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 ~ Introduction
 ~ Methods
 ~ Results
 ~ Discussion
 ~ Conclusion
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  Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 37  |  Issue : 4  |  Page : 496-501
 

Effectiveness of hand hygiene promotional program based on the WHO multimodal hand hygiene improvement strategy, in terms of compliance and decontamination efficacy in an indian tertiary level neonatal surgical intensive care unit


1 National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Pediatric Surgery, Advanced Pediatric Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
4 Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission03-Feb-2020
Date of Acceptance24-Mar-2020
Date of Web Publication18-May-2020

Correspondence Address:
Dr. Sukhwinder Kaur
National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmm.IJMM_20_47

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 ~ Abstract 

Background: The WHO Multimodal Hand Hygiene Improvement Strategy (MHHIS) has been proposed to improve the Hand Hygiene (HH) compliance of the WHO recommendations on HH.Therefore, the current study was planned in our neonatal unit with the objective of evaluating the effectiveness of a Hand Hygiene Promotional Program (HHPP) based on the WHO MHHIS, in terms of compliance and decontamination efficacy among the health-care workers (HCWs) in the unit. Objective: The objective of the study was to evaluate the effectiveness of the WHO MHHIS on HH compliance and decontamination efficacy. Methods: The HHPP was carried out in our neonatal surgical intensive care unit from July to August 2013. A pre-intervention phase consisted of assessment of ward infrastructure, HH knowledge and perception, determination of HH compliance and collection of hand rinse samples from the HCWs before and after handwashing. Intervention phase consisted of changing traditional to elbow-operated taps, display of posters and reminders, placement of soaps in water draining trays, autoclaved single-use paper towels for hand drying, availability of hand rubs and training sessions for health-care providers. In the post-intervention phase, all the assessments and observations of pre-intervention phase were repeated. Results: HHPP resulted in a significant increase in overall HH compliance from 26.6% (95% confidence interval [CI] 23.9–29.3) to 65.3% (95% CI 62.4–68.2) (P < 0.001) and reduction in load of microorganisms (P = 0.013). There was a significant improvement in HH knowledge (P < 0.001), and perception surveys revealed high appreciation of each strategy component by the participants. Conclusion: To the best of our knowledge, this is the first study about the effect of implementation of the WHO MHHIS from an Indian hospital. HHPP was found to be effective in terms of HH compliance and decontamination efficacy. Its implementation is highly recommended to promote HH in a developing country like India.


Keywords: India, neonatal surgical intensive care unit, WHO Hand Hygiene Promotional Program


How to cite this article:
Thomas AM, Kaur S, Biswal M, N Rao K L, Vig S. Effectiveness of hand hygiene promotional program based on the WHO multimodal hand hygiene improvement strategy, in terms of compliance and decontamination efficacy in an indian tertiary level neonatal surgical intensive care unit. Indian J Med Microbiol 2019;37:496-501

How to cite this URL:
Thomas AM, Kaur S, Biswal M, N Rao K L, Vig S. Effectiveness of hand hygiene promotional program based on the WHO multimodal hand hygiene improvement strategy, in terms of compliance and decontamination efficacy in an indian tertiary level neonatal surgical intensive care unit. Indian J Med Microbiol [serial online] 2019 [cited 2020 Sep 28];37:496-501. Available from: http://www.ijmm.org/text.asp?2019/37/4/496/284530



