Original Studies
Assessment of Hand Hygiene Resources and Practices at the 2 Children’s Hospitals in Greece Sofia Kouni, MD, MSc,* Georgia Kourlaba, MSc, PhD,* Katerina Mougkou, MD,* Stefania Maroudi, MSc,* Betty Chavela,* Chara Nteli, MSc,† Athanasia Lourida, MD,* Nikos Spyridis, MD, PhD,‡ Theoklis Zaoutis, MD, MSCE,*§ and Susan Coffin, MD, MPH§ Background: Hand hygiene (HH) is the most effective way to prevent health care-associated infections and the spread of antimicrobial-resistant pathogens. The aim of our study was to assess the existing HH resources and current HH practices at 2 hospitals in Athens, Greece. Methods: Observational HH data and an inventory of HH resources were collected from 13 wards including medical/surgical, oncology/transplant and intensive care units, during 65, 1-hour observations periods. Results: A total of 1271 HH opportunities were observed during the study period, including 944 of Health Care Workers (HCW) and 327 of visitors and parents. The nursing HH compliance was highest (49%) followed by medical compliance (24%, P < 0.001). HCW HH compliance was highest in intensive care units and the transplant unit (64–87%). The rate of appropriate HH for HCW was 22.6%. HCW most commonly used soap and water (76.1%). The HH procedure was more likely to be appropriate when soap and water were used as compared with alcohol based hand rub (64.6% and 47.5%, P = 0.006). A marginally significant association was identified between the HH compliance rate and the number of alcohol based hand rub dispensers per room (P = 0.057). In visitors and parents, the HH compliance was found to be 19%, whereas the rate of appropriate HH was 8.9%. Conclusions: Low levels of HH were observed. Key Words: compliance, hand hygiene, resources, quality improvement (Pediatr Infect Dis J 2014;33:e247–e251)
H
and hygiene (HH) is the most effective way to prevent health care-associated infections (HAI) and the spread of antimicrobial-resistant pathogens.1–4 Despite the fact that HH is a simple and very effective method for reducing the rates of HAI, the lack of compliance with HH in healthcare settings remains a major problem.5 Measurement of HH compliance associated with regular feedback of data as one of the most effective measures to improve HH practice.6,7 Barriers to appropriate HH including lack of knowledge, increased workload and inaccessible HH supplies contribute to low HH compliance among health care workers (HCWs).8 Limited availability of the resources needed to perform HH, such as a functional
Accepted for publication April 9, 2014. From the *The Stavros Niarchos Foundation-Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), University of Athens School of Medicine; †Pediatric Intensive Care Unit; ‡Second Department of Pediatrics, University of Athens, Aglaia Kuriakou Children’s Hospital, Athens, Greece; and §Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia, UPENN School of Medicine, Philadelphia, PA. All authors have seen and agreed to the submitted version of the paper. No material has been published elsewhere. The authors have no funding or conflicts of interest to disclose. Address for correspondence: Sofia Kouni, MD, MSc, “Agia Sophia” Children’s Hospital, Thivon & Papadiamantopoulou, Goudi, Athens, 115 27, Greece. E-mail: [email protected], [email protected]. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0891-3668/14/3310-e247 DOI: 10.1097/INF.0000000000000376
sink with soap, single use towels and alcohol based hand rub (ABHR), has been cited as an easily modifiable contributor to poor HH.9,10 The issue of HH is particularly timely and important to address in Greece at this time. As a result of the ongoing economic crisis, there is increased financial burden on public hospitals, which has led to understaffing, lack of supplies, increased admissions and crowding. These are factors that increase the risk of HAI and further exacerbate the economic burden of the healthcare system. In particular, public healthcare in Greece has among the highest rates of inappropriate antibiotic prescribing in Europe, the highest rates of multiresistant organisms, and high rates of HAI. There are very limited data regarding HH practices and resources in Greece, particularly in children. Therefore, given the current healthcare crisis and the lack of data, the aim of our study was to assess the existing HH resources and current HH practices in Greece to provide local data to clinicians and guide future improvement work. This approach can serve as a guide to other institutions embarking on work to improve HH.
