ORIGINAL ARTICLE
Hand Hygiene Adherence Among Health Care Workers at Japanese Hospitals: A Multicenter Observational Study in Japan Tomoko Sakihama, RN, CNIC, MSN,* Hitoshi Honda, MD,† Sanjay Saint, MD, MPH,‡§ Karen E. Fowler, MPH,‡ Taro Shimizu, MD, MPH,k Toru Kamiya, MD,¶ Yumiko Sato, RN, CNIC,# Soichi Arakawa, MD, PhD,** Jong Ja Lee, RN, CNIC,** Kentaro Iwata, MD, MSc,†† Mutsuko Mihashi, RN, PhD,‡‡ and Yasuharu Tokuda, MD, MPHk Background: Although proper hand hygiene among health care workers is an important component of efforts to prevent health care–associated infection, there are few data available on adherence to hand hygiene practices in Japan. Objectives: The aim of this study was to examine hand hygiene adherence at teaching hospitals in Japan. Methods: An observational study was conducted from July to November 2011 in 4 units (internal medicine, surgery, intensive care, and/or emergency department) in 4 geographically diverse hospitals (1 university hospital and 3 community teaching hospitals) in Japan. Hand hygiene practice before patient contact was assessed by an external observer. Results: In a total of 3545 health care worker–patient observations, appropriate hand hygiene practice was performed in 677 (overall adherence, 19%; 95% confidence interval, 18%–20%). Subgroup rates of hand hygiene adherence were 15% among physicians and 23% among nurses. The ranges of adherence were 11% to 25% between hospitals and 11% to 31% between units. Adherence of the nurses and the physicians to hand hygiene was correlated within each hospital. There was a trend toward higher hand hygiene adherence in hospitals with infection control nurses, compared with hospitals without them (29% versus 16%). Conclusions: The hand hygiene adherence in Japanese teaching hospitals in our sample was low, even lower than reported mean values from other international studies. Greater adherence to hand hygiene should be encouraged in Japan. Key Words: hand hygiene, health care worker, health care–associated infection, infection control nurse, adherence (J Patient Saf 2016;12: 11–17)
H
ealth care–associated infections (HAIs) are common and potentially lethal. In the United States, approximately 1.7 million
From the *Kurume University Graduate school of Medicine, Kurume City Fukuoka, Japan; †Division of Infectious Diseases, Department of General Internal Medicine, Teine Keijinkai Medical Center, Sapporo, Hokkaido, Japan; ‡VA Ann Arbor Healthcare System, Ann Arbor, Michigan; §University of Michigan Medical School, Ann Arbor, Michigan; kDepartment of Medicine, Mito Kyodo General Hospital, University of Tsukuba, Mito City, Ibaraki, Japan; ¶Division of General Internal Medicine & Infection Diseases, Rakuwakai Otowa Hospital, Kyoto, Japan; #Division of Infection Control, Teine Keijinkai Medical Center, Sapporo, Hokkaido, Japan; **Department of Infection Control and Prevention, Kobe University Hospital, Kobe City, Hyogo, Japan; ††Division of Infectious Diseases Therapeutics, Department of Microbiology and Infectious Diseases, Kobe University Graduate School of Medicine, Kobe City, Hyogo, Japan; and ‡‡Department of Nursing, Kurume University School of Nursing, Kurume City Fukuoka, Japan. Correspondence: Yasuharu Tokuda, MD, MPH, Department of Medicine, Mito Kyodo General Hospital, University of Tsukuba, 3-2-7 Miya-machi, Mito City, Ibaraki, 310-0015 Japan (e‐mail: [email protected]). The authors disclose no conflict of interest. Copyright © 2014 by Wolters Kluwer Health, Inc. All rights reserved.
J Patient Saf • Volume 12, Number 1, March 2016
such infections occur annually, resulting in approximately 99,000 deaths per year.1 Health care–associated infections are also important in Japan, where approximately 9% of intensive care unit (ICU) patients develop HAIs during hospitalization2 and 5% of all hospitalized patients are infected with methicillin-resistant Staphylococcus aureus (MRSA).3 Health care–associated infections can increase health care costs in 2 ways. First, treatment of patients with HAIs requires additional resources such as antimicrobial therapy and diagnostic tests. Increased use of antimicrobial agents further contributes to the development of antimicrobial resistance and the spread of multidrug-resistant (MDR) pathogens including MRSA and MDR gram-negative organisms. Second, developing an HAI is associated with an increase in the overall hospital length of stay. Studies estimate that surgical site infection and bloodstream infection increase length of stay by 9.7 days and 10 days, respectively.4,5 The annual direct medical costs of HAIs are estimated to range between $28.4 and $33.8 billion in the United States.6 Annual estimated costs for the management of HAI accounts for approximately 4% to 5% of total annual health care costs in Japan, and of these costs, up to approximately $6.8 billion (566 billion yen) are estimated to be potentially preventable.7 Although there are various measures to prevent HAIs, implementing hand hygiene is a key approach.8 Several strategies have been proposed to improve hand hygiene among health care workers (HCWs). One traditional strategy is the placement of sinks equipped with soap and water between the hospital ward room doors and patients’ beds. However, it is sometimes difficult to build these sinks because many hospitals already have sinks located in an inconvenient position. Another strategy is the use of waterless alcohol-based hand rubs, which are now considered to be more effective than hand washing in reducing bacteria and viruses on hands.9 Multiple studies have reported that greater use of alcohol hand rub is associated with a significant reduction in HAIs and MRSA transmission.10,11 Moreover, alcohol-based hand rub causes fewer side effects even when used frequently.12 For these reasons, both the U.S. Centers for Disease Control and Prevention and the World Health Organization (WHO) strongly recommend increased use of alcoholbased hand rub in acute care hospitals.12,13 Although a few studies to evaluate hand hygiene adherence among HCWs in Japanese hospitals were found using a PubMed citation search (www.ncbi.nlm.nih.gov), these previous studies evaluated hand hygiene practice by questionnaire or the amount of consumption of alcohol hand rubs.14–17 To reduce the burden of HAIs in Japanese hospitals, appropriate monitoring of hand hygiene adherence among HCWs is imperative. Thus, we designed a multicenter study for examining hand hygiene adherence by direct observation at teaching hospitals in Japan. www.journalpatientsafety.com