 ~ Introduction Top


Hand hygiene (HH) is an essential component in preventing the significant burden of hospital-acquired infection in developing countries. Unfortunately, the compliance of HH among health-care workers (HCWs) is frequently suboptimal. There are often multiple reasons for low compliance. A heavy workload, inadequate staff: patient ratio, poor infrastructure, ignorance and stakeholder indifference are some of these reasons. To address these concerns, the WHO Multimodal Hand Hygiene Improvement Strategy (MHHIS) has been proposed to translate into practice the WHO recommendations on HH.[1] Basically, this strategy is composed of (1) system change, (2) training and education of HCWs, (3) evaluation and feedback, (4) reminders in the workplace and (5) institutional safety climate has been proposed to translate into practice the WHO recommendations on HH.[1] This is an evidence-based framework for developing a locally adapted implementation plan for HH promotion. Globally, more than 17,254 health-care institutions in both developed and developing countries have adopted this strategy. Allegranzi et al. found that the implementation is feasible and sustainable across a range of settings in different countries and leads to significant compliance and knowledge improvement in HCWs, supporting recommendation for use worldwide.[2] To the best of our knowledge, there is no study about the effect of the implementation of the WHO MHHIS from an Indian hospital. In our tertiary care referral hospital in North India, there was a need to implement this practice as there is low compliance.[3] Therefore, the current study was planned in our neonatal unit with the objective of evaluating the effectiveness of a Hand Hygiene Promotional Program (HHPP) based on the WHO MHHIS, in terms of compliance and decontamination efficacy among the HCWs in the unit.


 ~ Methods Top


Setting and participants

This study was carried out in a 25-bedded neonatal surgical intensive care unit (ICU) of the hospital. All the nurses and doctors in the ICU who provided direct patient care and who were willing to participate in the study were included by total enumeration. Written consent was obtained from the participants before the commencement of the study and the study was approved by the Institute Ethics Committee (Reference No. NK/769/M. Sc. Nursing).

Study design

A pre-experimental research design was employed. The study participants formed a single group pre- and post-interventional group without a control group. The study was conducted in the months of July and August, 2013.

Pilot study

A pilot study was conducted in the neonatal nursery ward for a period of 1 week. The reliability testing of the Observation Form for HH Compliance (WHO tool) was performed using inter-rater method. The two raters were two trained infection control nurses of the hospital infection control team. Ninety-five opportunities were assessed over a total duration of 2 h. The observers sat near each other but not close enough to see each other's observation forms. After each opportunity was observed and recorded, the observers would confer to determine whether they had observed and documented the same opportunity. Inter-rater reliability of each item was performed by kappa reliability statistics and the kappa value was found to be above 0.90 for all the HH indications, hand rub use, hand wash, missed opportunities and glove use. The reliability of 'Hand Hygiene Perception Survey for Healthcare Providers' (WHO) and 'Hand Hygiene Knowledge Questionnaire for Healthcare Providers' (WHO) was checked by test–retest method and Cronbach's alpha was 0.86 and 0.810, respectively.

Tools for data collection

The tools used for data collection were taken from the WHO implementation kit:[3] Ward Infrastructure Survey, Observation Form for HH Compliance, HH Knowledge Questionnaire for Healthcare Providers, HH Perception Survey for Healthcare Providers: Part A and B, microbiological assessment to evaluate decontamination efficacy and a general feedback questionnaire were also used in the study.

Pre-intervention (1 week duration)

It consisted of assessment of infrastructure for HH in the ICU and knowledge and perceptions of the HCWs regarding HH. There were very few hand hygiene reminders and posters It was assessed that the taps were hand operated and poor-availability of soaps and alcohol hand rubs (AHRs). The soaps were not properly placed leading to contamination of the soap bars. There was availability of only two hand driers in the whole unit. Cloth towels used for hand drying were changed infrequently.

A total of 1056 HH opportunities were observed by direct observation method using the WHO Observation Form for HH Compliance. The sessions lasted for 20 min each and were randomly distributed between 4 am and 11 pm.

To assess the decontamination efficacy of HH practices, hand rinse samples from the HCWs were collected in Brain Heart Infusion Broth (BHIB). This sample was collected at indication 1 of WHO 'My 5 Moments for Hand Hygiene' i.e., 'before touching the patient'. The participants were instructed to dip each hand from wrist to finger tips into a sterile bag containing 50 ml BHIB and rub their fingers for 2 min. Then, they were instructed to perform handwashing and the second sample was collected. The samples were coded by the researcher, transported to and processed within 2 h of collection. The broth was inoculated undiluted and 10-1 dilution onto blood agar plates and incubated at 37°C. The plates were read at 24–48 h of incubation. To estimate the decontamination efficacy, the individual microorganisms were identified and the total colony-forming unit counts per sample were estimated. Samples were also collected from the water, soaps and towels in the ICU in all the 3 phases of the study.

