surgical site infections. Evidence of the impact of this measure on surgical site infection rates is mixed, and further prospective trials comparing standardized protocols for showering with plain soap or chlorhexidine gluconate (CHG)-containing soap, or bathing with 2% CHG-impregnated cloths are needed to establish the most effective approach. Current evidence favors the use of alcohol-containing solutions, often containing CHG or povidone-iodine, for surgical site preparation of the skin. Preparation of vaginal mucosa prior to gynecologic surgery may be performed using either povidone-iodine or CHG. Surgical hand antisepsis can be performed by scrubbing with an antimicrobial soap or by handrubbing using an alcohol-based handrub. Addition of CHG to alcohol-based handrubs intended for surgical hand antisepsis is not necessary if they meet recommended efficacy criteria. Daily CHG bathing of intensive care unit patients has been shown to reduce a variety of health care-associated infections, most commonly bloodstream infections (BSIs). Achieving and maintaining optimum application protocols may be challenging, suggesting the need for ongoing staff education, monitoring, and feedback. Additional studies are needed to determine the impact of daily CHG bathing of non-intensive care unit patients. Alcoholic CHG is currently the preferred antiseptic for skin preparation prior to insertion of central and arterial intravascular catheters. CHG-impregnated dressings have been shown to reduce catheter-associated BSI. Because of the widespread use of antiseptics, especially CHG, surveillance for emergence of increased tolerance or resistance is warranted. Antiseptics are applied to the skin for a variety of purposes in health care. Common scenarios in which topical antiseptics are used include preoperative bathing, surgical site preparation, surgical hand hygiene, daily bathing of intensive care unit patients, and prevention of intravascular catheter-associated BSI. The purpose of this article is to review recent evidence regarding the best products for skin antisepsis.

Background Health care workers routinely contaminate skin and clothing when doffing personal protective equipment (PPE). Alternative doffing strategies, such as hand hygiene on gloved hands and double gloving, have been suggested but not validated by comparison against the standard Centers for Disease Control and Prevention procedures. Methods Participants were assigned to doff PPE following 1 of 4 specific strategies. Prior to doffing, PPE was “contaminated” with Glo Germ and fluorescing Staphylococcus epidermidis at the recommended level of 1.5 × 108 colony forming units/mL. After doffing, areas of self-contamination were detected using a black light. Cultures were taken from these areas using cotton swabs, inoculated onto blood agar plates, and incubated for 48hours. Each participant completed a survey regarding usability. The Fisher exact test and the Kruskal-Wallis test were used for data analysis with SAS 9.4. Results There were 51 participants who completed the study. Breaches in PPE were observed in only 5 of 51 doffs (10%). However, 46 of 51 (90%) had areas of self-contamination that was apparent by transfer of Glo Germ to skin or clothing. A subset (16%) of these sites also grew fluorescing S epidermidis. Assigned doffing strategy was associated with bacterial contamination (P = .0151), but not usability (P = .2372). Conclusions Participants experienced self-contamination when doffing PPE with both a surrogate marker and live bacteria. Close attention to doffing technique is necessary for optimal results, and one-step procedures may be more effective.

Background Hand hygiene (HH) is the primary measure in the prevention of health care–associated infections; however, from published studies, compliance of health care workers (HCWs) to HH guidelines is low. There is currently no review on HH compliance rates in developing countries, specifically sub-Saharan Africa (SSA), or the barriers to compliance. We therefore, through a narrative review, sought to identify the compliance with and the barriers to HH in SSA. Methods From 3 databases, we performed a search of peer-reviewed studies from SSA, conducted among HCWs, published in the English language between 2005 and 2017. Only studies that reported HH compliance and/or barriers were included. Results A total of 278 articles were identified, and the final sample of 27 articles was analyzed in full length. Overall, the HH compliance rate was estimated to be 21.1%, and doctors had better compliance irrespective of the type of patient contact. The main barriers identified were heavy workload, infrastructural deficit (eg, lack of water, soap, hand sanitizers, and blocked/leaking sinks), and poorly positioned facilities. Conclusions HH compliance is poor among SSA HCWs. There is a need for more reports of HH compliance in SSA, and emphasis needs to be placed on surgical wards in which surgical site infections—the most common form of health care—associated infections in SSA—are most likely to occur. Barriers identified in this review are consistent with the findings of studies conducted elsewhere; however, it appears that heavy workload, infrastructural deficit, and poorly positioned facilities are more likely in developing countries.