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METHODS Participating Hospitals We aimed to determine hand hygiene adherence among physicians and nurses at a purposeful sample of 4 teaching hospitals from various geographical areas in Japan. The characteristics of each participating hospital are shown in Table 1. Hospital A is a national, tertiary care academic medical center with 874 beds, located in West Japan. Hospital A’s infection control and prevention unit was established in 1999. Two Japanese board-certified infection control nurses (1 full time and 1 part time) are responsible for the hand hygiene education of physicians and nurses. Hospital B is a university-affiliated, community-based, tertiary care medical center with 250 beds in East Japan. The residency program was established in 2009. The hospital did not have an infection prevention unit or designated infection control nurses when the observations were performed. Hospital C is a community-based, tertiary care medical center with 428 beds, located in West Japan. Although the facility has no infection control nurses, a physician certified by the American Board of Internal Medicine and Infectious Diseases (ABIM-ID) provided educational sessions with the nurses and residents in each hospital unit. He periodically assessed hand hygiene adherence among HCWs by direct observation. Hospital D, located in Northern Japan, is a community-based, tertiary care medical center with 550 beds. The infection prevention unit was established in 2010 and included 1 full-time and 2 part-time board-certified infection control nurses. Hand hygiene education by infection control nurses and intensive lectures from an ABIM-ID–certified physician was also provided.
Observation of Hand Hygiene Adherence To assess hand hygiene adherence, we directly observed 13 distinct units across 4 participating hospitals during a 5-month period between July and November 2011. We focused on 4 types of hospital units: the inpatient internal medicine ward, the inpatient surgical ward, the ICU, and the emergency department. An external observer was instructed to assess hand hygiene practice among HCWs of Japanese hospitals using a predefined set of criteria. One of the study authors (T. Sakihama), a Japanese board-certified infection control nurse, served as the sole external observer to assess hand hygiene practices. To minimize intraobserver variation, observer training included (1) e-learning (WHO Guidelines on Hand Hygiene in Health Care; Guide to Implementation; and SAVE LIVES: Clean Your Hands Educational Session for Trainers, Observers and Health-Care Workers),12,18,19 (2) clinical training from an infection control nurse at a university hospital in Tokyo, and (3) pilot testing of observation methods at a university-based hospital in Tokyo. Proper hand hygiene for this study was defined as use of soap and water or alcohol hand rub before touching the patient, which corresponds to moment 1 of the 5 moments of hand hygiene described in the WHO Guidelines on Hand Hygiene in Health Care.12 The observer recorded hand hygiene practice before patient contact for each individual provider-patient encounter using the hand hygiene observation form adapted from a previous study by Saint et al.20–22 The observation form included the following information: the unit in which observations were performed, the time of initiation and completion of observations, the HCW subgroup (physician or nurse), and the type of hand hygiene before contact with the patient (i.e., hand washing with soap and water, use of alcohol-based hand rub, or no hand hygiene). On the day of observation, the staff and trainee physicians and nurses in the
12
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observation unit were informed that their clinical practices were to be observed; however, the focus (i.e., hand hygiene practice) was not disclosed. The observer was given strict instructions to keep a distance so as to not interfere with clinical care delivery by the observed HCWs. If asked to leave for medical or other reasons related to patients’ confidentiality, the observer was to comply immediately. The goal was to observe 134 physicianpatient and 134 nurse-patient hand hygiene encounters on each unit, which would provide enough power to detect future changes in compliance. This led to observing approximately 800 to 900 encounters in each hospital.
Statistical Analyses The data were entered into a Microsoft Access database (Microsoft Corporation, Redmond, Wash) and assessed for extreme values, missing data, and possible coding errors. Hand hygiene adherence rates were calculated and compared between HCW subgroup and by hospital unit including medicine, surgery, ICU, and emergency department. Data analysis was performed using JMP 9.0 and SAS 9.3 (SAS Institute Inc, Cary, NC). Pearson χ2 tests were conducted, and 95% confidence intervals were estimated using binomial distribution. Pearson correlations were used to determine the relationship of hand hygiene between physicians and nurses in the same unit. Twotailed P value of less than 0.05 was considered as statistically significant. The study protocol was reviewed and approved by the ethics committee at the coordinating hospital. On the basis of this approval, the ethics committees of the other participating hospitals waived additional review and approved the study.
