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Multimodal intervention program to improve hand hygiene compliance: effectiveness and challenges

Multimodal intervention program to improve hand hygiene compliance: effectiveness and challenges Background: Hand hygiene (HH) is considered the most important measure to tackle the transmission of healthcare-associated pathogens. However, compliance with recommendations is usually low and effective improvement strategies are needed. We aimed to assess the effectiveness of an intervention targeting hand hygiene promotion among healthcare workers (HCWs). Methods: We conducted a pre-post interventional study design in the university hospital Sahloul, Sousse, Tunisia, from January 2015 to December 2016. The intervention program consisted of training sessions and distribution of posters of hand hygiene guidelines. To assess the evolution of HH observance at pre- and post-intervention, the same observation form was distributed and collected at healthcare workers’ workplace. Results: Of the 1201 and 1057 opportunities for hand hygiene observed among all categories of HCWs, overall compliance enhanced significantly from 32.1 to 39.4% (p < 0.001) respectively at pre- and post-intervention. Nurses were the most compliant with a significant improvement from 34.1 to 45.7% (p < 0.001) respectively at pre- and post-intervention. Furthermore, analysis by department showed significant improvement of compliance in orthopedic department (p < 0.001), maxillofacial-surgery department (p < 0.001), pediatrics department (p = 0.013), and emergencies (p = 0.038). Conclusion: This study showed the feasibility and effectiveness of a health-setting-based intervention to enhance hand hygiene observance in the context of a developing country. Keywords: Hand hygiene, Compliance, Intervention 1 Background countries, where little data are available. In developed In Tunisia, several studies have uncovered the alarming countries, these infections costs an additional €7 billion per fact that up to 17% of inpatients develop healthcare- year in Europe, considering direct costs only [7]and USA associated infections (HAIs) [1–3]. Patients sustaining a $ 6.5 billion annually for the care of inpatients in the USA HAI compared with those who do not, have significantly [8]. This alarming global burden is avoidable. It is well higher morbidity, mortality, and length of stay [4–6]. That established that the hands of healthcare workers (HCWs) vicious circle of uncontrolled speeding up of HAIs and in- are the main way of pathogen transmission from one pa- creasing financial losses would ultimately weaken health- tient to another and within the healthcare environment care systems especially in low- and middle-income during the healthcare delivery [9, 10]. Therefore, the key element in interruption of the HAIs spread is sustainable * Correspondence: sihembenfredj2015@gmail.com hand hygiene (HH). Evidence-based models and prospect- Department of Prevention and Care Safety, University Hospital Sahloul, 4011 ive studies backed the importance of HH adherence to de- Sousse, Tunisia Full list of author information is available at the end of the article crease the HAIs occurrence and to improve the patient © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Ben Fredj et al. Journal of the Egyptian Public Health Association (2020) 95:11 Page 2 of 8 outcome [11]. However, HCWs usually comply poorly with All hospital departments were included except for oper- recommendations particularly in settings with limited re- ating theaters, laboratories, and administrative units. sources reflecting a gap between evidence and real practice The included departments were the Medical Intensive [12]. Amazian et al. demonstrated that compliance with Care Unit, Surgical Intensive Care Unit, departments of hand hygiene varied greatly between countries and settings General Surgery, Internal Medicine, Cardiology, Ortho- but was globally low (27%) in 22 hospitals in four Mediter- pedics, Physical Medicine, Nephrology, Gastrology, ranean countries. The HH compliance rates were 52.8%, Cardio-vascular and Thoracic Surgery, Maxillofacial Sur- 32.3%, 18.6%, and 16.9%, respectively for Egypt, Tunisia, gery, Dental Medicine, Neurology, Emergencies, Neuro- Algeria, and Morocco [13]. surgery, Urology, and Pediatrics department. Promotion of effective measures to enhance HH ad- According to the WHO recommendations for sample herence is a core component of the WHO initiative size determination [24], the minimal sample size re- “save lives clean your hands” launched in 2009 in order quired was 992 observations. The required number of to improve patient safety [14]. Thereby, WHO developed opportunities to be observed was at both time periods, a multimodal implementation strategy and measures for and based on an improvement in the hand hygiene com- hand hygiene [15] which proved its effectiveness and pliance of 10% between the pre and post intervention. adaptability to different healthcare settings with different To compensate for possible nonresponse, a total of 1190 cultures, local specificities, and habits [16–23]. Our observations were planned for the study. study aimed to demonstrate the feasibility and effective- ness of a health-setting intervention targeting hand hy- 2.3 Study design giene promotion based on the WHO multimodal This study adopted a pre-post interventional study design strategy in all the wards of University Hospital Center with one group of HCWs working in all the departments Sahloul in Sousse, Tunisia. of UHC Sahloul, Sousse, from January 2015 to December 2016. It was designed and reported according to the 2 Methods WHO hand hygiene improvement strategy [15], which 2.1 Setting has been implemented and succeeded in many institutions The study was conducted at the University Hospital Cen- across the world [23]. We adapted the strategy as per our ter (UHC) of Sahloul in eastern Sousse, Tunisia. It is a institution organizational characteristics (Fig. 1). The glo- 690-bed tertiary-level teaching hospital with ten medical bal approach was based on the following 4 steps [25]. departments, ten surgical departments, and three labora- tories. It is supported by 1141 healthcare professionals; 2.3.1 Step 1, preparedness among them are 173 physicians and 647 paramedical staff. Two months prior to the first evaluation of HH compli- ance, the Department of Prevention and Care Safety en- 2.2 Sample for study sured the institution preparedness by providing the Target population was all HCW categories (physicians, necessary resources, making available alcohol-based nurses, and housekeeping staff) agreeing to participate. hand rub at the point of care, reviewing the main issues, Fig. 1 The study design of the interventional study at the University Hospital Sahloul, Sousse, Tunisia (2015-2016) Ben Fredj et al. Journal of the Egyptian Public Health Association (2020) 95:11 Page 3 of 8 and clarifying the plan schema of the strategy. For that, 2.3.3.4 Institutional safety climate We introduced a we informed all departments’ heads and the general dir- compelling communication to motivate the stakeholders ector of the hospital about the study. to be involved in creating an environment that promotes and encourages patient safety. We were seeking to get 2.3.2 Step 2, baseline assessment the support of all HCWs. Therefore, we tried to obtain a The research team conducted a pre-intervention baseline formal and clear commitment from the senior hospital assessment of HH compliance during 2 months. The managers for the promotion of HH in order to maximize trained data collectors observed directly the selected the HCWs involvement in this project. professionals, for 2 h daily during the morning shift. Each observation was broken down into sessions of 20 2.3.4 Step 4, post-intervention assessment min distributed equally throughout the study duration. This step consisted of the follow-up and feedback HCWs were not informed about neither the actual goal period. The post-intervention evaluation of the HH of the observations nor the schedule of the observations’ compliance was continued. time. They were not aware of when exactly these obser- vations were being made. 2.4 Definition of terms Five indications/moments for HH are based on those de- 2.3.3 Step 3, intervention fined by the WHO guidelines [27]. The intervention program was launched in step 3. A moment or indication is when there is a perceived The intervention program started in January 2016 and or actual risk of pathogen transmission from one surface lasted 7 months. It comprised two periods of passages in to another via the HCWs hands (gloved or ungloved) order to reinforce the educational program for hand hy- while undertaking a succession of tasks [28]. giene promotion. The intervention strategy was based According to the WHO guidelines, the hands should on the key components of the WHO multimodal strat- be washed with soap or rubbed with alcoholic