Compliance with hand hygiene: reference data from the national hand hygiene campaign in Germany

Compliance with hand hygiene: reference data from the national hand hygiene campaign in Germany

Accepted Manuscript Compliance with hand hygiene: reference data from the national hand hygiene campaign in Germany W. Wetzker, K. Bunte-Schönberger, ...

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Accepted Manuscript Compliance with hand hygiene: reference data from the national hand hygiene campaign in Germany W. Wetzker, K. Bunte-Schönberger, J. Walter, G. Pilarski, P. Gastmeier, Ch. Reichardt PII:

S0195-6701(16)00093-1

DOI:

10.1016/j.jhin.2016.01.022

Reference:

YJHIN 4745

To appear in:

Journal of Hospital Infection

Received Date: 30 July 2015 Accepted Date: 31 January 2016

Please cite this article as: Wetzker W, Bunte-Schönberger K, Walter J, Pilarski G, Gastmeier P, Reichardt C, Compliance with hand hygiene: reference data from the national hand hygiene campaign in Germany, Journal of Hospital Infection (2016), doi: 10.1016/j.jhin.2016.01.022. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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W. Wetzker et al.

Compliance with hand hygiene: reference data from the national hand hygiene campaign in Germany W. Wetzker, K. Bunte-Schönberger, J. Walter, G. Pilarski, P. Gastmeier*, Ch. Reichardt Institute of Hygiene and Environmental Medicine, Charité ‒ University Medicine Berlin, _____________________ *

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Berlin, Germany

Corresponding author. Address: Charité ‒ Universitätsmedizin Berlin, Institut für Hygiene

und Umweltmedizin, Hindenburgdamm 27, D-12203 Berlin. Tel.: +49 (0)30 450 577 612; fax: +49 (0)30 450 570 920.

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E-mail address: [email protected] (W. Wetzker). SUMMARY

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Hand hygiene is a key measure to prevent healthcare-associated infection. To promote hand hygiene nationally the German campaign ‘Aktion Saubere Hände’ was launched in January 2008, based on the World Health Organization’s ‘Clean Care is Safer Care’ initiative. We report the first set of findings from this initiative. Data were based on submissions from 109 participating hospitals collected from 576 wards between January 1st and December 31st, 2014. The overall median compliance was 73%, ranging from 55% (10th percentile) to 89%

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(90th percentile). The results demonstrated only small differences between adult and nonadult intensive care units (ICUs) with neonatal ICUs and paediatric non-ICUs maintaining higher compliance than adult care units. Performance among nurses was better than physicians, and overall rates of hand hygiene performance were significantly higher after

Keywords:

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Benchmarking

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patient contact than before.

Compliance

Hand hygiene

National campaign

Observational study Introduction

There is good evidence that hand hygiene (HH) contributes to the prevention of healthcare-associated infections (HCAIs).1,2 It becomes even more significant as multidrugresistant organisms (MDROs) emerge as a growing threat to global public health. To promote HH and to ensure universal recognition of infection prevention and control as an essential component of patient safety, the World Health Organization (WHO) initiated its global 1

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campaign ‘Clean Care is Safer Care’ in 2005.3 Based on this initiative, the German national hand hygiene campaign, ‘Aktion Saubere Hände’ (ASH, aktion-sauberehaende.de/ash) was launched in January 2008.4 ASH supports implementation of multimodal infection prevention interventions in participating hospitals and healthcare institutions, for example by providing training material and video tutorials for healthcare workers (HCWs). On a voluntary basis, 1840 healthcare institutions were participating in June 2015, representing almost 50% of

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~2000 German hospitals.

Another core objective of ASH is to collect data from healthcare institutions to monitor the effectiveness of interventions over the campaign period. Since 2008 the

evaluation of alcohol-based hand-rub consumption (AHC) data was established as a surrogate

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parameter for HH performance. Several studies have demonstrated a positive association between AHC and reduction in HCAI, and have used AHC as a benchmarking tool to

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compare wards and hospitals.5‒7 A module named Hand-KISS was created within the national surveillance system of hospital infections (KISS). Data are analysed and published on a regular basis.8 Additionally HH compliance can be evaluated by direct observation following WHO’s ‘My five moments for hand hygiene’, which is considered a gold standard. All hospitals are encouraged to perform these compliance observations. For the first time since ASH commenced in 2008, we report here findings from a full

of patient safety. Methods

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year of data collection, providing a baseline benchmark and a focus for further improvement

