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Does hand hygiene compliance among health care workers change when patients are in contact precaution rooms in ICUs?
Does hand hygiene compliance among health care workers change when patients are in contact precaution rooms in ICUs? Kirven Gilbert, Cortney Stafford, MPH, Kali Crosby, RN, Edna Fleming, RN, and Robert Gaynes, MD Atlanta, Georgia
Background: Hand hygiene compliance rates among health care workers (HCW) rarely exceed 50%. Contact precautions are thought to increase HCWs’ hand hygiene awareness. We sought to determine any differences in hand hygiene compliance rates for HCW between patients in contact precaution and those not in any isolation. Methods: In a hospital’s medical (MICU) and surgical (SICU) intensive care units, a trained observer directly observed hand hygiene by the type of room (contact precaution or noncontact precaution) and the type of HCW (nurse or doctor). Results: The SICU had similar compliance rates (36/75 [50.7%] in contact precaution rooms vs 223/431 [51.7%] compliance in noncontact precaution rooms, P . .5); the MICU also had similar hand hygiene compliance rates (67/132 [45.1%] in contact precaution rooms vs 96/213 [50.8%] in noncontact precaution rooms, P . .10). Hand hygiene compliance rates stratified by HCW were similar with 1 exception. The MICU nurses had a higher rate of hand hygiene compliance in contact precaution rooms than in rooms with noncontact precautions (66.7% vs 51.6%, respectively). Conclusion: Compliance with hand hygiene among HCWs did not differ between contact precaution rooms and rooms with noncontact precautions with the exception of the nurses in the MICU. Key Words: Hand hygiene; contact precautions; compliance. Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. (Am J Infect Control 2010;38:515-7.)
Whereas hand hygiene remains the single most effective way to prevent most nosocomial infections, compliance rates in hospitals among health care workers (HCW) rarely exceed 50%; physicians have the lowest compliance among HCW.1-5 The use of contact precautions in health care facilities is designed for patients with a large number of pathogenic or resistant microorganisms and clinical syndromes.6 The use of contact precautions should increase HCWs’ hand hygiene awareness because these patients pose a higher risk of transmission of microorganisms compared with nonisolated patients. Our goal was to determine any differences in hand hygiene compliance rates for HCW between patients in contact precautions and patients who were not in any form of isolation precautions. From the Atlanta Veterans’ Affairs Medical Center, Atlanta, GA. Address correspondence to Robert Gaynes, MD, Atlanta Veterans’ Affairs Medical Center Mailstop 111, 1670 Clairmont Rd, Atlanta, GA 30329. E-mail: [email protected]. Conflicts of interest: None to report. 0196-6553/$36.00 Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2009.11.005
METHODS The study took place in Atlanta, Georgia, during June 2009 in a 173-bed acute care hospital. Our study was limited to the medical intensive care unit (MICU), a 12-bed unit, and the surgical intensive care unit (SICU), a 10-bed unit. A trained observer performed direct observations of HCWs in both units. Each unit was observed over a period of two-and-a-half weeks. Observation lengths lasted from 1 hour to 4 hours on weekdays, from 7:00 AM to 5:00 PM. Unit personnel were not told that the observer was monitoring hand hygiene but was collecting data on the number of visits to each ICU room to keep track of the need for supplies.7 The observer monitored hand hygiene compliance; the type of room (contact precaution or noncontact precaution); the type of HCW including nurses (including registered nurses and licensed practicing nurses), physicians (attendings, residents, fellows, and medical students), or other types of HCW; whether the hand hygiene took place before patient contact and/or after patient contact; and the use of gown and gloves in contact precaution rooms. No nursing students were observed during the study. Hand hygiene was considered compliant if hands were washed thoroughly with soap and water for at least 15 seconds or an alcohol-based sanitizer was 515
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Table 1. Hand hygiene compliance by room type, unit, and health care worker
Ward
Contact precaution, % (n)
No contact precaution, % (n)
P value*
SICU overall Nurses Doctors MICU overall Nurses Doctors
50.7 (38/75) 61.4 (28/49) 38.9 (7/18) 45.1 (67/132) 66.7 (52/78) 23.3 (10/43)
51.2 (223/431) 57.1 (191/311) 22 (18/82) 50.8 (96/213) 51.6 (63/122) 28.8 (17/59)
..5 ..5 ..10 ..10 ,.05 ..5
Table 2. Hand hygiene compliance by unit, health care worker, and ‘‘before’’ and ‘‘after’’ Ward
*Fisher exact test or x2 test.
