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Assessing sustainability of hand hygiene adherence 5 years after a contest-based intervention in 3 Japanese hospitals

Open AccessPublished:July 23, 2019DOI:https://doi.org/10.1016/j.ajic.2019.06.017

      Highlights

      • Physician and nurse hand hygiene was studied in 3 Japanese hospitals over 5 years.
      • We conducted direct observation of hand hygiene before patient contact.
      • A multimodal hand hygiene intervention had been successfully implemented 5 years prior.
      • Hand hygiene improved from 18% before to 33% 6 months after the intervention.
      • Hand hygiene at 5 years after the intervention was unchanged at 32%.

      Background

      Our goal was to evaluate the 5-year sustainability of a multimodal intervention that included a prize to the hospital with the highest overall hand hygiene adherence rates among health care workers.

      Methods

      We conducted an observational study in 3 Japanese tertiary care hospitals using unobtrusive direct observation of physician and nurse hand hygiene adherence. Observations were performed by a trained observer on inpatient medical, surgical, intensive care, and emergency units. The primary outcome was hand hygiene adherence rates before patient contact. Secondary outcomes were health care worker survey responses to a World Health Organization (WHO) questionnaire on hand hygiene practices.

      Results

      Hand hygiene adherence rates had improved significantly after the introduction of a multimodal intervention (based on principles recommend by the WHO) in 2012 and 2013 (from 18.0% pre-intervention to 32.7% 6 months post-intervention; P < .001). No significant changes were found in hand hygiene adherence in these hospitals 5 years after the original intervention (31.9% 5 years after intervention; P = .53); however, substantial variability in hand hygiene adherence by unit and health care worker type was noted.

      Conclusions

      A multimodal hand hygiene initiative achieved sustained improvement in hand hygiene adherence in 3 Japanese hospitals 5 years after the original intervention.

      Graphical abstract

      Key Words

      Introduction

      Appropriate hand hygiene practices among health care workers have been promoted internationally as an evidence-based measure to prevent infection.
      • Burke JP
      Infection control - a problem for patient safety.
      Unfortunately, adherence to hand hygiene is generally suboptimal worldwide,
      • Pittet D
      Hand hygiene: from research to action.
      • Saint S
      • Bartoloni A
      • Virgili G
      • Mannelli F
      • Fumagalli S
      • di Martino P
      • et al.
      Marked variability in adherence to hand hygiene: a 5-unit observational study in Tuscany.
      including in Japan, as we have previously shown.
      • Sakihama T
      • Honda H
      • Saint S
      • Fowler KE
      • Shimizu T
      • Kamiya T
      • et al.
      Hand hygiene adherence among health care workers at Japanese hospitals: a multicenter observational study in Japan.
      About 10% of patients admitted to intensive care units (ICUs) in Japan develop a health care–associated infection (HAI), and approximately 5% of all inpatients have newly acquired infections caused by methicillin-resistant Staphylococcus aureus.
      • Kimura S
      Economical efficiency of infection control.
      The economic burden of HAIs in Japan is high, with an annual cost directly related to all HAIs among large (>600 bed) hospitals estimated to be at least 2,000,000,000 Japanese yen (about US$20,000,000).
      • Kimura S
      Economical efficiency of infection control.
      • Suka M
      • Yoshida K
      • Takezawa J
      Epidemiological approach to nosocomial infection surveillance data: the Japanese Nosocomial Infection Surveillance System.
      Further, the use of antimicrobials for HAIs has enhanced the emergence of resistant organisms in Japanese hospitals.
      • Suka M
      • Yoshida K
      • Takezawa J
      Epidemiological approach to nosocomial infection surveillance data: the Japanese Nosocomial Infection Surveillance System.
      Improving adherence rates to health care worker hand hygiene practices has been recommended by the World Health Organization (WHO),

      World Health Organization. WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. Available at: https://www.who.int/infection-prevention/publications/hand-hygiene-2009/en/. Accessed March 28, 2019.

