UNCORRECTED PROOF - inicc

ARTICLE IN PRESS
3 Reduction in nosocomial infection with
4 improved hand hygiene in intensive
5 care units of a tertiary care hospital
6 in Argentina
½Q2Š
V. D. Rosenthal, MD, MSc, CIC, a S. Guzman, RN, a and N. Safdar, MD b
Buenos Aires, Argentina, and Madison, Wisconsin
14 Background: Hand hygiene is a fundamental measure for the control of nosocomial infection. However, sustained compliance with
15 hand hygiene in health care workers is poor. We attempted to enhance compliance with hand hygiene by implementing education,
16 training, and performance feedback. We measured nosocomial infections in parallel.
17 Methods: We monitored the overall compliance with hand hygiene during routine patient care in intensive care units (ICUs;
18 1 medical surgical ICU and 1 coronary ICU) of 1 hospital in Buenos Aires, Argentina, before and during implementation of a hand
19 ½Q3Š hygiene education, training, and performance feedback program. Observational surveys were done twice a week from September
20 2000 to May 2002. Nosocomial infections in the ICUs were identified using the National Nosocomial Infections Surveillance (NNIS)
21 criteria, with prospective surveillance.
22 Results: We observed 4347 opportunities for hand hygiene in both ICUs. Compliance improved progressively (handwashing
23 adherence, 23.1% (268/1160) to 64.5% (2056/3187) (RR, 2.79; 95% CI: 2.46-3.17; P , .0001). During the same period, overall
24 nosocomial infection in both ICUs decreased from 47.55 per 1000 patient-days (104/2187) to 27.93 per 1000 patient days (207/
25 7409) RR, 0.59; 95% CI: 0.46-0.74, P , .0001).
26 Conclusion: A program consisting of focused education and frequent performance feedback produced a sustained improvement in
27 compliance with hand hygiene, coinciding with a reduction in nosocomial infection rates in the ICUs. (Am J Infect Control
28 2005;n:nnn-nnn.)
29 Nosocomial infections are associated with consid- In a previous study in Argentina, with education and 45
44 mains elusive. 5 The study was conducted in 2 ICUs of a private, 180- 58
30 erable morbidity, extra cost, and attributable mortality. performance feedback, adherence to hand hygiene 46
31 We have previously reported a very high rate of improved considerably. 13 We noted disappointing 47
32 nosocomial infection in Argentina. 1,2 Hand hygiene is compliance rates with hand hygiene in our institution 48
33 a fundamental aspect of infection control, with several and developed a program consisting of focused, 49
34 studies showing a decline in nosocomial infection rates frequent education of health care workers, emphasiz- 50
35 when compliance with hand hygiene is enhanced. 3-8 ing adherence to published guidelines and perfor- 51
36 Despite universal acknowledgement of the pivotal role mance feedback. We measured nosocomial infection 52
37 that hand hygiene plays in reducing nosocomial rates at baseline 1 and during the intervention to 53
38 infection, compliance among health care workers determine whether improved compliance would be 54
39 remains poor, with rates ranging from 16% to 81%. 9-11 associated with a reduction in nosocomial infections. 55
40 Numerous strategies have been attempted to enhance
41 compliance with hand hygiene: some of which have
42 resulted in improved short-term compliance 9,10,12 METHODS
56
;
43 however, achievement of sustained improvement re- Setting
57
bed tertiary care teaching hospital situated in the city 59
½Q1Š
From the Section of Infectious Diseases and Hospital Epidemiology,
Colegiales Hospital, Buenos Aires, Argentina a ; and the Section of
Infectious Diseases, Department of Medicine, University of Wisconsin
Medical School, Madison, WI. b
Reprint requests:
0196-6553/$30.00
Copyright ª 2005 by the Association for Professionals in Infection
Control and Epidemiology, Inc.