used. Hand hygiene was to be performed both before a HCW entered the patient’s room and interacted with either the patient or items in the patient’s room and after the HCW finished interacting with either the patient or the environment. Using gloves as a substitute for proper hand hygiene was not considered compliant.8 HCW who complied with hand hygiene upon leaving a room, touched nothing else, and then walked into another patient room was considered compliant but occurred only 3 times in the study. Handwashing sinks were located in every patient room along with an accessible sink outside patient rooms but within the unit. Alcohol-based hand sanitizers were located outside of every patient’s room adjacent to the door. Additional hand sanitizers were placed inside several patient rooms and near exit doors of the units. Education for all new employees on proper hand hygiene continued through the study. Posters reminding all HCWs on proper hand hygiene were present, but no specific hygiene campaign occurred prior to or during the study. Contact precaution rooms had carts supplied with gowns and gloves and were positioned right outside of the patient’s room. No observations were made in rooms in which patients were on airborne precautions during our study. We used a x2 test and Fisher exact test, as appropriate, for the statistical analysis of hand hygiene compliance rates.
RESULTS The overall hand hygiene compliance for the SICU was 51.6% with 506 observations and 47.2% for the MICU with 345 observations (Table 1). When these compliance rates were stratified by contact precaution status, the SICU had similar compliance rates. In the MICU, we also observed similar hand hygiene compliance rates. We stratified by type of HCW: nurses, physicians, or others (Table 1). For the SICU nurses, there was no statistically significant difference between their contact precaution room hand hygiene compliance rate and noncontact precaution room compliance rate (61.4% and 57.1%, respectively, P . .5). However, the MICU
Before, % (n)
After, % (n)
P value*
32.7 (73/223) 40.5 (62/153) 16 (8/50) 27.3 (42/154) 31 (26/84) 14.6 (7/48)
66.4 (188/283) 75.8 (157/207) 34 (17/50) 63.3 (121/191) 76.7 (89/116) 37 (20/54)
,.001 ,.0001 ,.05 ,.0001 ,.0001 ,.025
SICU Nurses Doctors MICU Nurses Doctors
*Fisher exact test or x2 test.
nurses were more compliant with hand hygiene compliance in contact precaution rooms than noncontact precaution rooms (66.7% and 51.6%, respectively, P , .05). Physician compliance rates were not significantly different either between contact precaution rooms and noncontact precaution rooms (P . .5). The ‘‘other’’ type of HCWs did not have a large enough number of observations for accurate analysis of hand hygiene compliance rates in either the SICU or the MICU. After stratifying the data by HCW type, we further stratified the data into the times when HCW complied with hand hygiene ‘‘before’’ patient contact and ‘‘after’’ patient contact (Table 2). Contact precaution compliance rates did not statistically differ from noncontact precaution rates for any of the ‘‘before’’ or ‘‘after’’ observations with the exception of the MICU nurses ‘‘after’’ rates. The MICU nurses had a hand hygiene compliance rate of 87% when leaving contact precaution rooms, whereas their hand hygiene compliance rate after patient contact in noncontact precaution rooms was 70% (P , .05). Both nurses and physicians in the SICU and MICU had statistically significant differences between ‘‘before’’ patient contact hand hygiene compliance and ‘‘after’’ patient contact hand hygiene compliance. We also observed compliance in the use of gown and gloves by HCW in the SICU and MICU. Because gown compliance and glove compliance were identical, the data were combined. Both the SICU and MICU nurses did significantly better than their physician counterparts. The SICU nurses had a 68% (68/100) gown/glove compliance rate, and SICU doctors had a 40% (16/40) compliance rate (P , .01). MICU nurses had an 84.3% (172/204) gown/glove compliance rate, and the MICU physicians had a 70% (77/110) gown/glove compliance rate. Additionally, MICU nurses were significantly better at gown/glove compliance than SICU nurses (P , .01), and MICU physicians were significantly better at gown/glove than SICU doctors (P , .01).