disinfect- egy [25]: ant [29]: 2.3.3.1 System change We used a checklist to review Moment 1: before patient contact once a month the availability of alcohol-based hand rub, Moment 2: before a procedure or an aseptic task the liquid soap, washbasins, washbasins/bed ratio, and Moment 3: after a body fluid exposure risk hand towels for single use. Alcohol-based hand rub, li- Moment 4: after touching a patient quid soap, and towels were distributed at points of pa- Moment 5: after touching patient surroundings tient care not available. The damaged where they were washbasins were either fixed or replaced. Opportunity for HH is a situation whenever one of the moments for hand hygiene is present and observed dur- 2.3.3.2 Educational activities The implementation ap- ing patient care. Two indications for HH may co-occur proach of the training program was based on the WHO for one opportunity. tools for HH promotion [26]. Whereby, we rolled out Compliance with HH was defined as either washing the open sensitization days, educational sessions, showing hands (gloved or ungloved) with water and plain soap or educational films followed by interactive discussion and rubbing the hands with an antiseptic solution when an op- presentation of the pre-intervention results. We deliv- portunity occurred. Departure from the room after patient ered an attendance certificate for encouraging HCWs to care without HH and failure to remove gloves after patient participate in the workshops. These different methods contact or contact between a dirty and a clean body site targeted an awareness-raising about the burden of the on the same patient were considered noncompliance [30]. hospital acquired infections (e.g., morbidity, mortality, HH compliance, the main outcome measure, was calcu- and costs), the concept of HH and its key role in the lated as the proportion of HH indications for which HCW prevention of hospital acquired infections and the cor- performed a correct action [31]: rect techniques of HH. number of acts of HH when the indication exists  100 HH compliance ¼ total number of HH opportunities 2.3.3.3 Reminders in the workplace HH leaflets were distributed to each department and posters were bonded in strategic areas of the hospital departments. They in- 2.5 Instruments of measurement cluded key messages and emphasized the HH import- We assessed HCWs adherence to HH guidelines at pre ance as the cornerstone of infection control. They also and 6-months post-intervention with a validated tool. It showed the techniques of hand washing with soap and was constructed by the WHO [31], and composed of five water or cleaning with alcohol-based hand rub. parts. The first part was about the general information Ben Fredj et al. Journal of the Egyptian Public Health Association (2020) 95:11 Page 4 of 8 of the study setting and sessions’ execution. The second 3 Results part included the professional’s category, the indication, A total number of 2258 opportunities for HH were ob- and the HH action whether it was a hand washing, served, 1201 at the baseline assessment and 1057 oppor- alcohol-based hand rub, or no action was taken. Wear- tunities in the 2 months of observation that followed. ing gloves was considered to be no action. Overall compliance enhanced significantly from 32.1 at baseline to 39.4% (p < 0.001) at follow-up. We ob- 2.6 Data analysis served striking differences in the level of compliance Statistical analysis was carried out using the program among the three professional categories. Markedly im- SPSS v. 21 software for windows. The absolute and rela- proved adherence was recorded among nurses. Their tive frequencies were given for the qualitative variables. compliance improved significantly from 34.1 to 45.7% (p Proportions were compared by using chi-square tests to < 0.001) respectively at pre- and post-intervention. HH compare the HH compliance among HCWs according compliance among doctors decreased insignificantly to their categories, specialties, and departments. Multiple from 30.7 in 2015 to 23.1% in 2016 (p = 0.06). House- logistic regression analysis was used in order to seek po- keeping staff recorded the lowest HH compliance which tential determinants of HH compliance. The adjusted dropped from 19.8 to 16.1% (Table 1). odds ratios (aOR) and 95% confidence interval (CI95%) Improvement was observed across all medical special- were calculated. The significance level was set at 0.05. ties. In medicine, HH compliance averaged 29.3% at pre- Table 1 Hand hygiene compliance among health care professionals, before and after intervention, at University Hospital Sahloul, Sousse, Tunisia 2015–2016 Pre-intervention Post-intervention p value Subgroups Compliance n (%) CI95% Compliance n (%) CI95% −3 Overall 385 (32.1) 29.5 – 34.8 416 (39.4) 36.4–42.3 <10 Professional category −3 Nurses 269 (34.1) 30.8–37.5 355 (45.7) 42.2–49.3 <10 Physicians 99 (30.4) 25.7–36.0 52 (23.1) 17.8–29.2 0.06 Housekeeping staff 17 (19.8) 12.3–29.1 9 (16.1) 8.1–27.4 0.57 Medical speciality Intensive Care 197 (41.4) 36.2–45.1 129 (48.9) 42.7–55.0 0.029 −3 Surgery 63 (20.9) 16.8–26.3 158 (34.6) 30.2–39.1 <10 Medicine 107 (29.3) 24.7–34.3 110 (36.2) 30.7–41.7 0.05 Emergency 18 (36.0) 23.2–50.8 19 (59.4) 40.7–75.7 0.038 Department Nephrology 22 (31.4) 21.1–43.7 5 (9.6) 3.5–21.7 0.004 Physical Medicine 15 (16.5) 9.8–26.0 10 (18.2) 9.5–31.3 0.79 Urology 10 (24.4) 12.9–40.6 22 (24.4) 16.2–34.8 0.99 Neurology 17 (37.0) 23.5–52.4 10 (31.3) 15.7–50.1 0.60 General Surgery 13 (24.1) 13.9–37.9 21 (33.3) 22.2–46.4 0.27 Cardiology 30 (35.3) 25.4–46.4 33 (35.1) 25.7–45.7 0.98 −3 Orthopedics 4 (7.0) 2.2–17.8 48 (37.8) 29.4–46.8 <10 Surgical Intensive Care 56 (35.7) 28.3–43.7 31 (37) 26.8–48.1 0.85 Gastrology 24 (29.6) 20.2–40.9 13 (40.6) 24.2–59.2 0.26 Neurosurgery 11 (26.8) 14.7–43.2 24 (45.3) 31.8–59.4 0.06 −3 Maxillofacial Surgery 2 (4.3) 0.7–15.7 28 (46.7) 33.8–59.9 <10 Internal Medicine 25 (36.8) 25.6–49.3 17 (51.5) 33.8–68.8 0.15 Thoracic and Cardiovascular Surgery 28 (41.2) 29.5–53.7 34 (53.1) 40.3–65.5 0.17 Medical Intensive Care 36 (38.7) 28.9–49.4 15 (50.0) 31.6–68.3 0.27 Pediatrics 58 (47.2) 38.1–56.3 78 (63.0) 53.7–71.2 0.013 Dental Medicine 16 (55.2) 35.9–72.3 8 (25.0) 12.1–43.7 0.016 Ben Fredj et al. Journal of the Egyptian Public Health Association (2020) 95:11 Page 5 of 8 intervention and 36.2% at post-intervention. In surgery, assessment. However, the improvement was observed only HH compliance averaged 20.9% at pre-intervention and among nurses, and a slight decrease in HH compliance 34.6% at post-intervention. The intensive care units, was recorded among physicians. Similarly to most studies, whether they were medical or surgical, had the highest the nurses showed a higher HH compliance than did the compliance rate in the two periods of the study (Table 1). other professionals [19, 37–39]. In the present study, the Furthermore, analysis by department indicated signifi- poor HH adherence among physicians comparing to cant improvement of HH compliance from baseline to nurses may be explained by the limited attendance of doc- the intervention period within the majority of hospital tors in training sessions. Hence, making changes to HH ad- departments. It increased significantly in the orthopedic herence is challenging in our context, particularly to face department from 7 to 37.8% (p < 0.001), in the maxillo- defective behaviors and routines that may be already estab- facial surgery department from 4.3 to 46.7% (p < 0.001), lished with HCWs. Although the HH is a simple act to do in the pediatric ward from 47.2 to 63% (p = 0.013), and and a core component in infection control, it seems that it in the emergency department from 36 to 59.4% (p = is hardly incorporated into clinical practice especially that 0.016). Nevertheless, HH compliance declined signifi- physicians showed no significant change in HH compliance cantly in nephrology department from 31.4 to 9.6% (p < [40]. This phenomenon would be the consequence of po- −3 10 ). tential interferences that impede the best HH practice [41]. HH compliance was enhanced across all indications The behavioral determinants were conceptualized as two for HH; however, it was only significant for “before asep- themes by Maura et al. in a systematic qualitative literature tic task” (Table 2). review, according to a theoretical background. The first After adjusting all variables to each other in a logistic component was the motivational factors including the so- regression analysis model, the study showed that HCWs cial influences, acuity of patient care, self-protection, and were more significantly (aOR = 1.34, CI95% 1.11–1.62) use of cues. The second component was the perception of compliant after the HH intervention; nurses were signifi- the work environment whether it concerns the resources, cantly (aOR = 2.03, CI95% 1.66–2.49) more compliant the knowledge, the information, or the organizational cul- compared with physicians and other HCWs; compliance ture [42]. The contributing