METHODS Study Design and Setting This study was a cross sectional observational study of HCW and visitor compliance with HH. The study was carried out between October 2012 and January 2013 at the 2 largest pediatric hospitals in Athens in Greece, which include about 1000 beds and account for approximately two-thirds of pediatric tertiary care admissions in the country. These 2 hospitals are physically connected by bridges but do not share medical or nursing staff. Similar clinical services are offered at both hospitals. Observational HH data and an inventory of HH resources were collected from 13 wards (selected based on patient acuity and size) in the 2 pediatric hospitals, including medical/surgical, oncology, transplant (BMTU), intensive care units (ICUs) and emergency departments.
Hand Hygiene Observations Observations of HH practices were carried out on each of the participating units for 5, 1-hour periods. Observations were collected during morning, noon and afternoon shifts in each ward, times that were selected were based on increased clinical activity. The same times of the day were used for HH observations for all units to guarantee comparability. A data collection form and a protocol for collecting HH observations were developed based upon tools from the World Health Organization (WHO; Appendix).1,2 The HCW were aware why the auditor was present. To maintain HCW anonymity, individual identities were not captured although the subject’s occupational role was recorded. No more than 3 events were recorded for an individual during a single observation period. Observations of HH practices of HCWs (ie, doctors and nurses) as well as parents and visitors were collected. The audit team had 3 members, 1 doctor and 2 nurses who separately made the observations. All the members of the team were trained on HH methods. A pilot observation period in which
The Pediatric Infectious Disease Journal • Volume 33, Number 10, October 2014
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Kouni et al
The Pediatric Infectious Disease Journal • Volume 33, Number 10, October 2014
the inter-rater reliability of observers was checked, took place at the beginning of the study.
Hand Hygiene Resources A protocol was developed to structure the collection of data about HH resources based upon a previous study.9 The assessment of HH resources was carried out at the beginning of the study period for every unit and included detailed data about each of the unit’s HH resources, such as the number of functional sinks (defined by the availability of soap and single use towels at a sink with running water) and the number of ABHRs dispensers. All potential hand cleaning stations, in patient rooms, examination rooms and nurse’s stations were assessed.
Definitions HH opportunities were defined as any episode of care that met 1 of the WHO’s Five Moments of Hand Hygiene (1. before patient contact; 2. before aseptic procedure; 3. after contact with body fluids; 4. after patient contact; and 5. after contact with patient’s surroundings).11 Each opportunity was classified by the method used (either rubbing the hands with ABHR or hand washing with soap and water) or as “missed” if no attempt to clean hands was observed. Each HH attempt was designated as either appropriate HH or inappropriate HH according to the CDC recommendations.2 Appropriate HH using ABHR was defined by (1) using a dime size volume of ABHR, (2) rubbing so that the ABHR covered all surfaces of the hands and (3) rubbing until hands were dry. Appropriate HH using soap and water was defined when (1) soap and clean water were used to cover all surfaces of the hands and (2) a single use towel was used to dry the hands. Duration of hand washing was not included in the determination of appropriate hand washing. The HH compliance rate was defined as the number of hand hygiene attempts (either appropriate or inappropriate) divided by the number of HH opportunities. The appropriate HH rate was defined as the number of HH attempts that were appropriate divided by the total number of opportunities.
Statistical Analysis Categorical data were summarized using frequencies and proportions, whereas continuous data were presented as median values and interquartile ranges. The Pearson χ2 test was used. Multilevel multiple logistic regression analyses were performed for the overall sample, with participants nested within wards to assess associations between participants’ role, shift, moments, number of ABHRs per 10 beds and HH compliance rate and appropriate HH rate. The results are presented as odds ratios and 95% confidence interval (95% CI). All reported P values were based on 2-sided
tests. The level of statistical significance was set at P < 0.05. The STATA 12.0 (STATA Corp, College Station, TX) statistical software was used for all statistical analyses.
