JIPH-318; No. of Pages 5
ARTICLE IN PRESS
Journal of Infection and Public Health (2014) xxx, xxx—xxx
SHORT REPORT
A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center Hasan M. Al-Dorzi a,b, Amal Matroud c, Khaled A. Al Attas d, Ahmad I. Azzam e, Adel Musned f, Brintha Naidu g, Tamara Govender h, Zandile Yeni i, Chinette Abarintos j, David White k, Hanan Balkhy l, Yaseen M. Arabi a,b,∗ a
Intensive Care Department, King Abdulaziz Medical City-Riyadh, Riyadh 11426, Saudi Arabia b College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh 11426, Saudi Arabia c Adult ICU, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia d Anesthesiology Department, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia e Infection Prevention and Control Department, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia f Respiratory Services Department, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia g Surgical Intensive Care Unit, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia h Burn Unit, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia i Intermediate Care Unit, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia j Neuro ICU, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia
∗ Corresponding author at: Intensive Care Department, King Abdulaziz Medical City-Riyadh, Riyadh 11426, Saudi Arabia. Tel.: +966 1 8011111x18855/18877; fax: +966 1 8011111x18880. E-mail addresses: [email protected] (H.M. Al-Dorzi), [email protected] (A. Matroud), [email protected] (K.A. Al Attas), [email protected] (A.I. Azzam), [email protected] (A. Musned), [email protected] (B. Naidu), [email protected] (T. Govender), [email protected] (Z. Yeni), [email protected] (C. Abarintos), [email protected] (D. White), [email protected] (H. Balkhy), [email protected], [email protected] (Y.M. Arabi).
http://dx.doi.org/10.1016/j.jiph.2014.02.003 1876-0341/© 2014 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Al-Dorzi HM, et al. A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center. J Infect Public Health (2014), http://dx.doi.org/10.1016/j.jiph.2014.02.003
JIPH-318; No. of Pages 5
ARTICLE IN PRESS
2
H.M. Al-Dorzi et al.
k
Critical Care Services, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia l Infection Control and Prevention Program, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia Received 4 September 2013; received in revised from 9 February 2014; accepted 11 February 2014
KEYWORDS Hand hygiene; Critical care; Quality improvement; Intensive care unit
Summary: A multidisciplinary team was formed to improve hand hygiene (HH) practices in a tertiary-care ICU. At baseline, an audit revealed that the overall HH compliance was 64% and was significantly lower at night than during the day shift. After implementing a stepwise multifaceted approach that included education, workplace reminders, active feedback and later universal contact precautions, the HH compliance improved significantly to >80%, and the improvement was sustained over several months. This improvement was noted during the day and night and affected different healthcare workers as well as visitors. © 2014 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.
Rationale Adequate hand hygiene (HH) is crucial to preventing healthcare-associated infections. Improving HH practices in intensive care units (ICUs) is a major patient safety initiative because HH compliance in these units is often low (30—40%) [1] and critically ill patients are at high risk of healthcare-associated infections. The World Health Organization (WHO) recommends the implementation of a multidisciplinary, multifaceted and multimodal program to improve adherence of healthcare workers (HCWs) [2]. This study evaluated a quality improvement project to improve HH practices in a tertiary-care ICU.