doi:10.1016/j.ajic.2004.08.009
of Buenos Aires. There is an infection control team
composed of a medical doctor (with formal education
and background in internal medicine, infectious diseases,
and hospital epidemiology), an infection control
nurse, and personnel support. 1 There is 1 medical
surgical intensive care unit (12 beds) and 1 coronary
intensive care unit (12 beds). Handwashing facilities
are available, with 3 sinks in each intensive care unit
with 4% chlorhexidine handwash dispensers and
paper towels. The study proposal was submitted to
UNCORRECTED PROOF
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2 Vol. n No. n Rosenthal, Guzman, and Safdar
70 the infection control committee, which included rep-
71 resentative leadership of each hospital and ICU per-
72 sonnel. The institutional review board at each center
73 approved the study protocol. Patient confidentiality
74 was protected by coding the recorded information only
75 identifiable by infection control teams.
76 Hand hygiene definition
77 According with the last Guidelines for Hand Hygiene
78 in Health-Care Settings, we defined hand hygiene as a
79 general term that applies to either handwashing,
80 antiseptic handwash, or antiseptic handrub. We de-
81 fined handwashing as washing the hands with plain,
82 nonantimicrobial soap and water. Antiseptic handrub
83 was defined as a process when applying an antiseptic
84 handrub product to all surfaces of the hands to reduce
14
85 ½Q4Š the number of microorganisms present.
86 Hand hygiene intervention
87 The hand hygiene program started in September
88 2000. We divided the program into 2 phases: phase 1 (or
89 baseline handwashing compliance), from September
90 to December 2000 (4 months); and phase 2 (or inter-
91 vention period), from January 2001 to May 2002 (17
92 months). A comprehensive infection control manual
93 was distributed to health care workers (HCW), and we
94 used the Association for Professionals in Infection
95 Control (APIC) hand hygiene guideline as an educational
96 tool for this study. 15 Baseline and postintervention data
97 regarding compliance of HCW with hand hygiene
98 before contact with patients were collected in the ICUs
99 by a trained infection control practitioner, who covertly
100 observed the handwashing techniques of the health
101 care workers at random times, including all shifts, for
102 30-minute intervals during each phase of the study. Data
103 on handwashing compliance including unit, shift, sex,
104 and category of HCW (physician, nurse, and ancillary
105 staff) were recorded on a specially designed form.
106 Interventions to improve hand hygiene compliance
107 included monthly meetings at which visual displays of
108 handwashing rates were presented. These were also
109 posted monthly in the 2 ICUs. Focused education of all
110 HCWs was provided. Educational classes were given in
111 1-hour group sessions for all shifts every day for 1 week.
112 Each participant was given the infection control man-
113 ual, and the APIC hand hygiene guideline was used as
114 an educational tool to reinforce classroom teaching.
115 Attendance was voluntary, supported by the admin-
116 istrator, and monitored. Each HCW could attend the
117 course as many times as desired. Theoretic and
118 practical indications for the use of hand hygiene
119 were reviewed. The guidelines were also posted at a
120 strategic location in each ICU. Posttests to evaluate
121 retention of educational material were given 1 month
later. The primary investigator routinely held infection
control review classes to provide an opportunity for
infection control questions and share surveillance
data. Frequent feedback was provided regarding hand
hygiene rates and nosocomial infection rates, consisting
of reports to the ICU manager and administrator,
graphic presentations of hand hygiene rates displayed
in meetings, and feedback data posted in the ICUs. We
did not change soap or antibiotic use. The senior
hospital management provided full administrative
support for the study. No external funding was
provided. The human resources for the intervention
were those of the infection control program.
Outcome measures
UNCORRECTED PROOF
122
123
124
125
126
127
128
129
130
131
132
133
134
135
2002 with standardized methods.
Hand hygiene compliance was observed simulta- 136
neously along with multiple other infection control 137
responsibilities in the ICU. The infection control 138
program is well-known by the ICU staff, and, although 139
the HCWs were informed that their hand hygiene 140
practices were being monitored, the staff was not 141
aware of precisely when these observations were being 142
made. We commenced education on January 2001 and 143
started performance feedback on May 2001, after 144
which HCWs were aware that their hand hygiene 145
practices were being monitored. Trained staff observed 146
the handwashing technique of physicians, nursing 147
staff, and technicians at random times twice a week, 148
including all work shifts for 30-minute intervals during 149
each phase of the study.