RESULTS A total of 1271 HH opportunities were observed during the study period, including 944 from HCW and 327 from visitors and parents. Among HCWs, the most commonly identified HH opportunities were after child contact (n = 269), before child contact (n = 267) and after contact with child’s surroundings (n = 264; Table 1). HH was attempted for approximately one-third of HCW HH opportunities (355 of 944, 37.6%). The rate of appropriate HH for HCW was 22.6% (213 of 944 opportunities). HH compliance for HCW was greatest after contact with body fluids (37/54, 68.5%) but was much lower for all other HH moments (Table 1). Physicians had lower compliance (24%) compared with nurses (49%; P < 0.001; Table 1). Additionally, no difference was detected in HH compliance rate before aseptic procedures between doctors and nurses (P = 0.166). For most other moments of HH, compliance was higher in nurses as compared with doctors (Table I). With regards to the time of observation, it was found that HCW had significantly lower rates of HH compliance during the morning (22.1%) compared with noon (45.7%) and afternoon shift (43.2%; P < 0.001). The rate of HH compliance varied by ward. HCW’s HH compliance was highest in ICUs and transplant unit (64–87%), whereas lower rates (14.7–25.7%) were observed in other units (Table 2). Many attempts from HCW had been conducted using soap and water (273/355; 76.1%). Stratified analysis for physicians and nurses showed that the use of soap and water was more common in both of these groups (72.6% and 78.6%, respectively) as compared to ABHR. In regards to type of department, the use of ABHR was found to be significantly higher in surgical wards (70.6%) when compared with the other wards where ABHR use ranged from 10.7% in NICUs to 30.8% in emergency departments (P < 0.001). Among HCWs, the appropriate HH rate was 22.6% (213 of 944). However, appropriate HH technique was observed during more than half of HH attempts (213 of 351, 60.7%). We examined the reasons for inappropriate HH. Improper drying technique was observed at 48 of 138 (34.8%) HH attempts. Improper cleansing was observed at 15 (10.9%) attempts and improper drying and cleansing at 75 (54.3%) attempts. The HH procedure was more likely to be appropriate when soap and water were used when compared with ABHR (64.6% and 47.5%, P = 0.006). Among visitors and parents, 62 attempts out of 327 opportunities were detected (19.0% HH compliance). HH compliance for visitors/parents was greatest before child contact (39/109, 35.8%). This was much lower compared with “after child contact” and
TABLE 1. HCW Hand Hygiene Attempts by Event Type No.(%) of Opportunities Event Type
Physicians
Nurses
HCW
5 Moment of Hand Hygiene
HH Attempted
Total No. of Opportunities
HH Attempted
Total No. of Opportunities
HH Attempted
Total No. of Opportunities
Before patient contact Before aseptic procedure After contact with body fluids After patient contact After contact with patient’s surroundings Total
35 (23.0%) 7 (25.9%) 6 (40.0%) 37 (27.2%) 21 (20.0%) 106 (24.4%)
152 27 15 136 105 435
38 (33.0%) 26 (41.3%) 31 (79.5%)* 80 (60.2%)* 74 (46.5%)* 249 (48.9%)*
115 63 39 133 159 509
73 (27.3%) 33 (36.7%) 37 (68.5%) 117 (43.5%) 95 (36.0%) 355 (37.6%)
267 90 54 269 264 944
*P < 0.001 for comparison of HH attempted between physicians and nurses.
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TABLE 2. HCW Hand Hygiene Attempts by Department. Proportion of Opportunities
Job Category
Oncology Unit
NICU
PICU
General Pediatric Unit
Emergency Department Unit
BMTU
Surgery Department
All
Medical compliance 16/60 (27)* 7/34 (21) 35/63 (56) 13/68 (19) 17/118 (14) 8/8 (100) 10/84 (12) 106/435 (24) Nursing compliance 20/80 (25) 77/96 (80) 70/101 (70) 17/61 (28) 9/59 (15) 32/38 (84) 24/74 (32) 249/509 (49) HCW’s compliance 36/140 (25.7%) 84/130 (64.6%) 105/164 (64.0%) 30/129 (23.3%) 26/177 (14.7%) 40/46 (87.0%) 34/158 (21.5%) 355/944 (37.6%) Data is presented as HH attempts/HH opportunities (%). PICU, Pediatrics Intensive Care Unit.