Methods This study was a quality improvement project conducted at the Intensive Care Department of King Abdulaziz Medical City-Riyadh, Saudi Arabia. The hospital was a 900-bed tertiary-care hospital that had an active infection prevention program and was a pilot site for the WHO ‘‘Clean Care is Safer Care’’ initiative in 2008. The ICU was a 21-bed medicalsurgical closed unit, was continuously covered by onsite board-certified intensivists and registrars, had a nurse-to-patient ratio of 1:1 and used an open visiting policy. As part of this project, we evaluated the ICU’s HH infrastructure using the System Change section of the WHO Hand Hygiene Self-Assessment Framework questionnaire; its score was determined
to be 100%. To evaluate HH practices and improve them, a multidisciplinary HH team was formed by the department chairman in February 2011 and included ICU physicians, nurses, respiratory therapists and an infection control specialist. Trained ICU staff audited HH practices of HCWs and visitors using the WHO audit tool, modified to additionally note the appropriateness of the HH technique (performance of all WHO recommended steps) and procedure time (categorized into day shift from 0700 to 1859 and night shift from 1900 to 0659). The compliance rate was calculated by adherence to the WHO five moments of HH [2] by hand washing or alcohol-based hand rub. The team met on a regular basis (initially weekly then monthly), reviewed audit results and implemented the following interventions in a stepwise and escalating manner: HH education for staff, new hires, rotating residents and visitors using videos, coaching and online modules; workplace reminders including HH breaks at 1100 and 2200, during which all ICU staff demonstrated proper alcohol-based hand rub; addressing perceived HH barriers; active feedback of HH compliance to all staff by direct communication and emails; empowerment of staff to educate and stop violators; and warning letters from the chairman for repetitive violations. In addition, universal contact precautions were instituted for all patients from February 2012 onwards due to the outbreak of multidrug-resistant organisms in the ICU. The Chisquare test was used to assess differences among groups. HH compliance rates were reported as run charts.
Please cite this article in press as: Al-Dorzi HM, et al. A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center. J Infect Public Health (2014), http://dx.doi.org/10.1016/j.jiph.2014.02.003
JIPH-318; No. of Pages 5
ARTICLE IN PRESS
A multifaceted approach to improve hand hygiene practices
3
Hand hygiene audit with monthly feedback Empowerment of staff to stop noncompliant staff Hand hygiene breaks Universal contact precautions
100 80 60
all 40 20 0 100 80 60 40
physicians nurses
20
respiratory therapists other healthcare workers
0 100 80 60
visitors 40 20 0
Hand hygiene awareness days
Figure 1 Run charts describing hand hygiene (HH) compliance rates of different healthcare workers and visitors from July 2011 to October 2012. The baseline HH audit was performed in February and March 2011.
Results Based on 836 observations, the baseline HH compliance rate (February—March, 2011) for all HCWs was 64% (68% for physicians and 62% for both nurses and respiratory therapists). The compliance rate was significantly lower before patient contact (53%) than after contact (78%, p < 0.001) and lower during night shifts (53%) than during day shifts (78%, p < 0.001). The HH technique was frequently inappropriate (72% for physicians and 57% for nurses and respiratory therapists, p = 0.01).
ICU visitors had a low HH rate (24%). A subsequent audit consisted of 5626 observations from July 2011 to October 2012. Fig. 1 shows the run charts of monthly HH compliance and reveals that the compliance gradually increased starting November 2011, with a steep improvement in March 2012, after which HH compliance was sustained at above 80%. This compliance coincided with the universal application of contact precautions. Fig. 2 shows that the improvement occurred in the day and night shifts and affected HH technique as well.
Please cite this article in press as: Al-Dorzi HM, et al. A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center. J Infect Public Health (2014), http://dx.doi.org/10.1016/j.jiph.2014.02.003
JIPH-318; No. of Pages 5
ARTICLE IN PRESS
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Figure 2 Monthly rates of HH compliance in the day and night shifts and of inappropriate HH technique. The baseline period was February and March 2011. *Day shift: 0700—1859; night shift: 1900—0659; **when hand hygiene was performed.
Discussion We reported on our project to improve HH practices in a tertiary-care ICU and found that a stepwise multifaceted approach that included universal contact precautions led to a significant and sustained improvement in HH. At baseline, we found that HH rates were significantly lower in the night than the day, when the workload is usually higher. This result was opposite to the finding of a multicenter study in which mornings and afternoons were associated with decreased HH compliance compared to nights based on multivariate analysis [3]. This discrepancy can be explained by HH monitoring being conducted only during the regular working hours before our project and by the low staff number during the night shifts. We also noted that the HH technique was frequently inappropriate, which could be related to inadequate knowledge or due to a theory—practice gap [4]. Our improvements in HH practices resulted from a system redesign that required crucial factors for success, such as leadership involvement and support, development of a multidisciplinary team and establishment of performance appraisal systems [5]. The multidisciplinary HH team implemented multifaceted interventions and continuously monitored the process. Applying universal contact precautions, an aspect of system redesign, was closely related to HH improvements and may have represented a form of forcing functions to improve
guideline adherence. However, another study found that gown-use requirement was associated with a small improvement only in after-care HH compliance (48% versus 41%, p = 0.02) based on adjusted analysis [6]. In conclusion, the development of a multidisciplinary team with a multifaceted approach was associated with sustained improvement in HH practices in a tertiary-care ICU.