150
The contacts were monitored with direct observa- 151
tion, and the infection control practitioners (ICPs) 152
recorded the handwashing processes before contact 153
with each patient. One nurse was trained to detect 154
handwashing compliance and to record it on a form 155
designed for the study. To provide feedback, bar charts 156
of handwashing rates were displayed at monthly 157
meetings and posted each month in the ICUs.
158
Nococomial infections were identified by a trained 159
infection control nurse in the ICUs according to 160
adapted standard definitions of the Centers for Disease 161
Control and Prevention. 16 The ICP obtained such 162
information from the medical records nurse charts, 163
microbiology laboratory reports, and other laboratory 164
results, including white cell counts, radiographs, and 165
other available studies. We followed the patients for 48 ½Q5Š 166
hours after discharge from the ICUs. Prospective 167
surveillance for nosocomial infections has been car- 168
ried out in our hospital since September 2000 to May
169
170
Nosocomial infection definitions
171
Ventilator-associated pneumonia. Criterion 1: a
mechanically ventilated patient has rales or dullness
172
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Rosenthal, Guzman, and Safdar n 2005 3
174 to percussion on physical examination of the chest and
175 at least 1 of the following: new onset of purulent
176 sputum or change in character of sputum; organism
177 cultured from blood; isolation of an etiologic agent
178 from a specimen obtained by transtracheal aspirate,
179 bronchial brushing, or biopsy. 16
180 Criterion 2: a mechanically ventilated patient has
181 a chest radiographic examination that shows a new
182 or progressive infiltrate, consolidation, cavitation, or
183 pleural effusion and at least 1 of the following: new
184 onset of purulent sputum or change in character of
185 sputum; organism cultured from blood; isolation of an
186 etiologic agent from a specimen obtained by trans-
187 tracheal aspirate, bronchial brushing, or biopsy; or
188 histopathologic evidence of pneumonia. 16
189 Laboratory-confirmed, catheter-associated blood-
190 stream infection. A patient with a central venous
191 catheter has a recognized pathogen cultured from 1 or
192 more percutaneous blood cultures, after 48 hours of
193 vascular catheterization, and the pathogen cultured
194 from the blood is not related to an infection at another
195 site and patient has at least 1 of the following signs or
196 symptoms: fever ($38°C), chills, or hypotension. With
197 common skin commensals (eg, diphtheroids, Bacillus
198 species, Propionibacterium species, coagulase-nega-
199 tive staphylococci, or micrococci), the organism is
200 cultured from 2 or more blood cultures drawn on
201 separate occasions. 16
202 Clinically suspected, catheter-associated blood-
203 stream infection. A patient with a central venous
204 catheter has at least 1 of the following clinical signs,
205 with no other recognized cause: fever ($38°C), hypo-
206 tension (systolic blood pressure #90 mm Hg), or
207 oliguria (#20 mL/hr); but blood cultures were not
208 obtained or no organisms were recovered from blood
209 cultures, but there is no apparent infection at another
210 site and the physician institutes treatment. 16
211 Symptomatic catheter-associated urinary tract in-
212 fection. Criterion 1: A patient with a foley urinary
213 catheter has 1 or more of the following with no other
214 recognized cause: fever ($38°C), urgency, frequency,
215 or suprapubic tenderness, and the urine culture is
216 positive for $10 5 CFU/mL with no more than 2
217 microorganisms. 16
218 Criterion 2: A patient with a foley urinary catheter
219 has at least 2 of the following signs of infection with
220 no other recognized cause: positive dipstick for
221 leukocyte esterase and/or nitrate; pyuria ($10 WBC/
222 mL); organisms are seen on Gram’s stain; physician
223 diagnoses a urinary tract infection; or physician
224 initiates appropriate therapy for a urinary tract
225 infection. 16 Nosocomial infection rates were calcu-
226 lated by dividing the total number of nosocomial
227 infections by the number of patient-days and multi-
228 plied by 1000.