“after contact with child’s surroundings” (9.8% and 8.5%, respectively). HH attempts by parents varied by unit. HH compliance was relatively high in the Pediatrics Intensive Care Unit (44%), NICU (56%) and BMTU (36%), although it was lower than 10% in all other units. Appropriate visitors/parents HH was observed in 29 attempts (8.9% appropriate). HH resources were examined in the same 13 units, which included 114 patient rooms and 273 patient beds. Nine (7.9%) and 12 (10.5%) of 114 patient rooms lacked sinks and HH stations, respectively. Most patients’ rooms had 1 functional sink. The availability of ABHR was limited in examination rooms, nurse’s stations and in patients’ rooms in the surgery and general pediatric units. Additionally, a lack of towels and soap was observed in hand washing stations on the surgery and general pediatric units (Table 3). No statistically significantly association was detected between HH compliance rate and the number of HH stations (P = 0.120) but a marginally significant association was identified between the HH compliance rate and the number of ABHR dispensers per room (P = 0.057). Multilevel logistic regression showed that the probability of being compliant with HH procedures was almost 2-fold higher in noon shift (P = 0.001) and marginally significantly higher by 50% in the afternoon (P = 0.079) as compared to the morning shift. Moreover, it was detected that doctors were less likely to be compliant compared to nurses. In particular, doctors were almost 50% less likely to be compliant (P < 0.001). Finally, the probability of being compliant was lower by almost 80% before child contact (P < 0.001), by 60% after child contact (P = 0.022), by 30% before aseptic procedure (P = 0.003) and by 80% after surroundings contact (P < 0.001) compared with after body fluid exposure. A marginally significant association was detected between number of ABHR per 10 beds and HH compliance rate. To be more precise, 1 ABHR per 10 beds increase results in 12% increase to probability of being compliant with HH procedures (P = 0.060; Table 4) As concerns the factors that seems to be independently associated with appropriate HH rate, multilevel logistic regression showed
that participants who worked in noon shift were almost 2.5 times more likely to perform appropriate HH compared with those who worked in morning (P = 0.003), whereas no difference was detected between those worked in morning and afternoon (P = 0.263). Moreover, similarly with HH compliance, doctors were significantly less likely to perform appropriate HH compared to nurses (P < 0.001). With regards to 5 HH moments, the appropriate HH rate was found to be significantly lower after surroundings contact compared to after body fluid exposure (P = 0.024). Finally, increase of ABHRs by one per 10 beds was found to result in 11% increase to probability of performing appropriate HH (P = 0.086; Table 5).
DISCUSSION The purpose of this study was to observe HH compliance of HCW and visitors in 2 children’s hospitals. HAI rates in Greece are among the highest in Europe and there are no national estimates of HAI in children hospitalized in Greek hospitals. The need for surveillance and infection control programs may have particular urgency for Greek hospitals.12 In the current study, we found that rate of HH compliance in 2 children’s hospitals was very low (33%) and that appropriate HH was observed in only 19% of opportunities. These rates of overall HH compliance are similar to median compliance rate between 30% and 40% reported in cross sectional studies was ranged between 30% and 40%.5 From our results, the overall HH compliance among physicians was approximately half of that observed among nurses, which is consistent with what has been observed by other studies showing lower compliance among physicians than among nurses.13 We observed marked differences in the rates of HH compliance across participating units, with the highest levels in ICUs and BMTU. Our results are in line with higher compliance rates resulting in 60% average in ICUs and BMTU and 13–20% in other units. This difference might reflect easier access to HH resources because of the open configuration of the ICUs, even though the ratio of HH stations to beds was higher than observed in other units.
TABLE 3. Hand Hygiene Resources by Room Type Units (No)
No of Beds
HH Stations/Bed
ABHR/Bed*
57 50 16 71 62 17 34
1 0.8 1.4 0.5 0.5 1.8 1.75
0.67 0.7 1 0.50 0.40 0.90 0.93
Oncology Units (2) NICUs (2) PICUs (2) General Pediatric Units (2) Surgery Departments (2) BMTU (1) Examination rooms† Nurses’ stations‡
HH Stations With Towels (%)
HH Stations With Soap (%)
43 60 60 9 31 100 89 88
50 80 100 85 63 100 98 75
* Mean number. †Emergency department and other units. ‡At every unit.
