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Effectiveness over time of a multimodal intervention to improve compliance with standard hygiene precautions in an intensive care unit of a large teaching hospital

Effectiveness over time of a multimodal intervention to improve compliance with standard hygiene... Background: Standard hygiene precautions are an effective way of controlling healthcare-associated infections. Nevertheless, compliance with hand hygiene (HH) guidelines among healthcare workers (HCWs) is often poor, and evidence regarding appropriate use of gloves and gowns is limited and not encouraging. In this study, we evaluated the ability over time of a multimodal intervention to improve HCWs compliance with standard hygiene precautions. Methods: Trend analysis of direct observations of compliance with HH guidelines and proper glove or gown use was conducted in the medical/surgical intensive care unit (ICU) of Umberto I Teaching Hospital of Sapienza University of Rome. The study consisted of two phases: a six-month baseline phase and a 12-month post-intervention phase. The multimodal intervention was based on the World Health Organization strategy and included education and training of HCWs, together with performance feedback. Results: A total of 12,853 observations were collected from November 2016 to April 2018. Overall compliance significantly improved from 41.9% at baseline to 62.1% (p < 0.001) after the intervention and this improvement was sustained over the following trimesters. Despite variability across job categories and over the study period, a similar trend was observed for most investigations. The main determinants of compliance were job category (with nurses having the highest compliance rates), being a member of ICU staff and whether delivering routine, as opposed to emergency, care. HH compliance was modified by glove use; unnecessary gloving negatively affected HH behaviour while appropriate gloving positively influenced it. Conclusions: The multimodal intervention resulted in a significant improvement in compliance with standard hygiene precautions. However, regular educational reinforcement and feedback is essential to maintain a high and uniform level of compliance. Keywords: Compliance, Standard hygiene precautions, WHO multimodal strategy, Infection control * Correspondence: valentina.baccolini@uniroma1.it Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 2 of 10 Introduction training on standard hygiene precautions guidelines, but it Adherence to standard hygiene precautions leads to a re- is difficult for them to observe the HCWs without being duction in infection rates healthcare-associated infections noticed, resulting in a marked Hawthorne effect. On the (HAIs) [1, 2], representing the most effective way of other hand, enrolling staff ward promotes widespread preventing cross-transmission of microorganisms [3, 4]. acceptance and participation in the activities to improve Several economic evaluations show that the promotion of compliance, even though they might be not completely hand hygiene (HH) is a cost-effective intervention, par- reliable in rating their colleagues. Therefore, to minimize ticularly in intensive care unit (ICU) settings [5–7]. the Hawthorne effect and to increase staff engagement, However, healthcare worker (HCW) compliance with we selected as observers the two physicians and three standard hygiene precautions remains a longstanding nurses of the ICU that take part in the active surveillance challenge. In fact, several studies have highlighted the fact of HAIs that has been carried out in the ICU in collabor- that relatively few HCWs follow correct HH procedures ation with the Hospital Hygiene Unit of the Umberto I [3, 8], while data on the appropriate use of gloves are more Teaching Hospital since May 2016. In October 2016, at limited but not encouraging [9]. The World Health the beginning of the study, they were trained to perform Organization (WHO) has develop an evidence-based covert observations of compliance with HH guidelines guideline; key for systematic adherence to standard hy- and proper glove or gown use. The training consisted of a giene precautions is education and training of all HCWs, two-hour session that included a lecture and an open dis- coupled with staff evaluation and performance feedback cussion of the contents of the WHO Hand Hygiene Tech- [4, 10–12]. Moreover, direct observation is recommended nical Reference Manual (21) and it was conducted by the as the gold standard for monitoring HCW compliance resident physicians of the Department of Public Health [13]. Although successful, such WHO strategy has proved and Infectious Diseases of Sapienza University of Rome. that adherence to good practice varies according to the For the following two weeks, between 17th and 30th country, local setting, habit, culture and availability of October 2016, the observers were asked to test the usability resources [14]. In the Italian context, only a few studies of an observation form specifically developed to collect have investigated compliance with HH guidelines [15–17], data on compliance with standard hygiene precautions and while a similar number have analyzed changes after educa- based on the “My Five Moments for Hand Hygiene” ap- tional interventions [14, 18, 19]. Moreover, data on adher- proach [21]. Finally, they were invited to discuss together ence to standard hygiene precautions, which relate to with the trainers the registered observations on 31st Octo- both HH and glove or gown use, are scarce [15]. Further- ber 2016 to compare their data and make as uniform as more, a detailed long-term assessment of improvements possible their observation strategy. in practice after education is lacking. From 1st November 2016 to 30th April 2018, the five The purpose of this study is to evaluate the impact of a observers officially monitored their colleagues during daily multimodal intervention aimed at improving HCW adher- care activities and collected data using the aforementioned ence to standard hygiene precautions with an assessment anonymous observation form. The check-sheet focused of its effectiveness over time. We tested the hypothesis on four possible types of interaction between HCWs and that focusing on the essential features of HAIs, discussing patients: ‘touching a patient’, ‘device manipulation’, ‘touch- local evidence of microbial cross-contamination and pro- ing patient surroundings’ and ‘invasive procedure or body viding HCWs with education and training on correct pro- fluid exposure’. For each type of interaction, the WHO cedures of hand hygiene and proper glove or gown use guidelines specifically recommend HH practice both be- could lead to a substantial behavioural improvement. fore and afterwards, except for ‘before touching patient surroundings’ that, although it is not strictly mentioned by Methods the WHO, it was included as a relevant opportunity for Setting HH. Additionally, the observers were asked to record The study was conducted in the medical/surgical ICU of glove use during each interaction. For ‘invasive procedure the Umberto I hospital, Sapienza University of Rome, a or body fluid exposure’, they also monitored disposable 1200-bed public hospital. The ICU is divided into five gown wearing. As a result, a total of thirteen different rooms of two beds each, one large seven-bed room and recommendations for standard hygiene precautions were one room for isolation. The ward staff consists of twenty- investigated; eight related to HH, four to proper glove use eight physicians, forty nurses and four healthcare assistants. and one to gown use. Both the use of alcohol hand rub and handwashing were part of the HH protocol. Observation strategy The anonymous form also required the following informa- There are several advantages and disadvantages in deter- tion: date, day of the week, work shift, observed HCW job mining who will conduct the observations [20]. On the category, observed HCW gender, context of delivered care one hand, using infection preventionists require minimum and type of ICU staff. The HCW job categories included Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 3 of 10 physician, nurse, healthcare assistant and other HCW cat- test was used to compare the average compliance rate in egories (i.e. medical student, technician, therapist). each trimester with respect to the first trimester. A join- Throughout the whole study period, the HCWs were point regression was performed to identify time periods aware that they were being observed for compliance with with statistically distinct trends (monthly percent change, standard hygiene precautions, but they were not told who MPC) in the overall compliance rate over the study period the observers were or when the observations took place. using the Join-point Regression Program, Version 4.6.0.0, TherateofcompliancewithHHguidelines was National Cancer Institute. The χ test was also used to measured as the number of HH actions appropriately compare ‘before’ and ‘after’ indications for HH and to performed against the total number of opportunities to do compare HH compliance before and after gloving. Finally, so. Since WHO recommends not to use personal protective in the univariate analysis, the χ test was used to assess equipment (such as gloves and gowns) in absence of poten- possible associations between