Infection Control & Hospital Epidemiology (2019), 40, 187–193 doi:10.1017/ice.2018.261
Original Article
A multimodal regional intervention strategy framed as friendly competition to improve hand hygiene compliance
Manon D. van Dijk MSc1,a, Sanne A. Mulder BSc2,a, Vicki Erasmus PhD2, A. H. Elise van Beeck MSc2, Joke M. J. J. Vermeeren MSc3, Xiaona Liu PhD2, Ed F. van Beeck PhD2 and Margreet C. Vos PhD1 1Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands, 2Department of
Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands and 3Department of Quality and Patient Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
Abstract
Objective: To investigate the effects of friendly competition on hand hygiene compliance as part of a multimodal intervention program. Design: Prospective observational study in which the primary outcome was hand hygiene compliance. Differences were analyzed using the Pearson χ2 test. Odds ratios (ORs) with 95% confidence interval were calculated using multilevel logistic regression. Setting: Observations were performed in 9 public hospitals and 1 rehabilitation center in Rotterdam, Netherlands. Participants: From 2014 to 2016, at 5 time points (at 6-month intervals) in 120 hospital wards, 20,286 hand hygiene opportunities were observed among physicians, nurses, and other healthcare workers (HCWs). Intervention: The multimodal, friendly competition intervention consisted of mandatory interventions: monitoring and feedback of hand hygiene compliance and optional interventions (ie, e-learning, kick-off workshop, observer training, and team training). Hand hygiene opportunities, as formulated by the World Health Organization (WHO), were unobtrusively observed at 5 time points by trained observers. Compliance data were presented to the healthcare organizations as a ranking. Results: The overall mean hand hygiene compliance at time point 1 was 42.9% (95% confidence interval [CI], 41.4–44.4), which increased to 51.4% (95% CI, 49.8–53.0) at time point 5 (P<.001). Nurses showed a significant improvement between time points 1 and 5 (P<.001), whereas the compliance of physicians and other HCWs remained unchanged. In the multilevel logistic regressions, time points, type of ward, and type of HCW showed a significant association with compliance. Conclusion: Between the start and the end of the multimodal intervention program in a friendly competition setting, overall hand hygiene compliance increased significantly.
(Received 7 May 2018; accepted 24 September 2018)
According to the World Health Organization (WHO), adverse events in healthcare are a growing problem worldwide, and healthcare-associated infections (HAIs) are among the most fre- quent events.1 An HAI is an infection that a patient acquires during hospitalization, which increases the risk of morbidity, mortality, and a prolonged hospital stay.2–4 In European acute- care hospitals, the prevalence of HAI was 6.0% in 2012.5 Fur- thermore, the overall cost of HAIs per year is US$8 billion in Europe and US$4.5 billion in the United States.1,6
Author for correspondence: Prof Dr Margreet C. Vos, Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center Rotter- dam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands. E-mail:
m.vos@erasmusmc.nl PREVIOUS PRESENTATION. The results of this study were presented at the 22nd International Forum on Quality and Safety in Healthcare by Joke M. J. J. Vermeeren on April 26–28, 2017, in London, United Kingdom. The results of this manuscript were also presented as a poster presentation (abstract no. 6225) by Manon D. van Dijk at the 28th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) on April
21–24, 2018, in Madrid, Spain. aAuthors of equal contribution.
Cite this article: van Dijk M D, et al. (2019). A multimodal regional intervention
strategy framed as friendly competition to improve hand hygiene compliance. Infection Control & Hospital Epidemiology 2019, 40, 187–193. doi: 10.1017/ice.2018.261
The prevalence of HAI is strongly associated with the type of
medical service provided and the behavior of healthcare workers (HCWs).7 This includes the hand hygiene behavior of HCWs. The contaminated hands of HCWs have been identified as the cause of several outbreaks.8,9 An effective and recommended solution to prevent transmission of microorganisms is improving hand hygiene compliance in healthcare organizations. Hand hygiene can consist of (1) hand washing with water and soap followed by drying the hands with paper towels or (2) hand disinfection with an alcohol-based hand rub (ABHR). HCWs in the Netherlands are required to follow the guidelines for hand hygiene as provided by the WHO.10 Adherence to these guidelines is monitored by infection prevention professionals within organizations, as well as the national health inspectorate. TheWHOrefers to Five Moments of Hand Hygiene: (1) before touching a patient, (2) before a clean procedure, (3) after body fluid exposure, (4) after touching a patient, and (5) after touching a patients’ environment.11 Despite clear guidelines and monitoring, hand hygiene com-
pliance among HCWs in healthcare organizations is unacceptably low.12 Furthermore, research shows that, among others, the type of ward and the type of HCW (eg, nurses, physicians, or other) in
© 2019 by The Society for Healthcare Epidemiology of America. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. All rights reserved.
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