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Kouni et al
TABLE 4. Factors Associated With the Compliance Rate—Results From Multilevel Logistic Regression Independent Variables Shift Morning Noon Afternoon Role Nurse Doctor Moments After body fluid exposure Before child contact After child contact Before aseptic procedure After surroundings contact Number of ABHR per 10 beds
OR (95% CI)
P value
Ref 2.25 (1.39–3.63) 1.57 (0.95–2.60)
— 0.001 0.079
Ref 0.48 (0.35–0.68) Ref 0.21 (0.10–0.45) 0.43 (0.21–0.89) 0.29 (0.13–0.66) 0.19 (0.09–0.39)
—
Assessment of Hand Hygiene Resources and Practices at the 2 Children’s Hospitals in Greece Sofia Kouni, MD, MSc,* Georgia Kourlaba, MSc, PhD,* Katerina Mougkou, MD,* Stefania Maroudi, MSc,* Betty Chavela,* Chara Nteli, MSc,† Athanasia Lourida, MD,* Nikos Spyridis, MD, PhD,‡ Theoklis Zaoutis, MD, MSCE,*§ and Susan Coffin, MD, MPH§ Background: Hand hygiene (HH) is the most effective way to prevent health care-associated infections and the spread of antimicrobial-resistant pathogens. The aim of our study was to assess the existing HH resources and current HH practices at 2 hospitals in Athens, Greece. Methods: Observational HH data and an inventory of HH resources were collected from 13 wards including medical/surgical, oncology/transplant and intensive care units, during 65, 1-hour observations periods. Results: A total of 1271 HH opportunities were observed during the study period, including 944 of Health Care Workers (HCW) and 327 of visitors and parents. The nursing HH compliance was highest (49%) followed by medical compliance (24%, P < 0.001). HCW HH compliance was highest in intensive care units and the transplant unit (64–87%). The rate of appropriate HH for HCW was 22.6%. HCW most commonly used soap and water (76.1%). The HH procedure was more likely to be appropriate when soap and water were used as compared with alcohol based hand rub (64.6% and 47.5%, P = 0.006). A marginally significant association was identified between the HH compliance rate and the number of alcohol based hand rub dispensers per room (P = 0.057). In visitors and parents, the HH compliance was found to be 19%, whereas the rate of appropriate HH was 8.9%. Conclusions: Low levels of HH were observed. Key Words: compliance, hand hygiene, resources, quality improvement (Pediatr Infect Dis J 2014;33:e247–e251)
H
and hygiene (HH) is the most effective way to prevent health care-associated infections (HAI) and the spread of antimicrobial-resistant pathogens.1–4 Despite the fact that HH is a simple and very effective method for reducing the rates of HAI, the lack of compliance with HH in healthcare settings remains a major problem.5 Measurement of HH compliance associated with regular feedback of data as one of the most effective measures to improve HH practice.6,7 Barriers to appropriate HH including lack of knowledge, increased workload and inaccessible HH supplies contribute to low HH compliance among health care workers (HCWs).8 Limited availability of the resources needed to perform HH, such as a functional
Accepted for publication April 9, 2014. From the *The Stavros Niarchos Foundation-Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), University of Athens School of Medicine; †Pediatric Intensive Care Unit; ‡Second Department of Pediatrics, University of Athens, Aglaia Kuriakou Children’s Hospital, Athens, Greece; and §Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia, UPENN School of Medicine, Philadelphia, PA. All authors have seen and agreed to the submitted version of the paper. No material has been published elsewhere. The authors have no funding or conflicts of interest to disclose. Address for correspondence: Sofia Kouni, MD, MSc, “Agia Sophia” Children’s Hospital, Thivon & Papadiamantopoulou, Goudi, Athens, 115 27, Greece. E-mail: [email protected], [email protected]. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0891-3668/14/3310-e247 DOI: 10.1097/INF.0000000000000376
sink with soap, single use towels and alcohol based hand rub (ABHR), has been cited as an easily modifiable contributor to poor HH.9,10 The issue of HH is particularly timely and important to address in Greece at this time. As a result of the ongoing economic crisis, there is increased financial burden on public hospitals, which has led to understaffing, lack of supplies, increased admissions and crowding. These are factors that increase the risk of HAI and further exacerbate the economic burden of the healthcare system. In particular, public healthcare in Greece has among the highest rates of inappropriate antibiotic prescribing in Europe, the highest rates of multiresistant organisms, and high rates of HAI. There are very limited data regarding HH practices and resources in Greece, particularly in children. Therefore, given the current healthcare crisis and the lack of data, the aim of our study was to assess the existing HH resources and current HH practices in Greece to provide local data to clinicians and guide future improvement work. This approach can serve as a guide to other institutions embarking on work to improve HH.
METHODS Study Design and Setting This study was a cross sectional observational study of HCW and visitor compliance with HH. The study was carried out between October 2012 and January 2013 at the 2 largest pediatric hospitals in Athens in Greece, which include about 1000 beds and account for approximately two-thirds of pediatric tertiary care admissions in the country. These 2 hospitals are physically connected by bridges but do not share medical or nursing staff. Similar clinical services are offered at both hospitals. Observational HH data and an inventory of HH resources were collected from 13 wards (selected based on patient acuity and size) in the 2 pediatric hospitals, including medical/surgical, oncology, transplant (BMTU), intensive care units (ICUs) and emergency departments.