      the US Centers for Disease Control and Prevention,
      • Boyce JM
      • Pittet D
      Healthcare Infection Control Practices Advisory CommitteeHICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force
      Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
      and others as a key approach to reducing HAIs.
      • Ellingson K
      • Haas JP
      • Aiello AE
      • Kusek L
      • Maragakis LL
      • Olmsted RN
      • et al.
      Strategies to prevent healthcare-associated infections through hand hygiene.
      We therefore implemented a multimodal intervention in 3 hospitals in Japan in 2012 that was largely consistent with the recommendations of WHO and included educating health care workers about the importance of hand hygiene and the dissemination of alcohol-based hand rub. The interventions were described in detail in our previous study.
      • Sakihama T
      • Honda H
      • Saint S
      • Fowler KE
      • Kamiya T
      • Sato Y
      • et al.
      Improving healthcare worker hand hygiene adherence before patient contact: a multimodal intervention of hand hygiene practice in three Japanese tertiary care centers.
      Each facility could determine which components of the intervention they chose to implement. All hospitals provided alcohol-based hand rub in patient rooms, staff education, posters, and feedback to the infection control committee and department leads, in addition to internally monitoring hand hygiene through either direct observation or hand rub consumption. Some hospitals also provided portable alcohol-based hand rub to staff, formed a hand hygiene team, and obtained executive leadership and middle management support. The intervention was combined with a novel institutional-level contest with a financial incentive. Specifically, the hospital with the highest adherence after the intervention was awarded US$5,000 and a trophy designating the hospital as the champion. This resulted in significant overall improvement in hand hygiene rates among health care workers (from 18% pre-intervention to 33% post-intervention), although improvement varied markedly among the 3 hospitals (hospital A, +29%; hospital B, +5%; hospital C, +8%). Hospital A earned the contest trophy and financial incentive after achieving a 40% post-intervention adherence rate.
      • Sakihama T
      • Honda H
      • Saint S
      • Fowler KE
      • Kamiya T
      • Sato Y
      • et al.
      Improving healthcare worker hand hygiene adherence before patient contact: a multimodal intervention of hand hygiene practice in three Japanese tertiary care centers.
      We were curious if these findings could be sustained (or even improved), given that the overall hand hygiene adherence rates in these Japanese hospitals remained relatively low compared to reported rates from other countries.
      • Erasmus V
      • Daha TJ
      • Brug H
      • Richardus JH
      • Behrendt MD
      • Vos MC
      • et al.
      Systematic review of studies on compliance with hand hygiene guidelines in hospital care.
      For this reason, we conducted a 5-year post-intervention study to assess the sustainability of the intervention.

      Methods

      Overall design, study setting, and participants

      The current rate of hand hygiene among physicians and nurses was observed at 3 hospitals in Japan. These data were compared with earlier data collected both before and soon after implementation of a multimodal intervention that occurred approximately 5 years prior to this evaluation. Hand hygiene practices were evaluated in at least 3 wards of each hospital, including inpatient surgical wards, inpatient medicine wards, ICUs, and emergency wards.
      The participating hospitals have been described in detail previously.
      • Sakihama T
      • Honda H
      • Saint S
      • Fowler KE
      • Kamiya T
      • Sato Y
      • et al.
      Improving healthcare worker hand hygiene adherence before patient contact: a multimodal intervention of hand hygiene practice in three Japanese tertiary care centers.
      Hospital A—a 312-bed, university-affiliated, acute care medical center in eastern Japan—showed the greatest improvement in hand hygiene rates after the initial intervention. The leadership at this hospital was very supportive of the intervention and in 2012 employed an infection prevention nurse who served as a champion for hand hygiene. All components of the intervention were implemented. In 2015, the hospital introduced an infection prevention support system linked with electronic medical records. Hospital B, located in midwestern Japan, is a tertiary care medical center with 428 beds. A physician certified by the American Board of Internal Medicine and Infectious Diseases and a designated infection prevention nurse have continued providing educational sessions regarding hand hygiene for physicians and nurses since the initial intervention in 2012. The intervention at this site included most recommended practices; however, they did not form a hand hygiene team and did not receive the same level of leadership support as hospital A did. Hospital C is a tertiary care medical center with 562 beds located in northern Japan. At the time of the intervention, this hospital had 3 infection prevention nurses and a designated infection prevention physician specializing in infectious diseases; however, the infection prevention staffing has since decreased to only 1 infection prevention nurse and no infectious disease physician. The hospital did not provide portable hand rub to staff, internally monitor staff hand hygiene through direct observation, form a hand hygiene team, or receive leadership support for infection prevention activities.