variables and the overall tial exposure to blood or body fluids [3], glove nonuse was compliance, compliance with HH guidelines and compli- deemed appropriate during ‘touching a patient’ and ‘touch- ance with proper glove or gown use. ing patient surroundings,’ in contrast to ‘device manipula- Multiple logistic regression models were built to iden- tion’ and ‘invasive procedure or body fluid exposure’ where tify factors independently associated with the overall glove use was considered appropriate. Similarly, disposable compliance (Model 1), HH compliance (Model 2) and gown wearing ‘during invasive procedure or body fluid compliance with proper glove or gown use (Model 3). exposure’ was considered correct. Variables were included in the models when the p-value The study protocol was approved by the Ethics Commit- of the univariate analysis was lower than 0.25 or when tee of the Umberto I Teaching Hospital (reference number: they were considered relevant to the outcome. As a 4707/2017). result, the following variables were used to build the three models: trimester; day of the week; work shift; Study design and intervention observed HCW job category; observed HCW gender; The study was made up of two distinct phases; a six-month type of ICU staff; context of delivered care. In Model 2, baseline phase and a 12-month post-intervention phase. the variable indication type (before/after patient contact) From 1st May to 15th May 2017, five identical educational was also included. Interaction terms were tested using a interventions were conducted with the ICU staff to allow significance level cut-off of 0.15. Adjusted OR and 95% all HCWs to take part. During these two-hour sessions, confidence intervals (CIs) were calculated. education and training consisted of a lecture on the defin- All statistical analyses were performed with STATA 15 ition, impact and burden of HAIs, with the first part focus- (StataCorp LLC, 4905 Lakeway Drive, College Station, ing on major patterns of pathogentransmission andonthe Texas, USA). A p-value less than 0.05 was considered critical role of good HH practice and proper glove and statistically significant. gown use in reducing infection rates. The second part of each session presented the results of an active surveillance Results of HAIs performed during the previous year, giving some Characteristics of recorded observations evidence of clonal transmission and environmental isola- Over the 18-month study period, a total of 12,853 obser- tion of some microorganisms (Acinetobacter baumannii, vations were collected with a mean of 2142 observations Klebsiella pneumoniae). In the final part of each session, a per trimester; of these, 3854 were recorded during the targeted feedback on the results of the first six months of baseline phase and 8999 during the post-intervention this survey was provided to the healthcare personnel to phase [see Additional file 1: Table S1]. reinforce good practice and specifically address the most Observations of compliance with HH procedures critical noncompliance rates. Lastly, since the WHO multi- accounted for 61.5% of the total with 7908 registered obser- modal strategy outlines the importance of actively engaging vations. The four types of interaction were similarly repre- HCWs in HH campaigns [4], we encouraged the ICU staff sented, with ‘touching a patient’ the most frequently to positively provide peer feedback to their colleagues and observed (16.5%, 2115 opportunities) and ‘device manipula- motivate them during care activities in order to facilitate tion’ the least frequently observed (14.1%, 1810 opportun- awareness-raising about patient safety issues and promote a ities). ‘Touching patient surroundings’ and ‘invasive long-lasting behavioural change. procedure or body fluid exposure’ accounted for 15.6 and 15.4%, respectively. By contrast, observations of compliance Statistical analysis with proper glove use accounted for 30.8% of the total ob- Observations of compliance with HH guidelines and servations, whereas only 7.7% were of gown use [Additional proper glove or gown use were grouped into six trimesters file 1:Table S1]. (two at baseline, four in the post-intervention phase). De- The observed staff were largely nursing personnel with scriptive statistics for all variables were calculated. The χ 7984 registered observations, accounting for 62.1% of the Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 4 of 10 total; physicians were observed in 4469 cases (34.7%), procedure or body fluid exposure’ remained steadily high while only a small number of observations concerned over time. Proper use of gloves ‘during device manipula- other categories of HCW (2.8%). The observed HCWs tion’ significantly improved until a decrease started in the were mainly female (63.2%) and members of the ICU staff fourth trimester. By contrast, proper nonuse of gloves (88.7%). Most observations were recorded during morning while ‘touching a patient’ registered low compliance rates shifts (41.3%), followed by afternoon and night shifts (32.8 throughout the whole study period without showing a and 25.6%, respectively). Almost three-quarters of the significant improvement. Proper glove nonuse while observations were performed during week days (73.9%) ‘touching patient surroundings’ recorded a significant and the vast majority of observations were of routine care decrease after the intervention and gradually increased (88.1%) [Additional file 1: Table S1]. subsequently, with the proper nonuse rates of the last two trimesters significantly higher than baseline. Lastly, proper Overall compliance with HH guidelines and proper glove wearing of gowns ‘during invasive procedure or body fluid or gown use exposure’ significantly increased after the intervention and After the intervention, the overall compliance rate signifi- this improvement was maintained over time. cantly improved from 41.9% at baseline (first trimester) to 62.1% in the third trimester (p < 0.001). This result was Determinants of compliance maintained during the following three trimesters with an Univariate comparisons revealed no statistically significant overall compliance rate of 69.0, 66.0 and 63.5% (all compar- differences in the overall compliance rate among shifts isons with the first trimester p < 0.05). Comparing the first (morning: 59.7%, afternoon: 59.9%, night: 58.6%, p =0.47), two trimesters at baseline, the overall compliance rate sig- between weekdays and weekend days (59.4% versus 58.1%, nificantly increased from 41.9 to 46.8% (p =0.004), mostly p = 0.25) and between male and female HCWs (59.1% ver- due to the statistically significant increase in proper glove sus 59.7%, p = 0.48). A statistically significant higher over- or gown use (56.8% versus 65.5%, p = 0.001). Over the 18 all compliance rate was found when delivering routine months, proper glove- or gown-use compliance was always care rather than emergency care (60.2% versus 52.8%, p < higher than HH compliance, both at baseline and during 0.001) and for internal ICU staff rather than staff external the post-intervention phase, with the smallest differences to the unit (60.6% versus 48.0%, p < 0.001). With regard to being in the third and fourth trimester [Fig. 1 A]. HCW job category, the overall compliance rate for physi- In the join-point regression analysis, a significant trend cians was always lower than the rate for nursing staff, both variation (MPC: 6.46, p < 0.001) in the overall compli- in the first trimester (40.2% versus 46.0%, p =0.042) and ance rate was apparent over the first 11 months, while during the first two post-intervention trimesters (54.1% the last 7-month period showed a non-significant vari- versus 67.1%; 64.9% versus 73.3%, both comparisons p < ation (MPC: − 2.10, p = 0.1) [Fig. 1 B]. 0.05), but in the last two trimesters the difference was no longer significant (66.2% versus 66.8%, p = 0.76; 62.9% ver- Compliance with HH guidelines sus 64.1%, p = 0.64). Similar results were obtained when Observations of HH practice were analyzed according to compliance with HH and proper glove- or gown-use were the four types of interaction between HCWs and patients. considered separately; in both univariate analyses, statisti- Only those instances concerning ‘touching a patient’ and cally significant higher compliance rates were found for ‘invasive procedure or body fluid exposure’ are displayed in nurses rather than physicians, being internal staff rather Fig. 2 A, showing that: i) each compliance rate significantly than external and delivering routine care rather than improved from baseline to post-intervention phase and this emergency care, while the other comparisons did not result was maintained in the following trimesters (all com- reveal significant differences (data not shown). parisons with the first trimester: p < 0.05); ii) the HH indi- Three multiple logistic regression models were built in cations before approaching patients (i.e. before ‘touching a order to better investigate the determinants of the overall patient’ and before ‘invasive procedure or body fluid expos- compliance (Model 1), compliance with HH guidelines ure’) registered lower compliance rates both at baseline (Model 2) and compliance with proper glove or gown use and during the post-intervention phase compared to the (Model 3) [Table 1]. HH indications after approaching patients (all compari- In the first