Intervention phase (2 weeks duration)

All the traditional hand-operated taps were changed to elbow-operated taps. Soaps were placed in elevated water draining trays at all the handwashing areas. AHRs were made available at the entry to each unit and at all the bedsides. Self-developed HH reminders and WHO HH posters were displayed in the ICU at patient bedside and all wash basins. All the health-care providers were provided training sessions on HH using the WHO HH 'Slides for Education Session', demonstration and return demonstration of the right HH technique and WHO ' Hand hygiene, when and how' leaflets were also distributed. A gap of 2 weeks was permitted before the next phase.

Post-intervention phase (1 week duration)

All the assessments and observations of the pre-intervention phase were repeated and information about the HHPP and preferences about the HH methods were collected using an open feedback questionnaire.

Statistical analysis

Data were analysed using the Statistical Package for the Social Sciences Samples were also collected from the water, soaps and towels in the ICU in all the 3 phases of the study. (IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp). HH compliance was expressed as the proportion of pre-defined opportunities met by HH actions and the change in compliance before and after the HHPP was compared using the Chi-square test. Knowledge questionnaire scores were calculated for each respondent as the sum of all questions answered correctly (each equalling 1 point) and the total scores were compared using paired t-test. Health-care provider's perceptions about various components of HHPP were summarized as the medians of points given by respondents (7-point Likert scale) with their interquartile range and were compared using Wilcoxon signed-rank test. The change in bacterial load was expressed as the log10 Reduction Factor (RF) of bacteria released from the skin and was calculated using the formula.[3]

Log10 reduction factor (RF) = Log10 pre–value − log10 post–value.

All tests were two sided and P < 0.05 was considered to be statistically significant and P < 0.001 as highly significant.


 ~ Results Top


Thirty-four health-care providers (19 nurses and 6 doctors) were included in the study, between the age group of 23–48 years. Most of the participants (n = 29) were females and half of the HCWs had <5 years of professional experience.

A total of 1056 HH opportunities were observed in the pre- and post-interventional phases. Compliance to HH increased overall from 26.6% (95% confidence interval [CI]: 23.9–29.3) to 65.3% (95% CI: 62.4–68.2) (P < 0.001) and individually at all five WHO moments (P < 0.001) [Figure 1]. Significant improvement was noted in the compliance of all professional categories, day–night and weekday-weekend periods (P < 0.001) [Table 1]. In the pre-intervention phase, the perceived compliance was 74.7% against the actual compliance of 26.61%. In the post-intervention phase, it was 90.88% against the actual 65.34%.
Figure 1: Comparison of overall hand hygiene compliance and hand hygiene compliance at WHO 5 indications for hand hygiene both Pre and Post Hand Hygiene Promotional Program. There was significant increase in overall hand hygiene compliance and compliance at all 5 indications of hand hygiene. (P < 0.001)

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{Table 1}

The total scores obtained by HCWs in the questionnaire increased from 16.2 ± 2.3 (mean ± standard deviation [SD]) to 22.9 ± 1.9 (P < 0.001). Maximum scores were obtained in areas related to the most frequent sources of germs responsible for nosocomial infections, choice of HH method and measures to prevent hand colonisation. There was an increase in the awareness of the health-care providers regarding various aspects of HH [Table 2]. There was a remarkable improvement in the decontamination efficacy of the handwashing protocol followed by the HCWs [Table 3]. The microbiological load reduction factor (RF) increased from 0.603 ± 1.297 (mean ± SD) to 1.606 ± 1.825 (P = 0.013).{Table 2}{Table 3}

Most (67%) of the health-care providers preferred AHR to soap and water. All the participants expressed appreciation of improvement in physical infrastructure, training sessions, posters and the feedback provided.