Statistical analysis
Our a priori hypothesis was that we could increase
hand hygiene compliance to 70%, with reduction in
nosocomial infection by 30% in keeping with results of
the SENIC study. 18 Differences in proportions were
compared by x 2 tests providing relative risk, corresponding
95% confidence intervals, and P value.
Changes in compliance over time were estimated in a
univariate analysis with the first survey as the reference
point (Epi Info, version 6.04b, Centers for Disease
Control and Prevention, Atlanta, GA). Two-tailed P
values of less than .05 were considered to indicate
statistical significance.
RESULTS
UNCORRECTED PROOF
229
230
231
232
233
234
235
236
237
238
239
240
241
242
Between September 2000 and May 2002, we 243
obtained data on a total of 4347 opportunities for 244
hand hygiene ( Table 1). The baseline phase (or phase 1) ½T1Š245
was from September 2000 to December 2000 (4 246
months), and the intervention phase (or phase 2) was 247
from January 2001 to May 2002 (17 months). Overall 248
compliance improved from 23.1% in phase 1 to 64.5% 249
in phase 2 (RR, 2.79; 95% CI: 2.46-3.17; P , .0001) 250
(Table 1).
251
Divided into 4 periods, period 1 (from September to 252
December 2000), period 2 (from January to June 2001), 253
period 3 (from July to December 2001) and period 4 254
(from January to May 2002), we found that the 255
compliance was higher comparing period 2 (724/ 256
1353, 53.5%) with period 1 (268/1160, 23.1%) (RR, 257
2.32; 95% CI: 2.01-2.66; P = .0000). The compliance 258
was higher comparing period 3 (828/1148, 72.1%) with 259
period 2 (724/1353, 53.5%) (RR, 1.35; 95% CI: 1.22- 260
1.49; P = .0000). The compliance was similar com- 261
paring period 4 (518/701, 73.8%) with period 3 (828/ 262
1148, 72.1%) (RR, 1.02; 95% CI: 0.92-1.14, P = .665) ½Q6Š 263
( Table 2).
½T2Š264
The compliance was higher for nurses (59.6%) 265
compared with physicians (30.8%) (RR, 1.31; 95% CI: 266
1.11-1.54; P = .0012). The compliance was higher for ½Q7Š 267
nurses (59.6%) compared with ancillary staff (37.1%) 268
(RR, 1.39; 95% CI: 1.18-1.64; P , .0001). The compli- 269
ance was similar for physicians (30.8%) compared 270
with ancillary staff (37.1%) (RR, 0.94; 95% CI: 0.76- 271
1.17; P = .6010). The compliance was higher for 272
women (57.8%) compared with men (43.2%) (RR, 273
1.23; 95% CI: 1.09-1.38; P = .0005). The compliance 274
was higher for superficial (56.7%) compared with 275
invasive procedures (48.1%) (RR, 1.21; 95% CI: 1.08- 276
1.35; P = .0008). The compliance was higher during 277
the night work shift (66.0%) compared with afternoon 278
work shift (50.2%) (RR, 1.18; 95% CI: 1.02-1.37; 279
P = .02). The compliance was similar during the night 280
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4 Vol. n No. n Rosenthal, Guzman, and Safdar
Table 1. Improvement in compliance rates in 2 phases
Year Opportunities for hand hygiene Observed handwashing episodes Adherence (%) RR 95% CI P value
2000 1160 268 23.1% 2.79 2.46-3.17 ,.0001
2001-2002 3187 2056 64.5%
Table 2. Improvement in compliance rates in 4 phases
Period Year Months Opportunities for HH Observed HH episodes HH adherence (%) RR 95% CI P value
1 2000 9-12 1160 268 23.10
2 2001 1-6 1353 724 53.5 1 vs 2 = 2.32 2.01-2.66 .0000
3 2001 7-12 1148 828 72.1 2 vs 3 = 1.35 1.22-1.49 .0000
4 2002 1-5 701 518 73.8 3 vs 4 = 1.02 0.92-1.14 .665
HH, hand hygiene.