Background Hand hygiene compliance is low among anesthesia providers in the operating room, which places patients at risk of preventable infections. The goal of this project was to improve hand hygiene compliance by educating anesthesia providers on the World Health Organization's 5 indications for hand hygiene, and increasing access to hand hygiene products in the operating room. Methods Observations of hand hygiene in the operating room took place in 3 phases: preimplementation, postimplementation, and 60 days postimplementation. Results The results showed significant improvements in compliance for each of the 5 indications for hand hygiene as well as overall compliance. Each of the 3 phases of anesthesia demonstrated significant improvement as well. The results also showed a significant decrease in both glove use and use of the portable hand sanitizer device. Discussion Education and monitoring of hand hygiene among anesthesia providers in the operating room can improve hand hygiene compliance. Conclusions Although the use of the portable device declined, further studies could focus on observing single anesthesia providers instead of a preceptor/student combination, and also examine proximity to hand hygiene products in relation to compliance.

Covert observation (CO) is reliable for measuring hand hygiene compliance (HHC). However, the benefit of adding CO to overt observation (OO) is uncertain. We evaluated whether incorporating CO into an OO-based hand hygiene (HH) promotion program improves HH rate.Health care worker's HH activities were observed through 5 monitoring sessions (2 in phases 1 and 2 and 1 in phase 3) of simultaneous CO and OO. An intervention was applied-barrier identification interview-only in phase 2.Overall HHC was 91.0% for OO, and 49.3% for CO. HHC in phase 1 was not changed by repeated CO (34.7% and 34.0%, P = .70). HHC based on CO increased to 66.9% in phase 2 after the application of an intervention (P.01), but decreased to 57.5% in phase 3 (P.01). HHC based on OO increased significantly between only the first and second sessions in phase 2 (90.8% and 94.5%, respectively, P = .01).Although CO did not significantly change behavior, HHC with CO responded promptly to the application and cessation of a new intervention.CO reflects HHC change more reliably than does OO. However, it is uncertain whether CO will improve HHC.

Background Improving hand hygiene compliance among healthcare professionals is the most effective way to reduce healthcare–acquired infections. Electronic systems developed to increase hand hygiene performance show promise but might not maintain staff participation over time. In this study, we investigated an intermittent deployment strategy to overcome potentially declining participation levels. Methods An electronic monitoring system was deployed 3times at 6-month intervals on a musculoskeletal rehabilitation nursing unit in Toronto. Each deployment lasted 4 consecutive weeks. Each wall-mounted soap and hand rub dispenser was outfitted with an activation counter to assess the impact of system deployments on overall handwashing activity. Results System deployments took place in October 2016, April 2017, and October 2017. A total of 76,130 opportunities were recorded, with an aggregate hand hygiene performance of 67.43%. A total of 515,156 dispenser activations were recorded. There was a significant increase in aggregate dispenser use with every deployment and a decrease over several weeks following each withdrawal. Participation was high at the beginning of each deployment and declined during each deployment but was restored to a high level with the start of the next deployment. Conclusions Intermittent deployment of an electronic monitoring intervention counteracts potential declines in participation rates sometimes seen with continuous system use. However, adoption of this strategy requires the acceptance of lower periods of performance between each deployment.

Background Hand hygiene is crucial for preventing nosocomial infections; however, adherence rates need further attention. Prevention of nosocomial infections through regular hand hygiene monitoring and feedback is recommended by the World Health Organization. Technology holds the potential for achieving this goal. The aim of this study was to assess the influence of technological behavior monitoring innovations on hand hygiene adherence and their acceptance by healthcare professionals. Methods A rapid review of the literature was conducted. A literature search was performed in electronic databases (Cochrane Library, Scopus, PubMed, CINAHL, PsycINFO, PsycARTICLES, PSYNDEX) and via citation tracking in November 2017. Records were screened for eligibility. Included studies were analyzed and synthesized in a narrative, tabular way. Results Overall, 2,426 studies were identified, and 12 were included. Findings indicated that behavior monitoring technology improves hand hygiene adherence, resulting in adherence increases between 6.40%-54.97%. The majority of systems provided real-time feedback. Factors influencing acceptance of technology by healthcare professionals include transparency and confidentiality, user attitude and environment, device function, and device usability. Conclusions Recognizing the importance of hand hygiene adherence, active communication between behavior monitoring technology and healthcare workers seems to mediate improvement in sustainable hand hygiene adherence behavior.