RESULTS Data were collected from July to November 2011. Hand hygiene adherence rates are shown in Table 2. Hand hygiene was observed in a total of 3545 occasions throughout the 4 facilities. Table 3 shows the rates of hand hygiene adherence in all hospitals combined. In all 3545 observations, hand hygiene was performed 677 times (19%; 95% confidence interval, 18%–20%). Of those who performed hand hygiene, approximately 67% used alcohol hand rub and 33% used soap and water. The hand hygiene rate among all physicians was 15% (263/1712), and the rate among nurses was 23% (414/1833). Across all occasions, when clinicians practiced hand hygiene, the physicians used alcohol hand rub 74% (194/263) of the time and the nurses used alcohol hand rub 63% (261/414) of the time (P = 0.004). Hand hygiene adherence rates by facility, hospital unit, and HCW subgroup are shown in Table 3. Overall, hand hygiene adherence rates among the 4 participating hospitals ranged from 11% to 25%. Hand hygiene adherence rates among each hospital unit ranged from 10% to 31%. Physician hand hygiene compliance ranged from 2% to 33%, whereas the compliance among the nurses ranged from 8% to 40%. Regarding the relationship between hand hygiene adherence rates and infection control practitioner deployment by facility, hospital unit, and HCW subgroup, correlation in adherence rates between the physicians and the nurses was not significant (r = 0.15; P = 0.64). We observed a higher adherence among the nurses in hospitals A and D, which employed infection control nurses (29% adherence), compared with hospitals B and C, which did not (16% adherence) (P < 0.001). Hospital C, where an infection control physician was present, had the highest physician adherence (27% versus 11%; P < 0.001). Hospital B, which lacked an infection control practitioner, demonstrated © 2014 Wolters Kluwer Health, Inc. All rights reserved.
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J Patient Saf • Volume 12, Number 1, March 2016
Hand Hygiene Adherence Among HCWs
TABLE 1. Characteristics of the Participating Institutions for Evaluation of Hand Hygiene Adherence Among HCWs Hospital A
Hospital B
Hospital C
Hospital D
Hospital overview Location West Japan East Japan Midwest Japan Northern Japan No. beds 874 250 428 550 No. employees 1688 398 1035 1500 No. physicians 535 73 179 207 No. nurses 808 172 410 616 Hospital type University based University affiliated Community based Community based Residency program Yes Yes Yes Yes Level of care Tertiary care Tertiary care Tertiary care Tertiary care Infection control at the study institutions Establishment of infection prevention units, y 1995 N/A N/A 2010 Employment of certified nurses in infection control, n (FTE, n) 2 (1.5) 0 0 3 (1.5) Employment of ABIM-ID certified physician 1 0 1 1 Infrastructure Wash basin in each room Yes No Yes Yes Alcohol hand rub available in each room Yes Yes Yes Yes Portable alcohol hand rub provided for each HCW No No No No Ongoing intervention during hand hygiene observation Periodic educational seminar and lecture Yes No Yes Yes Poster campaign Yes Yes Yes Yes Routine evaluation for hand hygiene adherence Direct observation No No Yes No Monitoring the amount of alcohol hand rub consumption Yes No Yes Yes FTE, full-time equivalent; N/A, not applicable.
the lowest adherence among both physicians and nurses (range, 8%–14%).
DISCUSSION Despite the importance of evaluating hand hygiene adherence in health care settings, the rate of adherence to hand hygiene among HCWs in Japanese institutions has previously been evaluated using questionnaires or the amount of consumption of alcohol hand rubs. Although a previous study showed that hand hygiene at Japanese institutions was approximately 34%, the accuracy of this result was limited because the rate was assessed by questionnaire.16 Our study successfully assessed hand hygiene adherence by direct observation, which is the criterion standard method of hand hygiene assessment.12 Although it may not be entirely appropriate to compare hand hygiene
adherence rates in this study with previously reported rates given the difference in circumstances of health care settings and the focus of studies (e.g., the moment of observation), the overall hand hygiene adherence rate at 4 Japanese hospitals was remarkably low. Low hand hygiene adherence rates among HCWs have been documented in various institutions and countries,20,23,24 with reported rates of adherence ranging from 4% to 100%, with a mean of approximately 40%.23 Understanding and increasing hand hygiene adherence are crucial for preventing spread of MDR pathogens in health care settings. We performed direct observation to identify differences in hand hygiene adherence rates across participating hospitals, HCW subgroups (i.e., physicians or nurses), and hospital units (i.e., medical wards, surgical wards, ICUs, and emergency departments) (Table 4). All 4 hospitals were teaching hospitals with residency programs. The participating institutions consisted of
TABLE 2. Hand Hygiene Observations of the 4 Participating Hospitals
Total no. observations No. observation for nurses No. observation for physicians No. observations per session, mean (range) Minutes of observation per session, mean (range) Total days of observation Total minutes of observation, min (hr)
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Hospital A
Hospital B
Hospital C
Hospital D
Total
866 448 418 27.9 (15–30) 21.3 (15–30) 4 660 (11)
928 486 442 21.1 (5–30) 26.1 (10–30) 5 1150 (19)
867 438 429 28.0 (12–30) 21.8 (10–30) 3 675 (11)
884 461 423 26.0 (6–30) 23.7 (15–30) 4 805 (13)
3545 1833 1712 25.3 (5–30) 23.5 (10–30) 16 3290 (55)
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Sakihama et al
TABLE 3. Overall Hand Hygiene Adherence Among HCW Subgroups HCW Subgroup
Hand hygiene action No. observations Proper hand hygiene performed Proper hand hygiene not performed Hand hygiene adherence rate,* % Type of hand hygiene, n (%) Alcohol hand rub Soap and water
Nurse
Physician
All
1833 414 1419 22.6†
1712 263 1449 15.4†
3545 677 2868 19.1
194 (73.8) 69(26.2)
455 (67.2) 222(32.8)
261 (63.0) 153(37.0)
*Hand hygiene adherence rate was calculated using total number of proper hand hygiene performed 100/total number of observations. † Differences in hand hygiene adherence rates between nurses and physicians were statistically significant (P < 0.001).