 ~ Discussion Top


This study to the best of our knowledge is the first study that compares the effectiveness of an interventional program based on the WHO MHHIS from India. As was seen in other countries,[4],[5] implementation of this strategy resulted in a significant increase in HH compliance in our study participants. There was a huge improvement at multiple other levels such as physical infrastructure, knowledge and perception. In our hospital, we have previously conducted HH awareness programmes.[2] However, the multipronged strategy applied in the present study, especially changing the infrastructure resulted in a vastly improved result.

There were few interesting findings which have emerged in the study. The perceived compliance was nearly 2–3 times greater than the actual compliance in both pre- and post-intervention. This finding has been seen in many other studies.[2],[6],[7] The tendency of the healthcare providers in privileging oneself more than the patient is apparent in the fact that average compliance was higher when HCWs felt the need to protect themselves rather than the patient.[2],[8] This is also apparent in the knowledge survey where one of the areas of poor scoring pertained to aspects that differentiated the HH indications aimed at preventing transmission of germs to the patients from those that prevented the transmission of germs to the HCWs. This knowledge increases our understanding behind the psychology of handwashing by HCWs. Research into the behavioural determinants of HH practice and perceptions such as these should be actively pursued.

It is noteworthy that the compliance 'after patient surroundings' remained low even after intensive training. This has been postulated to be because HCWs underestimate the environment as a source of transmission of infection.[9] Future training sessions should focus on increasing compliance at this opportunity. Although the compliance of nurses has been reported to be higher than that of doctors in many studies,[10],[11],[12] we did not find any significant difference in our study. Neither did we find a diurnal or weekend versus weekday difference although some studies have reported differences.[13]

A small proportion (8.24%) of the participants, during pre-intervention, believed that both hand rubbing and handwashing were to be performed sequentially. While this may be true before invasive procedures, it is not required in most settings and leads to wastage of already meagre HH products in resource poor countries.

A good role model was felt to be the most significant factor in increasing compliance. However, the concept of 'patients invited to remind healthcare providers to perform hand hygiene' was felt to be one of the least effective. A recent growing body of evidence suggests that the patient can play an important supportive role in increasing HH compliance in hospitals.[14] This factor has been reported to be effective in studies conducted in developed countries.[15] No study on the role of the patient as a factor in HH has been conducted in India. This definitely needs to be explored in another study.

Although the HCWs believed that they were washing their hands properly as required before any opportunity, it was found to be inadequate for removal of microorganisms. Up to 6.05 log10 of pathogenic microbes like Klebsiella, Acinetobacter and Staphylococcus aureus were isolated from HCWs' hands in the pre-intervention phase, after performing handwashing. This evidence given as feedback to the HCWs demonstrated the importance of using the correct technique for HH to them. During the post-intervention phase, few samples showed an increase in microbial load of ASBs, the exact reason for which could not be elicited. This can be attributed to a temporary contamination in the soap or cloth towels used.

This study has few limitations. The study was of short duration and small sample size. It does not provide information about the sustainability of the findings due to lack of follow-up observations. The Hawthorne effect could not be avoided as we could not employ any covert and advanced technologies for recording compliance. The increase in hand decontamination was not correlated with decrease in patient sepsis rates. However, the effect of increasing HH compliance on the decrease in the incidence of HCAIs and the resulting substantial savings is an established finding.[16]


 ~ Conclusion Top


Implementation of HHPP on a larger scale is highly recommended on the basis of this study. This article generates robust scientific evidence that this strategy which has been tested in mainly developed countries[17] is feasible and highly effective in developing countries also. Findings of the current study represent powerful support for decision and policymakers to enforce the implementation of HHPP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ~ References Top

1.
A guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy: 2009. Available from: http://apps.who.int/iris/handle/10665/70030. [Last accessed on 2013 Feb 02].  Back to cited text no. 1
    