factors could be also classified was more significant in the indication before aseptic task according to their type: individual or organizational deter- (aOR = 1.56, CI95% 1.25–1.94) (Table 3). minants. The individual determinants’ concern mainly the perception of HAIs risk [43], the knowledge and skill gap 4 Discussion [40] or else the forgetfulness [44], dermatology problems, As far as we know, this study was the first to report the im- and poor acceptance [45] and obviously, HCWs compli- plementation of the WHO hand hygiene improvement ance is influenced by senior’srolemodel [46]. Moreover, strategy using a multifaceted approach in a Tunisian hand hygiene adherence among HCWs is frequently sub- healthcare setting. At baseline, HH compliance (31.6%) of optimal and resistant to improvement as shown by Larson HCWs in the university hospital of Sahloul was compar- et al. [47]. The organizational determinants could be sum- able to that shown in the literature [18, 32–34]. However, marized by the work environment characteristics such as it was still far from other results [20, 35, 36]. Remarkably, the information accessibility and access to HH resources, the intervention program resulted in a significant improve- especially at patient bedside [42] and the high workload ment in HH compliance which reached the 39.4% in post- [30]. In addition, as a developing country, other factors Table 2 Hand hygiene compliance according to the WHO 5 indications, before and after intervention, at University Hospital Sahloul, Sousse, Tunisia 2015–2016 Pre-intervention Post-intervention Indications for hand hygiene Hand hygiene Compliance n CI95% Hand Hygiene Compliance n CI95% p opportunitiesn (%) opportunities n (%) value Before patient contact 453 107 (23.6) 19.6– 340 81 (23.8) 20.1– 0.94 27.6 29.7 Before aseptic task 294 71 (24.1) 19.1– 196 210 (38.1) 34.4– 0.01 29.1 48.5 After body fluid exposure risk 73 34 (46.6) 34.9– 40 20 (50.0) 36.8– 0.72 58.5 70.7 After patient contact 407 206 (50.6) 44.6– 438 213 (48.6) 44.9– 0.56 54.5 54.5 After contact with patient 158 44 (27.8) 21.1– 83 23 (27.7) 22.5– 0.89 surroundings 35.6 42.7 Ben Fredj et al. Journal of the Egyptian Public Health Association (2020) 95:11 Page 6 of 8 Table 3 Binary logistic regression model of potential factors hygiene observance in the context of a developing coun- determining hand hygiene compliance at University Hospital try. It suggests the need to incorporate the HH training Sahloul, Sousse, Tunisia 2015–2016 as a part of the academic course and the professional Variable aOR CI95% diploma. A deeper analysis should be performed to fur- Event ther assess the determinant factors of compliance with hand hygiene. Future studies also should determine Pre-intervention Reference whether sustainable intervention program could slow Post-intervention 1.34 1.11–1.62 the HAI transmission by targeting the HH compliance HCWs and obviously regular maintenance of the medical and Physicians and other HCWs Reference paramedic equipment. Nurses 2.03 1.66–2.49 Acknowledgements Indications Not applicable Other indications Reference Authors’ contributions Before aseptic task 1.56 1.25–1.94 This project was carried out in collaboration between all authors. Authors aOR adjusted odds ratio, CI95% 95% confidence interval HSL, LD, and SB contributed to the design of the study research protocol. Author HSL was the principal investigator. Authors HSL, SB, SBF, HG, SK, LM, should be considered in the implementation of infection and MBR coordinated and participated in the intervention program. Authors SBF, SB, and HG participated in the coordination of data collection and entry. control program including costs, procurement constraints, Authors SBF, ABC, MBR, and HSL participated in the data analysis, deficient infrastructure, cultural issues, and lack of know- interpretation of results, and the manuscript redaction. All authors read and ledge [48]. Therefore, a multidimensional approach is the approved the final manuscript. appropriate strategy to face such multiple constraints. Funding However, the high workload was a heavy barrier in our This work did not receive any financial support. health setting. First, the current personnel number is lim- ited in relation to the growing demand for healthcare [49]. Availability of data and materials The data used to support the findings of this study are available from the Second, the Tunisian government adopted a rigid strategy corresponding author upon request. in recent years. Accordingly, we face challenges backfilling missing personnel. Third, we noted a mismanagement of Ethics approval and consent to participate the available human resources following the administration Ethical approval for this study was obtained from Ethics Committee of the University Hospital Sahloul in January 2015. We have also obtained an laxity in particular after the revolution in 2011. Neverthe- informed verbal consent from participants to participate since the study was less, the overall enhancement of the HH compliance was a part of hospital infection control program. The ethics committee approved promising. Our intervention to positively influence HH be- the verbal consent. We sent an information letter to all the heads of the departments and we obtained support from them before starting project havior was effective as we hoped. The same trend was ob- activities. Data was anonymized and confidential. served in most departments. Similar results were shown through literature around the world [1, 10, 12, 13, 15, 17, Consent for publication Not applicable since data is anonymous and confidentiality was ensured. 29–33] reflecting the ability of multimodal interventions to raise awareness about the HH importance. However, it was Competing interests not always the case. Some studies concluded that the inter- The authors declare that they have no competing interests. vention does not affect HH compliance [50, 51]. Author details Department of Prevention and Care Safety, University Hospital Sahloul, 4011 4.1 Limitations of the study Sousse, Tunisia. Department of Epidemiology, University Hospital Ibn El Strengths of our study include the participation of all hos- Jazzar, 3100 Kairouan, Tunisia. Faculty of Medicine of Sousse, University of Sousse, 4000 Sousse, Tunisia. pital departments, the use of the WHO intervention strat- egy that is highly reproducible and sufficient time study Received: 25 February 2019 Accepted: 25 February 2020 (beyond 1 year) to demonstrate significant changes. The main limitations of the study were the lack of control References group since it was a single-center study and thus, the edu- 1. Kallel H, Bahoul M, Ksibi H, Dammak H, Chelly H, Hamida CB, et al. cational program would have spread easily. Besides, the Prevalence of hospital-acquired infection in a Tunisian hospital. J Hosp Hawthorne effect may change the HCW behavior when Infect. 2005;59(4):343–7. 2. Mahjoub M, Bouafia N, Cheikh AB, Ezzi O, Njah M. Culture sécurité des they are aware of a professional observing them. This patients par la réponse non-punitive à l’erreur et la liberté d’expression des phenomenon has the potential to add bias to an outcome. soignants, Patient safety culture based on a non-punitive response to error and freedom of expression of healthcare professionals. Santé Publique. 2016;28(5):641–6. 5 Conclusion 3. Ben Salem K, El Mhamdi S, Letaief M, Bchir M, Soltani MS. Epidemiological Our study revealed the feasibility and effectiveness of a profile of health-care-associated infections in the central-east area of health-setting-based intervention to enhance hand Tunisia. East Mediterr Health J. 2011;17(6):485–9. Ben Fredj et al. Journal of the Egyptian Public Health Association (2020) 95:11 Page 7 of 8 4. Rejeb MB, Sahli J, Chebil D, Khefacha-Aissa S, Jaidane N, Kacem B, Hmouda improvement strategy in a referral hospital in Mali. Africa. Infect Control H, Dhidah L, Said-Latiri H, Naija W. Mortality among patients with Hosp Epidemiol. 2010;31(2):133–41. nosocomial infections in tertiary intensive care units of Sahloul hospital, 24. Sax H, Allegranzi B, Chraïti M-N, Boyce J, Larson E, Pittet D. The World Sousse, Tunisia. Arch Iran Med. 2016;19(3):179–85. Health Organization hand hygiene observation method. Am J Infect 5. Prowle JR, Echeverri JE, Ligabo EV, Sherry N, Taori GC, Crozier TM, et al. Control. 2009;37(10):827–34. Acquired bloodstream infection in the intensive care unit: incidence and 25. Wold Health Organization. A guide to the implementation of the WHO attributable mortality. Crit Care Lond Engl. 2011;15(2):R100. multimodal hand hygiene improvement strategy. Geneva 2009. availble at: http://www.who.int/gpsc/5may/Guide_to_Implementation.pdf (Accessed 10 6. Barrasa-Villar JI, Aibar-Remón C, Prieto-Andrés P, Mareca-Doñate R, Moliner- Lahoz J. Impact on morbidity, mortality, and length of stay of hospital- Oct 2018). acquired infections by resistant microorganisms. Clin Infect Dis. 2017;65(4): 26. Wold Health Organization. Tools for training and education. Geneva 2009. 