The impact of an education program on hand hygiene compliance and nosocomial infection incidence in an urban Neonatal Intensive Care Unit: An intervention study with before and after comparison
Introduction
The survival rate of very low birth weight (VLBW) infants (<1500 g) has improved over the past decades. Consequently, a fragile population survives at high risk of nosocomial bloodstream infections due to immature host defense and invasive procedures. The incidence of nosocomial bloodstream infection among VLBW infants in neonatal intensive care units (NICUs) worldwide varies between 11% and 53% (Aziz et al., 2005, Ng et al., 2004, Stoll et al., 2002). These infections are associated with increased mortality and morbidity (Makhoul et al., 2002, Stoll et al., 2004). In addition, infected infants need to stay longer in hospital and utilize more resources than non-affected infants (Mahieu et al., 2001). Compliance with hand hygiene protocols among healthcare professionals in NICUs is recognized as one of the most important means of preventing hospital acquired infections (Helder and Latour, 2009, O’Grady et al., 2002).
Nosocomial bloodstream infections are in part caused by horizontal transmission of commensals or pathogens due to inappropriate hygiene practices (Kampf and Kramer, 2004). Various sources have reported poor compliance among healthcare professionals (Grol and Grimshaw, 2003, Pittet et al., 2000), Therefore, the most effective strategy to decrease nosocomial bloodstream infections is to improve hand hygiene practices (Kampf and Kramer, 2004, Lam et al., 2004, Yildirim et al., 2008).
Researchers have tested a wide range of interventions and combinations of interventions to improve hand hygiene (Gould et al., 2007, Grimshaw et al., 2004a, Grimshaw et al., 2004b, Grol and Grimshaw, 2003, Naikoba and Hayward, 2001). The question whether a combination of interventions would be more effective than a single intervention is still debated however.
The aim of the study reported here was to assess the impact of an education program on compliance with hand hygiene and its influence on the incidence of nosocomial bloodstream infections in VLBW infants. Additionally, differences for infants nursed in incubators and cribs were determined.
Section snippets
Study design
We observed hygienic behavior as process outcome in a pretest design and infection rates in an interrupted time series. The study was performed in the level IIID NICU at the Erasmus MC - Sophia Children's Hospital in Rotterdam, the Netherlands, from 1 January 2003 to 31 December 2006. The multifaceted intervention comprised an education program, encouragement of key players to perform correct hygienic behavior, and effecting a culture shift to better hand hygiene. Hand hygiene compliance was
Results
A total of 1360 structured observations were performed during the two pretests and two posttests periods (Fig. 1). Sixty observations for rescue procedures were excluded from analysis. In these observations the drying time was less than the prescribed 30 s, which, for that matter, is acceptable for emergent life-saving interventions. Ninety-nine observations of visiting healthcare professionals (e.g. laboratory workers and X-ray technicians) were analyzed separately since they did not
Discussion
Adequate hand hygiene of healthcare professionals is the single most effective means of preventing nosocomial bloodstream infections. Hand hygiene compliance is based on disinfecting hands at appropriate moments, complete hand rubbing, and sufficiently long drying time. Most earlier studies in this area reported only percentages of healthcare professionals applying hand disinfection or washing hands. This study explored the impact of a multifaceted intervention on hand hygiene practices in a
Acknowledgments
We wish to thank Marlous op de Weegh and Marcia Wouterson who participated in the data collection. We thank Ko Hagoort for text editing.
Conflict of interest: None declared.
Funding: There was no source of funding.
Ethical approval: The Erasmus MC Institutional Review Board approved the study under number MEC-2007-182.
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