281 work shift (66.0%) and morning work shift (52.2%)
282 (RR, 1.08; 95% CI: 0.93-1.25; P = .294). The compli-
283 ance was similar during the morning work shift
284 (52.2%) compared with afternoon work shift (50.2%)
285 (RR, 1.09; 95% CI: 0.97-1.23; P = .1420). The compli-
286 ance was similar for medical surgical ICU (53.5%)
287 compared with coronary care unit (53.6) (RR, 1.0; 95%
288 ½T3Š CI: 0.9-1.11; P = .97) ( Table 3). During the same period,
289 overall nosocomial infection in both ICUs decreased
290 from 47.55 per 1000 patient-days (104/2187) to 27.93
291 per 1000 patient days (207/7409) (RR, 0.59; 95% CI:
292 ½T4Š 0.46-0.74; P , .0001) ( Table 4).
293 DISCUSSION
294 A large body of literature exists on the challenging
295 task of achieving compliance with hand-hygiene rec-
296 ommendations in the health care setting. Pittet et al
297 studied predictors of noncompliance with hand hy-
298 giene in an observational study and found that, in
299 multivariate analysis, physicians and nursing assistants
300 had lower compliance rates than nurses. Of concern,
301 compliance was lower in ICUs and during procedures
302 that carried a high risk of contamination. 19 In a more
303 recent cross-sectional survey of 163 physicians, the
304 same investigators reported that adherence to hand
305 hygiene was associated with awareness of being
306 observed and ready availability of handrubs. Gaps in
307 knowledge regarding guidelines and the importance of
308 hand hygiene is another barrier reported in the
309 literature. 20 Larson et al have reported some perceived
310 barriers include ignorance of the importance and
311 impact of hand hygiene and lack of information
312 regarding the existence of published guidelines. 21
313 Several interventions have been attempted to improve
314 hand hygiene practices; among the most effective have
315 been those that emphasize targeted education and
316 frequent performance feedback. 10,22-25 Dubbert et al
317 found that, although education alone improved com-
318 pliance rates transiently, performance feedback re-
UNCORRECTED PROOF
to 40% in the follow-up period.
represent an ongoing challenge to improve.
sulted in a more sustained improvement in 319
compliance 10 ; rates of infection were, however, not 320
reported in this study. More recently, patient education 321
has received attention as a possible means of improv- 322
ing adherence to hand hygiene in HCWs. In a pre- and 323
postintervention study in an inpatient rehabilitation 324
unit, McGuckin et al used a patient education model 325
consisting of patients asking HCWs coming into con- 326
tact with them whether they had washed their hands. 327
Compliance (measured through soap/sanitizer usage 328
per resident-day) improved to 94% during the 6-week 329
intervention. However, adherence to hand hygiene fell
330
331
Our study expands the current body of literature by 332
showing the impact of a relatively low-cost strategy– 333
education and performance feedback–in not only 334
increasing adherence to hand hygiene but also a 335
decline in nosocomial infection in a developing coun- 336
try and is the first showing reduction of nosocomial 337
infection by improving hand hygiene in Latin America. 338
We found a 42% relative reduction in nosocomial 339
infection rates by emphasizing compliance with hand 340
hygiene. Our results are in keeping with those of other 341
studies that reported a considerable decline in noso- 342
comial infections after enhanced compliance with 343
hand hygiene. 4,6 We found lower adherence among 344
physicians, and during invasive procedures, which is 345
similar to the results reported by Pittet et al and
346
347
In our study, we did not make a change in the choice 348
of hand hygiene agent. Prior randomized trials using 349
nosocomial infections as the outcome measure have 350
found that handwashing with 2% to 4% chlorhexidine 351
is associated with lower rates of nosocomial infec- 352
tion. 4,27,28 More recently, the use of alcohol-based 353
hand sanitizers has become widespread. Alcohol-based 354
handrubs are recommended in the most recent CDC 355
hand hygiene guideline 29 and have been associated 356
with increased compliance with hand hygiene and, in 357
some studies, lower nosocomial infection rates. 5,6 358
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Rosenthal, Guzman, and Safdar n 2005 5
Table 3. Adherence to hand hygiene
Variable Opportunities for HH Observed HH episodes Adherence (%) RR 95% CI P value
MS-ICU 1271 680 53.5 MS-ICU vs CO-CU = 1.0 0.9-1.11 .97
CO-CU 1293 693 53.6
Women 1701 972 57.8 Women vs men = 1.23 1.09-1.38 .0005
Men 862 401 43.2
Nurse 1806 1047 59.6 Nurse vs physician = 1.31 1.11-1.54 .001
Physician 375 166 30.8
Ancillary staff 383 160 37.1
Superficial 1534 882 56.7 Superfic vs invas = 1.21 1.08-1.35 .0008
Invasive 1030 491 48.1
Night 428 253 66.0 Night vs morning = 1.18 1.02-0.37 .02
Morning 1107 605 52.2
Afternoon 1029 515 50.2
MS-ICU, medical surgical intensive care unit; CO-CU, coronary care unit; superfic, superficial contact; invas, invasive contact; HH, hand hygiene.