644–52. http://www.who.int/gpsc/5may/tools/training_education/en/ (Accessed 7. Annual epidemiological report on communicable diseases in Europe 2008. October 15, 2018). Report on the state of communicable diseases in the EU and EEA/EFTA 27. World Health Organization. Guidelines on hand hygiene in health care. countries. Stockholm, European Centre for Disease Prevention and Control, Geneva: WHO; 2009. Avalible at http://www.who.int/gpsc/5may/tools/ 2008. 9789241597906/en/ (Accessed 16 Oct 2018). 8. Klevens RM, Edwards JR, Richards CL, Horan TC, Gaynes RP, Pollock DA, et al. 28. Martín-Madrazo C, Cañada-Dorado A, Salinero-Fort MA, Abanades-Herranz Estimating health care-associated infections and deaths in U.S. hospitals, JC, Arnal-Selfa R, García-Ferradal I, et al. Effectiveness of a training 2002. Public Health Rep Wash DC 1974. 2007;122(2):160–6. programme to improve hand hygiene compliance in primary healthcare. 9. Pittet D, Allegranzi B, Sax H, Dharan S, Pessoa-Silva CL, Donaldson L, et al. BMC Public Health. 2009;9:469. Evidence-based model for hand transmission during patient care and the 29. Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. “My five moments role of improved practices. Lancet Infect Dis. 2006;6(10):641–52. for hand hygiene”: a user-centred design approach to understand, train, 10. Goel S, Tank R, Singh A, Khichi SK, Bypareddy R, Goyal P, et al. Are doctor’s monitor and report hand hygiene. J Hosp Infect. 2007;67(1):9–21. hands contributing in spreading nosocomial pathogens? Rapid appraisal 30. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching from a tertiary care health center of Northern India. Int J Res Med Sci. 2017; hospital. Infection Control Program. Ann Intern Med. 1999;130(2):126–30. 4(6):1978–82. 31. World Health Organization. Hand hygiene technical reference manual. 11. Gould DJ, Drey NS, Moralejo D, Grimshaw J, Chudleigh J. Interventions to Geneva 2009. Available at: http://www.who.int/gpsc/5may/tools/evaluation_ improve hand hygiene compliance in patient care. J Hosp Infect. 2008;68(3): feedback/en/index.html (Accessed 17 Oct 2018). 193–202. 32. Mu X, Xu Y, Yang T, Zhang J, Wang C, Liu W, et al. Improving hand hygiene 12. Karabey S, Ay P, Derbentli S, Nakipoglu Y, Esen F. Handwashing frequencies compliance among healthcare workers: an intervention study in a Hospital in an intensive care unit. J Hosp Infect. 2002;50(1):36–41. in Guizhou Province. China. Braz J Infect Dis Off Publ Braz Soc Infect Dis. 2016;20(5):413–8. 13. Amazian K, Abdelmoumène T, Sekkat S, Terzaki S, Njah M, Dhidah L, et al. Multicentre study on hand hygiene facilities and practice in the 33. Salama MF, Jamal WY, Mousa HA, Al-Abdulghani KA, Rotimi VO. The effect Mediterranean area: results from the NosoMed Network. J Hosp Infect. 2006; of hand hygiene compliance on hospital-acquired infections in an ICU 62(3):311–8. setting in a Kuwaiti teaching hospital. J Infect Public Health. 2013;6(1):27–34. 14. World Health Organization. Patient safety, a world alliance for safer health care. 34. Abela N, Borg MA. Impact on hand hygiene compliance following Suggested key messages to use. Available at: http://www.who.int/gpsc/5may/ migration to a new hospital with improved resources and the sequential resources/slcyh_briefing-kit_key-messages.pdf?ua=1 (Accessed 15 Oct 2018). introduction of World Health Organization recommendations. Am J Infect 15. Pittet D, Allegranzi B, Storr J. The WHO Clean Care is Safer Care programme: Control. 2012;40(8):737–41. field-testing to enhance sustainability and spread of hand hygiene 35. von Lengerke T, Lutze B, Krauth C, Lange K, Stahmeyer JT, Chaberny IF. improvements. J Infect Public Health. 2008;1(1):4–10. Promoting hand hygiene compliance. Dtsch Arzteblatt Int. 2017;114(3):29–36. 16. Pfäfflin F, Tufa TB, Getachew M, Nigussie T, Schönfeld A, Häussinger D, et al. 36. Ye L-P, Zhang X-P, Lai X-Q. Does hospital ownership influence hand Implementation of the WHO multimodal hand hygiene improvement hygiene compliance? J Huazhong Univ Sci Technol Med Sci Hua Zhong Ke strategy in a University Hospital in Central Ethiopia. Antimicrob Resist Infect Ji Xue Xue Bao Yi Xue Ying Wen Ban Huazhong Keji Daxue Xuebao Yixue Yingdewen Ban. 2017;37(5):787–94. Control. 2017;6:3. 17. Santosaningsih D, Erikawati D, Santoso S, Noorhamdani N, Ratridewi I, 37. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Candradikusuma D, et al. Intervening with healthcare workers’ hand Effectiveness of a hospital-wide programme to improve compliance with hygiene compliance, knowledge, and perception in a limited-resource hand hygiene. Infection Control Programme. Lancet Lond Engl. 2000; hospital in Indonesia: a randomized controlled trial study. Antimicrob Resist 356(9238):1307–12. Infect Control. 2017;6:23. 38. Lam BCC, Lee J, Lau YL. Hand hygiene practices in a neonatal intensive care 18. Farhoudi F, Sanaei Dashti A, Hoshangi Davani M, Ghalebi N, Sajadi G, unit: a multimodal intervention and impact on nosocomial infection. Taghizadeh R. Impact of WHO hand hygiene improvement program Pediatrics. 2004;114(5):e565–71. implementation: a quasi-experimental trial. BioMed Res Int. 2016;2016: 39. Donowitz LG. Handwashing technique in a pediatric intensive care unit. Am 7026169. J Dis Child 1960. 1987;141(6):683–5. 19. Lee SS, Park SJ, Chung MJ, Lee JH, Kang HJ, Lee J, et al. Improved hand 40. Squires JE, Linklater S, Grimshaw JM, Graham ID, Sullivan K, Bruce N, et al. hygiene compliance is associated with the change of perception toward hand Understanding practice: factors that influence physician hand hygiene hygiene among medical personnel. Infect Chemother. 2014;46(3):165–71. compliance. Infect Control Amp Hosp Epidemiol. 2014;35(12):1511–20. 20. Mahfouz AA, Al-Zaydani IA, Abdelaziz AO, El-Gamal MN, Assiri AM. Changes 41. Larson E, Killien M. Factors influencing handwashing behavior of patient in hand hygiene compliance after a multimodal intervention among health- care personnel. Am J Infect Control. 1982;10(3):93–9. care workers from intensive care units in Southwestern Saudi Arabia. J 42. Smiddy MP, O’ Connell R, Creedon SA. Systematic qualitative literature Epidemiol Glob Health. 2014;4(4):315–21. review of health care workers’ compliance with hand hygiene guidelines. 21. Mestre G, Berbel C, Tortajada P, Alarcia M, Coca R, Gallemi G, et al. “The 3/3 Am J Infect Control. 2015;43(3):269–74. strategy”: a successful multifaceted hospital wide hand hygiene intervention 43. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. based on WHO and continuous quality improvement methodology. PLoS Hand hygiene among physicians: performance, beliefs, and perceptions. ONE. 2012;7(10):e47200. Ann Intern Med. 2004;141(1):1–8. 22. Monistrol O, Calbo E, Riera M, Nicolás C, Font R, Freixas N, et al. Impact of a 44. Erasmus V, Brouwer W, van Beeck EF, Oenema A, Daha TJ, Richardus JH, hand hygiene educational programme on hospital-acquired infections in et al. A qualitative exploration of reasons for poor hand hygiene among medical wards. Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect hospital workers: lack of positive role models and of convincing evidence Dis. 2012;18(12):1212–8. that hand hygiene prevents cross-infection. Infect Control Hosp Epidemiol. 23. Allegranzi B, Sax H, Bengaly L, Richet H, Minta DK, Chraiti M, et al. Successful 2009;30(5):415–9. implementation of the World Health Organization hand hygiene 45. Kingston LM, Slevin BL, O’Connell NH, Dunne CP. Attitudes and practices of Irish hospital-based physicians towards hand hygiene and hand rubbing Ben Fredj et al. Journal of the Egyptian Public Health Association (2020) 95:11 Page 8 of 8 using alcohol-based hand rub: a comparison between 2007 and 2015. J Hosp Infect. 2017;97(1):17–25. 46. Lankford MG, Zembower TR, Trick WE, Hacek DM, Noskin GA, Peterson LR. Influence of role models and hospital design on the hand hygiene of health-care workers. Emerg Infect Dis. 2003;9(2):217–23. 47. Larson EL, Early E, Cloonan P, Sugrue S, Parides M. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med Wash DC. 2000;26(1):14–22. 48. Shears P. Poverty and infection in the developing world: healthcare-related infections and infection control in the tropics. J Hosp Infect. 2007;67(3):217– 49. World Health Organization. Health system profile Tunisia. Regional office for the Eastern Mediterranean, WHO 2006. Availble at: http://apps.who.int/ medicinedocs/documents/s17312e/s17312e.pdf (Accessed 28 Oct 2017). 50. Dorsey ST, Cydulka RK, Emerman CL. Is handwashing teachable?: failure to improve handwashing behavior in an urban emergency department. Acad Emerg Med Off J Soc Acad Emerg Med. 1996;3(4):360–5.. 51. Muto CA, Sistrom MG, Farr BM. Hand hygiene rates unaffected by installation of dispensers of a rapidly acting hand antiseptic. Am J Infect Control. 2000;28(3):273–6. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the Egyptian Public Health Association Springer Journals