ASH HH compliance reference data are based on observational data submitted by the

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participating hospitals and collected between January 1st and December 31st, 2014. Observation followed the five indications for HH according to the WHO. Compliance was

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measured by trained staff following a standardized observation tool developed on basis of the WHO guidelines.9,10 Data input was achieved directly by mobile devices such as smartphones and tablets (‘webApp’) or through surveillance sheets and data transfer using the online platform (‘webKess’). Data have been summarized by hospital and categorized as intensive care units (ICUs), non-ICUs, and type of unit. For the latter category, data are only published here if HH was observed on more than 10 units of the same type. Interdisciplinary units were also excluded as a category, although they represented the highest proportion of units. Further stratifications were: type of indication and groups of HCWs (physicians or nurses). Comparisons of HH compliance rates between groups were performed by using the chisquared test. Results 2

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In 2014, a total of 109 hospitals performed direct observation and data were collected from 576 wards; in total 120,809 HH opportunities were observed. HH was achieved in 87,449 (72%) (Table I), together with the distribution in ICUs and non-ICUs. The median compliance for 142 ICUs was 74% and 72% for 434 non-ICUs. Hand hygiene compliance varied depending on the WHO indication. The median HH compliance before patient contact (67% before touching a patient; 73% before an aseptic

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procedure) was significantly lower than the median HH compliance after patient contact (84% after procedure and exposure risk to body fluids and 81% after touching a patient) (P < 0.01) (Table II).

The leaders in HH compliance were neonatal ICUs with a mean of 83% and a median

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of 90%: significantly better than surgical and medical ICU units (P < 0.01) (Table III). For non-ICUs, median compliance ranged from 70% for rehabilitation units, through 71% and

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73% for medical and surgical units to 77% for paediatric units (P < 0.01) (Table IV). Overall compliance of nurses (78%) was significantly higher than for physicians (67%, P < 0.01) (Table V). Discussion

Hand hygiene compliance rates have been reported within several national HH campaigns for more than a decade. Our study is the first in Europe to present national

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reference data collected by direct observation in acute care hospitals for a given year, allowing evaluation and benchmark analysis.

Data for 2014 HH compliance were similar for ICUs and non-ICUs, which is different from other studies showing that compliance is often lower in ICUs; this is usually explained

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by the higher activity level and higher workload in ICUs.11,12 Rates of HH performance for all types of HCW were significantly higher after patient

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contact than before. This tendency of HCWs to be more inclined to protect themselves from the risk of infection or contamination has been identified in multiple studies.12 In addition, our data showed a considerable variation in compliance among participating institutions, especially for the HH indication ‘before an aseptic procedure’. HH performance at this point of care is inconsistent, and further evaluation and intervention should be considered. For ICUs, the highest standards in HH compliance were observed for neonatal units. Median compliance on neonatal ICUs was significantly higher than on medical or surgical ICUs (Table III). Neonatal units have also led observed HH compliance in previous studies.13 For non-ICUs similar results were achieved for paediatric units. In summary, our data showed that both neonatal ICUs and paediatric non-ICUs maintained a higher HH compliance than care units where adult patients were treated. 3

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Another consistent finding in studies has been a significantly better HH performance among nurses than among physicians.12 In our study, not only was compliance among nurses higher than among physicians, but there were more outliers with low HH compliance among medical staff (41%) than among nursing staff (59%). These data from direct observation complement and support our findings from previous evaluations of AHC as a surrogate marker for HH performance, and set an important

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benchmark for the national hospital infection surveillance system. For AHC the overall

median increase between baseline (2007) and 2010 was 36%; the latest data record further progress.8 Over a period of eight years, hospital-wide hand-rub consumption increased by 81%.14 The data collected from direct observation showed a less marked improvement, but

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still an upward trend in overall HH compliance.4 As inter-server reliability is hard to achieve, quantitative interpretation requires caution. However, it is only through observation that an

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accurate picture of the current state of HH compliance can be achieved. Observation also provides an opportunity to analyse the behaviour of HCWs and to recognize common mistakes on which to improve further hand hygiene interventions.