various types of hospitals, including university-based, universityaffiliated, and community-based hospitals. Moreover, the participating hospitals were diversely located in Japan. The data consisted of more than 3500 observations by a single observer to minimize interobserver variation. The number of observations was equally distributed among the participating hospitals. We performed pretest validation of the observational method to minimize intraobserver variation. Given the diverse study settings and participants, we believe that the hand hygiene practice findings in this study can be generalized to other similar Japanese hospitals. In this study, we observed substantial variation in hand hygiene adherence rates by HCW subgroups and hospital units. These variations may suggest that focusing on overall hand hygiene adherence rate may not be adequate and instead focusing on certain subgroups may be more beneficial.20 Recognizing variation in hand hygiene adherence rates may help identify areas of focus for intervention. We observed a trend toward lower overall hand hygiene adherence among the physicians compared with the nurses. The overall hand hygiene rate among the physicians ranged from 2% to 33% (mean, 15% [263/ 1712]), whereas the rate among the nurses ranged from 8% to 40% (mean, 23% [414/1833]). Previous studies in other countries reported similar findings.20,24,25 Although there was a trend toward better hand hygiene adherence among the nurses in the hospitals with the presence of infection control nurses (hospitals A and D) and among the physicians when an infection control physician provided the hand hygiene education (hospital C), it remains unclear whether the presence of infection control staff is independently associated with improving hand hygiene adherence among HCWs. This issue may warrant further study. Consistent with previous studies, we observed substantial variation in hand hygiene adherence rates across hospital unit types and between units in the same hospital. A Spanish study found that the hand hygiene adherence rate among HCWs was highest in ICUs, whereas higher rates of hand hygiene adherence were observed in medical and surgical wards in a study from Switzerland.11,24 Another study revealed that hand hygiene adherence rates among HCWs in neonatal ICUs were distinctively high.26 There may be a wide range of factors contributing to the variation in hand hygiene adherence by hospital units, such as differences in infrastructure, level of behavioral control, and patient population. As demonstrated in the limited number of HCWs engaged in infection prevention programs in each participating hospital,
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Japanese institutions face challenges in obtaining adequate resources to operate an effective infection prevention program, resulting in a decline in the quality of these programs. The Japanese Nursing Association started the 6-month certified-nurse infection control educational program in 2000, and only since 2007 has Japanese law required hospitals to have infection control policies.27,28 On the basis of survey data from 423 teaching hospitals in Japan, only 26% of hospitals had a certified infection control nurse, and only 65 hospitals hired full-time infection control nurses.29 Even within relatively limited resource settings, a trend toward higher hand hygiene adherence was observed in hospitals with a full-time infection control practitioner.29 Our findings suggest that hospitals should consider employing full-time infection control practitioners to improve infection prevention practice. Another potential factor in the results of our study could be the apparent unawareness of appropriate hand hygiene practice. This is likely due to insufficient hand hygiene education for HCWs. We noticed that many HCWs used nonsterile gloves without performing hand cleaning by alcohol hand rub or hand washing. Although many HCWs have been wearing gloves to adhere to standard or contact precautions when indicated, they do not recognize that the use of gloves does not replace hand hygiene practice. In 1 study, the implementation of universal gloving for patient care resulted in increased transmission of MDR pathogens, which was potentially due to a decrease in hand hygiene during the universal gloving period.30 Hand hygiene before and after wearing gloves is also important because hands can be contaminated by unrecognized glove leaks or when removing gloves.12 One evaluation demonstrated that bacteria were recovered from approximately 60% of gloves after use, and microbiological contamination of HCWs’ hands occurred in 13% of those who used contaminated gloves.30 Repetitive and frequent educational opportunities for appropriate hand hygiene are crucial to increase hand hygiene adherence. Inadequate infrastructure for hand hygiene practice may also influence the hand hygiene adherence rate. In all 4 participating hospitals, there were usually 4 to 6 beds per room in medical and surgical wards and 1 bed per room in ICUs. In Japanese hospitals, a single dispenser of alcohol hand rub was usually placed at the entrance of each room but not at each bedside. This may be for safety reasons, including prevention of accidental oral intake of alcohol hand rubs and the restriction of placing flammable substances near patients. However, easier access to alcohol hand rubs (e.g., placement of alcohol hand rubs at each © 2014 Wolters Kluwer Health, Inc. All rights reserved.
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J Patient Saf • Volume 12, Number 1, March 2016
Hand Hygiene Adherence Among HCWs
TABLE 4. Hand Hygiene Adherence Rate by Hospital, Unit, and HCW Subgroup Unit Hospital A Surgery
Medicine
ICU
All
Hospital B Surgery
Medicine
ICU
ED
All
Hospital C Surgery
Medicine
ED
All
Hospital D Surgery
Medicine
ICU
P
HCW Subgroup No. Observations No. Using Proper Hand Hygiene Hand Hygiene Adherence Rate, % Nurse Physician All Nurse Physician All Nurse Physician All Nurse Physician All
163 135 298 143 143 286 142 140 282 448 418 866
34 34 68 54 15 69 40 18 58 128 67 195
20.9 25.2 22.8 37.8 10.5 24.1 28.2 12.9 20.6 28.6 16.0 22.5
0.375
Nurse Physician All Nurse Physician All Nurse Physician All Nurse Physician All Nurse Physician All
147 136 283 158 157 315 151 57 208 30 92 122 486 442 928
12 19 31 16 18 34 17 4 21 4 11 15 49 52 101
8.2 14.0 11.0 10.1 11.5 10.8 11.3 7.0 10.1 13.3 12.0 12.3 10.1 11.8 10.9
0.118
Nurse Physician All Nurse Physician All Nurse Physician All Nurse Physician All
152 142 294 146 147 293 140 140 280 438 429 867
45 47 92 30 47 77 23 22 45 98 116 214
29.6 33.1 31.3 20.6 32.0 26.3 16.4 15.7 16.1 22.4 27.0 24.7
0.519
Nurse Physician All Nurse Physician All Nurse Physician All
156 146 302 151 131 282 154 146 300
32 12 44 61 2 63 46 14 60
20.5 8.2 14.6 40.4 1.5 22.3 29.9 9.6 20.0
0.003