Multimodal intervention program to improve hand hygiene compliance: effectiveness and challenges

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10.1186/s42506-020-00039-w
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Abstract

Background: Hand hygiene (HH) is considered the most important measure to tackle the transmission of healthcare-associated pathogens. However, compliance with recommendations is usually low and effective improvement strategies are needed. We aimed to assess the effectiveness of an intervention targeting hand hygiene promotion among healthcare workers (HCWs). Methods: We conducted a pre-post interventional study design in the university hospital Sahloul, Sousse, Tunisia, from January 2015 to December 2016. The intervention program consisted of training sessions and distribution of posters of hand hygiene guidelines. To assess the evolution of HH observance at pre- and post-intervention, the same observation form was distributed and collected at healthcare workers’ workplace. Results: Of the 1201 and 1057 opportunities for hand hygiene observed among all categories of HCWs, overall compliance enhanced significantly from 32.1 to 39.4% (p < 0.001) respectively at pre- and post-intervention. Nurses were the most compliant with a significant improvement from 34.1 to 45.7% (p < 0.001) respectively at pre- and post-intervention. Furthermore, analysis by department showed significant improvement of compliance in orthopedic department (p < 0.001), maxillofacial-surgery department (p < 0.001), pediatrics department (p = 0.013), and emergencies (p = 0.038). Conclusion: This study showed the feasibility and effectiveness of a health-setting-based intervention to enhance hand hygiene observance in the context of a developing country. Keywords: Hand hygiene, Compliance, Intervention 1 Background countries, where little data are available. In developed In Tunisia, several studies have uncovered the alarming countries, these infections costs an additional €7 billion per fact that up to 17% of inpatients develop healthcare- year in Europe, considering direct costs only [7]and USA associated infections (HAIs) [1–3]. Patients sustaining a $ 6.5 billion annually for the care of inpatients in the USA HAI compared with those who do not, have significantly [8]. This alarming global burden is avoidable. It is well higher morbidity, mortality, and length of stay [4–6]. That established that the hands of healthcare workers (HCWs) vicious circle of uncontrolled speeding up of HAIs and in- are the main way of pathogen transmission from one pa- creasing financial losses would ultimately weaken health- tient to another and within the healthcare environment care systems especially in low- and middle-income during the healthcare delivery [9, 10]. Therefore, the key element in interruption of the HAIs spread is sustainable * Correspondence: sihembenfredj2015@gmail.com hand hygiene (HH). Evidence-based models and prospect- Department of Prevention and Care Safety, University Hospital Sahloul, 4011 ive studies backed the importance of HH adherence to de- Sousse, Tunisia Full list of author information is available at the end of the article crease the HAIs occurrence and to improve the patient © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Ben Fredj et al. Journal of the Egyptian Public Health Association (2020) 95:11 Page 2 of 8 outcome [11]. However, HCWs usually comply poorly with All hospital departments were included except for oper- recommendations particularly in settings with limited re- ating theaters, laboratories, and administrative units. sources reflecting a gap between evidence and real practice The included departments were the Medical Intensive [12]. Amazian et al. demonstrated that compliance with Care Unit, Surgical Intensive Care Unit, departments of hand hygiene varied greatly between countries and settings General Surgery, Internal Medicine, Cardiology, Ortho- but was globally low (27%) in 22 hospitals in four Mediter- pedics, Physical Medicine, Nephrology, Gastrology, ranean countries. The HH compliance rates were 52.8%, Cardio-vascular and Thoracic Surgery, Maxillofacial Sur- 32.3%, 18.6%, and 16.9%, respectively for Egypt, Tunisia, gery, Dental Medicine, Neurology, Emergencies, Neuro- Algeria, and Morocco [13]. surgery, Urology, and Pediatrics department. Promotion of effective measures to enhance HH ad- According to the WHO recommendations for sample herence is a core component of the WHO initiative size determination [24], the minimal sample size re- “save lives clean your hands” launched in 2009 in order quired was 992 observations. The required number of to improve patient safety [14]. Thereby, WHO developed opportunities to be observed was at both time periods, a multimodal implementation strategy and measures for and based on an improvement in the hand hygiene com- hand hygiene [15] which proved its effectiveness and pliance of 10% between the pre and post intervention. adaptability to different healthcare settings with different To compensate for possible nonresponse, a total of 1190 cultures, local specificities, and habits [16–23]. Our observations were planned for the study. study aimed to demonstrate the feasibility and effective- ness of a health-setting intervention targeting hand hy- 2.3 Study design giene promotion based on the WHO multimodal This study adopted a pre-post interventional study design strategy in all the wards of University Hospital Center with one group of HCWs working in all the departments Sahloul in Sousse, Tunisia. of UHC Sahloul, Sousse, from January 2015 to December 2016. It was designed and reported according to the 2 Methods WHO hand hygiene improvement strategy [15], which 2.1 Setting has been implemented and succeeded in many institutions The study was conducted at the University Hospital Cen- across the world [23]. We adapted the strategy as per our ter (UHC) of Sahloul in eastern Sousse, Tunisia. It is a institution organizational characteristics (Fig. 1). The glo- 690-bed tertiary-level teaching hospital with ten medical bal approach was based on the following 4 steps [25]. departments, ten surgical departments, and three labora- tories. It is supported by 1141 healthcare professionals; 2.3.1 Step 1, preparedness among them are 173 physicians and 647 paramedical staff. Two months prior to the first evaluation of HH compli- ance, the Department of Prevention and Care Safety en- 2.2 Sample for study sured the institution preparedness by providing the Target population was all HCW categories (physicians, necessary resources, making available alcohol-based nurses, and housekeeping staff) agreeing to participate. hand rub at the point of care, reviewing the main issues, Fig. 1 The study design of the interventional study at the University Hospital Sahloul, Sousse, Tunisia (2015-2016) Ben Fredj et al. Journal of the Egyptian Public Health Association (2020) 95:11 Page 3 of 8 and clarifying the plan schema of the strategy. For that, 2.3.3.4 Institutional safety climate We introduced a we informed all departments’ heads and the general dir- compelling communication to motivate the stakeholders ector of the hospital about the study. to be involved in creating an environment that promotes and encourages patient safety. We were seeking to get 2.3.2 Step 2, baseline assessment the support of all HCWs. Therefore, we tried to obtain a The research team conducted a pre-intervention baseline formal and clear commitment from the senior hospital assessment of HH compliance during 2 months. The managers for the promotion of HH in order to maximize trained data collectors observed directly the selected the HCWs involvement in this project. professionals, for 2 h daily during the morning shift. Each observation was broken down into sessions of 20 2.3.4 Step 4, post-intervention assessment min distributed equally throughout the study duration. This step consisted of the follow-up and feedback HCWs were not informed about neither the actual goal period. The post-intervention evaluation of the HH of the observations nor the schedule of the observations’ compliance was continued. time. They were not aware of when exactly these obser- vations were being made. 2.4 Definition of terms Five indications/moments for HH are based on those de- 2.3.3 Step 3, intervention fined by the WHO guidelines [27]. The intervention program was launched in step 3. A moment or indication is when there is a perceived The intervention program started in January 2016 and or actual risk of pathogen transmission from one surface lasted 7 months. It comprised two periods of passages in to another via the HCWs hands (gloved or ungloved) order to reinforce the educational program for hand hy- while undertaking a succession of tasks [28]. giene promotion. The intervention strategy was based According to the WHO guidelines, the hands should on the key components of the WHO multimodal strat- be washed with soap or rubbed with alcoholic