2.
Allegranzi B, Gayet-Ageron A, Damani N, Bengaly L, McLaws ML, Moro ML, et al. Global implementation of WHO's multimodal strategy for improvement of hand hygiene: A quasi-experimental study. Lancet Infect Dis 2013;13:843-51.  Back to cited text no. 2
    
3.
Biswal M, Singh NV, Kaur R, Sebastian T, Dolkar R, Appananavar SB, et al. Adherence to hand hygiene in high-risk units of a tertiary care hospital in India. Am J Infect Control 2013;41:1114-5.  Back to cited text no. 3
    
4.
Allegranzi B, Sax H, Bengaly L, Richet H, Minta DK, Chraiti MN, et al. Successful implementation of the World Health Organization hand hygiene improvement strategy in a referral hospital in Mali, Africa. Infect Control Hosp Epidemiol 2010;31:133-41.  Back to cited text no. 4
    
5.
O'Boyle CA, Henly SJ, Larson E. Understanding adherence to hand hygiene recommendations: The theory of planned behavior. Am J Infect Control 2001;29:352-60.  Back to cited text no. 5
    
6.
Sax H, Uçkay I, Richet H, Allegranzi B, Pittet D. Determinants of good adherence to hand hygiene among healthcare workers who have extensive exposure to hand hygiene campaigns. Infect Control Hosp Epidemiol 2007;28:1267-74.  Back to cited text no. 6
    
7.
Lee A, Chalfine A, Daikos GL, Garilli S, Jovanovic B, Lemmen S, et al. Hand hygiene practices and adherence determinants in surgical wards across Europe and Israel: A multicenter observational study. Am J Infect Control 2011;39:517-20.  Back to cited text no. 7
    
8.
FitzGerald G, Moore G, Wilson AP. Hand hygiene after touching a patient's surroundings: The opportunities most commonly missed. J Hosp Infect 2013;84:27-31.  Back to cited text no. 8
    
9.
Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000;356:1307-12.  Back to cited text no. 9
    
10.
Rosenthal VD, Pawar M, Leblebicioglu H, Navoa-Ng JA, Villamil-Gómez W, Armas-Ruiz A, et al. Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach over 13 years in 51 cities of 19 limited-resource countries from Latin America, Asia, the Middle East, and Europe. Infect Control Hosp Epidemiol 2013;34:415-23.  Back to cited text no. 10
    
11.
Scheithauer S, Oude-Aost J, Heimann K, Haefner H, Schwanz T, Waitschies B, et al. Hand hygiene in pediatric and neonatal intensive care unit patients: Daily opportunities and indication- and profession-specific analyses of compliance. Am J Infect Control 2011;39:732-7.  Back to cited text no. 11
    
12.
Sahay S, Panja S, Ray S, Rao BK. Diurnal variation in hand hygiene compliance in a tertiary level multidisciplinary intensive care unit. Am J Infect Control 2010;38:535-9.  Back to cited text no. 12
    
13.
McGuckin M, Govednik J. Patient empowerment and hand hygiene, 1997-2012. J Hosp Infect 2013;84:191-9.  Back to cited text no. 13
    
14.
Pittet D, Panesar SS, Wilson K, Longtin Y, Morris T, Allan V, et al. Involving the patient to ask about hospital hand hygiene: A National Patient Safety Agency feasibility study. J Hosp Infect 2011;77:299-303.  Back to cited text no. 14
    
15.
Gagné D, Bédard G, Maziade PJ. Systematic patients' hand disinfection: Impact on meticillin-resistant Staphylococcus aureus infection rates in a community hospital. J Hosp Infect 2010;75:269-72.  Back to cited text no. 15
    
16.
Pittet D, Allegranzi B, Storr J, Bagheri Nejad S, Dziekan G, Leotsakos A, et al. Infection control as a major World Health Organization priority for developing countries. J Hosp Infect 2008;68:285-92.  Back to cited text no. 16
    
17.
Pittet D, Allegranzi B, Storr J, et al. Infection control as a major World Health Organization priority for developing countries. J. Hosp. Infect. 2008;68:285-92.  Back to cited text no. 17
    


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