Interventions to improve hand hygiene compliance in patient care

Background Health care‐associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure. This is an update of a previously published review. Objectives To assess the short‐ and long‐term success of strategies to improve compliance to recommendations for hand hygiene, and to determine whether an increase in hand hygiene compliance can reduce rates of health care‐associated infection. Search methods We conducted electronic searches of the Cochrane Register of Controlled Trials, PubMed, Embase, and CINAHL. We conducted the searches from November 2009 to October 2016. Selection criteria We included randomised trials, non‐randomised trials, controlled before‐after studies, and interrupted time series analyses (ITS) that evaluated any intervention to improve compliance with hand hygiene using soap and water or alcohol‐based hand rub (ABHR), or both. Data collection and analysis Two review authors independently screened citations for inclusion, extracted data, and assessed risks of bias for each included study. Meta‐analysis was not possible, as there was substantial heterogeneity across studies. We assessed the certainty of evidence using the GRADE approach and present the results narratively in a 'Summary of findings' table. Main results This review includes 26 studies: 14 randomised trials, two non‐randomised trials and 10 ITS studies. Most studies were conducted in hospitals or long‐term care facilities in different countries, and collected data from a variety of healthcare workers. Fourteen studies assessed the success of different combinations of strategies recommended by the World Health Organization (WHO) to improve hand hygiene compliance. Strategies consisted of the following: increasing the availability of ABHR, different types of education for staff, reminders (written and verbal), different types of performance feedback, administrative support, and staff involvement. Six studies assessed different types of performance feedback, two studies evaluated education, three studies evaluated cues such as signs or scent, and one study assessed placement of ABHR. Observed hand hygiene compliance was measured in all but three studies which reported product usage. Eight studies also reported either infection or colonisation rates. All studies had two or more sources of high or unclear risks of bias, most often associated with blinding or independence of the intervention. Multimodal interventions that include some but not all strategies recommended in the WHO guidelines may slightly improve hand hygiene compliance (five studies; 56 centres) and may slightly reduce infection rates (three studies; 34 centres), low certainty of evidence for both outcomes. Multimodal interventions that include all strategies recommended in the WHO guidelines may slightly reduce colonisation rates (one study; 167 centres; low certainty of evidence). It is unclear whether the intervention improves hand hygiene compliance (five studies; 184 centres) or reduces infection (two studies; 16 centres) because the certainty of this evidence is very low. Multimodal interventions that contain all strategies recommended in the WHO guidelines plus additional strategies may slightly improve hand hygiene compliance (six studies; 15 centres; low certainty of evidence). It is unclear whether this intervention reduces infection rates (one study; one centre; very low certainty of evidence). Performance feedback may improve hand hygiene compliance (six studies; 21 centres; low certainty of evidence). This intervention probably slightly reduces infection (one study; one centre) and colonisation rates (one study; one centre) based on moderate certainty of evidence. Education may improve hand hygiene compliance (two studies; two centres), low certainty of evidence. Cues such as signs or scent may slightly improve hand hygiene compliance (three studies; three centres), low certainty of evidence. Placement of ABHR close to point of use probably slightly improves hand hygiene compliance (one study; one centre), moderate certainty of evidence. Authors' conclusions With the identified variability in certainty of evidence, interventions, and methods, there remains an urgent need to undertake methodologically robust research to explore the effectiveness of multimodal versus simpler interventions to increase hand hygiene compliance, and to identify which components of multimodal interventions or combinations of strategies are most effective in a particular context

Ionising radiation exposure from medical imaging – A review of Patient's (un) awareness

Introduction: Medical imaging is the main source of artificial radiation exposure. Evidence, however, suggests that patients are poorly informed about radiation exposure when attending diagnostic scans. This review provides an overview of published literature with a focus on nuclear medicine patients on the level of awareness of radiation exposure from diagnostic imaging. Methods: A review of available literature on awareness, knowledge and perception of ionising radiation in medical imaging was conducted. Articles that met the inclusion criteria were subjected to critical appraisal using the Mixed Methods Appraisal Tool. Results: 140 articles identified and screened for eligibility, 24 critically assessed and 4 studies included in synthesis. All studies demonstrated that patients were generally lacking awareness about radiation exposure and highlighted a lack of communication between healthcare professionals and patients with respect to radiation exposure. Conclusion: Studies demonstrate a need to better inform patients about their radiation exposure, and further studies focusing on nuclear medicine patients are particularly warranted. Implications for practice: Adequate and accurate information is crucial to ensure the principle of informed consent is present