Conflict of interest Funding: No funding sources. Competing interests: None declared. Ethical approval: Not required.
References [1] Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283—94. [2] Pittet D, Allegranzi B, Boyce J, World Health Organization World Alliance for Patient Safety First Global Patient Safety Challenge Core Group of E. The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations. Infect Control Hosp Epidemiol 2009;30:611—22. [3] Rosenthal VD, Pawar M, Leblebicioglu H, Navoa-Ng JA, Villamil-Gomez W, Armas-Ruiz A, et al. Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach over 13 years in 51
Please cite this article in press as: Al-Dorzi HM, et al. A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center. J Infect Public Health (2014), http://dx.doi.org/10.1016/j.jiph.2014.02.003
JIPH-318; No. of Pages 5
ARTICLE IN PRESS
A multifaceted approach to improve hand hygiene practices cities of 19 limited-resource countries from Latin America, Asia, the Middle East, and Europe. Infect Control Hosp Epidemiol 2013;34:415—23. [4] Mortell M. Hand hygiene compliance: is there a theory—practice—ethics gap? Br J Nurs 2012;21(17): 1011—4.
5
[5] Wang MC, Hyun JK, Harrison M, Shortell SM, Fraser I. Redesigning health systems for quality: lessons from emerging practices. Jt Comm J Qual Patient Saf 2006;32:599—611. [6] Golan Y, Doron S, Griffith J, El Gamal H, Tanios M, Blunt K, et al. The impact of gown-use requirement on hand hygiene compliance. Clin Infect Dis 2006;42:370—6.
Available online at www.sciencedirect.com
ScienceDirect
Please cite this article in press as: Al-Dorzi HM, et al. A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center. J Infect Public Health (2014), http://dx.doi.org/10.1016/j.jiph.2014.02.003
ARTICLE IN PRESS
Journal of Infection and Public Health (2014) xxx, xxx—xxx
SHORT REPORT
A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center Hasan M. Al-Dorzi a,b, Amal Matroud c, Khaled A. Al Attas d, Ahmad I. Azzam e, Adel Musned f, Brintha Naidu g, Tamara Govender h, Zandile Yeni i, Chinette Abarintos j, David White k, Hanan Balkhy l, Yaseen M. Arabi a,b,∗ a
Intensive Care Department, King Abdulaziz Medical City-Riyadh, Riyadh 11426, Saudi Arabia b College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh 11426, Saudi Arabia c Adult ICU, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia d Anesthesiology Department, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia e Infection Prevention and Control Department, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia f Respiratory Services Department, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia g Surgical Intensive Care Unit, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia h Burn Unit, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia i Intermediate Care Unit, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia j Neuro ICU, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia
∗ Corresponding author at: Intensive Care Department, King Abdulaziz Medical City-Riyadh, Riyadh 11426, Saudi Arabia. Tel.: +966 1 8011111x18855/18877; fax: +966 1 8011111x18880. E-mail addresses: [email protected] (H.M. Al-Dorzi), [email protected] (A. Matroud), [email protected] (K.A. Al Attas), [email protected] (A.I. Azzam), [email protected] (A. Musned), [email protected] (B. Naidu), [email protected] (T. Govender), [email protected] (Z. Yeni), [email protected] (C. Abarintos), [email protected] (D. White), [email protected] (H. Balkhy), [email protected], [email protected] (Y.M. Arabi).
http://dx.doi.org/10.1016/j.jiph.2014.02.003 1876-0341/© 2014 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Al-Dorzi HM, et al. A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center. J Infect Public Health (2014), http://dx.doi.org/10.1016/j.jiph.2014.02.003
JIPH-318; No. of Pages 5
ARTICLE IN PRESS
2
H.M. Al-Dorzi et al.