Hand Hygiene Adherence Among Health Care Workers at Japanese Hospitals: A Multicenter Observational Study in Japan Tomoko Sakihama, RN, CNIC, MSN,* Hitoshi Honda, MD,† Sanjay Saint, MD, MPH,‡§ Karen E. Fowler, MPH,‡ Taro Shimizu, MD, MPH,k Toru Kamiya, MD,¶ Yumiko Sato, RN, CNIC,# Soichi Arakawa, MD, PhD,** Jong Ja Lee, RN, CNIC,** Kentaro Iwata, MD, MSc,†† Mutsuko Mihashi, RN, PhD,‡‡ and Yasuharu Tokuda, MD, MPHk Background: Although proper hand hygiene among health care workers is an important component of efforts to prevent health care–associated infection, there are few data available on adherence to hand hygiene practices in Japan. Objectives: The aim of this study was to examine hand hygiene adherence at teaching hospitals in Japan. Methods: An observational study was conducted from July to November 2011 in 4 units (internal medicine, surgery, intensive care, and/or emergency department) in 4 geographically diverse hospitals (1 university hospital and 3 community teaching hospitals) in Japan. Hand hygiene practice before patient contact was assessed by an external observer. Results: In a total of 3545 health care worker–patient observations, appropriate hand hygiene practice was performed in 677 (overall adherence, 19%; 95% confidence interval, 18%–20%). Subgroup rates of hand hygiene adherence were 15% among physicians and 23% among nurses. The ranges of adherence were 11% to 25% between hospitals and 11% to 31% between units. Adherence of the nurses and the physicians to hand hygiene was correlated within each hospital. There was a trend toward higher hand hygiene adherence in hospitals with infection control nurses, compared with hospitals without them (29% versus 16%). Conclusions: The hand hygiene adherence in Japanese teaching hospitals in our sample was low, even lower than reported mean values from other international studies. Greater adherence to hand hygiene should be encouraged in Japan. Key Words: hand hygiene, health care worker, health care–associated infection, infection control nurse, adherence (J Patient Saf 2016;12: 11–17)
H
ealth care–associated infections (HAIs) are common and potentially lethal. In the United States, approximately 1.7 million
From the *Kurume University Graduate school of Medicine, Kurume City Fukuoka, Japan; †Division of Infectious Diseases, Department of General Internal Medicine, Teine Keijinkai Medical Center, Sapporo, Hokkaido, Japan; ‡VA Ann Arbor Healthcare System, Ann Arbor, Michigan; §University of Michigan Medical School, Ann Arbor, Michigan; kDepartment of Medicine, Mito Kyodo General Hospital, University of Tsukuba, Mito City, Ibaraki, Japan; ¶Division of General Internal Medicine & Infection Diseases, Rakuwakai Otowa Hospital, Kyoto, Japan; #Division of Infection Control, Teine Keijinkai Medical Center, Sapporo, Hokkaido, Japan; **Department of Infection Control and Prevention, Kobe University Hospital, Kobe City, Hyogo, Japan; ††Division of Infectious Diseases Therapeutics, Department of Microbiology and Infectious Diseases, Kobe University Graduate School of Medicine, Kobe City, Hyogo, Japan; and ‡‡Department of Nursing, Kurume University School of Nursing, Kurume City Fukuoka, Japan. Correspondence: Yasuharu Tokuda, MD, MPH, Department of Medicine, Mito Kyodo General Hospital, University of Tsukuba, 3-2-7 Miya-machi, Mito City, Ibaraki, 310-0015 Japan (e‐mail: [email protected]). The authors disclose no conflict of interest. Copyright © 2014 by Wolters Kluwer Health, Inc. All rights reserved.
J Patient Saf • Volume 12, Number 1, March 2016
such infections occur annually, resulting in approximately 99,000 deaths per year.1 Health care–associated infections are also important in Japan, where approximately 9% of intensive care unit (ICU) patients develop HAIs during hospitalization2 and 5% of all hospitalized patients are infected with methicillin-resistant Staphylococcus aureus (MRSA).3 Health care–associated infections can increase health care costs in 2 ways. First, treatment of patients with HAIs requires additional resources such as antimicrobial therapy and diagnostic tests. Increased use of antimicrobial agents further contributes to the development of antimicrobial resistance and the spread of multidrug-resistant (MDR) pathogens including MRSA and MDR gram-negative organisms. Second, developing an HAI is associated with an increase in the overall hospital length of stay. Studies estimate that surgical site infection and bloodstream infection increase length of stay by 9.7 days and 10 days, respectively.4,5 The annual direct medical costs of HAIs are estimated to range between $28.4 and $33.8 billion in the United States.6 Annual estimated costs for the management of HAI accounts for approximately 4% to 5% of total annual health care costs in Japan, and of these costs, up to approximately $6.8 billion (566 billion yen) are estimated to be potentially preventable.7 Although there are various measures to prevent HAIs, implementing hand hygiene is a key approach.8 Several strategies have been proposed to improve hand hygiene among health care workers (HCWs). One traditional strategy is the placement of sinks equipped with soap and water between the hospital ward room doors and patients’ beds. However, it is sometimes difficult to build these sinks because many hospitals already have sinks located in an inconvenient position. Another strategy is the use of waterless alcohol-based hand rubs, which are now considered to be more effective than hand washing in reducing bacteria and viruses on hands.9 Multiple studies have reported that greater use of alcohol hand rub is associated with a significant reduction in HAIs and MRSA transmission.10,11 Moreover, alcohol-based hand rub causes fewer side effects even when used frequently.12 For these reasons, both the U.S. Centers for Disease Control and Prevention and the World Health Organization (WHO) strongly recommend increased use of alcoholbased hand rub in acute care hospitals.12,13 Although a few studies to evaluate hand hygiene adherence among HCWs in Japanese hospitals were found using a PubMed citation search (www.ncbi.nlm.nih.gov), these previous studies evaluated hand hygiene practice by questionnaire or the amount of consumption of alcohol hand rubs.14–17 To reduce the burden of HAIs in Japanese hospitals, appropriate monitoring of hand hygiene adherence among HCWs is imperative. Thus, we designed a multicenter study for examining hand hygiene adherence by direct observation at teaching hospitals in Japan. www.journalpatientsafety.com