model, the overall compliance significantly in- sons: p < 0.05). Similar results were obtained for the inter- creased after the first trimester, with the highest OR in the action categories ‘touching patient surroundings’ and fourth (p < 0.001). Overall compliance was also positively ‘device manipulation’ (data not shown). associated with being a nurse rather than a physician (p < 0.001), being an internal staff member rather than external Compliance with proper glove or gown use (p < 0.001) and when delivering routine care rather than Compliance with proper glove or gown use was analyzed emergency care (p < 0.001). By contrast, being a healthcare by category [Fig. 2 B]. Proper glove use ‘during invasive assistant or another HCW job category was negatively Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 5 of 10 Fig. 1 Compliance with standard hygiene precautions over the study period in the intensive care unit of Umberto I Teaching Hospital of Sapienza University of Rome. Results are shown in terms of overall compliance, compliance with hand hygiene (HH) guidelines and compliance with proper glove or gown use over six trimesters (a) and in terms of overall compliance in the joinpoint regression (b) associated with the outcome (both p < 0.001). Finally, day Model 3, the results were comparable with the first model of the week, work shift and observed HCW gender did not with a few exceptions: being an internal staff member or show a significant association with the overall compliance. another HCW job category did not correlate with proper Similar associations were found in the second and third glove or gown use, while working during morning shifts model. In Model 2, multivariate analysis confirmed the re- was negatively associated with compliance [Table 1]. sults of Model 1 with the exception of work shift, where HH compliance was modified by glove use. In par- working at night negatively affected compliance with HH ticular, unnecessary gloving negatively affected HH guidelines (p = 0.006). Additionally, HH indications after behaviour while appropriate gloving positively influ- patient contact were found to be the strongest determi- enced it. Indeed, both before and after approaching nants of the outcome (OR: 5.43, 95%CI: 4.86–6.08). In patients, HH compliance rates were significantly lower Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 6 of 10 Fig. 2 Compliance with standard hygiene precautions over the study period in the intensive care unit of Umberto I Teaching Hospital of Sapienza University of Rome. Results are shown in terms of compliance with hand hygiene guidelines over six trimesters by interaction type (a) and in terms of compliance with proper glove or gown use over six trimesters by category (b) when HCWs wore gloves incorrectly for ‘touching a Discussion patient’ and ‘touching patient surroundings’ (all com- This study consisted of two phases, a baseline phase and a parisons: p <0.05). By contrast, HH compliance rates post-intervention phase, during which direct observations before and after necessary gloving were significantly of compliance with standard hygiene precautions were re- higher both during ‘device manipulation’ and ‘invasive corded. The implementation of a multimodal intervention procedure or body fluid exposure’ if HCWs wore led to a significant compliance improvement across all gloves (all comparisons: p < 0.05) [see Additional file types of HH indications and most glove- or gown-use ob- 1:Table S2]. servations, with a mean compliance increase comparable Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 7 of 10 Table 1 Logistic regression models regarding overall compliance (Model 1), compliance with hand hygiene (HH) procedures (Model 2) and compliance with proper glove or gown use (Model 3) over the study period in the Intensive Care Unit (ICU) of the Umberto I Teaching Hospital of Sapienza University of Rome Model 1 Overall compliance P value Model 2 HH compliance P value Model 3 Proper glove or P value OR (95%CI) gown use compliance OR (95%CI) OR (95%CI) Trimester First trimester Ref. Ref. Ref. Second trimester 1.17 (1.02–1.35) 0.029 1.12 (0.91–1.37) 0.282 1.34 (1.07–1.69) 0.012 Third trimester 2.29 (1.94–2.70) < 0.001 4.03 (3.18–5.10) < 0.001 1.41 (1.08–1.84) 0.013 Fourth trimester 2.92 (2.52–3.39) < 0.001 4.38 (3.55–5.41) < 0.001 2.39 (1.87–3.05) < 0.001 Fifth trimester 2.32 (2.00–2.68) < 0.001 3.21 (2.62–3.94) < 0.001 1.99 (1.57–2.54) < 0.001 Sixth trimester 2.08 (1.78–2.43) < 0.001 2.53 (2.03–3.15) < 0.001 2.13 (1.63–2.76) < 0.001 Day Week day Ref. Ref. Ref. Weekend day 1.10 (0.99–1.22) 0.064 1.13 (0.98–1.30) 0.106 1.10 (0.92–1.32) 0.282 Work shift Morning Ref. Ref. Ref. Afternoon 1.07 (0.97–1.17) 0.184 0.95 (0.83–1.08) 0.400 1.32 (1.12–1.55) 0.001 Night 0.93 (0.84–1.03) 0.144 0.82 (0.72–0.95) 0.006 1.08 (0.91–1.29) 0.354 Observed healthcare worker (HCW) job category Physician Ref. Ref. Ref. Nurse 1.23 (1.12–1.34) < 0.001 1.18 (1.04–1.33) 0.008 1.38 (1.19–1.60) < 0.001 Healthcare assistant 0.18 (0.12–0.26) < 0.001 0.09 (0.05–0.15) < 0.001 0.26 (0.16–0.45) < 0.001 Other 0.36 (0.24–0.52) < 0.001 0.19 (0.11–0.35) < 0.001 0.57 (0.31–1.06) 0.076 Observed HCW gender Female Ref. Ref. Ref. Male 0.99 (0.92–1.08) 0.944 0.96 (0.86–1.07) 0.496 1.05 (0.91–1.21) 0.521 Observed ICU staff External Ref. Ref. Ref. Internal 1.61 (1.39–1.87) < 0.001 2.55 (2.05–3.18) < 0.001 1.14 (0.89–1.45) 0.289 Observed care context Emergency care Ref. Ref. Ref. Routine care 1.64 (1.42–1.88) < 0.001 2.17 (1.77–2.65) < 0.001 1.38 (1.10–1.74) 0.006 Indication type Before patient contact – Ref. – After patient contact – 5.43 (4.86–6.08) < 0.001 – Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 8 of 10 with other post-intervention studies [22]. In line with adherence gradually peaked after the intervention, com- other findings [23, 24], compliance with most recommen- pliance with HH practices ‘before invasive procedure or dations reached a peak after which performance began to body fluid exposure’ decreased immediately after the decline. This highlights the difficulty in maintaining a high third trimester; as shown in other studies [9, 32], this rate of adherence to recommended practice over time and drop may be due to the hard to change wrong percep- the importance of providing educational reinforcement tion that HH is not necessary prior to wearing gloves. and performance feedback to HCWs so that improve- With regard to gloves or gown recommendations, we ments can be sustained [25]. In most cases, decreases in observed that compliance with their proper use was compliance began between the fourth and sixth trimester, greater than compliance with HH indications, as reported suggesting that repeating the intervention within twelve by Pan et al. [15]. Furthermore, in the investigations where months of the first implementation could maximize its ef- gloving or gowning was required, the intervention was ef- fectiveness over time, as proposed by van de Mortel et al. fective in significantly improving such compliance rates, [26]. Interestingly, we also observed a statistically signifi- except for ‘glove use during invasive procedure or body cant compliance increment in the second trimester of the fluid exposure’ where HCWs were already compliant at baseline phase, which is probably due to the observer baseline. By contrast, for those interactions where gloving effect, while the improvement in the second trimester of was unnecessary, the intervention did not bring about a the post-intervention phase might be due to a combin- significant steady increase in appropriate use. Actually, we ation of peer monitoring and peer feedback. As shown in registered an inappropriate glove overuse both for ‘while other studies [27, 28], such increase may confirm that touching patient surroundings’ and ‘while touching a pa- approaches creating an environment that promote and tient’ immediately after the intervention, which probably motivate HCWs to change can contribute to a more means that the educational sessions were not effective in effective and lasting improvement in compliance. addressing the correct indications for glove use and Compliance varied across professional categories and in HCWs have preferred gloving, even if unnecessary. relation to several factors. Nurses started with and Notably, the impact of wearing gloves on adherence to achieved the highest level of compliance, both in general HH guidelines was twofold. On the one hand, although and with HH recommendations, as reported by the vast glove use is not a substitute for HH [3], inappropriate majority of other studies [8, 25, 29]. Physician compliance glove use adversely affected HH compliance. This may be was always lower than that of nursing staff but registered due to the erroneous belief that glove use alone is suffi- a greater increase after the intervention. Conversely, cient to limit the spread of microorganisms and therefore healthcare assistants and other HCW categories were as- it obviated the need for good HH practice. On the other sociated with lower compliance rates. hand, proper glove use was positively associated with hand Other factors appeared to negatively affect compliance, disinfection as shown in other studies [9, 15]. Therefore, including being external to the ICU and delivering care since inappropriate glove overuse might contribute to during emergency situations, the latter of