Hand Hygiene Observations Observations of HH practices were carried out on each of the participating units for 5, 1-hour periods. Observations were collected during morning, noon and afternoon shifts in each ward, times that were selected were based on increased clinical activity. The same times of the day were used for HH observations for all units to guarantee comparability. A data collection form and a protocol for collecting HH observations were developed based upon tools from the World Health Organization (WHO; Appendix).1,2 The HCW were aware why the auditor was present. To maintain HCW anonymity, individual identities were not captured although the subject’s occupational role was recorded. No more than 3 events were recorded for an individual during a single observation period. Observations of HH practices of HCWs (ie, doctors and nurses) as well as parents and visitors were collected. The audit team had 3 members, 1 doctor and 2 nurses who separately made the observations. All the members of the team were trained on HH methods. A pilot observation period in which
The Pediatric Infectious Disease Journal • Volume 33, Number 10, October 2014
www.pidj.com | e247
Kouni et al
The Pediatric Infectious Disease Journal • Volume 33, Number 10, October 2014
the inter-rater reliability of observers was checked, took place at the beginning of the study.
Hand Hygiene Resources A protocol was developed to structure the collection of data about HH resources based upon a previous study.9 The assessment of HH resources was carried out at the beginning of the study period for every unit and included detailed data about each of the unit’s HH resources, such as the number of functional sinks (defined by the availability of soap and single use towels at a sink with running water) and the number of ABHRs dispensers. All potential hand cleaning stations, in patient rooms, examination rooms and nurse’s stations were assessed.
Definitions HH opportunities were defined as any episode of care that met 1 of the WHO’s Five Moments of Hand Hygiene (1. before patient contact; 2. before aseptic procedure; 3. after contact with body fluids; 4. after patient contact; and 5. after contact with patient’s surroundings).11 Each opportunity was classified by the method used (either rubbing the hands with ABHR or hand washing with soap and water) or as “missed” if no attempt to clean hands was observed. Each HH attempt was designated as either appropriate HH or inappropriate HH according to the CDC recommendations.2 Appropriate HH using ABHR was defined by (1) using a dime size volume of ABHR, (2) rubbing so that the ABHR covered all surfaces of the hands and (3) rubbing until hands were dry. Appropriate HH using soap and water was defined when (1) soap and clean water were used to cover all surfaces of the hands and (2) a single use towel was used to dry the hands. Duration of hand washing was not included in the determination of appropriate hand washing. The HH compliance rate was defined as the number of hand hygiene attempts (either appropriate or inappropriate) divided by the number of HH opportunities. The appropriate HH rate was defined as the number of HH attempts that were appropriate divided by the total number of opportunities.
Statistical Analysis Categorical data were summarized using frequencies and proportions, whereas continuous data were presented as median values and interquartile ranges. The Pearson χ2 test was used. Multilevel multiple logistic regression analyses were performed for the overall sample, with participants nested within wards to assess associations between participants’ role, shift, moments, number of ABHRs per 10 beds and HH compliance rate and appropriate HH rate. The results are presented as odds ratios and 95% confidence interval (95% CI). All reported P values were based on 2-sided
tests. The level of statistical significance was set at P < 0.05. The STATA 12.0 (STATA Corp, College Station, TX) statistical software was used for all statistical analyses.