      Observation of health care worker hand hygiene practices

      One of the study authors, who conducted observations in our previous studies, observed hand hygiene practices at all participating hospitals. Using the same method as the prior evaluations, she conducted observations in 3 units of each hospital, for a total of 9 units. The observation method focused on hand hygiene before contact with patients, aligning with Moment 1 of the WHO My Five Moments for Hand Hygiene.

      World Health Organization. WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. Available at: https://www.who.int/infection-prevention/publications/hand-hygiene-2009/en/. Accessed March 28, 2019.

      We defined appropriate hand hygiene as hand washing with soap and water or use of alcohol-based hand rub immediately before contact with patients. Hand hygiene prior to donning gloves was also included. Physician and nurse interactions with patients were observed during rounds, vital sign measurements, physical examinations, and medication administration. Consistent with our prior work, the hospital staff were informed that the observer was going to conduct a survey of clinical practices, but they were not informed of the specific purpose of the observations.

      Health care worker self-assessment of hand hygiene practices

      To evaluate awareness and attitudes about hand hygiene practice, we asked infection prevention nurses in all 3 hospitals to complete the WHO Hand Hygiene Self-Assessment Framework (HHSAF) during the observation period.

      World Health Organization. Hand Hygiene Self-Assessment Framework 2010: introduction and user instructions. Available at: https://www.who.int/gpsc/country_work/hhsa_framework_October_2010.pdf?ua=1. Accessed March 27, 2019.

      The HHSAF is a validated, structured, self-assessment tool to analyze hand hygiene resources, promotion, and practices within health care institutions.
      • Stewardson AJ
      • Allegranzi B
      • Perneger TV
      • Attar H
      • Pittet D
      Testing the WHO Hand Hygiene Self-Assessment Framework for usability and reliability.
      It was designed to enhance the development of action plans for facilitating hand hygiene programs in health care institutions. This assessment is divided into 5 components based on 27 individual indicators. The component scores are then combined to calculate a summary score ranging from 0 to 500, divided into the following categories: inadequate (0-125), basic (126-250), intermediate (251-375), or advanced (376-500).

      Statistical analyses

      Hand hygiene adherence rates were calculated for physicians and nurses in all 3 hospitals. Data were double entered into a MS Access (Microsoft Corporation; Redmond, WA) database and checked for errors accordingly. The adherence rates were compared between provider groups (physicians and nurses) in each hospital. These were also compared between the 5-year post-intervention assessment (current data) and immediately after the intervention (previous study data). Comparisons were made using the Pearson's χ2 test, where a 2-tailed P value ≤ .05 was considered statistically significant. The ethics committees at the International University of Health and Welfare (Tokyo, Japan) reviewed and approved the study protocol (No 17-Ig-10).

      Results

      Hand hygiene by hospital

      Data for the current study were collected between September and December 2017 at the 3 participating hospitals. An additional 2,485 observations were conducted during this 5-year post-intervention assessment. These observations were compared to 2,679 observations from the pre-intervention period and 2,982 observations from the 6-month post-intervention period.
      Figure 1 shows the summary findings for each hospital. In hospital A, hand hygiene adherence improved by 29% between pre- and post-intervention (P < .001) but did not change significantly between the post-intervention (39.9%) and the 5-year assessment (38.3%; P = .47). In hospital B, hand hygiene adherence improved by 5.3% from pre- to post-intervention (P = .01), with minimal changes seen between post-intervention (30.0%) and the 5-year assessment (30.4%; P = .87). Hospital C's hand hygiene adherence improved by 7.6% from pre- to post-intervention (P < .001), but then remained largely unchanged between post-intervention (26.5%) and the 5-year assessment (26.1%; P = .84). For all hospitals combined, there was significant improvement between pre-intervention (18.0%) and post-intervention (32.7%; P < .001), but no significant changes were seen between the post-intervention and the 5-year assessment (31.9%; P = .53).
      Fig 1
      Fig 1Comparison of hand hygiene adherence rates among 3 time periods (pre-intervention and at 6 months post-intervention and 5 years post-intervention ). In each hospital, there were significant improvements in hand hygiene adherence between the pre-intervention and post-intervention time points (hospital A, +29.0%, P < .001; hospital B, +5.3%, P = .009; hospital C, +7.6%, P < .001). However, no significant changes were seen between the 6 months post-intervention and the 5-year assessment (hospital A, –1.6%, P = .47; hospital B, +0.4%, P = .87; hospital C, –0.4%, P = .84). In total, hand hygiene adherence for all participating hospitals improved between pre-intervention (18.0%) and post-intervention (32.7%; P < .001), but no significant changes were observed between the 6 months post-intervention and 5-year assessment time points (31.9%; P = .53)