DISCUSSION Our study suggests that compliance with hand hygiene among HCWs did not differ between contact precaution rooms and rooms with noncontact precautions
Gilbert et al.
www.ajicjournal.org Vol. 38 No. 7
with the exception of the nurses in the MICU, who had a higher rate of hand hygiene compliance in contact precaution rooms than in rooms with noncontact precautions. Two previous studies have examined hand hygiene compliance in patients in contact precautions, although each studied had different methods from the present one.9,10 Both these studies suggested that hand hygiene compliance was somewhat better in isolation rooms in contrast to our findings. The MICU nurses had higher hand hygiene compliance in contact precaution rooms in our study, but the reason for this exception in our findings is unclear and may have been due to chance alone. However, because of difference in methodology, direct comparison with the other 2 studies is difficult. Overall compliance rates in this study were consistent with hand hygiene compliance rates in previous studies.2,5,9,10 Physicians in our study had a lower hand hygiene compliance rate compared with nurses, which has been described in previous studies.4,5 Whereas our data indicate that physicians and nurses need to increase their hand hygiene compliance rates, the results suggest that interventions designed to improve hand hygiene compliance should differ for physicians compared with nurses. Physicians need interventions designed to improve their overall hand hygiene compliance rates, whereas interventions for nurses should be directed more towards improving hand hygiene before donning gloves. In our study, the compliance rates for glove/gown use was consistent with previous studies, which has mostly ranged from 22% to 60% compliance.10-12 Additionally, our data were consistent with most older studies that reported better compliance among nurses than physicians.10-12 Our study should be interpreted with some cautions. Although we attempted to conceal the observer’s purpose of hand hygiene monitoring, the observer’s known presence in the units may have affected compliance. Because this study was performed during the day shifts, no conclusions can be drawn regarding the night shifts’ compliance rates. We did not attempt to correlate any infections to hand hygiene compliance by HCWs. This study only examined hand hygiene in ICUs. Monitoring hand hygiene in general care wards may have yielded different results but is logistically difficult at the facility. Last, we employed direct observation to monitor hand hygiene compliance, which has been suggested as an accurate measure; however, some opportunities for hand hygiene observation could have been missed.13 Despite these limitations, our study suggested that overall hand hygiene compliance among HCWs is similar for patients in contact precautions compared with those not in isolation. This finding may limit the effectiveness of these precautions because the
517
compliance was low. Additionally, one third of patients hospitalized at the Atlanta VA are on contact precautions, and approximately half of patients on contact precautions are in these precautions because of the MRSA Directive (Methicillin-resistant Staphylococcus aureus Initiative VHA Directive 2010-006; www1.va. gov/vhapublications). Isolation ‘‘fatigue’’ may affect the effectiveness of this directive. Because all HCW were significantly better in compliance ‘‘after’’ patient contact than ‘‘before,’’ an intervention method should be implemented that focuses on improving the ‘‘before’’ patient contact compliance rate. Our data support previous reports that physicians and nurses may have different mind-sets and reasons for hand hygiene compliance and thus need different interventional approaches.14