Background Stethoscopes harbor pathogens that can be transferred to patients when proper sanitary measures are not taken. Our aim was to assess medical provider stethoscope cleaning and hand hygiene in an emergency department setting. Methods The frequency and methods of stethoscope cleaning during and after provider-patient encounters were observed anonymously in an emergency department of the VA San Diego Healthcare System. Results Among the total of 426 encounters, 115 (26.9%) involved the use of a personal stethoscope. In 15 of these 115 encounters (13.0%), the provider placed a glove over the stethoscope before patient contact. In 13 of these 115 encounters (11.3%), the provider cleaned the stethoscope with an alcohol swab after patient interaction. Stethoscope hygiene with water and a hand towel before patient interaction was observed in 5 of these 115 encounters (4.3%). Hand sanitizer use or handwashing was observed in 213 of the 426 encounters (50.0%) before patient interaction. Gloves were used before patient interaction in 206 of these 426 encounters (48.4%). Hand sanitizer or handwashing was used in 332 of the 426 encounters (77.9%) after patient interaction. Conclusions Rates of stethoscope and hand hygiene performance were lower than expected. Further investigation of stethoscope contamination and the associated risk of nosocomial infection are needed. Perhaps clearer guidelines on proper stethoscope cleaning would reduce this risk.

HIGHLIGHTS • Infection control nurses have greater hand hygiene knowledge than registered nurses. • Perception, attitude, and role model scores positively correlate. • Hygiene perception, attitude, and role models correlate with hygiene performance., Background We assessed the current status of knowledge, perception, attitude, and role model regarding hand hygiene (HH) among infection control nurses (ICNs) and identified the factors influencing these variables. Methods A structured questionnaire was adapted from a World Health Organization survey. Data were collected from November 8, 2017, to February 2, 2018. Results ICNs showed the following scores (mean ± SD): knowledge (19.5 ± 2.3), perception (69.9 ± 8.9), attitude (46.9 ± 5.8), and role model (39.2 ± 6.0). HH performance of health care workers (HCWs) was 75.2 ± 15.5. Mean HH performance scores of HCWs (P = .007) differed significantly according to infection control experience (3 groups: ≤12 months, 13-24 months, >24 months). Perception, attitude, and role model scores showed positive correlations with each other (P < .01). The regression model for HH performance of HCWs was calculated as follows: Y1 = 31.638 + 0.067X1 (perception of ICNs) + 0.133X2 (attitude of ICNs) + 0.825X3 (role model of ICNs) (P < .001; adjusted R2 = 0.115). Discussion Perception, attitude, and role model scores of ICNs were significant predictors of HH performance of HCWs. Conclusions Specialized well-structured HH education programs should be developed for ICNs that will help improve HH performance of HCWs.

Background: Recently, innovative technologies for hand hygiene (HH) monitoring have been developed to improve HH adherence in health care. This study explored health care workers' experiences of using an electronic monitoring system to assess HH adherence. Methods: An electronic monitoring system with digital feedback was installed on a surgical ward and interviews with health care workers using the system (n = 17) were conducted. The data were analyzed according to grounded theory by Strauss and Corbin. Results: Health care workers' experiences were expressed in terms of having trust in the monitoring system, requesting system functionality and ease of use and becoming aware of one's own performance. This resulted in the core category of learning to interact with new technology, summarized as the main strategy when using an electronic monitoring system in clinical settings. The system with digital feedback improved the awareness of HH and individual feedback was preferable to group feedback. Conclusions: Being involved in using and managing a technical innovation for assessing HH adherence in health care is a process of formulating a strategy for learning to interact with new technology. The importance of inviting health care workers to participate in the co-design of technical innovations is crucial, as it creates both trust in the innovation per se and trust in the process of learning how to use it. (C) 2021 The Author(s). Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.

Background In the era of COVID-19 pandemic, there is an upsurge of healthcare-associated infections (HAI) in COVID intensive care units (ICUs), which can be reduced by following proper hand hygiene (HH) practice. Performing HH auditing in COVID ICU and providing timely feedback to the stake holders is crucial to reduce HAIs. Methods From November 2020- April 2021, HH audit was conducted in COVID ICUs. HH complete adherence rate (HHCAR), HH partial adherence rate (HHPAR) and HH total adherence rate (HHTAR) were analyzed. Profession-specific HHTAR and moment-specific HHTAR (for each WHO moment) were also calculated. Results HHCAR, HHPAR and HHTAR were found as 30.8%, 34.5% and 65.3% respectively. There was a significant increase in the monthly HHTAR from 26.7% to 68.4% (P < .001). The profession-specific HHAR was found to be highest among doctors (67.5%) and nurses (66.4%). As the HHTAR increases there is a significant decrease in device associated infection (DAI) rate from 24.7 to 11.5 per 1,000 device days. Conclusions Auditing HH and providing timely feedback significantly improved HH compliance. The need of the hour is to regularly conduct HH audit in COVID locations of all healthcare facilities to reduce HAI rate among the COVID- 19 infected patients in ICUs.