Table 4. Nosocomial infections distribution by phase
Phase 1 2 RR 95% CI P value
Period September 2000-December 2000 January 2001-May 2002
Central vascular catheter-associated LCBI 15 12
Central vascular catheter-associated CSEP 21 11
Peripheral vascular catheter-associated LCBI 3 4
Peripheral vascular catheter-associated CSEP 1 2
Ventilator-associated pneumonia 29 69
Pnuemonia not associated to ventilator 10 51
Catheter-associated UTI 25 56
UTI not associated to catheter 0 2
Total nosocomial infections 104 207
Bed days 2187 7409
Nosocomial infections per 1000 bed days 47.55 27.93 0.59 0.46-0.74 .0000
½Q9Š LCBI, Laboratory confirmed bloodstream infections; CSEP, clinical sepsis; UTI, urinary tract infection.
359 Our study has several limitations. This was not a
360 randomized study; randomization of hand hygiene
361 versus no hand hygiene is not feasible because of
362 ethical reasons and the recognized value of handwash-
363 ing. The Hawthorne effect must be taken into consid-
364 eration in every behavioral study in which a short-term
365 impact of the intervention may be seen as a result of
366 behavior change stemming from being observed. The
367 relatively long follow-up period of our study and
368 demonstration of sustained improvement in hand
369 hygiene adherence make this effect less of a concern.
370 Its quasiexperimental design and implementation of
371 other simultaneous specific infection control interven-
372 tions to reduce CVC-associated bloodstream infec-
373 tions, 30 and urinary catheter-associated UTIs, 31 make
374 the true impact of the hand hygiene program difficult
375 to assess.
376 Our results have, in part, been published in 2
377 previous reports, one reporting on rates of catheter-
378 associated UTI, 31 which overlapped for 17 of 21 months
379 with the present study and the other reporting rates of
380 CVC-associated bloodstream infections, 30 which over-
381 lapped for 7 of 21 months with the present study. These
2 previous studies analyzed only catheter-associated
UTI and CVC-associated bloodstream infections. We
expand these results in our current study to include the
effect of hand hygiene on the following nosocomial
infections beyond those but including those previously
reported: ventilator-associated pneumonia, nosocomial
pneumonia not associated with ventilators, central
vascular catheter-associated bloodstream infections,
peripheral vascular catheter-associated bloodstream
infections, catheter-associated UTI, and UTI not associated
with catheterization. The performance feedback
was effective in achieving increased adherence to hand
hygiene; however, this strategy requires considerable
institutional commitment and environmental changes
to enhance compliance.
In conclusion, our study shows that a program
focused on education and performance feedback of
HCWs is effective in promoting hand hygiene and
lowering nosocomial infection rates. Although institutional
support and frequent observation is required for
such a program to be successful, it is a relatively lowcost
approach that may be especially attractive in
developing countries.
UNCORRECTED PROOF
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
399
400
401
402
403
404
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6 Vol. n No. n Rosenthal, Guzman, and Safdar
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