k
Critical Care Services, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia l Infection Control and Prevention Program, King Abdulaziz Medical City-Riyadh, PO Box 22490, Riyadh 11426, Saudi Arabia Received 4 September 2013; received in revised from 9 February 2014; accepted 11 February 2014
KEYWORDS Hand hygiene; Critical care; Quality improvement; Intensive care unit
Summary: A multidisciplinary team was formed to improve hand hygiene (HH) practices in a tertiary-care ICU. At baseline, an audit revealed that the overall HH compliance was 64% and was significantly lower at night than during the day shift. After implementing a stepwise multifaceted approach that included education, workplace reminders, active feedback and later universal contact precautions, the HH compliance improved significantly to >80%, and the improvement was sustained over several months. This improvement was noted during the day and night and affected different healthcare workers as well as visitors. © 2014 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.
Rationale Adequate hand hygiene (HH) is crucial to preventing healthcare-associated infections. Improving HH practices in intensive care units (ICUs) is a major patient safety initiative because HH compliance in these units is often low (30—40%) [1] and critically ill patients are at high risk of healthcare-associated infections. The World Health Organization (WHO) recommends the implementation of a multidisciplinary, multifaceted and multimodal program to improve adherence of healthcare workers (HCWs) [2]. This study evaluated a quality improvement project to improve HH practices in a tertiary-care ICU.
Methods This study was a quality improvement project conducted at the Intensive Care Department of King Abdulaziz Medical City-Riyadh, Saudi Arabia. The hospital was a 900-bed tertiary-care hospital that had an active infection prevention program and was a pilot site for the WHO ‘‘Clean Care is Safer Care’’ initiative in 2008. The ICU was a 21-bed medicalsurgical closed unit, was continuously covered by onsite board-certified intensivists and registrars, had a nurse-to-patient ratio of 1:1 and used an open visiting policy. As part of this project, we evaluated the ICU’s HH infrastructure using the System Change section of the WHO Hand Hygiene Self-Assessment Framework questionnaire; its score was determined
to be 100%. To evaluate HH practices and improve them, a multidisciplinary HH team was formed by the department chairman in February 2011 and included ICU physicians, nurses, respiratory therapists and an infection control specialist. Trained ICU staff audited HH practices of HCWs and visitors using the WHO audit tool, modified to additionally note the appropriateness of the HH technique (performance of all WHO recommended steps) and procedure time (categorized into day shift from 0700 to 1859 and night shift from 1900 to 0659). The compliance rate was calculated by adherence to the WHO five moments of HH [2] by hand washing or alcohol-based hand rub. The team met on a regular basis (initially weekly then monthly), reviewed audit results and implemented the following interventions in a stepwise and escalating manner: HH education for staff, new hires, rotating residents and visitors using videos, coaching and online modules; workplace reminders including HH breaks at 1100 and 2200, during which all ICU staff demonstrated proper alcohol-based hand rub; addressing perceived HH barriers; active feedback of HH compliance to all staff by direct communication and emails; empowerment of staff to educate and stop violators; and warning letters from the chairman for repetitive violations. In addition, universal contact precautions were instituted for all patients from February 2012 onwards due to the outbreak of multidrug-resistant organisms in the ICU. The Chisquare test was used to assess differences among groups. HH compliance rates were reported as run charts.
Please cite this article in press as: Al-Dorzi HM, et al. A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center. J Infect Public Health (2014), http://dx.doi.org/10.1016/j.jiph.2014.02.003
JIPH-318; No. of Pages 5
ARTICLE IN PRESS
A multifaceted approach to improve hand hygiene practices
3
Hand hygiene audit with monthly feedback Empowerment of staff to stop noncompliant staff Hand hygiene breaks Universal contact precautions
100 80 60
all 40 20 0 100 80 60 40
physicians nurses
20
respiratory therapists other healthcare workers
0 100 80 60
visitors 40 20 0
Hand hygiene awareness days
Figure 1 Run charts describing hand hygiene (HH) compliance rates of different healthcare workers and visitors from July 2011 to October 2012. The baseline HH audit was performed in February and March 2011.
Results Based on 836 observations, the baseline HH compliance rate (February—March, 2011) for all HCWs was 64% (68% for physicians and 62% for both nurses and respiratory therapists). The compliance rate was significantly lower before patient contact (53%) than after contact (78%, p < 0.001) and lower during night shifts (53%) than during day shifts (78%, p < 0.001). The HH technique was frequently inappropriate (72% for physicians and 57% for nurses and respiratory therapists, p = 0.01).