References 1. Aiello A, Larson E. What is the evidence for a causal link between hygiene and infections? Infect Dis 2002;2:103-10. 2. Girou E, Legrand P, Soing-Altrach S, Lemire A, Poulain C, Allaire A, et al. Association between hand hygiene compliance and methicillinresistant Staphylococcus aureus prevalence in a French rehabilitation hospital. Infect Control Hosp Epidemiol 2006;27:1128-30. 3. Bischoff W, Reynolds T, Sessler C, Edmond M, Wenzel R. Handwashing compliance by health care workers. Arch Intern Med 2000;160:1017-21. 4. Jefferson J, Mermel L, Ben-David D, Parenteau S, Monti S, Hyde M. Monitoring hand hygiene compliance in a university-affiliated medical center (abstract). Am J Infect Control 2005;33:E47-8. 5. Pittet D, Philippe M, Perneger T. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999;130:126-30. 6. Siegel JD, Rhinehart E, Jackson M. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007;35(Suppl 2):S65-164. 7. Bittner M, Rich E, Turner P, Arnold W Jr. Limited impact of sustained simple feedback based on soap and paper towel consumption on the frequency of hand washing in an adult intensive care unit. Infect Control Hosp Epidemiol 2002;23:120-6. 8. Pittet D, Allegranzi B, Boyce J. The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations. Infect Control Hosp Epidemiol 2009;30:611-23. 9. Swoboda S, Earsing K, Strauss K, Lane S, Lipsett P. Electronic monitoring and voice prompts improve hand hygiene and decrease nosocomial infections in an intermediate care unit. Crit Care Med 2004;32:358-63. 10. Bearman G, Marra A, Sessler C, Smith W, Rosato A, Laplante J, et al. A controlled trial of universal gloving versus contact precautions for preventing the transmission of multidrug-resistant organisms. Am J Infect Control 2007;35:650-5. 11. Vidal-Trecan G, Delamare N, Tcherny-Lessenot S, Lamory J, Baudin F, de Prittwitz M, et al. Multidrug-resistant bacteria infection control: study of compliance with isolation precautions in a Paris university hospital. Infect Control Hosp Epidemiol 2001;22:109-11. 12. Weber D, Sickbert-Bennett E, Brown V, Brooks R, Kittrell I, Featherstone B, et al. Compliance with isolation precautions at a university hospital. Infect Control Hosp Epidemiol 2007;28:358-61. 13. Haas JP, Larson EL. Measurement of compliance with hand hygiene. J Hosp Infect 2007;66:6-14. 14. Erasmus V, Brouwer W, van Beeck E, Oenema A, Daha T, Richardus J, et al. A qualitative exploration of reason for poor hand hygiene among hospital workers: lack of positive role models and of convincing evidence that hand hygiene prevents cross-infection. Infect Control Hosp Epidemiol 2009;30:415-9.
Background: Hand hygiene compliance rates among health care workers (HCW) rarely exceed 50%. Contact precautions are thought to increase HCWs’ hand hygiene awareness. We sought to determine any differences in hand hygiene compliance rates for HCW between patients in contact precaution and those not in any isolation. Methods: In a hospital’s medical (MICU) and surgical (SICU) intensive care units, a trained observer directly observed hand hygiene by the type of room (contact precaution or noncontact precaution) and the type of HCW (nurse or doctor). Results: The SICU had similar compliance rates (36/75 [50.7%] in contact precaution rooms vs 223/431 [51.7%] compliance in noncontact precaution rooms, P . .5); the MICU also had similar hand hygiene compliance rates (67/132 [45.1%] in contact precaution rooms vs 96/213 [50.8%] in noncontact precaution rooms, P . .10). Hand hygiene compliance rates stratified by HCW were similar with 1 exception. The MICU nurses had a higher rate of hand hygiene compliance in contact precaution rooms than in rooms with noncontact precautions (66.7% vs 51.6%, respectively). Conclusion: Compliance with hand hygiene among HCWs did not differ between contact precaution rooms and rooms with noncontact precautions with the exception of the nurses in the MICU. Key Words: Hand hygiene; contact precautions; compliance. Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. (Am J Infect Control 2010;38:515-7.)