As Latham et al. cite in their case study of national hand hygiene campaigns in Europe, ‘evaluations are essential to judge the success of public health programmes’, but HH campaigns remain under-evaluated on a national level.15 Only half of the 36 HH campaigns

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performed in 20 countries between 2000 and 2012 included relevant evaluation. Therefore it is hard to find national reference data for analysis in comparison to outcome from our study. Due to methodological differences in study design, data collection, and programme setting, it is also difficult to achieve comparability on a global level. However, the outcome of our

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evaluation shows a similar distribution of values to the Australian National Hand Hygiene Initiative. A study by Grayson et al. reported that at the end of the first two years of this

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initiative, HH compliance rates were 74% among nursing staff and 52% among medical staff. Also similar to our study, compliance was higher after patient contact than before; in Australia compliance rates were 64% before touching a patient, 68% before an aseptic procedure, 79% after a procedure or body fluid exposure risk, and 77% after patient contact at the end of the intervention period.16,17 The Australian study reported a decline in the incidence of meticillin-resistant Staphylococcus aureus bacteraemia. Such evidence is not yet available for our national hand hygiene campaign. As Kirkland et al. suggested in their single hospital study, the infection rate reduction lags behind progress in HH compliance.13 A minimum threshold of HH compliance is also required before a measurable effect on infection rates is statistically demonstrable. A monthly pairwise correlation of HCAI data and unit-specific HH compliance 4

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rate was recorded, showing that the infection index rate was significantly lower as soon as the compliance rate exceeded the threshold of 80%. These findings are supported by other studies.18 A median HH compliance rate of 73% in our study suggests that many participating hospitals have not yet achieved sufficiently high compliance rates to see a benefit in reduction in HCAI. Our study has some limitations. First, only 109 out of ~2000 German hospitals

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submitted compliance data for direct observation in 2014. Second, the main bias for

surveillance by direct observation can be attributed to the Hawthorne effect. HH compliance during observation periods is usually higher as HCWs who know that they are under

observation tend to perform better. Hagel et al. have been able to quantify the Hawthorne

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effect in HH compliance through comparing direct observation with automated HH

monitoring.19 They observed an average increase from eight HH events per hour without

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direct observation to 21 HH events per hour in the presence of an observer. Sixty-one percent of the total variability in HH events may be explained by the presence or absence of a direct observer. Finally, we must point out that HH compliance rates are not the sole determinants of the risk of infection and transmission of pathogens. Infection prevention is always multifactorial, and multi-modal strategies are recommended to reduce the rate of HCAI.7 Further evaluation of HH campaigns and research into quantifying the impact of individual

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interventions on disease outcomes is required to improve healthcare and patient safety. Conflict of interest statement None. Funding source

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‘Aktion Saubere Hände’ campaign.

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References 1.

Pittet D, Allegranzi B, Sax H, et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006;6:641‒652.

2.

Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 2009;73:305‒315.

3.

World Health Organization. WHO guidelines on hand hygiene in health care: first Global

4.

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Patient Safety Challenge: Clean Care is Safer Care. Geneva: WHO; 2009.

Reichardt C, Königer D, Bunte-Schönberger K, et al. Three years of national hand

hygiene campaign in Germany: what are the key conclusions for clinical practice? J Hosp Infect 2013;83:11‒16.

Sroka S, Gastmeier P, Meyer E. Impact of alcohol hand-rub use on meticillin-resistant

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5.

Staphylococcus aureus: an analysis of the literature. J Hosp Infect 2010;74:204‒211. Stone SP, Fuller C, Savage J, et al. Evaluation of the national Cleanyourhands campaign

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6.

to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study. BMJ 2012;344:e3005. 7.

Allegranzi B, Sax H, Pittet D. Hand hygiene and healthcare system change within multimodal promotion: a narrative review. J Hosp Infect 2013;83:3‒10. Behnke M, Gastmeier P, Geffers C, Mönch N, Reichardt C. Establishment of a national

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8.

surveillance system for alcohol-based hand rub consumption and change in consumption over 4 years. Infect Control Hosp Epidemiol 2012;33:618‒620. 9.