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METHODS Participating Hospitals We aimed to determine hand hygiene adherence among physicians and nurses at a purposeful sample of 4 teaching hospitals from various geographical areas in Japan. The characteristics of each participating hospital are shown in Table 1. Hospital A is a national, tertiary care academic medical center with 874 beds, located in West Japan. Hospital A’s infection control and prevention unit was established in 1999. Two Japanese board-certified infection control nurses (1 full time and 1 part time) are responsible for the hand hygiene education of physicians and nurses. Hospital B is a university-affiliated, community-based, tertiary care medical center with 250 beds in East Japan. The residency program was established in 2009. The hospital did not have an infection prevention unit or designated infection control nurses when the observations were performed. Hospital C is a community-based, tertiary care medical center with 428 beds, located in West Japan. Although the facility has no infection control nurses, a physician certified by the American Board of Internal Medicine and Infectious Diseases (ABIM-ID) provided educational sessions with the nurses and residents in each hospital unit. He periodically assessed hand hygiene adherence among HCWs by direct observation. Hospital D, located in Northern Japan, is a community-based, tertiary care medical center with 550 beds. The infection prevention unit was established in 2010 and included 1 full-time and 2 part-time board-certified infection control nurses. Hand hygiene education by infection control nurses and intensive lectures from an ABIM-ID–certified physician was also provided.
Observation of Hand Hygiene Adherence To assess hand hygiene adherence, we directly observed 13 distinct units across 4 participating hospitals during a 5-month period between July and November 2011. We focused on 4 types of hospital units: the inpatient internal medicine ward, the inpatient surgical ward, the ICU, and the emergency department. An external observer was instructed to assess hand hygiene practice among HCWs of Japanese hospitals using a predefined set of criteria. One of the study authors (T. Sakihama), a Japanese board-certified infection control nurse, served as the sole external observer to assess hand hygiene practices. To minimize intraobserver variation, observer training included (1) e-learning (WHO Guidelines on Hand Hygiene in Health Care; Guide to Implementation; and SAVE LIVES: Clean Your Hands Educational Session for Trainers, Observers and Health-Care Workers),12,18,19 (2) clinical training from an infection control nurse at a university hospital in Tokyo, and (3) pilot testing of observation methods at a university-based hospital in Tokyo. Proper hand hygiene for this study was defined as use of soap and water or alcohol hand rub before touching the patient, which corresponds to moment 1 of the 5 moments of hand hygiene described in the WHO Guidelines on Hand Hygiene in Health Care.12 The observer recorded hand hygiene practice before patient contact for each individual provider-patient encounter using the hand hygiene observation form adapted from a previous study by Saint et al.20–22 The observation form included the following information: the unit in which observations were performed, the time of initiation and completion of observations, the HCW subgroup (physician or nurse), and the type of hand hygiene before contact with the patient (i.e., hand washing with soap and water, use of alcohol-based hand rub, or no hand hygiene). On the day of observation, the staff and trainee physicians and nurses in the
12
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observation unit were informed that their clinical practices were to be observed; however, the focus (i.e., hand hygiene practice) was not disclosed. The observer was given strict instructions to keep a distance so as to not interfere with clinical care delivery by the observed HCWs. If asked to leave for medical or other reasons related to patients’ confidentiality, the observer was to comply immediately. The goal was to observe 134 physicianpatient and 134 nurse-patient hand hygiene encounters on each unit, which would provide enough power to detect future changes in compliance. This led to observing approximately 800 to 900 encounters in each hospital.
Statistical Analyses The data were entered into a Microsoft Access database (Microsoft Corporation, Redmond, Wash) and assessed for extreme values, missing data, and possible coding errors. Hand hygiene adherence rates were calculated and compared between HCW subgroup and by hospital unit including medicine, surgery, ICU, and emergency department. Data analysis was performed using JMP 9.0 and SAS 9.3 (SAS Institute Inc, Cary, NC). Pearson χ2 tests were conducted, and 95% confidence intervals were estimated using binomial distribution. Pearson correlations were used to determine the relationship of hand hygiene between physicians and nurses in the same unit. Twotailed P value of less than 0.05 was considered as statistically significant. The study protocol was reviewed and approved by the ethics committee at the coordinating hospital. On the basis of this approval, the ethics committees of the other participating hospitals waived additional review and approved the study.
RESULTS Data were collected from July to November 2011. Hand hygiene adherence rates are shown in Table 2. Hand hygiene was observed in a total of 3545 occasions throughout the 4 facilities. Table 3 shows the rates of hand hygiene adherence in all hospitals combined. In all 3545 observations, hand hygiene was performed 677 times (19%; 95% confidence interval, 18%–20%). Of those who performed hand hygiene, approximately 67% used alcohol hand rub and 33% used soap and water. The hand hygiene rate among all physicians was 15% (263/1712), and the rate among nurses was 23% (414/1833). Across all occasions, when clinicians practiced hand hygiene, the physicians used alcohol hand rub 74% (194/263) of the time and the nurses used alcohol hand rub 63% (261/414) of the time (P = 0.004). Hand hygiene adherence rates by facility, hospital unit, and HCW subgroup are shown in Table 3. Overall, hand hygiene adherence rates among the 4 participating hospitals ranged from 11% to 25%. Hand hygiene adherence rates among each hospital unit ranged from 10% to 31%. Physician hand hygiene compliance ranged from 2% to 33%, whereas the compliance among the nurses ranged from 8% to 40%. Regarding the relationship between hand hygiene adherence rates and infection control practitioner deployment by facility, hospital unit, and HCW subgroup, correlation in adherence rates between the physicians and the nurses was not significant (r = 0.15; P = 0.64). We observed a higher adherence among the nurses in hospitals A and D, which employed infection control nurses (29% adherence), compared with hospitals B and C, which did not (16% adherence) (P < 0.001). Hospital C, where an infection control physician was present, had the highest physician adherence (27% versus 11%; P < 0.001). Hospital B, which lacked an infection control practitioner, demonstrated © 2014 Wolters Kluwer Health, Inc. All rights reserved.
