Prevention Care–Associated Infections

Multiple factors influence the development of HAIs, including patient variables (e.g., acuity of illness and overall health status), patient care variables (e.g., antibiotic use, invasive medical device use), administrative variables (e.g., ratio of nurses to patients, level of nurse education, permanent or temporary/float nurse), and variable use of aseptic techniques by health care staff. Although HAIs are commonly attributed to patient variables and provider care, researchers have also demonstrated that other institutional influences may contribute to adverse outcomes.^{35, 36} To encompass overall prevention efforts, a list of strategies are reviewed that apply to the clinical practice of an individual health care worker as well as institutional supportive measures. Adherence to these principles will demonstrate that you H.E.L.P. C.A.R.E. This acronym is used to introduce the following key concepts to reduce the incidence of health care–associated infections. It emphasizes the compassion and dedication of nurses where their efforts contribute to reduce morbidity and mortality from health care–associated infections.

Hand Hygiene

…so they shall wash their hands and their feet, that they die not:
and it shall be a statute for ever to them…
Exodus 30:21 Revised Standard Version

Overview

For the last 160 years, we have had the scientific knowledge of how to reduce hand contamination and thereby decrease patient infections from the seminal work on hand washing by the Hungarian obstetrician, Ignaz Semmelweis. Epidemiologic studies continue to demonstrate the favorable cost-benefit ratio and positive effects of simple hand washing for preventing transmission of pathogens in health care facilities.^{37, 38} The use of antiseptic hand soaps (i.e., ones containing chlorhexidine) and alcohol-based hand rubs also effectively reduce bacterial counts on hands when used properly. Even though the clear benefits of hand washing have been proven in multiple settings, the lack of consistent hand-washing practices remains a worldwide issue. In a resource-poor area of Pakistan, a recent household hand-washing campaign demonstrated a 50 percent lower incidence of pneumonia in children younger than 5 years compared to households that did not practice hand washing. Children under 15 years in hand-washing households had a 53 percent lower incidence of diarrhea and a 34 percent lower incidence of impetigo. Hand washing with plain soap prevented the majority of illnesses causing the largest number of childhood deaths globally.³⁹ The World Alliance for Patient Safety, formed by the World Health Organization, has adopted infection reduction programs—in both developed and developing countries—as its first goal.^{40, 41} The World Alliance for Patient Safety advocates a “clean care is safer care” program, in which health care leaders sign a pledge to take specific steps to reduce HAIs in their facilities. Hand hygiene is the first focus in this worldwide initiative.

Understaffing and hand hygiene

Hospitals with low nurse staffing levels and patient overcrowding leading to poor adherence to hand hygiene have been associated with higher adverse outcome rates and hospital outbreak investigations.^{34, 42, 43} In an ICU setting,⁴⁴ it was demonstrated that understaffing of nurses can facilitate the spread of MRSA through relaxed attention to basic infection control measures (e.g., hand hygiene). In a neonatal ICU outbreak,⁴⁵ the daily census was above the maximum capacity (25 neonates in a unit designed for 15), and the number of assigned staff members was fewer than the number necessitated by the workload, which resulted in relaxed attention to basic infection-control measures (use of multidose vials and hand hygiene). During the highest workload demands, staff washed their hands before contacting devices only 25 percent of the time, but hand washing increased to 70 percent after the end of the understaffing and overcrowding period. Ongoing surveillance determined that being hospitalized during this period was associated with a fourfold increased risk of acquiring an HAI. These studies illustrate an association between staffing workload, infections, and microbial transmission from poor adherence to hand hygiene policies.

Time demands

A perceived obstacle is that time to complete patient care duties competes with time needed for hand washing, particularly in technically intense settings such as an ICU. Hospital observational studies demonstrate that the frequency of hand washing varies between hospital wards and occurs an average of 5 to 30 times per shift, with more hand washing opportunities in an ICU.⁴⁶ With time limitations due to patient acuity demands or nurse-patient ratios and limited availability of sinks, the use of waterless, alcohol-based hand rubs has been shown to improve health care workers’ compliance with hand hygiene practices in the ICU.⁴⁷

Hand washing behaviors

Observational studies have found that on average, health care workers adhere to recommended hand hygiene procedures 40 percent of the time (with a range of 5 to 80 percent).⁴⁴ These studies implemented various interventions to improve hand washing, but summarized effects by measuring responses over a short time frame, without demonstrating long-lasting behavioral improvements. Two studies demonstrated the use of multidisciplinary interventions to change the organizational culture on frequency of hand washing that resulted in sustained improvements during a longer followup time period.^{48, 49}
Behavioral theories that examine the relationship of multiple factors affecting behavioral choices have been applied to the complex issue of hand washing compliance. These theories illustrate the influence of the individual intention to perform hand washing and organizational influences that affect the outcome behavior. The Theory of Planned Behavior has been studied in this context, acknowledging that the intention to wash hands involves a person’s (1) attitude whether or not the behavior is beneficial to themselves, (2) perception of pressure from peers, and (3) perceived control on the ease or difficulty in performing the behavior.^50–53 These perceptions are also influenced by the strength of the person’s beliefs about the significance of the outcomes of the behavior; the normative beliefs, which involve the individual evaluation of peer expectations; and control beliefs, which are based on a person’s perception of their ability to overcome obstacles that obstruct their completion of the behavior.

Monitoring compliance

Although standards for hand hygiene practices have been published with an evidence-based guideline⁴⁴ and professional collaborations have produced the How-to-Guide: Improving Hand Hygiene,⁵⁴ there is no standardized method or tool for measuring adherence to institutional policy. Varying quality improvement methodologies and a lack of consensus on how to measure hand hygiene compliance have made it difficult to determine the effectiveness of hand hygiene expectations within and across health care settings. The Joint Commission has instituted a partnership with major infection control leadership organizations in the United States and abroad to identify best approaches for measuring compliance with hand hygiene guidelines in health care organizations though its Consensus Measurement in Hand Hygiene (CMHH) project. The participating organizations include APIC, CDC, the Society for Healthcare Epidemiology of America, the World Health Organization World Alliance for Patient Safety, the Institute for Healthcare Improvement, and the National Foundation for Infectious Diseases. The final product of this project, due to be completed in early 2008, will be an educational monograph that recommends best practices for measuring hand hygiene compliance.⁵⁵

Summary

Hand hygiene adherence and promotion involve multiple factors at the individual and system level to provide an institutional safety climate for patients and health care staff. Methods used to promote improved hand hygiene require multidisciplinary participation to identify individual beliefs, adherence factors, and perceived barriers. Program successes have been summarized and should be reviewed to establish improved hand hygiene as a priority program at your facility.^{44, 56, 57}