which is probably poor HH compliance, further HCW education of proper due to the fact that HH in these situations is perceived as a glove use is required. Particularly, customized training waste of time [30]. Factors such as day of the week and courses focusing on the consequences of unnecessary use gender of the observed HCW did not influence the compli- of gloves will be scheduled with the HCWs in order to ance rates. Notably, the negative impact of working at night promote their correct use and investigate the behavioural on HH compliance and the adverse association between determinants of inappropriate overuse. working during morning shifts and compliance with proper Despite the significant improvements reported, HH glove or gown use may be related to either the observer compliance rates did not reach a uniform and optimal effect or peer monitoring and feedback. Particularly, they level of adherence. As indicated by previous studies [33– may have been less emphasized during night shifts, result- 35], to interrupt cross-transmission of microorganisms in ing in a significant decrease in HH compliance, and over- settings at high risk of infection, good HH practice needs represented during daily activities, when they led to an to be performed in at least 60–80% of the situations where inappropriate overuse of personal equipment. For these it is required. The heterogeneity we observed in compli- reasons, other training sessions will be conducted with the ance rates (either over time, or between staff) might be re- HCWs to further address the correct indications for com- sponsible for the lack of significant reduction in HAIs pliance with both HH and proper glove or gown use. after the intervention, as registered by the ICU surveil- For each HH indication, compliance significantly in- lance system. In fact, incidence rates of device-related in- creased after the intervention, but compliance remained fections remained higher than the 90th percentile (as highest for interactions that took place after approaching defined in the National Healthcare Safety Network report patients rather than before, in line with other studies [8, [36]) throughout the study period, in line with other Ital- 25, 31]. Interestingly, while for most investigations HH ian incidence rates [37], without a clearly decreasing trend Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 9 of 10 and with some evidence of clonal transmission of micro- of the Umberto I Teaching Hospital of Sapienza University of Rome. organisms (data not shown). Therefore, since no other Table S2. Compliance with hand hygiene (HH) procedures by indication in relation to glove use over the study period in the intensive care unit change or intervention was registered in the ICU over the of the Umberto I Teaching Hospital of Sapienza University of Rome. 18 months, we believe that the mean HH compliance rate (DOCX 25 kb) of 61.6% that we found suggests the need to further imple- ment effective measures in order to achieve higher com- Abbreviations pliance rates and obtain clinical benefits such as a HAI: Healthcare associated infection; HCW: Healthcare worker; HH: Hand hygiene; ICU: Intensive care unit; WHO: World Health Organization reduction in HAIs. This study has some strengths and limitations. The main Acknowledgments strength is the comprehensive evaluation of adherence to We wish to thank all the staff of the medical/surgical intensive care unit of Umberto I Teaching Hospital of Sapienza University of Rome who took part standard hygiene precautions and the changes in compli- in this study. ance rates over the ensuing trimesters. We also distin- guished HH indications according to the type of interaction Authors’ contributions VB: This author conceived and designed the study, participated in data between HCWs and patients. Additionally, we were able to collection, performed the data analysis, interpreted the data, wrote the correlate compliance rates with incidence of HAIs in the manuscript and has approved the publication of this version. She is same ICU over time. The limitations of our research are accountable for the accuracy and integrity of the work. VDE: This author participated in the study design and data collection. She has approved the mostly duetothe useofdirectobservation to monitor publication of this version. PDS: This author participated in the study design HCW behaviour. Even though HCWs did not know who and data collection. He has approved the publication of this version. GM: the observers were and which practices were recorded, This author participated in the data collection, analysis and interpretation. He has approved the publication of this version. AM: This author participated in compliance data may be influenced by the observer effect. the data collection and analysis. She has approved the publication of this Moreover, enrolling HCWs from the ICU to collect data version. FA: This author participated in the data collection. He has approved and perform the observations might have made them in- the publication of this version. GT: This author participated in the data collection. He has approved the publication of this version. CM: This author clined to rate their coworkers differently than outside ob- participated in the study design and data collection. She has approved the servers would. Differences among observers might also publication of this version. CDV: This author participated in the data analysis have affected accuracy. However, the impact of these biases and interpretation, and manuscript editing. He has approved the publication of this version. MVR: This author participated in the study design, data was probably limited by the large number of observations interpretation and manuscript editing. He has approved the publication of over time and the random selection of practices, as recom- this version. PV: This author participated in the study design, data mended by the WHO [3]. Lastly, sincewedid notassign interpretation and manuscript editing. He has approved the publication of this version. All authors read and approved the final manuscript. unique identifiers to each HCW, we could not compare compliance before and after theinterventionatanindivid- Funding ual level. Such a comparison could be an interesting area No funding was received for this study. for future investigations to further study individual predic- Availability of data and materials tors and factors that contribute to compliance. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Conclusions Ethics approval and consent to participate Despite variability across HCW job categories and types The study protocol was reviewed and approved by the Ethics Committee of of recommendation, the multimodal intervention was ef- the Umberto I Teaching Hospital; reference number 4707/2017. fective in improving compliance with standard hygiene Consent for publication precautions over time. However, since in the vast majority Not applicable. of the investigations the compliance started to decline be- tween six and twelve months after the educational inter- Competing interests The authors declare that they have no competing interests. vention, providing a tailored reinforcement of indications and procedures for good HH practice within one year Author details after its first implementation is advisable to achieve and Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy. Department of maintain a uniform and high level of adherence. Addition- Anesthesiology and Critical Care, Policlinico Umberto I, Sapienza University of ally, given that glove use seemed to significantly influence Rome, Rome, Italy. Anesthesia and Intensive Care Medicine, Policlinico di compliance with HH practices, promoting strategies to re- Sant’Orsola, Alma Mater Studiorum University of Bologna, Bologna, Italy. duce misuse and overuse of gloves are needed. Received: 13 March 2019 Accepted: 20 May 2019 Additional file References 1. Trick WE, Vernon MO, Welbel SF, DeMarais P, Hayden MK, Weinstein RA. Additional file 1: Table S1. Characteristics of recorded observations Multicenter intervention program to increase adherence to hand hygiene over the study period concerning compliance with hand hygiene (HH) recommendations and glove use and to reduce the incidence of guidelines and proper glove or gown use in the Intensive Care Unit (ICU) antimicrobial resistance. Infect Control Hosp Epidemiol. 2007;28(01):42–9. Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 10 of 10 2. World Health Organisation (WHO). Evidence of hand hygiene to reduce 25. Costers M, Viseur N, Catry B, Simon A. 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Haas JP, Larson EL. Impact of wearable alcohol gel dispensers on hand hygiene in an emergency department. Acad Emerg Med. 2008;15(4):393–6. 24. Staines A, Vanderavero P, Duvillard B, Deriaz P, Erard P, Kundig F, et al. Sustained improvement in hand hygiene compliance using a multi-modal improvement programme at a Swiss multi-site regional hospital. J Hosp Infect. 2018;100(2):176–82. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Antimicrobial Resistance & Infection Control Springer Journals

Effectiveness over time of a multimodal intervention to improve compliance with standard hygiene precautions in an intensive care unit of a large teaching hospital

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Copyright © 2019 by The Author(s).