Sax H, Allegranzi B, Chraïti MN, Boyce J, Larson E, Pittet D. The World Health

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Organization hand hygiene observation method. Am J Infect Control 2009;37:827‒834. 10. Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. ‘My five moments for hand

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hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 2007;67:9‒21. 11. McGuckin M, Waterman R, Govednik J. Hand hygiene compliance rates in the United States ‒ a one-year multicenter collaboration using product/volume usage measurement and feedback. Am J Med Qual 2009;24:205‒213. 12. Erasmus V, Daha TJ, Brug H, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283‒294. 13. Kirkland KB, Homa KA, Lasky RA, Ptak JA, Taylor EA, Splaine ME. Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series. BMJ Qual Saf 2012;21:1019‒1026. 6

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14. Behnke M, Clausmeyer JO, Reichardt C, Gastmeier P. Alcohol-based hand rub consumption surveillance in German hospitals – latest results. Antimicrob Resist Infect Control 2015;4(Suppl 1):293. 15. Latham JR, Magiorakos AP, Monnet DL, et al. The role and utilisation of public health evaluations in Europe: a case study of national hand hygiene campaigns. BMC Public Health 2014;14:131.

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16. Hand Hygiene Australia, National Data Period One 2015. Available at:

http://www.hha.org.au/LatestNationalData.aspx [last accessed February 2016].

17. Grayson LM, Russo PL, Cruickshank M, et al. Outcomes from the first 2 years of the Australian National Hand Hygiene Initiative. Med J Aust 2011;19:615‒619.

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18. Song X, Stockwell DC, Floyd T, Short BL, Singh N. Improving hand hygiene

compliance in health care workers: strategies and impact on patient outcomes. Am J

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Infect Control 2013;41:e101‒105.

19. Hagel S, Reischke J, Kesselmeier M, et al. Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observation with automated hand hygiene

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monitoring. Infect Control Hosp Epidemiol 2015;36:957‒962.

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Table I Hand hygiene (HH) compliance rates, January 1st to December 31st, 2014 Hospitals Units Opportunities Opportunities with HH Distribution of compliance (P: percentiles) P10

P25

P50

P75

P90

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Mean 109

576

120,809

87,449

72%

55% 63%

73%

81%

89%

Overall compliance, ICUs

92

142

32,935

24,330

74%

56% 63%

74%

84%

92%

Overall compliance, non-ICUs

97

434

87,874

63,119

72%

55% 62%

72%

81%

88%

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ICU, intensive care unit.

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Overall compliance

Table II

Hand hygiene (HH) compliance rates by World Health Organization hand hygiene ‘moments’

Before touching a patient

2

Before an aseptic procedure

3

After a procedure or body fluid exposure risk

108

575

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1

Hospitals Units Opportunities

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Indication

4

After touching a patient

5

After touching a patients surroundings

Opportunities with

Distribution of compliance (P:

HH

percentiles) Mean

P10

P25

P50

P75

P90 90%

29,988

19,949

67%

41% 53% 67% 81%

104

566

16,713

11,838

71%

40% 53% 73% 89% 100%

103

560

15,862

12,775

81%

57% 71% 84% 96% 100%

107

574

34,417

27,338

79%

58% 69% 81% 90%

95%

105

570

23,829

15,549

65%

35% 50% 68% 80%

90%

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‘Moment’

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Table III Hand hygiene (HH) compliance rates by intensive care unit (ICU) type Type of ICU Hospitals Units Opportunities Opportunities with HH Distribution of compliance (P: percentiles) P10

P25

P50

P75

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Mean

P90

17

25

6184

4728

76%

60%

69%

75%

87%

94%

Medical

14

14

2841

2183

77%

57%

64%

73%

86%

93%

Neonatal

11

11

1921

1601

83%

68%

79%

90%

96%

97%

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Surgical

Hand hygiene (HH) compliance rates by non-intensive care unit type

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Table IV

Type of unit Hospitals Units Opportunities Opportunities with HH Distribution of compliance (P: percentiles) Mean

P10

P25

P50

P75

P90

72%

57%

64%

73%

81%

90%

61

97

21,149

15,176

Medical

61

108

20,432

14,546

71%

54%

61%

71%

79%

88%

Paediatric

15

17

2950

2314

78%

62%

67%

77%

91%

99%

Rehabilitation

6

15

3051

2025

66%

42%

58%

70%

78%

79%

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Surgical

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Table V

Hand hygiene compliance rates by healthcare worker (HCW) category HCW category Hospitals Units Opportunities Opportunities with HH Distribution of compliance (P: percentiles) Mean

P10

P25

P50

P75

P90

Physicians

107

571

29,889

19,951

67%

41%

53%

67%

79%

89%

Nurses

109

576

75,655

57,792

76%

59%

67%

78%

86%

94%