RESULTS A total of 1271 HH opportunities were observed during the study period, including 944 from HCW and 327 from visitors and parents. Among HCWs, the most commonly identified HH opportunities were after child contact (n = 269), before child contact (n = 267) and after contact with child’s surroundings (n = 264; Table 1). HH was attempted for approximately one-third of HCW HH opportunities (355 of 944, 37.6%). The rate of appropriate HH for HCW was 22.6% (213 of 944 opportunities). HH compliance for HCW was greatest after contact with body fluids (37/54, 68.5%) but was much lower for all other HH moments (Table 1). Physicians had lower compliance (24%) compared with nurses (49%; P < 0.001; Table 1). Additionally, no difference was detected in HH compliance rate before aseptic procedures between doctors and nurses (P = 0.166). For most other moments of HH, compliance was higher in nurses as compared with doctors (Table I). With regards to the time of observation, it was found that HCW had significantly lower rates of HH compliance during the morning (22.1%) compared with noon (45.7%) and afternoon shift (43.2%; P < 0.001). The rate of HH compliance varied by ward. HCW’s HH compliance was highest in ICUs and transplant unit (64–87%), whereas lower rates (14.7–25.7%) were observed in other units (Table 2). Many attempts from HCW had been conducted using soap and water (273/355; 76.1%). Stratified analysis for physicians and nurses showed that the use of soap and water was more common in both of these groups (72.6% and 78.6%, respectively) as compared to ABHR. In regards to type of department, the use of ABHR was found to be significantly higher in surgical wards (70.6%) when compared with the other wards where ABHR use ranged from 10.7% in NICUs to 30.8% in emergency departments (P < 0.001). Among HCWs, the appropriate HH rate was 22.6% (213 of 944). However, appropriate HH technique was observed during more than half of HH attempts (213 of 351, 60.7%). We examined the reasons for inappropriate HH. Improper drying technique was observed at 48 of 138 (34.8%) HH attempts. Improper cleansing was observed at 15 (10.9%) attempts and improper drying and cleansing at 75 (54.3%) attempts. The HH procedure was more likely to be appropriate when soap and water were used when compared with ABHR (64.6% and 47.5%, P = 0.006). Among visitors and parents, 62 attempts out of 327 opportunities were detected (19.0% HH compliance). HH compliance for visitors/parents was greatest before child contact (39/109, 35.8%). This was much lower compared with “after child contact” and
TABLE 1. HCW Hand Hygiene Attempts by Event Type No.(%) of Opportunities Event Type
Physicians
Nurses
HCW
5 Moment of Hand Hygiene
HH Attempted
Total No. of Opportunities
HH Attempted
Total No. of Opportunities
HH Attempted
Total No. of Opportunities
Before patient contact Before aseptic procedure After contact with body fluids After patient contact After contact with patient’s surroundings Total
35 (23.0%) 7 (25.9%) 6 (40.0%) 37 (27.2%) 21 (20.0%) 106 (24.4%)
152 27 15 136 105 435
38 (33.0%) 26 (41.3%) 31 (79.5%)* 80 (60.2%)* 74 (46.5%)* 249 (48.9%)*
115 63 39 133 159 509
73 (27.3%) 33 (36.7%) 37 (68.5%) 117 (43.5%) 95 (36.0%) 355 (37.6%)
267 90 54 269 264 944
*P < 0.001 for comparison of HH attempted between physicians and nurses.
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The Pediatric Infectious Disease Journal • Volume 33, Number 10, October 2014 AssessmentofHandHygieneResourcesandPractices
TABLE 2. HCW Hand Hygiene Attempts by Department. Proportion of Opportunities
Job Category
Oncology Unit
NICU
PICU
General Pediatric Unit
Emergency Department Unit
BMTU
Surgery Department
All
Medical compliance 16/60 (27)* 7/34 (21) 35/63 (56) 13/68 (19) 17/118 (14) 8/8 (100) 10/84 (12) 106/435 (24) Nursing compliance 20/80 (25) 77/96 (80) 70/101 (70) 17/61 (28) 9/59 (15) 32/38 (84) 24/74 (32) 249/509 (49) HCW’s compliance 36/140 (25.7%) 84/130 (64.6%) 105/164 (64.0%) 30/129 (23.3%) 26/177 (14.7%) 40/46 (87.0%) 34/158 (21.5%) 355/944 (37.6%) Data is presented as HH attempts/HH opportunities (%). PICU, Pediatrics Intensive Care Unit.