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Biomedicine; Medical Microbiology; Drug Resistance; Infectious Diseases
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10.1186/s13756-019-0544-0
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Abstract

Background: Standard hygiene precautions are an effective way of controlling healthcare-associated infections. Nevertheless, compliance with hand hygiene (HH) guidelines among healthcare workers (HCWs) is often poor, and evidence regarding appropriate use of gloves and gowns is limited and not encouraging. In this study, we evaluated the ability over time of a multimodal intervention to improve HCWs compliance with standard hygiene precautions. Methods: Trend analysis of direct observations of compliance with HH guidelines and proper glove or gown use was conducted in the medical/surgical intensive care unit (ICU) of Umberto I Teaching Hospital of Sapienza University of Rome. The study consisted of two phases: a six-month baseline phase and a 12-month post-intervention phase. The multimodal intervention was based on the World Health Organization strategy and included education and training of HCWs, together with performance feedback. Results: A total of 12,853 observations were collected from November 2016 to April 2018. Overall compliance significantly improved from 41.9% at baseline to 62.1% (p < 0.001) after the intervention and this improvement was sustained over the following trimesters. Despite variability across job categories and over the study period, a similar trend was observed for most investigations. The main determinants of compliance were job category (with nurses having the highest compliance rates), being a member of ICU staff and whether delivering routine, as opposed to emergency, care. HH compliance was modified by glove use; unnecessary gloving negatively affected HH behaviour while appropriate gloving positively influenced it. Conclusions: The multimodal intervention resulted in a significant improvement in compliance with standard hygiene precautions. However, regular educational reinforcement and feedback is essential to maintain a high and uniform level of compliance. Keywords: Compliance, Standard hygiene precautions, WHO multimodal strategy, Infection control * Correspondence: valentina.baccolini@uniroma1.it Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 2 of 10 Introduction training on standard hygiene precautions guidelines, but it Adherence to standard hygiene precautions leads to a re- is difficult for them to observe the HCWs without being duction in infection rates healthcare-associated infections noticed, resulting in a marked Hawthorne effect. On the (HAIs) [1, 2], representing the most effective way of other hand, enrolling staff ward promotes widespread preventing cross-transmission of microorganisms [3, 4]. acceptance and participation in the activities to improve Several economic evaluations show that the promotion of compliance, even though they might be not completely hand hygiene (HH) is a cost-effective intervention, par- reliable in rating their colleagues. Therefore, to minimize ticularly in intensive care unit (ICU) settings [5–7]. the Hawthorne effect and to increase staff engagement, However, healthcare worker (HCW) compliance with we selected as observers the two physicians and three standard hygiene precautions remains a longstanding nurses of the ICU that take part in the active surveillance challenge. In fact, several studies have highlighted the fact of HAIs that has been carried out in the ICU in collabor- that relatively few HCWs follow correct HH procedures ation with the Hospital Hygiene Unit of the Umberto I [3, 8], while data on the appropriate use of gloves are more Teaching Hospital since May 2016. In October 2016, at limited but not encouraging [9]. The World Health the beginning of the study, they were trained to perform Organization (WHO) has develop an evidence-based covert observations of compliance with HH guidelines guideline; key for systematic adherence to standard hy- and proper glove or gown use. The training consisted of a giene precautions is education and training of all HCWs, two-hour session that included a lecture and an open dis- coupled with staff evaluation and performance feedback cussion of the contents of the WHO Hand Hygiene Tech- [4, 10–12]. Moreover, direct observation is recommended nical Reference Manual (21) and it was conducted by the as the gold standard for monitoring HCW compliance resident physicians of the Department of Public Health [13]. Although successful, such WHO strategy has proved and Infectious Diseases of Sapienza University of Rome. that adherence to good practice varies according to the For the following two weeks, between 17th and 30th country, local setting, habit, culture and availability of October 2016, the observers were asked to test the usability resources [14]. In the Italian context, only a few studies of an observation form specifically developed to collect have investigated compliance with HH guidelines [15–17], data on compliance with standard hygiene precautions and while a similar number have analyzed changes after educa- based on the “My Five Moments for Hand Hygiene” ap- tional interventions [14, 18, 19]. Moreover, data on adher- proach [21]. Finally, they were invited to discuss together ence to standard hygiene precautions, which relate to with the trainers the registered observations on 31st Octo- both HH and glove or gown use, are scarce [15]. Further- ber 2016 to compare their data and make as uniform as more, a detailed long-term assessment of improvements possible their observation strategy. in practice after education is lacking. From 1st November 2016 to 30th April 2018, the five The purpose of this study is to evaluate the impact of a observers officially monitored their colleagues during daily multimodal intervention aimed at improving HCW adher- care activities and collected data using the aforementioned ence to standard hygiene precautions with an assessment anonymous observation form. The check-sheet focused of its effectiveness over time. We tested the hypothesis on four possible types of interaction between HCWs and that focusing on the essential features of HAIs, discussing patients: ‘touching a patient’, ‘device manipulation’, ‘touch- local evidence of microbial cross-contamination and pro- ing patient surroundings’ and ‘invasive procedure or body viding HCWs with education and training on correct pro- fluid exposure’. For each type of interaction, the WHO cedures of hand hygiene and proper glove or gown use guidelines specifically recommend HH practice both be- could lead to a substantial behavioural improvement. fore and afterwards, except for ‘before touching patient surroundings’ that, although it is not strictly mentioned by Methods the WHO, it was included as a relevant opportunity for Setting HH. Additionally, the observers were asked to record The study was conducted in the medical/surgical ICU of glove use during each interaction. For ‘invasive procedure the Umberto I hospital, Sapienza University of Rome, a or body fluid exposure’, they also monitored disposable 1200-bed public hospital. The ICU is divided into five gown wearing. As a result, a total of thirteen different rooms of two beds each, one large seven-bed room and recommendations for standard hygiene precautions were one room for isolation. The ward staff consists of twenty- investigated; eight related to HH, four to proper glove use eight physicians, forty nurses and four healthcare assistants. and one to gown use. Both the use of alcohol hand rub and handwashing were part of the HH protocol. Observation strategy The anonymous form also required the following informa- There are several advantages and disadvantages in deter- tion: date, day of the week, work shift, observed HCW job mining who will conduct the observations [20]. On the category, observed HCW gender, context of delivered care one hand, using infection preventionists require minimum and type of ICU staff. The HCW job categories included Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 3 of 10 physician, nurse, healthcare assistant and other HCW cat- test was used to compare the average compliance rate in egories (i.e. medical student, technician, therapist). each trimester with respect to the first trimester. A join- Throughout the whole study period, the HCWs were point regression was performed to identify time periods aware that they were being observed for compliance with with statistically distinct trends (monthly percent change, standard hygiene precautions, but they were not told who MPC) in the overall compliance rate over the study period the observers were or when the observations took place. using the Join-point Regression Program, Version 4.6.0.0, TherateofcompliancewithHHguidelines was National Cancer Institute. The χ test was also used to measured as the number of HH actions appropriately compare ‘before’ and ‘after’ indications for HH and to performed against the total number of opportunities to do compare HH compliance before and after gloving. Finally, so. Since WHO recommends not to use personal protective in the univariate analysis, the χ test was used to assess equipment (such as gloves and gowns) in absence of poten- possible associations between variables and the overall tial exposure to blood or body fluids [3], glove nonuse was compliance, compliance with HH guidelines and compli- deemed appropriate during ‘touching a patient’ and ‘touch- ance with proper glove or gown use. ing patient surroundings,’ in contrast to ‘device manipula- Multiple logistic regression models were built to iden- tion’ and ‘invasive procedure or body fluid exposure’ where tify factors independently associated with the overall glove use was considered appropriate. Similarly, disposable compliance (Model 1), HH compliance (Model 2) and gown wearing ‘during invasive procedure or body fluid compliance with proper glove or gown use (Model 3). exposure’ was considered correct. Variables were included in the models when the p-value The study protocol was approved by the Ethics Commit- of the univariate analysis was lower than 0.25 or when tee of the Umberto I Teaching Hospital (reference number: they were considered relevant to the outcome. As a 4707/2017). result, the following variables were used to build the three models: trimester; day of the week; work shift; Study design and intervention observed HCW job category; observed HCW gender; The study was made up of two distinct phases; a six-month type of ICU staff; context of delivered care. In Model 2, baseline phase and a 12-month post-intervention phase. the variable indication type (before/after patient contact) From 1st May to 15th May 2017, five identical educational was also included. Interaction terms were tested using a interventions were conducted with the ICU staff to allow significance level cut-off of 0.15. Adjusted OR and 95% all HCWs to take part. During these two-hour sessions, confidence intervals (CIs) were calculated. education and training consisted of a lecture on the defin- All statistical analyses were performed with STATA 15 ition, impact and burden of HAIs, with the first part focus- (StataCorp LLC, 4905 Lakeway Drive, College Station, ing on major patterns of pathogentransmission andonthe Texas, USA). A p-value less than 0.05 was considered critical role of good HH practice and proper glove and statistically significant. gown use in reducing infection rates. The second part of each session presented the results of an active surveillance Results of HAIs performed during the previous year, giving some Characteristics of recorded observations evidence of clonal transmission and environmental isola- Over the 18-month study period, a total of 12,853 obser- tion of some microorganisms (Acinetobacter baumannii, vations were collected with a mean of 2142 observations Klebsiella pneumoniae). In the final part of each session, a per trimester; of these, 3854 were recorded during the targeted feedback on the results of the first six months of baseline phase and 8999 during the post-intervention this survey was provided to the healthcare personnel to phase [see Additional file 1: Table S1]. reinforce good practice and specifically address the most Observations of compliance with HH procedures critical noncompliance rates. Lastly, since the WHO multi- accounted for 61.5% of the total with 7908 registered obser- modal strategy outlines the importance of actively engaging vations. The four types of interaction were similarly repre- HCWs in HH campaigns [4], we encouraged the ICU staff sented, with ‘touching a patient’ the most frequently to positively provide peer feedback to their colleagues and observed (16.5%, 2115 opportunities) and ‘device manipula- motivate them during care activities in order to facilitate tion’ the least frequently observed (14.1%, 1810 opportun- awareness-raising about patient safety issues and promote a ities). ‘Touching patient surroundings’ and ‘invasive long-lasting behavioural change. procedure or body fluid exposure’ accounted for 15.6 and 15.4%, respectively. By contrast, observations of compliance Statistical analysis with proper glove use accounted for 30.8% of the total ob- Observations of compliance with HH guidelines and servations, whereas only 7.7% were of gown use [Additional proper glove or gown use were grouped into six trimesters file 1:Table S1]. (two at baseline, four in the post-intervention phase). De- The observed staff were largely nursing personnel with scriptive statistics for all variables were calculated. The χ 7984 registered observations, accounting for 62.1% of the Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 4 of 10 total; physicians were observed in 4469 cases (34.7%), procedure or body fluid exposure’ remained steadily high while only a small number of observations concerned over time. Proper use of gloves ‘during device manipula- other categories of HCW (2.8%). The observed HCWs tion’ significantly improved until a decrease started in the were mainly female (63.2%) and members of the ICU staff fourth trimester. By contrast, proper nonuse of gloves (88.7%). Most observations were recorded during morning while ‘touching a patient’ registered low compliance rates shifts (41.3%), followed by afternoon and night shifts (32.8 throughout the whole study period without showing a and 25.6%, respectively). Almost three-quarters of the significant improvement. Proper glove nonuse while observations were performed during week days (73.9%) ‘touching patient surroundings’ recorded a significant and the vast majority of observations were of routine care decrease after the intervention and gradually increased (88.1%) [Additional file 1: Table S1]. subsequently, with the proper nonuse rates of the last two trimesters significantly higher than baseline. Lastly, proper Overall compliance with HH guidelines and proper glove wearing of gowns ‘during invasive procedure or body fluid or gown use exposure’ significantly increased after the intervention and After the intervention, the overall compliance rate signifi- this improvement was maintained over time. cantly improved from 41.9% at baseline (first trimester) to 62.1% in the third trimester (p < 0.001). This result was Determinants of compliance maintained during the following three trimesters with an Univariate comparisons revealed no statistically significant overall compliance rate of 69.0, 66.0 and 63.5% (all compar- differences in the overall compliance rate among shifts isons with the first trimester p < 0.05). Comparing the first (morning: 59.7%, afternoon: 59.9%, night: 58.6%, p =0.47), two trimesters at baseline, the overall compliance rate sig- between weekdays and weekend days (59.4% versus 58.1%, nificantly increased from 41.9 to 46.8% (p =0.004), mostly p = 0.25) and between male and female HCWs (59.1% ver- due to the statistically significant increase in proper glove sus 59.7%, p = 0.48). A statistically significant higher over- or gown use (56.8% versus 65.5%, p = 0.001). Over the 18 all compliance rate was found when delivering routine months, proper glove- or gown-use compliance was always care rather than emergency care (60.2% versus 52.8%, p < higher than HH compliance, both at baseline and during 0.001) and for internal ICU staff rather than staff external the post-intervention phase, with the smallest differences to the unit (60.6% versus 48.0%, p < 0.001). With regard to being in the third and fourth trimester [Fig. 1 A]. HCW job category, the overall compliance rate for physi- In the join-point regression analysis, a significant trend cians was always lower than the rate for nursing staff, both variation (MPC: 6.46, p < 0.001) in the overall compli- in the first trimester (40.2% versus 46.0%, p =0.042) and ance rate was apparent over the first 11 months, while during the first two post-intervention trimesters (54.1% the last 7-month period showed a non-significant vari- versus 67.1%; 64.9% versus 73.3%, both comparisons p < ation (MPC: − 2.10, p = 0.1) [Fig. 1 B]. 