      Hand hygiene by unit type and health care worker subgroup

      Hand hygiene adherence rates varied based on unit type and health care worker group (Table 1). For example, although improvements were seen between pre- and post-intervention, both physicians and nurses in surgery units showed a 16.8% decrease in hand hygiene adherence between the post-intervention and 5-year assessment (from 41.4% at post-intervention to 24.6% at 5-year assessment; P < .001). Other unit types saw improvements in one health care worker subgroup but not in another. In internal medicine units, physician hand hygiene continued to improve after the 6-month post-evaluation period (32.5% at post-intervention to 53.2% at 5-year assessment; P < .001); however, no significant change was observed within the nursing staff (39.4% at post-intervention and 35.2% at 5-year assessment; P = .19). ICUs saw significant improvements in nurses’ hand hygiene (from 25.1% at post-intervention to 38.1% at 5-year assessment; P < .001), but no significant changes were observed in physicians (28.4% at post-intervention and 23.9% at 5-year assessment; P = .25). Of all the unit types, the emergency department had the lowest hand hygiene compliance rates at both 6 months post-intervention and at the 5-year assessment. Between those time points, nurse hand hygiene adherence significantly decreased by 10.1% (from 27.2% at post-intervention to 17.1% at 5-year assessment; P = .04). Adherence improved slightly in physicians, although not significantly (9.1% at post-intervention to 13.6% at 5-year assessment; P = .18).
      Table 1Hand hygiene adherence rates at all hospitals for each unit type by health care worker subgroup over time (pre-intervention, immediately after intervention, 5 years after intervention)
      Pre-intervention6 mo post-intervention5 y post-intervention
      Unit typeHealth care worker subgroupNo. of observationsHand hygiene adherence (%)No. of observationsHand hygiene adherence (%)Change from pre- to post-intervention (%)P valueNo. of observationsHand hygiene adherence (%)Change from 6 mo post-intervention to 5 y post-intervention (%)P value
      SurgeryNurse45519.648040.420.8<.00142825.5–14.9<.001
      Physician42418.444842.424.0<.00137723.6–18.8<.001
      Total87919.092841.422.4<.00180524.6–16.8<.001
      MedicineNurse45523.550839.415.9<.00141535.2–4.2.193
      Physician43515.445232.517.1<.00141953.220.7<.001
      Total89019.696036.116.5<.00183444.28.1<.001
      ICUNurse30520.737925.14.4.49732038.113.0<.001
      Physician2038.926828.419.5<.00125523.9–4.5.251
      Total50815.964726.410.5<.00157531.85.4.038
      EDNurse17015.917327.211.3.01314617.1–10.1.037
      Physician23214.22749.1-5.1.07612513.64.5.177
      Total40214.944716.11.2.63627115.5–0.6.829
      All unitsNurse138520.6154034.814.2<.001130930.7–4.1.021
      Physician129415.1144230.415.3<.001117633.22.8.126
      Total267918.0298232.714.7<.001248531.9–0.8.533
      ED, emergency department; ICU, intensive care unit.

      Hand hygiene self-assessment framework scores

      Each participating facility completed the WHO HHSAF around the time of the 5-year assessment. The hospitals’ total scores on the WHO HHSAF ranked in the same order as their hand hygiene adherence, with hospital A scoring highest (335, intermediate), hospital B second highest (290, intermediate), and Hospital C coming in third (232.5, basic).