Whereas hand hygiene remains the single most effective way to prevent most nosocomial infections, compliance rates in hospitals among health care workers (HCW) rarely exceed 50%; physicians have the lowest compliance among HCW.1-5 The use of contact precautions in health care facilities is designed for patients with a large number of pathogenic or resistant microorganisms and clinical syndromes.6 The use of contact precautions should increase HCWs’ hand hygiene awareness because these patients pose a higher risk of transmission of microorganisms compared with nonisolated patients. Our goal was to determine any differences in hand hygiene compliance rates for HCW between patients in contact precautions and patients who were not in any form of isolation precautions. From the Atlanta Veterans’ Affairs Medical Center, Atlanta, GA. Address correspondence to Robert Gaynes, MD, Atlanta Veterans’ Affairs Medical Center Mailstop 111, 1670 Clairmont Rd, Atlanta, GA 30329. E-mail: [email protected]. Conflicts of interest: None to report. 0196-6553/$36.00 Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2009.11.005
METHODS The study took place in Atlanta, Georgia, during June 2009 in a 173-bed acute care hospital. Our study was limited to the medical intensive care unit (MICU), a 12-bed unit, and the surgical intensive care unit (SICU), a 10-bed unit. A trained observer performed direct observations of HCWs in both units. Each unit was observed over a period of two-and-a-half weeks. Observation lengths lasted from 1 hour to 4 hours on weekdays, from 7:00 AM to 5:00 PM. Unit personnel were not told that the observer was monitoring hand hygiene but was collecting data on the number of visits to each ICU room to keep track of the need for supplies.7 The observer monitored hand hygiene compliance; the type of room (contact precaution or noncontact precaution); the type of HCW including nurses (including registered nurses and licensed practicing nurses), physicians (attendings, residents, fellows, and medical students), or other types of HCW; whether the hand hygiene took place before patient contact and/or after patient contact; and the use of gown and gloves in contact precaution rooms. No nursing students were observed during the study. Hand hygiene was considered compliant if hands were washed thoroughly with soap and water for at least 15 seconds or an alcohol-based sanitizer was 515
516
Gilbert et al.
American Journal of Infection Control September 2010
Table 1. Hand hygiene compliance by room type, unit, and health care worker
Ward
Contact precaution, % (n)
No contact precaution, % (n)
P value*
SICU overall Nurses Doctors MICU overall Nurses Doctors
50.7 (38/75) 61.4 (28/49) 38.9 (7/18) 45.1 (67/132) 66.7 (52/78) 23.3 (10/43)
51.2 (223/431) 57.1 (191/311) 22 (18/82) 50.8 (96/213) 51.6 (63/122) 28.8 (17/59)
..5 ..5 ..10 ..10 ,.05 ..5
Table 2. Hand hygiene compliance by unit, health care worker, and ‘‘before’’ and ‘‘after’’ Ward
*Fisher exact test or x2 test.
used. Hand hygiene was to be performed both before a HCW entered the patient’s room and interacted with either the patient or items in the patient’s room and after the HCW finished interacting with either the patient or the environment. Using gloves as a substitute for proper hand hygiene was not considered compliant.8 HCW who complied with hand hygiene upon leaving a room, touched nothing else, and then walked into another patient room was considered compliant but occurred only 3 times in the study. Handwashing sinks were located in every patient room along with an accessible sink outside patient rooms but within the unit. Alcohol-based hand sanitizers were located outside of every patient’s room adjacent to the door. Additional hand sanitizers were placed inside several patient rooms and near exit doors of the units. Education for all new employees on proper hand hygiene continued through the study. Posters reminding all HCWs on proper hand hygiene were present, but no specific hygiene campaign occurred prior to or during the study. Contact precaution rooms had carts supplied with gowns and gloves and were positioned right outside of the patient’s room. No observations were made in rooms in which patients were on airborne precautions during our study. We used a x2 test and Fisher exact test, as appropriate, for the statistical analysis of hand hygiene compliance rates.
RESULTS The overall hand hygiene compliance for the SICU was 51.6% with 506 observations and 47.2% for the MICU with 345 observations (Table 1). When these compliance rates were stratified by contact precaution status, the SICU had similar compliance rates. In the MICU, we also observed similar hand hygiene compliance rates. We stratified by type of HCW: nurses, physicians, or others (Table 1). For the SICU nurses, there was no statistically significant difference between their contact precaution room hand hygiene compliance rate and noncontact precaution room compliance rate (61.4% and 57.1%, respectively, P . .5). However, the MICU
Before, % (n)
After, % (n)
P value*
32.7 (73/223) 40.5 (62/153) 16 (8/50) 27.3 (42/154) 31 (26/84) 14.6 (7/48)
66.4 (188/283) 75.8 (157/207) 34 (17/50) 63.3 (121/191) 76.7 (89/116) 37 (20/54)
,.001 ,.0001 ,.05 ,.0001 ,.0001 ,.025
SICU Nurses Doctors MICU Nurses Doctors
*Fisher exact test or x2 test.