0.05), but in the last two trimesters the difference was no longer significant (66.2% versus 66.8%, p = 0.76; 62.9% ver- Compliance with HH guidelines sus 64.1%, p = 0.64). Similar results were obtained when Observations of HH practice were analyzed according to compliance with HH and proper glove- or gown-use were the four types of interaction between HCWs and patients. considered separately; in both univariate analyses, statisti- Only those instances concerning ‘touching a patient’ and cally significant higher compliance rates were found for ‘invasive procedure or body fluid exposure’ are displayed in nurses rather than physicians, being internal staff rather Fig. 2 A, showing that: i) each compliance rate significantly than external and delivering routine care rather than improved from baseline to post-intervention phase and this emergency care, while the other comparisons did not result was maintained in the following trimesters (all com- reveal significant differences (data not shown). parisons with the first trimester: p < 0.05); ii) the HH indi- Three multiple logistic regression models were built in cations before approaching patients (i.e. before ‘touching a order to better investigate the determinants of the overall patient’ and before ‘invasive procedure or body fluid expos- compliance (Model 1), compliance with HH guidelines ure’) registered lower compliance rates both at baseline (Model 2) and compliance with proper glove or gown use and during the post-intervention phase compared to the (Model 3) [Table 1]. HH indications after approaching patients (all compari- In the first model, the overall compliance significantly in- sons: p < 0.05). Similar results were obtained for the inter- creased after the first trimester, with the highest OR in the action categories ‘touching patient surroundings’ and fourth (p < 0.001). Overall compliance was also positively ‘device manipulation’ (data not shown). associated with being a nurse rather than a physician (p < 0.001), being an internal staff member rather than external Compliance with proper glove or gown use (p < 0.001) and when delivering routine care rather than Compliance with proper glove or gown use was analyzed emergency care (p < 0.001). By contrast, being a healthcare by category [Fig. 2 B]. Proper glove use ‘during invasive assistant or another HCW job category was negatively Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 5 of 10 Fig. 1 Compliance with standard hygiene precautions over the study period in the intensive care unit of Umberto I Teaching Hospital of Sapienza University of Rome. Results are shown in terms of overall compliance, compliance with hand hygiene (HH) guidelines and compliance with proper glove or gown use over six trimesters (a) and in terms of overall compliance in the joinpoint regression (b) associated with the outcome (both p < 0.001). Finally, day Model 3, the results were comparable with the first model of the week, work shift and observed HCW gender did not with a few exceptions: being an internal staff member or show a significant association with the overall compliance. another HCW job category did not correlate with proper Similar associations were found in the second and third glove or gown use, while working during morning shifts model. In Model 2, multivariate analysis confirmed the re- was negatively associated with compliance [Table 1]. sults of Model 1 with the exception of work shift, where HH compliance was modified by glove use. In par- working at night negatively affected compliance with HH ticular, unnecessary gloving negatively affected HH guidelines (p = 0.006). Additionally, HH indications after behaviour while appropriate gloving positively influ- patient contact were found to be the strongest determi- enced it. Indeed, both before and after approaching nants of the outcome (OR: 5.43, 95%CI: 4.86–6.08). In patients, HH compliance rates were significantly lower Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 6 of 10 Fig. 2 Compliance with standard hygiene precautions over the study period in the intensive care unit of Umberto I Teaching Hospital of Sapienza University of Rome. Results are shown in terms of compliance with hand hygiene guidelines over six trimesters by interaction type (a) and in terms of compliance with proper glove or gown use over six trimesters by category (b) when HCWs wore gloves incorrectly for ‘touching a Discussion patient’ and ‘touching patient surroundings’ (all com- This study consisted of two phases, a baseline phase and a parisons: p <0.05). By contrast, HH compliance rates post-intervention phase, during which direct observations before and after necessary gloving were significantly of compliance with standard hygiene precautions were re- higher both during ‘device manipulation’ and ‘invasive corded. The implementation of a multimodal intervention procedure or body fluid exposure’ if HCWs wore led to a significant compliance improvement across all gloves (all comparisons: p < 0.05) [see Additional file types of HH indications and most glove- or gown-use ob- 1:Table S2]. servations, with a mean compliance increase comparable Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 7 of 10 Table 1 Logistic regression models regarding overall compliance (Model 1), compliance with hand hygiene (HH) procedures (Model 2) and compliance with proper glove or gown use (Model 3) over the study period in the Intensive Care Unit (ICU) of the Umberto I Teaching Hospital of Sapienza University of Rome Model 1 Overall compliance P value Model 2 HH compliance P value Model 3 Proper glove or P value OR (95%CI) gown use compliance OR (95%CI) OR (95%CI) Trimester First trimester Ref. Ref. Ref. Second trimester 1.17 (1.02–1.35) 0.029 1.12 (0.91–1.37) 0.282 1.34 (1.07–1.69) 0.012 Third trimester 2.29 (1.94–2.70) < 0.001 4.03 (3.18–5.10) < 0.001 1.41 (1.08–1.84) 0.013 Fourth trimester 2.92 (2.52–3.39) < 0.001 4.38 (3.55–5.41) < 0.001 2.39 (1.87–3.05) < 0.001 Fifth trimester 2.32 (2.00–2.68) < 0.001 3.21 (2.62–3.94) < 0.001 1.99 (1.57–2.54) < 0.001 Sixth trimester 2.08 (1.78–2.43) < 0.001 2.53 (2.03–3.15) < 0.001 2.13 (1.63–2.76) < 0.001 Day Week day Ref. Ref. Ref. Weekend day 1.10 (0.99–1.22) 0.064 1.13 (0.98–1.30) 0.106 1.10 (0.92–1.32) 0.282 Work shift Morning Ref. Ref. Ref. Afternoon 1.07 (0.97–1.17) 0.184 0.95 (0.83–1.08) 0.400 1.32 (1.12–1.55) 0.001 Night 0.93 (0.84–1.03) 0.144 0.82 (0.72–0.95) 0.006 1.08 (0.91–1.29) 0.354 Observed healthcare worker (HCW) job category Physician Ref. Ref. Ref. Nurse 1.23 (1.12–1.34) < 0.001 1.18 (1.04–1.33) 0.008 1.38 (1.19–1.60) < 0.001 Healthcare assistant 0.18 (0.12–0.26) < 0.001 0.09 (0.05–0.15) < 0.001 0.26 (0.16–0.45) < 0.001 Other 0.36 (0.24–0.52) < 0.001 0.19 (0.11–0.35) < 0.001 0.57 (0.31–1.06) 0.076 Observed HCW gender Female Ref. Ref. Ref. Male 0.99 (0.92–1.08) 0.944 0.96 (0.86–1.07) 0.496 1.05 (0.91–1.21) 0.521 Observed ICU staff External Ref. Ref. Ref. Internal 1.61 (1.39–1.87) < 0.001 2.55 (2.05–3.18) < 0.001 1.14 (0.89–1.45) 0.289 Observed care context Emergency care Ref. Ref. Ref. Routine care 1.64 (1.42–1.88) < 0.001 2.17 (1.77–2.65) < 0.001 1.38 (1.10–1.74) 0.006 Indication type Before patient contact – Ref. – After patient contact – 5.43 (4.86–6.08) < 0.001 – Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 8 of 10 with other post-intervention studies [22]. In line with adherence gradually peaked after the intervention, com- other findings [23, 24], compliance with most recommen- pliance with HH practices ‘before invasive procedure or dations reached a peak after which performance began to body fluid exposure’ decreased immediately after the decline. This highlights the difficulty in maintaining a high third trimester; as shown in other studies [9, 32], this rate of adherence to recommended practice over time and drop may be due to the hard to change wrong percep- the importance of providing educational reinforcement tion that HH is not necessary prior to wearing gloves. and performance feedback to HCWs so that improve- With regard to gloves or gown recommendations, we ments can be sustained [25]. In most cases, decreases in observed that compliance with their proper use was compliance began between the fourth and sixth trimester, greater than compliance with HH indications, as reported suggesting that repeating the intervention within twelve by Pan et al. [15]. Furthermore, in the investigations where months of the first implementation could maximize its ef- gloving or gowning was required, the intervention was ef- fectiveness over time, as proposed by van de Mortel et al. fective in significantly improving such compliance rates, [26]. Interestingly, we also observed a statistically signifi- except for ‘glove use during invasive procedure or body cant compliance increment in the second trimester of the fluid exposure’ where HCWs were already compliant at baseline phase, which is probably due to the observer baseline. By contrast, for those interactions where gloving effect, while the improvement in the second trimester of was unnecessary, the intervention did not bring about a the post-intervention phase might be due to a combin- significant steady increase in appropriate use. Actually, we ation of peer monitoring and peer feedback. As shown in registered an inappropriate glove overuse both for ‘while other studies [27, 28], such increase may confirm that touching patient surroundings’ and ‘while touching a pa- approaches creating an environment that promote and tient’ immediately after the intervention, which probably motivate HCWs to change can contribute to a more means that the educational sessions were not effective in effective and lasting improvement in compliance. addressing the correct indications for glove use and Compliance varied across professional categories and in