disinfect- egy [25]: ant [29]: 2.3.3.1 System change We used a checklist to review Moment 1: before patient contact once a month the availability of alcohol-based hand rub, Moment 2: before a procedure or an aseptic task the liquid soap, washbasins, washbasins/bed ratio, and Moment 3: after a body fluid exposure risk hand towels for single use. Alcohol-based hand rub, li- Moment 4: after touching a patient quid soap, and towels were distributed at points of pa- Moment 5: after touching patient surroundings tient care not available. The damaged where they were washbasins were either fixed or replaced. Opportunity for HH is a situation whenever one of the moments for hand hygiene is present and observed dur- 2.3.3.2 Educational activities The implementation ap- ing patient care. Two indications for HH may co-occur proach of the training program was based on the WHO for one opportunity. tools for HH promotion [26]. Whereby, we rolled out Compliance with HH was defined as either washing the open sensitization days, educational sessions, showing hands (gloved or ungloved) with water and plain soap or educational films followed by interactive discussion and rubbing the hands with an antiseptic solution when an op- presentation of the pre-intervention results. We deliv- portunity occurred. Departure from the room after patient ered an attendance certificate for encouraging HCWs to care without HH and failure to remove gloves after patient participate in the workshops. These different methods contact or contact between a dirty and a clean body site targeted an awareness-raising about the burden of the on the same patient were considered noncompliance [30]. hospital acquired infections (e.g., morbidity, mortality, HH compliance, the main outcome measure, was calcu- and costs), the concept of HH and its key role in the lated as the proportion of HH indications for which HCW prevention of hospital acquired infections and the cor- performed a correct action [31]: rect techniques of HH. number of acts of HH when the indication exists  100 HH compliance ¼ total number of HH opportunities 2.3.3.3 Reminders in the workplace HH leaflets were distributed to each department and posters were bonded in strategic areas of the hospital departments. They in- 2.5 Instruments of measurement cluded key messages and emphasized the HH import- We assessed HCWs adherence to HH guidelines at pre ance as the cornerstone of infection control. They also and 6-months post-intervention with a validated tool. It showed the techniques of hand washing with soap and was constructed by the WHO [31], and composed of five water or cleaning with alcohol-based hand rub. parts. The first part was about the general information Ben Fredj et al. Journal of the Egyptian Public Health Association (2020) 95:11 Page 4 of 8 of the study setting and sessions’ execution. The second 3 Results part included the professional’s category, the indication, A total number of 2258 opportunities for HH were ob- and the HH action whether it was a hand washing, served, 1201 at the baseline assessment and 1057 oppor- alcohol-based hand rub, or no action was taken. Wear- tunities in the 2 months of observation that followed. ing gloves was considered to be no action. Overall compliance enhanced significantly from 32.1 at baseline to 39.4% (p < 0.001) at follow-up. We ob- 2.6 Data analysis served striking differences in the level of compliance Statistical analysis was carried out using the program among the three professional categories. Markedly im- SPSS v. 21 software for windows. The absolute and rela- proved adherence was recorded among nurses. Their tive frequencies were given for the qualitative variables. compliance improved significantly from 34.1 to 45.7% (p Proportions were compared by using chi-square tests to < 0.001) respectively at pre- and post-intervention. HH compare the HH compliance among HCWs according compliance among doctors decreased insignificantly to their categories, specialties, and departments. Multiple from 30.7 in 2015 to 23.1% in 2016 (p = 0.06). House- logistic regression analysis was used in order to seek po- keeping staff recorded the lowest HH compliance which tential determinants of HH compliance. The adjusted dropped from 19.8 to 16.1% (Table 1). odds ratios (aOR) and 95% confidence interval (CI95%) Improvement was observed across all medical special- were calculated. The significance level was set at 0.05. ties. In medicine, HH compliance averaged 29.3% at pre- Table 1 Hand hygiene compliance among health care professionals, before and after intervention, at University Hospital Sahloul, Sousse, Tunisia 2015–2016 Pre-intervention Post-intervention p value Subgroups Compliance n (%) CI95% Compliance n (%) CI95% −3 Overall 385 (32.1) 29.5 – 34.8 416 (39.4) 36.4–42.3 <10 Professional category −3 Nurses 269 (34.1) 30.8–37.5 355 (45.7) 42.2–49.3 <10 Physicians 99 (30.4) 25.7–36.0 52 (23.1) 17.8–29.2 0.06 Housekeeping staff 17 (19.8) 12.3–29.1 9 (16.1) 8.1–27.4 0.57 Medical speciality Intensive Care 197 (41.4) 36.2–45.1 129 (48.9) 42.7–55.0 0.029 −3 Surgery 63 (20.9) 16.8–26.3 158 (34.6) 30.2–39.1 <10 Medicine 107 (29.3) 24.7–34.3 110 (36.2) 30.7–41.7 0.05 Emergency 18 (36.0) 23.2–50.8 19 (59.4) 40.7–75.7 0.038 Department Nephrology 22 (31.4) 21.1–43.7 5 (9.6) 3.5–21.7 0.004 Physical Medicine 15 (16.5) 9.8–26.0 10 (18.2) 9.5–31.3 0.79 Urology 10 (24.4) 12.9–40.6 22 (24.4) 16.2–34.8 0.99 Neurology 17 (37.0) 23.5–52.4 10 (31.3) 15.7–50.1 0.60 General Surgery 13 (24.1) 13.9–37.9 21 (33.3) 22.2–46.4 0.27 Cardiology 30 (35.3) 25.4–46.4 33 (35.1) 25.7–45.7 0.98 −3 Orthopedics 4 (7.0) 2.2–17.8 48 (37.8) 29.4–46.8 <10 Surgical Intensive Care 56 (35.7) 28.3–43.7 31 (37) 26.8–48.1 0.85 Gastrology 24 (29.6) 20.2–40.9 13 (40.6) 24.2–59.2 0.26 Neurosurgery 11 (26.8) 14.7–43.2 24 (45.3) 31.8–59.4 0.06 −3 Maxillofacial Surgery 2 (4.3) 0.7–15.7 28 (46.7) 33.8–59.9 <10 Internal Medicine 25 (36.8) 25.6–49.3 17 (51.5) 33.8–68.8 0.15 Thoracic and Cardiovascular Surgery 28 (41.2) 29.5–53.7 34 (53.1) 40.3–65.5 0.17 Medical Intensive Care 36 (38.7) 28.9–49.4 15 (50.0) 31.6–68.3 0.27 Pediatrics 58 (47.2) 38.1–56.3 78 (63.0) 53.7–71.2 0.013 Dental Medicine 16 (55.2) 35.9–72.3 8 (25.0) 12.1–43.7 0.016 Ben Fredj et al. Journal of the Egyptian Public Health Association (2020) 95:11 Page 5 of 8 intervention and 36.2% at post-intervention. In surgery, assessment. However, the improvement was observed only HH compliance averaged 20.9% at pre-intervention and among nurses, and a slight decrease in HH compliance 34.6% at post-intervention. The intensive care units, was recorded among physicians. Similarly to most studies, whether they were medical or surgical, had the highest the nurses showed a higher HH compliance than did the compliance rate in the two periods of the study (Table 1). other professionals [19, 37–39]. In the present study, the Furthermore, analysis by department indicated signifi- poor HH adherence among physicians comparing to cant improvement of HH compliance from baseline to nurses may be explained by the limited attendance of doc- the intervention period within the majority of hospital tors in training sessions. Hence, making changes to HH ad- departments. It increased significantly in the orthopedic herence is challenging in our context, particularly to face department from 7 to 37.8% (p < 0.001), in the maxillo- defective behaviors and routines that may be already estab- facial surgery department from 4.3 to 46.7% (p < 0.001), lished with HCWs. Although the HH is a simple act to do in the pediatric ward from 47.2 to 63% (p = 0.013), and and a core component in infection control, it seems that it in the emergency department from 36 to 59.4% (p = is hardly incorporated into clinical practice especially that 0.016). Nevertheless, HH compliance declined signifi- physicians showed no significant change in HH compliance cantly in nephrology department from 31.4 to 9.6% (p < [40]. This phenomenon would be the consequence of po- −3 10 ). tential interferences that impede the best HH practice [41]. HH compliance was enhanced across all indications The behavioral determinants were conceptualized as two for HH; however, it was only significant for “before asep- themes by Maura et al. in a systematic qualitative literature tic task” (Table 2). review, according to a theoretical background. The first After adjusting all variables to each other in a logistic component was the motivational factors including the so- regression analysis model, the study showed that HCWs cial influences, acuity of patient care, self-protection, and were more significantly (aOR = 1.34, CI95% 1.11–1.62) use of cues. The second component was the perception of compliant after the HH intervention; nurses were signifi- the work environment whether it concerns the resources, cantly (aOR = 2.03, CI95% 1.66–2.49) more compliant the knowledge, the information, or the organizational cul- compared with physicians and other HCWs; compliance ture [42]. The contributing