      Discussion

      We assessed the long-term sustainability of a multimodal intervention to improve health care worker hand hygiene in 3 Japanese hospitals. After conducting over 8,000 hand hygiene observations at 3 different time points over a span of 5 years (pre-intervention and at 6 months post-intervention and 5 years post-intervention) we found that overall the improvements seen after the initial intervention implementation were still in effect.
      Overall, there was no significant change in hand hygiene adherence between the 6-month post-intervention evaluation and the 5-year assessment (–0.8%; p = .53); however, there was substantial variability by hospital unit and health care professional type. There was improvement among internal medicine physicians and ICU nurses but not among surgeons and nurses on the surgical units. Further, health care professionals in emergency departments did not show any improvement at either 6 months or 5 years post-intervention. The adherence among physicians from all units combined improved throughout the study (15.1% at baseline, 30.4% at 6 months post-intervention, and 33.2% at 5-year assessment); however, nurse adherence decreased slightly between the 6 months post-intervention and the 5-year assessment time periods (20.6% at baseline, 34.8% at 6 months post-intervention, and 30.7% at the 5-year assessment).
      There are likely multiple contributing factors for the sustainability of hand hygiene adherence in our study, including strong leadership and collaboration of infection prevention teams, commitment and support of hospital managers, and proactive education by health care professionals who served as role models. These results are consistent with previous successful cases of (1) effective collaboration between infection prevention nurses and hospitalist physicians as members of an infection prevention team,
      • Monistrol O
      • Calbo E
      • Riera M
      • Nicolas C
      • Font R
      • Freixas N
      • et al.
      Impact of a hand hygiene educational programme on hospital-acquired infections in medical wards.
      (2) organizational policy implementation and quality improvement,
      • Tromp M
      • Huis A
      • de Guchteneire I
      • van der Meer J
      • van Achterberg T
      • Hulscher M
      • et al.
      The short-term and long-term effectiveness of a multidisciplinary hand hygiene improvement program.
      (3) multimodal interventions recommended by a Cochrane Review that involve various health care professionals,
      • Gould DJ
      • Moralejo D
      • Drey N
      • Chudleigh JH
      • Taljaard M
      Interventions to improve hand hygiene compliance in patient care.
      and (4) use of educator role models as professionals with high social norms.
      • Lieber SR
      • Mantengoli E
      • Saint S
      • Fowler KE
      • Fumagalli C
      • Bartolozzi D
      • et al.
      The effect of leadership on hand hygiene: assessing hand hygiene adherence prior to patient contact in 2 infectious disease units in Tuscany.
      Kwok and colleagues
      • Kwok YL
      • Harris P
      • McLaws ML
      Social cohesion: the missing factor required for a successful hand hygiene program.
      also emphasized the importance of experienced leaders in individual units as well as the hospital as a whole.
      Hand hygiene adherence improved the greatest among physicians on medical floors during the sustainability period (from 32.5% at 6 months post-intervention to 53.2% at the 5-year assessment; P < .001). Inpatient medical floors are usually staffed by hospitalists (physicians focused on caring for hospitalized medical patients), which could contribute to this finding. Hospitalist physicians are important role models and educators for residents and other internal medicine physicians. Previous studies have suggested that hand hygiene adherence in hospitals is positively correlated with the behavior among attending physicians and role-model physicians.
      • Lieber SR
      • Mantengoli E
      • Saint S
      • Fowler KE
      • Fumagalli C
      • Bartolozzi D
      • et al.
      The effect of leadership on hand hygiene: assessing hand hygiene adherence prior to patient contact in 2 infectious disease units in Tuscany.
      • Kwok YL
      • Harris P
      • McLaws ML
      Social cohesion: the missing factor required for a successful hand hygiene program.
      Although adherence by physicians on medical floors improved, surgeons’ and surgery nurses’ hand hygiene adherence decreased between 6 months post-intervention and the 5-year assessment. We suspect that the surgery units were lacking strong physician and nurse hand hygiene champions and role models, but we cannot prove this hypothesis. Having both a physician and nurse champion on each floor can help sustain infection prevention activities.
      • Damschroder LJ
      • Banaszak-Holl J
      • Kowalski CP
      • Forman J