nurses were more compliant with hand hygiene compliance in contact precaution rooms than noncontact precaution rooms (66.7% and 51.6%, respectively, P , .05). Physician compliance rates were not significantly different either between contact precaution rooms and noncontact precaution rooms (P . .5). The ‘‘other’’ type of HCWs did not have a large enough number of observations for accurate analysis of hand hygiene compliance rates in either the SICU or the MICU. After stratifying the data by HCW type, we further stratified the data into the times when HCW complied with hand hygiene ‘‘before’’ patient contact and ‘‘after’’ patient contact (Table 2). Contact precaution compliance rates did not statistically differ from noncontact precaution rates for any of the ‘‘before’’ or ‘‘after’’ observations with the exception of the MICU nurses ‘‘after’’ rates. The MICU nurses had a hand hygiene compliance rate of 87% when leaving contact precaution rooms, whereas their hand hygiene compliance rate after patient contact in noncontact precaution rooms was 70% (P , .05). Both nurses and physicians in the SICU and MICU had statistically significant differences between ‘‘before’’ patient contact hand hygiene compliance and ‘‘after’’ patient contact hand hygiene compliance. We also observed compliance in the use of gown and gloves by HCW in the SICU and MICU. Because gown compliance and glove compliance were identical, the data were combined. Both the SICU and MICU nurses did significantly better than their physician counterparts. The SICU nurses had a 68% (68/100) gown/glove compliance rate, and SICU doctors had a 40% (16/40) compliance rate (P , .01). MICU nurses had an 84.3% (172/204) gown/glove compliance rate, and the MICU physicians had a 70% (77/110) gown/glove compliance rate. Additionally, MICU nurses were significantly better at gown/glove compliance than SICU nurses (P , .01), and MICU physicians were significantly better at gown/glove than SICU doctors (P , .01).
DISCUSSION Our study suggests that compliance with hand hygiene among HCWs did not differ between contact precaution rooms and rooms with noncontact precautions
Gilbert et al.
www.ajicjournal.org Vol. 38 No. 7
with the exception of the nurses in the MICU, who had a higher rate of hand hygiene compliance in contact precaution rooms than in rooms with noncontact precautions. Two previous studies have examined hand hygiene compliance in patients in contact precautions, although each studied had different methods from the present one.9,10 Both these studies suggested that hand hygiene compliance was somewhat better in isolation rooms in contrast to our findings. The MICU nurses had higher hand hygiene compliance in contact precaution rooms in our study, but the reason for this exception in our findings is unclear and may have been due to chance alone. However, because of difference in methodology, direct comparison with the other 2 studies is difficult. Overall compliance rates in this study were consistent with hand hygiene compliance rates in previous studies.2,5,9,10 Physicians in our study had a lower hand hygiene compliance rate compared with nurses, which has been described in previous studies.4,5 Whereas our data indicate that physicians and nurses need to increase their hand hygiene compliance rates, the results suggest that interventions designed to improve hand hygiene compliance should differ for physicians compared with nurses. Physicians need interventions designed to improve their overall hand hygiene compliance rates, whereas interventions for nurses should be directed more towards improving hand hygiene before donning gloves. In our study, the compliance rates for glove/gown use was consistent with previous studies, which has mostly ranged from 22% to 60% compliance.10-12 Additionally, our data were consistent with most older studies that reported better compliance among nurses than physicians.10-12 Our study should be interpreted with some cautions. Although we attempted to conceal the observer’s purpose of hand hygiene monitoring, the observer’s known presence in the units may have affected compliance. Because this study was performed during the day shifts, no conclusions can be drawn