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J Patient Saf • Volume 12, Number 1, March 2016
Hand Hygiene Adherence Among HCWs
TABLE 1. Characteristics of the Participating Institutions for Evaluation of Hand Hygiene Adherence Among HCWs Hospital A
Hospital B
Hospital C
Hospital D
Hospital overview Location West Japan East Japan Midwest Japan Northern Japan No. beds 874 250 428 550 No. employees 1688 398 1035 1500 No. physicians 535 73 179 207 No. nurses 808 172 410 616 Hospital type University based University affiliated Community based Community based Residency program Yes Yes Yes Yes Level of care Tertiary care Tertiary care Tertiary care Tertiary care Infection control at the study institutions Establishment of infection prevention units, y 1995 N/A N/A 2010 Employment of certified nurses in infection control, n (FTE, n) 2 (1.5) 0 0 3 (1.5) Employment of ABIM-ID certified physician 1 0 1 1 Infrastructure Wash basin in each room Yes No Yes Yes Alcohol hand rub available in each room Yes Yes Yes Yes Portable alcohol hand rub provided for each HCW No No No No Ongoing intervention during hand hygiene observation Periodic educational seminar and lecture Yes No Yes Yes Poster campaign Yes Yes Yes Yes Routine evaluation for hand hygiene adherence Direct observation No No Yes No Monitoring the amount of alcohol hand rub consumption Yes No Yes Yes FTE, full-time equivalent; N/A, not applicable.
the lowest adherence among both physicians and nurses (range, 8%–14%).
DISCUSSION Despite the importance of evaluating hand hygiene adherence in health care settings, the rate of adherence to hand hygiene among HCWs in Japanese institutions has previously been evaluated using questionnaires or the amount of consumption of alcohol hand rubs. Although a previous study showed that hand hygiene at Japanese institutions was approximately 34%, the accuracy of this result was limited because the rate was assessed by questionnaire.16 Our study successfully assessed hand hygiene adherence by direct observation, which is the criterion standard method of hand hygiene assessment.12 Although it may not be entirely appropriate to compare hand hygiene
adherence rates in this study with previously reported rates given the difference in circumstances of health care settings and the focus of studies (e.g., the moment of observation), the overall hand hygiene adherence rate at 4 Japanese hospitals was remarkably low. Low hand hygiene adherence rates among HCWs have been documented in various institutions and countries,20,23,24 with reported rates of adherence ranging from 4% to 100%, with a mean of approximately 40%.23 Understanding and increasing hand hygiene adherence are crucial for preventing spread of MDR pathogens in health care settings. We performed direct observation to identify differences in hand hygiene adherence rates across participating hospitals, HCW subgroups (i.e., physicians or nurses), and hospital units (i.e., medical wards, surgical wards, ICUs, and emergency departments) (Table 4). All 4 hospitals were teaching hospitals with residency programs. The participating institutions consisted of
TABLE 2. Hand Hygiene Observations of the 4 Participating Hospitals
Total no. observations No. observation for nurses No. observation for physicians No. observations per session, mean (range) Minutes of observation per session, mean (range) Total days of observation Total minutes of observation, min (hr)
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Hospital A
Hospital B
Hospital C
Hospital D
Total
866 448 418 27.9 (15–30) 21.3 (15–30) 4 660 (11)
928 486 442 21.1 (5–30) 26.1 (10–30) 5 1150 (19)
867 438 429 28.0 (12–30) 21.8 (10–30) 3 675 (11)
884 461 423 26.0 (6–30) 23.7 (15–30) 4 805 (13)
3545 1833 1712 25.3 (5–30) 23.5 (10–30) 16 3290 (55)
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J Patient Saf • Volume 12, Number 1, March 2016
Sakihama et al
TABLE 3. Overall Hand Hygiene Adherence Among HCW Subgroups HCW Subgroup
Hand hygiene action No. observations Proper hand hygiene performed Proper hand hygiene not performed Hand hygiene adherence rate,* % Type of hand hygiene, n (%) Alcohol hand rub Soap and water
Nurse
Physician
All
1833 414 1419 22.6†
1712 263 1449 15.4†
3545 677 2868 19.1
194 (73.8) 69(26.2)
455 (67.2) 222(32.8)
261 (63.0) 153(37.0)
*Hand hygiene adherence rate was calculated using total number of proper hand hygiene performed 100/total number of observations. † Differences in hand hygiene adherence rates between nurses and physicians were statistically significant (P < 0.001).