factors could be also classified was more significant in the indication before aseptic task according to their type: individual or organizational deter- (aOR = 1.56, CI95% 1.25–1.94) (Table 3). minants. The individual determinants’ concern mainly the perception of HAIs risk [43], the knowledge and skill gap 4 Discussion [40] or else the forgetfulness [44], dermatology problems, As far as we know, this study was the first to report the im- and poor acceptance [45] and obviously, HCWs compli- plementation of the WHO hand hygiene improvement ance is influenced by senior’srolemodel [46]. Moreover, strategy using a multifaceted approach in a Tunisian hand hygiene adherence among HCWs is frequently sub- healthcare setting. At baseline, HH compliance (31.6%) of optimal and resistant to improvement as shown by Larson HCWs in the university hospital of Sahloul was compar- et al. [47]. The organizational determinants could be sum- able to that shown in the literature [18, 32–34]. However, marized by the work environment characteristics such as it was still far from other results [20, 35, 36]. Remarkably, the information accessibility and access to HH resources, the intervention program resulted in a significant improve- especially at patient bedside [42] and the high workload ment in HH compliance which reached the 39.4% in post- [30]. In addition, as a developing country, other factors Table 2 Hand hygiene compliance according to the WHO 5 indications, before and after intervention, at University Hospital Sahloul, Sousse, Tunisia 2015–2016 Pre-intervention Post-intervention Indications for hand hygiene Hand hygiene Compliance n CI95% Hand Hygiene Compliance n CI95% p opportunitiesn (%) opportunities n (%) value Before patient contact 453 107 (23.6) 19.6– 340 81 (23.8) 20.1– 0.94 27.6 29.7 Before aseptic task 294 71 (24.1) 19.1– 196 210 (38.1) 34.4– 0.01 29.1 48.5 After body fluid exposure risk 73 34 (46.6) 34.9– 40 20 (50.0) 36.8– 0.72 58.5 70.7 After patient contact 407 206 (50.6) 44.6– 438 213 (48.6) 44.9– 0.56 54.5 54.5 After contact with patient 158 44 (27.8) 21.1– 83 23 (27.7) 22.5– 0.89 surroundings 35.6 42.7 Ben Fredj et al. Journal of the Egyptian Public Health Association (2020) 95:11 Page 6 of 8 Table 3 Binary logistic regression model of potential factors hygiene observance in the context of a developing coun- determining hand hygiene compliance at University Hospital try. It suggests the need to incorporate the HH training Sahloul, Sousse, Tunisia 2015–2016 as a part of the academic course and the professional Variable aOR CI95% diploma. A deeper analysis should be performed to fur- Event ther assess the determinant factors of compliance with hand hygiene. Future studies also should determine Pre-intervention Reference whether sustainable intervention program could slow Post-intervention 1.34 1.11–1.62 the HAI transmission by targeting the HH compliance HCWs and obviously regular maintenance of the medical and Physicians and other HCWs Reference paramedic equipment. Nurses 2.03 1.66–2.49 Acknowledgements Indications Not applicable Other indications Reference Authors’ contributions Before aseptic task 1.56 1.25–1.94 This project was carried out in collaboration between all authors. Authors aOR adjusted odds ratio, CI95% 95% confidence interval HSL, LD, and SB contributed to the design of the study research protocol. Author HSL was the principal investigator. Authors HSL, SB, SBF, HG, SK, LM, should be considered in the implementation of infection and MBR coordinated and participated in the intervention program. Authors SBF, SB, and HG participated in the coordination of data collection and entry. control program including costs, procurement constraints, Authors SBF, ABC, MBR, and HSL participated in the data analysis, deficient infrastructure, cultural issues, and lack of know- interpretation of results, and the manuscript redaction. All authors read and ledge [48]. Therefore, a multidimensional approach is the approved the final manuscript. appropriate strategy to face such multiple constraints. Funding However, the high workload was a heavy barrier in our This work did not receive any financial support. health setting. First, the current personnel number is lim- ited in relation to the growing demand for healthcare [49]. Availability of data and materials The data used to support the findings of this study are available from the Second, the Tunisian government adopted a rigid strategy corresponding author upon request. in recent years. Accordingly, we face challenges backfilling missing personnel. Third, we noted a mismanagement of Ethics approval and consent to participate the available human resources following the administration Ethical approval for this study was obtained from Ethics Committee of the University Hospital Sahloul in January 2015. We have also obtained an laxity in particular after the revolution in 2011. Neverthe- informed verbal consent from participants to participate since the study was less, the overall enhancement of the HH compliance was a part of hospital infection control program. The ethics committee approved promising. Our intervention to positively influence HH be- the verbal consent. We sent an information letter to all the heads of the departments and we obtained support from them before starting project havior was effective as we hoped. The same trend was ob- activities. Data was anonymized and confidential. served in most departments. Similar results were shown through literature around the world [1, 10, 12, 13, 15, 17, Consent for publication Not applicable since data is anonymous and confidentiality was ensured. 29–33] reflecting the ability of multimodal interventions to raise awareness about the HH importance. However, it was Competing interests not always the case. Some studies concluded that the inter- The authors declare that they have no competing interests. vention does not affect HH compliance [50, 51]. Author details Department of Prevention and Care Safety, University Hospital Sahloul, 4011 4.1 Limitations of the study Sousse, Tunisia. Department of Epidemiology, University Hospital Ibn El Strengths of our study include the participation of all hos- Jazzar, 3100 Kairouan, Tunisia. Faculty of Medicine of Sousse, University of Sousse, 4000 Sousse, Tunisia. pital departments, the use of the WHO intervention strat- egy that is highly reproducible and sufficient time study Received: 25 February 2019 Accepted: 25 February 2020 (beyond 1 year) to demonstrate significant changes. The main limitations of the study were the lack of control References group since it was a single-center study and thus, the edu- 1. Kallel H, Bahoul M, Ksibi H, Dammak H, Chelly H, Hamida CB, et al. cational program would have spread easily. Besides, the Prevalence of hospital-acquired infection in a Tunisian hospital. J Hosp Hawthorne effect may change the HCW behavior when Infect. 2005;59(4):343–7. 2. Mahjoub M, Bouafia N, Cheikh AB, Ezzi O, Njah M. Culture sécurité des they are aware of a professional observing them. This patients par la réponse non-punitive à l’erreur et la liberté d’expression des phenomenon has the potential to add bias to an outcome. soignants, Patient safety culture based on a non-punitive response to error and freedom of expression of healthcare professionals. Santé Publique. 2016;28(5):641–6. 5 Conclusion 3. Ben Salem K, El Mhamdi S, Letaief M, Bchir M, Soltani MS. Epidemiological Our study revealed the feasibility and effectiveness of a profile of health-care-associated infections in the central-east area of health-setting-based intervention to enhance hand Tunisia. East Mediterr Health J. 2011;17(6):485–9. Ben Fredj et al. Journal of the Egyptian Public Health Association (2020) 95:11 Page 7 of 8 4. Rejeb MB, Sahli J, Chebil D, Khefacha-Aissa S, Jaidane N, Kacem B, Hmouda improvement strategy in a referral hospital in Mali. Africa. Infect Control H, Dhidah L, Said-Latiri H, Naija W. Mortality among patients with Hosp Epidemiol. 2010;31(2):133–41. nosocomial infections in tertiary intensive care units of Sahloul hospital, 24. Sax H, Allegranzi B, Chraïti M-N, Boyce J, Larson E, Pittet D. The World Sousse, Tunisia. Arch Iran Med. 2016;19(3):179–85. Health Organization hand hygiene observation method. Am J Infect 5. Prowle JR, Echeverri JE, Ligabo EV, Sherry N, Taori GC, Crozier TM, et al. Control. 2009;37(10):827–34. Acquired bloodstream infection in the intensive care unit: incidence and 25. Wold Health Organization. A guide to the implementation of the WHO attributable mortality. Crit Care Lond Engl. 2011;15(2):R100. multimodal hand hygiene improvement strategy. Geneva 2009. availble at: http://www.who.int/gpsc/5may/Guide_to_Implementation.pdf (Accessed 10 6. Barrasa-Villar JI, Aibar-Remón C, Prieto-Andrés P, Mareca-Doñate R, Moliner- Lahoz J. Impact on morbidity, mortality, and length of stay of hospital- Oct 2018). acquired infections by resistant microorganisms. Clin Infect Dis. 2017;65(4): 26. Wold Health Organization. Tools for training and education. Geneva 2009. 