regarding the night shifts’ compliance rates. We did not attempt to correlate any infections to hand hygiene compliance by HCWs. This study only examined hand hygiene in ICUs. Monitoring hand hygiene in general care wards may have yielded different results but is logistically difficult at the facility. Last, we employed direct observation to monitor hand hygiene compliance, which has been suggested as an accurate measure; however, some opportunities for hand hygiene observation could have been missed.13 Despite these limitations, our study suggested that overall hand hygiene compliance among HCWs is similar for patients in contact precautions compared with those not in isolation. This finding may limit the effectiveness of these precautions because the
517
compliance was low. Additionally, one third of patients hospitalized at the Atlanta VA are on contact precautions, and approximately half of patients on contact precautions are in these precautions because of the MRSA Directive (Methicillin-resistant Staphylococcus aureus Initiative VHA Directive 2010-006; www1.va. gov/vhapublications). Isolation ‘‘fatigue’’ may affect the effectiveness of this directive. Because all HCW were significantly better in compliance ‘‘after’’ patient contact than ‘‘before,’’ an intervention method should be implemented that focuses on improving the ‘‘before’’ patient contact compliance rate. Our data support previous reports that physicians and nurses may have different mind-sets and reasons for hand hygiene compliance and thus need different interventional approaches.14
References 1. Aiello A, Larson E. What is the evidence for a causal link between hygiene and infections? Infect Dis 2002;2:103-10. 2. Girou E, Legrand P, Soing-Altrach S, Lemire A, Poulain C, Allaire A, et al. Association between hand hygiene compliance and methicillinresistant Staphylococcus aureus prevalence in a French rehabilitation hospital. Infect Control Hosp Epidemiol 2006;27:1128-30. 3. Bischoff W, Reynolds T, Sessler C, Edmond M, Wenzel R. Handwashing compliance by health care workers. Arch Intern Med 2000;160:1017-21. 4. Jefferson J, Mermel L, Ben-David D, Parenteau S, Monti S, Hyde M. Monitoring hand hygiene compliance in a university-affiliated medical center (abstract). Am J Infect Control 2005;33:E47-8. 5. Pittet D, Philippe M, Perneger T. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999;130:126-30. 6. Siegel JD, Rhinehart E, Jackson M. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control 2007;35(Suppl 2):S65-164. 7. Bittner M, Rich E, Turner P, Arnold W Jr. Limited impact of sustained simple feedback based on soap and paper towel consumption on the frequency of hand washing in an adult intensive care unit. Infect Control Hosp Epidemiol 2002;23:120-6. 8. Pittet D, Allegranzi B, Boyce J. The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations. Infect Control Hosp Epidemiol 2009;30:611-23. 9. Swoboda S, Earsing K, Strauss K, Lane S, Lipsett P. Electronic monitoring and voice prompts improve hand hygiene and decrease nosocomial infections in an intermediate care unit. Crit Care Med 2004;32:358-63. 10. Bearman G, Marra A, Sessler C, Smith W, Rosato A, Laplante J, et al. A controlled trial of universal gloving versus contact precautions for preventing the transmission of multidrug-resistant organisms. Am J Infect Control 2007;35:650-5. 11. Vidal-Trecan G, Delamare N, Tcherny-Lessenot S, Lamory J, Baudin F, de Prittwitz M, et al. Multidrug-resistant bacteria infection control: study of compliance with isolation precautions in a Paris university hospital. Infect Control Hosp Epidemiol 2001;22:109-11. 12. Weber D, Sickbert-Bennett E, Brown V, Brooks R, Kittrell I, Featherstone B, et al. Compliance with isolation precautions at a university hospital. Infect Control Hosp Epidemiol 2007;28:358-61. 13. Haas JP, Larson EL. Measurement of compliance with hand hygiene. J Hosp Infect 2007;66:6-14. 14. Erasmus V, Brouwer W, van Beeck E, Oenema A, Daha T, Richardus J, et al. A qualitative exploration of reason for poor hand hygiene among hospital workers: lack of positive role models and of convincing evidence that hand hygiene prevents cross-infection. Infect Control Hosp Epidemiol 2009;30:415-9.