The efficacy of saline washout technique in the management of exfoliant and vesicant chemotherapy extravasation: a historical case series report

This report presents the results from a historical case series of cytotoxic drug extravasations managed by saline washout; its purpose is to assess the efficacy of the procedure based on patient outcome. Eighty-nine patients were identified as having experienced a vesicant or exfoliant extravasation from incident reports filed over a 10-year period, from 1 April 2001 to 31 March 2011. Outcome was measured against the need for further surgical treatment being required. Of the 89 cases assessed for efficacy of saline washout one patient experienced a wound infection, which was treated effectively with oral antibiotics. There were no other complications reported and no patients required further treatment with surgical debridement. The majority of patients had no deferral of treatment as chemotherapy could be continued in their unaffected arm immediately following saline washout procedure. For patients where cannulation in their opposite arm for continuation of treatment was not advisable chemotherapy was delayed between 3 and 7 days. Hospitalisation as a result of the extravasation or subsequent treatment was not required in any of the 89 cases. Results indicate that saline washout technique is a safe and effective management strategy for the treatment of both vesicant and exfoliant chemotherapy extravasation

Routine hand hygiene audit by direct observation: has nemesis arrived?

Infection prevention and control experts have expended valuable health service time developing and implementing tools to audit health workers' hand hygiene compliance by direct observation. Although described as the ‘gold standard’ approach to hand hygiene audit, this method is labour intensive and may be inaccurate unless performed by trained personnel who are regularly monitored to ensure quality control. New technological devices have been developed to generate ‘real time’ data, but the cost of installing them and using them during routine patient care has not been evaluated. Moreover, they do not provide as much information about the hand hygiene episode or the context in which hand hygiene has been performed as direct observation. Uptake of hand hygiene products offers an inexpensive alternative to direct observation. Although product uptake would not provide detailed information about the hand hygiene episode or local barriers to compliance, it could be used as a continuous monitoring tool. Regular inspection of the data by infection prevention and control teams and clinical staff would indicate when and where direct investigation of practice by direct observation and questioning of staff should be targeted by highly trained personnel to identify local problems and improve practice

Radiation exposure awareness from patients undergoing nuclear medicine diagnostic 99mTc-MDP bone scans and 2-deoxy-2-(18F) fluoro-D-glucose PET/computed tomography scans

INTRODUCTION: Medical imaging is on average the largest source of artificial radiation exposure worldwide. This study seeks to understand patient's awareness of radiation exposure derived from nuclear medicine diagnostic scans and assess if current information provided by leaflets is adequate. METHODS: Single-centre cross-sectional questionnaire study applied to bone scan and FDG PET/computed tomography patients, at a nuclear medicine and PET/computed tomography department over a 15-week period in 2018. Questionnaires on dose comparators were designed in collaboration with patients, public, and experts in radiation exposure. Qualitative data were analysed using thematic analysis and quantitative data using SPSS (V. 24). RESULTS: A total of 102 questionnaires were completed (bone scan = 50; FDG PET/computed tomography = 52). Across both groups, 33/102 (32.4%) patients reported having a reasonable understanding of nuclear medicine and 21/102 (20.6%) reported a reasonable knowledge of ionising radiations. When asked to compare the exposure dose of respective scans with common comparators 8/50 (16%) of bone scan patients and 11/52 (21.2%) FDG PET/computed tomography answered correctly. On leaflet information, 15/85 (17.6%) patients reported the leaflets do not provide enough information on radiation exposure and of these 10/15 (66.7%) commented the leaflets should incorporate more information on radiation exposure dose. CONCLUSION: More observational and qualitative studies in collaboration with patients are warranted to evaluate patients' understanding and preferences in communication of radiation exposure from nuclear medicine imaging. This will ensure communication tools and guidelines developed to comply with ionising radiation (medical exposure) regulation 2017 are according to patients needs and preferences

Hand hygiene expectations in radiography: a critical evaluation of the opportunities for and barriers to compliance