various types of hospitals, including university-based, universityaffiliated, and community-based hospitals. Moreover, the participating hospitals were diversely located in Japan. The data consisted of more than 3500 observations by a single observer to minimize interobserver variation. The number of observations was equally distributed among the participating hospitals. We performed pretest validation of the observational method to minimize intraobserver variation. Given the diverse study settings and participants, we believe that the hand hygiene practice findings in this study can be generalized to other similar Japanese hospitals. In this study, we observed substantial variation in hand hygiene adherence rates by HCW subgroups and hospital units. These variations may suggest that focusing on overall hand hygiene adherence rate may not be adequate and instead focusing on certain subgroups may be more beneficial.20 Recognizing variation in hand hygiene adherence rates may help identify areas of focus for intervention. We observed a trend toward lower overall hand hygiene adherence among the physicians compared with the nurses. The overall hand hygiene rate among the physicians ranged from 2% to 33% (mean, 15% [263/ 1712]), whereas the rate among the nurses ranged from 8% to 40% (mean, 23% [414/1833]). Previous studies in other countries reported similar findings.20,24,25 Although there was a trend toward better hand hygiene adherence among the nurses in the hospitals with the presence of infection control nurses (hospitals A and D) and among the physicians when an infection control physician provided the hand hygiene education (hospital C), it remains unclear whether the presence of infection control staff is independently associated with improving hand hygiene adherence among HCWs. This issue may warrant further study. Consistent with previous studies, we observed substantial variation in hand hygiene adherence rates across hospital unit types and between units in the same hospital. A Spanish study found that the hand hygiene adherence rate among HCWs was highest in ICUs, whereas higher rates of hand hygiene adherence were observed in medical and surgical wards in a study from Switzerland.11,24 Another study revealed that hand hygiene adherence rates among HCWs in neonatal ICUs were distinctively high.26 There may be a wide range of factors contributing to the variation in hand hygiene adherence by hospital units, such as differences in infrastructure, level of behavioral control, and patient population. As demonstrated in the limited number of HCWs engaged in infection prevention programs in each participating hospital,
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Japanese institutions face challenges in obtaining adequate resources to operate an effective infection prevention program, resulting in a decline in the quality of these programs. The Japanese Nursing Association started the 6-month certified-nurse infection control educational program in 2000, and only since 2007 has Japanese law required hospitals to have infection control policies.27,28 On the basis of survey data from 423 teaching hospitals in Japan, only 26% of hospitals had a certified infection control nurse, and only 65 hospitals hired full-time infection control nurses.29 Even within relatively limited resource settings, a trend toward higher hand hygiene adherence was observed in hospitals with a full-time infection control practitioner.29 Our findings suggest that hospitals should consider employing full-time infection control practitioners to improve infection prevention practice. Another potential factor in the results of our study could be the apparent unawareness of appropriate hand hygiene practice. This is likely due to insufficient hand hygiene education for HCWs. We noticed that many HCWs used nonsterile gloves without performing hand cleaning by alcohol hand rub or hand washing. Although many HCWs have been wearing gloves to adhere to standard or contact precautions when indicated, they do not recognize that the use of gloves does not replace hand hygiene practice. In 1 study, the implementation of universal gloving for patient care resulted in increased transmission of MDR pathogens, which was potentially due to a decrease in hand hygiene during the universal gloving period.30 Hand hygiene before and after wearing gloves is also important because hands can be contaminated by unrecognized glove leaks or when removing gloves.12 One evaluation demonstrated that bacteria were recovered from approximately 60% of gloves after use, and microbiological contamination of HCWs’ hands occurred in 13% of those who used contaminated gloves.30 Repetitive and frequent educational opportunities for appropriate hand hygiene are crucial to increase hand hygiene adherence. Inadequate infrastructure for hand hygiene practice may also influence the hand hygiene adherence rate. In all 4 participating hospitals, there were usually 4 to 6 beds per room in medical and surgical wards and 1 bed per room in ICUs. In Japanese hospitals, a single dispenser of alcohol hand rub was usually placed at the entrance of each room but not at each bedside. This may be for safety reasons, including prevention of accidental oral intake of alcohol hand rubs and the restriction of placing flammable substances near patients. However, easier access to alcohol hand rubs (e.g., placement of alcohol hand rubs at each © 2014 Wolters Kluwer Health, Inc. All rights reserved.
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J Patient Saf • Volume 12, Number 1, March 2016
Hand Hygiene Adherence Among HCWs
TABLE 4. Hand Hygiene Adherence Rate by Hospital, Unit, and HCW Subgroup Unit Hospital A Surgery
Medicine
ICU
All
Hospital B Surgery
Medicine
ICU
ED
All
Hospital C Surgery
Medicine
ED
All
Hospital D Surgery
Medicine
ICU
P
HCW Subgroup No. Observations No. Using Proper Hand Hygiene Hand Hygiene Adherence Rate, % Nurse Physician All Nurse Physician All Nurse Physician All Nurse Physician All
163 135 298 143 143 286 142 140 282 448 418 866
34 34 68 54 15 69 40 18 58 128 67 195
20.9 25.2 22.8 37.8 10.5 24.1 28.2 12.9 20.6 28.6 16.0 22.5
0.375
Nurse Physician All Nurse Physician All Nurse Physician All Nurse Physician All Nurse Physician All
147 136 283 158 157 315 151 57 208 30 92 122 486 442 928
12 19 31 16 18 34 17 4 21 4 11 15 49 52 101
8.2 14.0 11.0 10.1 11.5 10.8 11.3 7.0 10.1 13.3 12.0 12.3 10.1 11.8 10.9
0.118
Nurse Physician All Nurse Physician All Nurse Physician All Nurse Physician All
152 142 294 146 147 293 140 140 280 438 429 867
45 47 92 30 47 77 23 22 45 98 116 214
29.6 33.1 31.3 20.6 32.0 26.3 16.4 15.7 16.1 22.4 27.0 24.7
0.519
Nurse Physician All Nurse Physician All Nurse Physician All
156 146 302 151 131 282 154 146 300
32 12 44 61 2 63 46 14 60
20.5 8.2 14.6 40.4 1.5 22.3 29.9 9.6 20.0
0.003