      • Saint S
      • Krein SL
      The role of the champion in infection prevention: results from a multisite qualitative study.
      Hospitals A and B provided portable alcohol-based hand rub to health care workers, which may have contributed to the improvements seen in those hospitals. Previous studies have shown that hand hygiene availability close to the point of use can improve health care worker adherence.
      • Munoz-Price LS
      • Patel Z
      • Banks S
      • Arheart K
      • Eber S
      • Lubarsky DA
      • et al.
      Randomized crossover study evaluating the effect of a hand sanitizer dispenser on the frequency of hand hygiene among anesthesiology staff in the operating room.
      However, as demonstrated in a study by Hass and Larson,
      • Haas JP
      • Larson EL
      Impact of wearable alcohol gel dispensers on hand hygiene in an emergency department.
      providing personal hand rub dispensers alone may not lead to sustained improvements in hand hygiene. The use of a contest (awarding a trophy and US$5,000 to the hospital with the best hand hygiene adherence) may have contributed to the improvements seen after the initial intervention implementation; however, it is unlikely that the contest was still affecting hand hygiene adherence 5 years after the initial intervention.
      Although our study showed improvements in hand hygiene adherence that were sustained for 5 years, the hand hygiene adherence rates found in our study were still lower than those reported in several other countries. In all 3 hospitals, we achieved a 31.9% hand hygiene adherence rate, which is below the global average of 40%.
      • Erasmus V
      • Daha TJ
      • Brug H
      • Richardus JH
      • Behrendt MD
      • Vos MC
      • et al.
      Systematic review of studies on compliance with hand hygiene guidelines in hospital care.
      The demonstrated sustainability in our study points to the success of our interventions, but other countries have achieved greater hand hygiene improvements. Australian investigators, for example, showed an improvement from 63.6% to 84.3% adherence in 937 hospitals after an 8-year follow-up study of a national intervention program.
      • Grayson ML
      • Stewardson AJ
      • Russo PL
      • Ryan KE
      • Olsen KL
      • Havers SM
      • et al.
      Effects of the Australian National Hand Hygiene Initiative after 8 years on infection control practices, health-care worker education, and clinical outcomes: a longitudinal study.
      Possible next steps that could help Japanese hospitals achieve improved health care worker hand hygiene adherence include obtaining stronger government and hospital leadership support,
      • Sakamoto F
      • Asano K
      • Sakihama T
      • Saint S
      • Greene MT
      • Patel P
      • et al.
      Changes in health care-associated infection prevention practices in Japan: results from 2 national surveys.
      ensuring that all Japanese hospitals have an appropriate number of infection prevention specialists,
      • Allegranzi B
      • Conway L
      • Larson E
      • Pittet D
      Status of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities.
      and possibly using electronic monitoring systems.
      • Edmisten C
      • Hall C
      • Kernizan L
      • Korwek K
      • Preston A
      • Rhoades E
      • et al.
      Implementing an electronic hand hygiene monitoring system: lessons learned from community hospitals.
      To improve the generally low adherence in emergency departments in Japan, education regarding the appropriate timing of hand hygiene may be required in such time-constrained environments.
      • Jeanes A
      • Coen PG
      • Drey NS
      • Gould DJ
      The development of hand hygiene compliance imperatives in an emergency department.
      Our study has several limitations. We were able to use the same expert observer to assess hand hygiene adherence in 3 different periods over the last 5 years, which eliminated inter-observer variation and provided reliable data. However, the direct observations might have affected behaviors among health care workers. Because most observations were conducted on weekday mornings, these results might not reflect the behaviors of health care workers during other shifts (afternoons, nights, weekends). We also did not collect other data that may have helped explain our findings, such as the severity of a patient's condition, staffing of each unit, longitudinal adherence among individual professionals, or HAI incidence.
      Despite these limitations, our study showed that hand hygiene adherence among Japanese doctors and nurses could be sustained even 5 years after a multimodal intervention and contest in 3 Japanese hospitals.

      Acknowledgments

      The authors thank the International Ann Arbor Safety Collaborative (http://i-aasc.org).

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