644–52. http://www.who.int/gpsc/5may/tools/training_education/en/ (Accessed 7. Annual epidemiological report on communicable diseases in Europe 2008. October 15, 2018). Report on the state of communicable diseases in the EU and EEA/EFTA 27. World Health Organization. Guidelines on hand hygiene in health care. countries. Stockholm, European Centre for Disease Prevention and Control, Geneva: WHO; 2009. Avalible at http://www.who.int/gpsc/5may/tools/ 2008. 9789241597906/en/ (Accessed 16 Oct 2018). 8. Klevens RM, Edwards JR, Richards CL, Horan TC, Gaynes RP, Pollock DA, et al. 28. Martín-Madrazo C, Cañada-Dorado A, Salinero-Fort MA, Abanades-Herranz Estimating health care-associated infections and deaths in U.S. hospitals, JC, Arnal-Selfa R, García-Ferradal I, et al. Effectiveness of a training 2002. Public Health Rep Wash DC 1974. 2007;122(2):160–6. programme to improve hand hygiene compliance in primary healthcare. 9. Pittet D, Allegranzi B, Sax H, Dharan S, Pessoa-Silva CL, Donaldson L, et al. BMC Public Health. 2009;9:469. Evidence-based model for hand transmission during patient care and the 29. Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. “My five moments role of improved practices. Lancet Infect Dis. 2006;6(10):641–52. for hand hygiene”: a user-centred design approach to understand, train, 10. Goel S, Tank R, Singh A, Khichi SK, Bypareddy R, Goyal P, et al. Are doctor’s monitor and report hand hygiene. J Hosp Infect. 2007;67(1):9–21. hands contributing in spreading nosocomial pathogens? Rapid appraisal 30. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching from a tertiary care health center of Northern India. Int J Res Med Sci. 2017; hospital. Infection Control Program. Ann Intern Med. 1999;130(2):126–30. 4(6):1978–82. 31. World Health Organization. Hand hygiene technical reference manual. 11. Gould DJ, Drey NS, Moralejo D, Grimshaw J, Chudleigh J. Interventions to Geneva 2009. Available at: http://www.who.int/gpsc/5may/tools/evaluation_ improve hand hygiene compliance in patient care. J Hosp Infect. 2008;68(3): feedback/en/index.html (Accessed 17 Oct 2018). 193–202. 32. Mu X, Xu Y, Yang T, Zhang J, Wang C, Liu W, et al. Improving hand hygiene 12. Karabey S, Ay P, Derbentli S, Nakipoglu Y, Esen F. Handwashing frequencies compliance among healthcare workers: an intervention study in a Hospital in an intensive care unit. J Hosp Infect. 2002;50(1):36–41. in Guizhou Province. China. Braz J Infect Dis Off Publ Braz Soc Infect Dis. 2016;20(5):413–8. 13. Amazian K, Abdelmoumène T, Sekkat S, Terzaki S, Njah M, Dhidah L, et al. Multicentre study on hand hygiene facilities and practice in the 33. Salama MF, Jamal WY, Mousa HA, Al-Abdulghani KA, Rotimi VO. The effect Mediterranean area: results from the NosoMed Network. J Hosp Infect. 2006; of hand hygiene compliance on hospital-acquired infections in an ICU 62(3):311–8. setting in a Kuwaiti teaching hospital. J Infect Public Health. 2013;6(1):27–34. 14. World Health Organization. Patient safety, a world alliance for safer health care. 34. Abela N, Borg MA. Impact on hand hygiene compliance following Suggested key messages to use. Available at: http://www.who.int/gpsc/5may/ migration to a new hospital with improved resources and the sequential resources/slcyh_briefing-kit_key-messages.pdf?ua=1 (Accessed 15 Oct 2018). introduction of World Health Organization recommendations. Am J Infect 15. Pittet D, Allegranzi B, Storr J. The WHO Clean Care is Safer Care programme: Control. 2012;40(8):737–41. field-testing to enhance sustainability and spread of hand hygiene 35. von Lengerke T, Lutze B, Krauth C, Lange K, Stahmeyer JT, Chaberny IF. improvements. J Infect Public Health. 2008;1(1):4–10. Promoting hand hygiene compliance. Dtsch Arzteblatt Int. 2017;114(3):29–36. 16. Pfäfflin F, Tufa TB, Getachew M, Nigussie T, Schönfeld A, Häussinger D, et al. 36. Ye L-P, Zhang X-P, Lai X-Q. Does hospital ownership influence hand Implementation of the WHO multimodal hand hygiene improvement hygiene compliance? J Huazhong Univ Sci Technol Med Sci Hua Zhong Ke strategy in a University Hospital in Central Ethiopia. Antimicrob Resist Infect Ji Xue Xue Bao Yi Xue Ying Wen Ban Huazhong Keji Daxue Xuebao Yixue Yingdewen Ban. 2017;37(5):787–94. Control. 2017;6:3. 17. Santosaningsih D, Erikawati D, Santoso S, Noorhamdani N, Ratridewi I, 37. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Candradikusuma D, et al. Intervening with healthcare workers’ hand Effectiveness of a hospital-wide programme to improve compliance with hygiene compliance, knowledge, and perception in a limited-resource hand hygiene. Infection Control Programme. Lancet Lond Engl. 2000; hospital in Indonesia: a randomized controlled trial study. Antimicrob Resist 356(9238):1307–12. Infect Control. 2017;6:23. 38. Lam BCC, Lee J, Lau YL. Hand hygiene practices in a neonatal intensive care 18. Farhoudi F, Sanaei Dashti A, Hoshangi Davani M, Ghalebi N, Sajadi G, unit: a multimodal intervention and impact on nosocomial infection. Taghizadeh R. Impact of WHO hand hygiene improvement program Pediatrics. 2004;114(5):e565–71. implementation: a quasi-experimental trial. BioMed Res Int. 2016;2016: 39. Donowitz LG. Handwashing technique in a pediatric intensive care unit. Am 7026169. J Dis Child 1960. 1987;141(6):683–5. 19. Lee SS, Park SJ, Chung MJ, Lee JH, Kang HJ, Lee J, et al. Improved hand 40. Squires JE, Linklater S, Grimshaw JM, Graham ID, Sullivan K, Bruce N, et al. hygiene compliance is associated with the change of perception toward hand Understanding practice: factors that influence physician hand hygiene hygiene among medical personnel. Infect Chemother. 2014;46(3):165–71. compliance. Infect Control Amp Hosp Epidemiol. 2014;35(12):1511–20. 20. Mahfouz AA, Al-Zaydani IA, Abdelaziz AO, El-Gamal MN, Assiri AM. Changes 41. Larson E, Killien M. Factors influencing handwashing behavior of patient in hand hygiene compliance after a multimodal intervention among health- care personnel. Am J Infect Control. 1982;10(3):93–9. care workers from intensive care units in Southwestern Saudi Arabia. J 42. Smiddy MP, O’ Connell R, Creedon SA. Systematic qualitative literature Epidemiol Glob Health. 2014;4(4):315–21. review of health care workers’ compliance with hand hygiene guidelines. 21. Mestre G, Berbel C, Tortajada P, Alarcia M, Coca R, Gallemi G, et al. “The 3/3 Am J Infect Control. 2015;43(3):269–74. strategy”: a successful multifaceted hospital wide hand hygiene intervention 43. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. based on WHO and continuous quality improvement methodology. PLoS Hand hygiene among physicians: performance, beliefs, and perceptions. ONE. 2012;7(10):e47200. Ann Intern Med. 2004;141(1):1–8. 22. Monistrol O, Calbo E, Riera M, Nicolás C, Font R, Freixas N, et al. Impact of a 44. Erasmus V, Brouwer W, van Beeck EF, Oenema A, Daha TJ, Richardus JH, hand hygiene educational programme on hospital-acquired infections in et al. A qualitative exploration of reasons for poor hand hygiene among medical wards. Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect hospital workers: lack of positive role models and of convincing evidence Dis. 2012;18(12):1212–8. that hand hygiene prevents cross-infection. Infect Control Hosp Epidemiol. 23. Allegranzi B, Sax H, Bengaly L, Richet H, Minta DK, Chraiti M, et al. Successful 2009;30(5):415–9. implementation of the World Health Organization hand hygiene 45. Kingston LM, Slevin BL, O’Connell NH, Dunne CP. Attitudes and practices of Irish hospital-based physicians towards hand hygiene and hand rubbing Ben Fredj et al. Journal of the Egyptian Public Health Association (2020) 95:11 Page 8 of 8 using alcohol-based hand rub: a comparison between 2007 and 2015. J Hosp Infect. 2017;97(1):17–25. 46. Lankford MG, Zembower TR, Trick WE, Hacek DM, Noskin GA, Peterson LR. Influence of role models and hospital design on the hand hygiene of health-care workers. Emerg Infect Dis. 2003;9(2):217–23. 47. Larson EL, Early E, Cloonan P, Sugrue S, Parides M. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med Wash DC. 2000;26(1):14–22. 48. Shears P. Poverty and infection in the developing world: healthcare-related infections and infection control in the tropics. J Hosp Infect. 2007;67(3):217– 49. World Health Organization. Health system profile Tunisia. Regional office for the Eastern Mediterranean, WHO 2006. Availble at: http://apps.who.int/ medicinedocs/documents/s17312e/s17312e.pdf (Accessed 28 Oct 2017). 50. Dorsey ST, Cydulka RK, Emerman CL. Is handwashing teachable?: failure to improve handwashing behavior in an urban emergency department. Acad Emerg Med Off J Soc Acad Emerg Med. 1996;3(4):360–5.. 51. Muto CA, Sistrom MG, Farr BM. Hand hygiene rates unaffected by installation of dispensers of a rapidly acting hand antiseptic. Am J Infect Control. 2000;28(3):273–6. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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