HCWs have preferred gloving, even if unnecessary. relation to several factors. Nurses started with and Notably, the impact of wearing gloves on adherence to achieved the highest level of compliance, both in general HH guidelines was twofold. On the one hand, although and with HH recommendations, as reported by the vast glove use is not a substitute for HH [3], inappropriate majority of other studies [8, 25, 29]. Physician compliance glove use adversely affected HH compliance. This may be was always lower than that of nursing staff but registered due to the erroneous belief that glove use alone is suffi- a greater increase after the intervention. Conversely, cient to limit the spread of microorganisms and therefore healthcare assistants and other HCW categories were as- it obviated the need for good HH practice. On the other sociated with lower compliance rates. hand, proper glove use was positively associated with hand Other factors appeared to negatively affect compliance, disinfection as shown in other studies [9, 15]. Therefore, including being external to the ICU and delivering care since inappropriate glove overuse might contribute to during emergency situations, the latter of which is probably poor HH compliance, further HCW education of proper due to the fact that HH in these situations is perceived as a glove use is required. Particularly, customized training waste of time [30]. Factors such as day of the week and courses focusing on the consequences of unnecessary use gender of the observed HCW did not influence the compli- of gloves will be scheduled with the HCWs in order to ance rates. Notably, the negative impact of working at night promote their correct use and investigate the behavioural on HH compliance and the adverse association between determinants of inappropriate overuse. working during morning shifts and compliance with proper Despite the significant improvements reported, HH glove or gown use may be related to either the observer compliance rates did not reach a uniform and optimal effect or peer monitoring and feedback. Particularly, they level of adherence. As indicated by previous studies [33– may have been less emphasized during night shifts, result- 35], to interrupt cross-transmission of microorganisms in ing in a significant decrease in HH compliance, and over- settings at high risk of infection, good HH practice needs represented during daily activities, when they led to an to be performed in at least 60–80% of the situations where inappropriate overuse of personal equipment. For these it is required. The heterogeneity we observed in compli- reasons, other training sessions will be conducted with the ance rates (either over time, or between staff) might be re- HCWs to further address the correct indications for com- sponsible for the lack of significant reduction in HAIs pliance with both HH and proper glove or gown use. after the intervention, as registered by the ICU surveil- For each HH indication, compliance significantly in- lance system. In fact, incidence rates of device-related in- creased after the intervention, but compliance remained fections remained higher than the 90th percentile (as highest for interactions that took place after approaching defined in the National Healthcare Safety Network report patients rather than before, in line with other studies [8, [36]) throughout the study period, in line with other Ital- 25, 31]. Interestingly, while for most investigations HH ian incidence rates [37], without a clearly decreasing trend Baccolini et al. Antimicrobial Resistance and Infection Control (2019) 8:92 Page 9 of 10 and with some evidence of clonal transmission of micro- of the Umberto I Teaching Hospital of Sapienza University of Rome. organisms (data not shown). Therefore, since no other Table S2. Compliance with hand hygiene (HH) procedures by indication in relation to glove use over the study period in the intensive care unit change or intervention was registered in the ICU over the of the Umberto I Teaching Hospital of Sapienza University of Rome. 18 months, we believe that the mean HH compliance rate (DOCX 25 kb) of 61.6% that we found suggests the need to further imple- ment effective measures in order to achieve higher com- Abbreviations pliance rates and obtain clinical benefits such as a HAI: Healthcare associated infection; HCW: Healthcare worker; HH: Hand hygiene; ICU: Intensive care unit; WHO: World Health Organization reduction in HAIs. This study has some strengths and limitations. The main Acknowledgments strength is the comprehensive evaluation of adherence to We wish to thank all the staff of the medical/surgical intensive care unit of Umberto I Teaching Hospital of Sapienza University of Rome who took part standard hygiene precautions and the changes in compli- in this study. ance rates over the ensuing trimesters. We also distin- guished HH indications according to the type of interaction Authors’ contributions VB: This author conceived and designed the study, participated in data between HCWs and patients. Additionally, we were able to collection, performed the data analysis, interpreted the data, wrote the correlate compliance rates with incidence of HAIs in the manuscript and has approved the publication of this version. She is same ICU over time. The limitations of our research are accountable for the accuracy and integrity of the work. VDE: This author participated in the study design and data collection. She has approved the mostly duetothe useofdirectobservation to monitor publication of this version. PDS: This author participated in the study design HCW behaviour. Even though HCWs did not know who and data collection. He has approved the publication of this version. GM: the observers were and which practices were recorded, This author participated in the data collection, analysis and interpretation. He has approved the publication of this version. AM: This author participated in compliance data may be influenced by the observer effect. the data collection and analysis. She has approved the publication of this Moreover, enrolling HCWs from the ICU to collect data version. FA: This author participated in the data collection. He has approved and perform the observations might have made them in- the publication of this version. GT: This author participated in the data collection. He has approved the publication of this version. CM: This author clined to rate their coworkers differently than outside ob- participated in the study design and data collection. She has approved the servers would. Differences among observers might also publication of this version. CDV: This author participated in the data analysis have affected accuracy. However, the impact of these biases and interpretation, and manuscript editing. He has approved the publication of this version. MVR: This author participated in the study design, data was probably limited by the large number of observations interpretation and manuscript editing. He has approved the publication of over time and the random selection of practices, as recom- this version. PV: This author participated in the study design, data mended by the WHO [3]. Lastly, sincewedid notassign interpretation and manuscript editing. He has approved the publication of this version. All authors read and approved the final manuscript. unique identifiers to each HCW, we could not compare compliance before and after theinterventionatanindivid- Funding ual level. Such a comparison could be an interesting area No funding was received for this study. for future investigations to further study individual predic- Availability of data and materials tors and factors that contribute to compliance. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Conclusions Ethics approval and consent to participate Despite variability across HCW job categories and types The study protocol was reviewed and approved by the Ethics Committee of of recommendation, the multimodal intervention was ef- the Umberto I Teaching Hospital; reference number 4707/2017. fective in improving compliance with standard hygiene Consent for publication precautions over time. However, since in the vast majority Not applicable. of the investigations the compliance started to decline be- tween six and twelve months after the educational inter- Competing interests The authors declare that they have no competing interests. vention, providing a tailored reinforcement of indications and procedures for good HH practice within one year Author details after its first implementation is advisable to achieve and Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy. Department of maintain a uniform and high level of adherence. Addition- Anesthesiology and Critical Care, Policlinico Umberto I, Sapienza University of ally, given that glove use seemed to significantly influence Rome, Rome, Italy. 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Published: May 31, 2019

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