ICU visitors had a low HH rate (24%). A subsequent audit consisted of 5626 observations from July 2011 to October 2012. Fig. 1 shows the run charts of monthly HH compliance and reveals that the compliance gradually increased starting November 2011, with a steep improvement in March 2012, after which HH compliance was sustained at above 80%. This compliance coincided with the universal application of contact precautions. Fig. 2 shows that the improvement occurred in the day and night shifts and affected HH technique as well.
Please cite this article in press as: Al-Dorzi HM, et al. A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center. J Infect Public Health (2014), http://dx.doi.org/10.1016/j.jiph.2014.02.003
JIPH-318; No. of Pages 5
ARTICLE IN PRESS
4
H.M. Al-Dorzi et al.
Figure 2 Monthly rates of HH compliance in the day and night shifts and of inappropriate HH technique. The baseline period was February and March 2011. *Day shift: 0700—1859; night shift: 1900—0659; **when hand hygiene was performed.
Discussion We reported on our project to improve HH practices in a tertiary-care ICU and found that a stepwise multifaceted approach that included universal contact precautions led to a significant and sustained improvement in HH. At baseline, we found that HH rates were significantly lower in the night than the day, when the workload is usually higher. This result was opposite to the finding of a multicenter study in which mornings and afternoons were associated with decreased HH compliance compared to nights based on multivariate analysis [3]. This discrepancy can be explained by HH monitoring being conducted only during the regular working hours before our project and by the low staff number during the night shifts. We also noted that the HH technique was frequently inappropriate, which could be related to inadequate knowledge or due to a theory—practice gap [4]. Our improvements in HH practices resulted from a system redesign that required crucial factors for success, such as leadership involvement and support, development of a multidisciplinary team and establishment of performance appraisal systems [5]. The multidisciplinary HH team implemented multifaceted interventions and continuously monitored the process. Applying universal contact precautions, an aspect of system redesign, was closely related to HH improvements and may have represented a form of forcing functions to improve
guideline adherence. However, another study found that gown-use requirement was associated with a small improvement only in after-care HH compliance (48% versus 41%, p = 0.02) based on adjusted analysis [6]. In conclusion, the development of a multidisciplinary team with a multifaceted approach was associated with sustained improvement in HH practices in a tertiary-care ICU.
Conflict of interest Funding: No funding sources. Competing interests: None declared. Ethical approval: Not required.
References [1] Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283—94. [2] Pittet D, Allegranzi B, Boyce J, World Health Organization World Alliance for Patient Safety First Global Patient Safety Challenge Core Group of E. The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations. Infect Control Hosp Epidemiol 2009;30:611—22. [3] Rosenthal VD, Pawar M, Leblebicioglu H, Navoa-Ng JA, Villamil-Gomez W, Armas-Ruiz A, et al. Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach over 13 years in 51
Please cite this article in press as: Al-Dorzi HM, et al. A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center. J Infect Public Health (2014), http://dx.doi.org/10.1016/j.jiph.2014.02.003
JIPH-318; No. of Pages 5
ARTICLE IN PRESS
A multifaceted approach to improve hand hygiene practices cities of 19 limited-resource countries from Latin America, Asia, the Middle East, and Europe. Infect Control Hosp Epidemiol 2013;34:415—23. [4] Mortell M. Hand hygiene compliance: is there a theory—practice—ethics gap? Br J Nurs 2012;21(17): 1011—4.
5
[5] Wang MC, Hyun JK, Harrison M, Shortell SM, Fraser I. Redesigning health systems for quality: lessons from emerging practices. Jt Comm J Qual Patient Saf 2006;32:599—611. [6] Golan Y, Doron S, Griffith J, El Gamal H, Tanios M, Blunt K, et al. The impact of gown-use requirement on hand hygiene compliance. Clin Infect Dis 2006;42:370—6.
Available online at www.sciencedirect.com
ScienceDirect
Please cite this article in press as: Al-Dorzi HM, et al. A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center. J Infect Public Health (2014), http://dx.doi.org/10.1016/j.jiph.2014.02.003