Introduction: Good hand hygiene practices reduce the risk of transmission of infection in healthcare. In common with other areas of healthcare, infection control knowledge and practice in radiography has potential for improvement. Regular hand hygiene compliance (HHC) monitoring indicated poor compliance in radiology which did not accurately reflect practice in one organisation. Using a quality improvement cycle, the process and context of work undertaken in radiology were examined in order to improve the validity and utility of HHC monitoring data collection process in the department. Methods: Following examination of the evidence base and with agreement from the radiology team, the chest X-ray process was observed and actions notated. This was then scored using the organisation and the World Health Organization five moments of hand hygiene tool. An alternative risk-based scoring system was developed. Results: The HHC score of 22% was obtained using standard measurements. Achievement of 100% compliance would require the radiographer to clean their hands nine times for each X-ray. The sequence of taking a chest X-ray was examined and two points in the process were identified as key points at which hand cleaning should take place to reduce the risk of transmission of infection. Conclusions: Cleaning hands frequently to achieve compliance expectations in this short low-risk process is neither feasible nor beneficial. A pragmatic risk-based approach to hand hygiene expectations in predictable procedures such as taking a chest X-ray reduces ambiguity and potentially increases compliance

Implementing clinical guidelines to prevent catheter-associated urinary tract infections and improve catheter care in nursing homes: Systematic review

BACKGROUND: Catheter-associated urinary tract infection is the most common health care-associated infection, is considered avoidable, and has cost implications for health services. Prevalence is high in nursing homes, but little research has been undertaken to establish whether implementing clinical guidelines can reduce infection rates in long-term care or improve quality of urinary catheter care. METHODS: Systematic search and critical appraisal of the literature. RESULTS: Three studies evaluated the impact of implementing a complete clinical guideline. Five additional studies evaluated the impact of implementing individual elements of a clinical guideline. CONCLUSIONS: Prevention of catheter-associated urinary tract infection in nursing homes has received little clinical or research attention. Studies concerned with whole guideline implementation emerged as methodologically poor using recognized criteria for critically appraising epidemiologic studies concerned with infection prevention. Research evaluating the impact of single elements of clinical guidelines is more robust, and their findings could be implemented to prevent urinary infections in nursing homes

Remote Sensing of Snow Cover

Snow was easily identified in the first image obtained from the Television Infrared Operational Satellite-1 (TIROS-1) weather satellite in 1960 because the high albedo of snow presents a good contrast with most other natural surfaces. Subsequently, the National Oceanic and Atmospheric Administration (NOAA) began to map snow using satellite-borne instruments in 1966. Snow plays an important role in the Earth s energy balance, causing more solar radiation to be reflected back into space as compared to most snow-free surfaces. Seasonal snow cover also provides a critical water resource through meltwater emanating from rivers that originate from high-mountain areas such as the Tibetan Plateau. Meltwater from mountain snow packs flows to some of the world s most densely-populated areas such as Southeast Asia, benefiting over 1 billion people (Immerzeel et al., 2010). In this section, we provide a brief overview of the remote sensing of snow cover using visible and near-infrared (VNIR) and passive-microwave (PM) data. Snow can be mapped using the microwave part of the electromagnetic spectrum, even in darkness and through cloud cover, but at a coarser spatial resolution than when using VNIR data. Fusing VNIR and PM algorithms to produce a blended product offers synergistic benefits. Snow-water equivalent (SWE), snow extent, and melt onset are important parameters for climate models and for the initialization of atmospheric forecasts at daily and seasonal time scales. Snowmelt data are also needed as input to hydrological models to improve flood control and irrigation management

The development of hand hygiene compliance imperatives in an emergency department

BACKGROUND: Monitoring results showing poor hand hygiene compliance in a major, busy emergency department prompted a quality improvement initiative to improve hand hygiene compliance. PURPOSE: To identify, remove, and reduce barriers to hand hygiene compliance in an emergency department. METHODS: A barrier identification tool was used to identify key barriers and opportunities associated with hand hygiene compliance. Hand hygiene imperatives were developed and agreed on with clinicians, and a framework for monitoring and improving hand hygiene compliance was developed. RESULTS: Barriers to compliance were ambiguity about when to clean hands, the pace and urgency of work in some areas of the department, which left little time for hand hygiene and environmental and operational issues. Sore hands were a problem for some staff. Expectations of compliance were agreed on with staff, and changes were made to remove barriers. A monitoring tool was designed to monitor progress. Gradual improvement occurred in all areas, except in emergency situations, which require further improvement work. CONCLUSIONS: The context of care and barriers to compliance should be reflected in hand hygiene expectations and monitoring. In the emergency department, the requirement to deliver urgent live-saving care can supersede conventional hand hygiene expectations