“after contact with child’s surroundings” (9.8% and 8.5%, respectively). HH attempts by parents varied by unit. HH compliance was relatively high in the Pediatrics Intensive Care Unit (44%), NICU (56%) and BMTU (36%), although it was lower than 10% in all other units. Appropriate visitors/parents HH was observed in 29 attempts (8.9% appropriate). HH resources were examined in the same 13 units, which included 114 patient rooms and 273 patient beds. Nine (7.9%) and 12 (10.5%) of 114 patient rooms lacked sinks and HH stations, respectively. Most patients’ rooms had 1 functional sink. The availability of ABHR was limited in examination rooms, nurse’s stations and in patients’ rooms in the surgery and general pediatric units. Additionally, a lack of towels and soap was observed in hand washing stations on the surgery and general pediatric units (Table 3). No statistically significantly association was detected between HH compliance rate and the number of HH stations (P = 0.120) but a marginally significant association was identified between the HH compliance rate and the number of ABHR dispensers per room (P = 0.057). Multilevel logistic regression showed that the probability of being compliant with HH procedures was almost 2-fold higher in noon shift (P = 0.001) and marginally significantly higher by 50% in the afternoon (P = 0.079) as compared to the morning shift. Moreover, it was detected that doctors were less likely to be compliant compared to nurses. In particular, doctors were almost 50% less likely to be compliant (P < 0.001). Finally, the probability of being compliant was lower by almost 80% before child contact (P < 0.001), by 60% after child contact (P = 0.022), by 30% before aseptic procedure (P = 0.003) and by 80% after surroundings contact (P < 0.001) compared with after body fluid exposure. A marginally significant association was detected between number of ABHR per 10 beds and HH compliance rate. To be more precise, 1 ABHR per 10 beds increase results in 12% increase to probability of being compliant with HH procedures (P = 0.060; Table 4) As concerns the factors that seems to be independently associated with appropriate HH rate, multilevel logistic regression showed
that participants who worked in noon shift were almost 2.5 times more likely to perform appropriate HH compared with those who worked in morning (P = 0.003), whereas no difference was detected between those worked in morning and afternoon (P = 0.263). Moreover, similarly with HH compliance, doctors were significantly less likely to perform appropriate HH compared to nurses (P < 0.001). With regards to 5 HH moments, the appropriate HH rate was found to be significantly lower after surroundings contact compared to after body fluid exposure (P = 0.024). Finally, increase of ABHRs by one per 10 beds was found to result in 11% increase to probability of performing appropriate HH (P = 0.086; Table 5).
DISCUSSION The purpose of this study was to observe HH compliance of HCW and visitors in 2 children’s hospitals. HAI rates in Greece are among the highest in Europe and there are no national estimates of HAI in children hospitalized in Greek hospitals. The need for surveillance and infection control programs may have particular urgency for Greek hospitals.12 In the current study, we found that rate of HH compliance in 2 children’s hospitals was very low (33%) and that appropriate HH was observed in only 19% of opportunities. These rates of overall HH compliance are similar to median compliance rate between 30% and 40% reported in cross sectional studies was ranged between 30% and 40%.5 From our results, the overall HH compliance among physicians was approximately half of that observed among nurses, which is consistent with what has been observed by other studies showing lower compliance among physicians than among nurses.13 We observed marked differences in the rates of HH compliance across participating units, with the highest levels in ICUs and BMTU. Our results are in line with higher compliance rates resulting in 60% average in ICUs and BMTU and 13–20% in other units. This difference might reflect easier access to HH resources because of the open configuration of the ICUs, even though the ratio of HH stations to beds was higher than observed in other units.
TABLE 3. Hand Hygiene Resources by Room Type Units (No)
No of Beds
HH Stations/Bed
ABHR/Bed*
57 50 16 71 62 17 34
1 0.8 1.4 0.5 0.5 1.8 1.75
0.67 0.7 1 0.50 0.40 0.90 0.93
Oncology Units (2) NICUs (2) PICUs (2) General Pediatric Units (2) Surgery Departments (2) BMTU (1) Examination rooms† Nurses’ stations‡
HH Stations With Towels (%)
HH Stations With Soap (%)
43 60 60 9 31 100 89 88
50 80 100 85 63 100 98 75
* Mean number. †Emergency department and other units. ‡At every unit.
© 2014 Lippincott Williams & Wilkins
www.pidj.com | e249
The Pediatric Infectious Disease Journal • Volume 33, Number 10, October 2014
Kouni et al
TABLE 4. Factors Associated With the Compliance Rate—Results From Multilevel Logistic Regression Independent Variables Shift Morning Noon Afternoon Role Nurse Doctor Moments After body fluid exposure Before child contact After child contact Before aseptic procedure After surroundings contact Number of ABHR per 10 beds
OR (95% CI)
P value
Ref 2.25 (1.39–3.63) 1.57 (0.95–2.60)
— 0.001 0.079
Ref 0.48 (0.35–0.68) Ref 0.21 (0.10–0.45) 0.43 (0.21–0.89) 0.29 (0.13–0.66) 0.19 (0.09–0.39)
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