Resident-Driven Quality Improvement Project in Perioperative Hand Hygiene.

OBJECTIVES: The goal of the project was to improve hand hygiene compliance in the perioperative setting while involving anesthesia residents in quality improvement. To achieve this goal, we facilitated direct trainee participation on patient safety and quality improvement initiatives. The result was a project for perioperative hand hygiene improvement conceived and led by anesthesiology residents. METHODS: Anesthesiology residents contributed project ideas and participated in problem-based learning discussions to develop several interventions for improving perioperative hand hygiene compliance. Interventions included electronic and laminated posters, reminder cards, monthly aggregated performance feedback, and a simulation-based hand hygiene workshop. Monthly hand hygiene compliance data were gathered during unannounced observations for a 29-month period. Run chart analysis and χ test were used to determine the impact of these interventions on compliance rates. RESULTS: A total of 1122 hand hygiene observations were made for 29 months. Run chart analysis showed a nonrandom shift and increasing trend during the postintervention period. The baseline hand hygiene rate was 68% (95% CI [65%-72%], n = 661), which increased to 79% post-intervention (95% CI [76%-83%], n = 461, P < 0.01). CONCLUSIONS: Our resident-led hand hygiene program used a multifaceted approach to drive sustained increases in perioperative hand hygiene compliance, while directly engaging house staff in quality improvement initiatives.

Hand-hygiene compliance does not predict rates of resistant infections in critically ill surgical patients.

BACKGROUND: Our institution had a major outbreak of multi-drug-resistant Acinetobacter (MDRA) in its general surgical and trauma intensive care units (ICUs) in 2011, requiring implementation of an aggressive infection-control response. We hypothesized that poor hand-hygiene compliance (HHC) may have contributed to the outbreak of MDRA. A response to the outbreak including aggressive environmental cleaning, cohorting, and increased hand hygiene compliance monitoring may have led to an increase in HHC after the outbreak and to a consequent decrease in the rates of infection by the nosocomial pathogens methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridium difficile. METHODS: Hand-hygiene compliance, tracked in monthly audits by trained and anonymous observers, was abstracted from an infection control database. The incidences of nosocomial MRSA, VRE, and C. difficile were calculated from a separate prospectively collected data base for 6 mo before and 12 mo after the 2011 outbreak of MDRA in the institution's general surgical and trauma ICUs, and data collected prospectively from two unaffected ICUs (the thoracic surgical ICU and medical intensive care unit [MICU]). We created a composite endpoint of "any resistant pathogen," defined as MRSA, VRE, or C. difficile, and compared incidence rates over time, using the Wilcoxon signed rank test and Pearson product-moment correlation coefficient to measure the correlations among these rates. RESULTS: Rates of HHC before and after the outbreak of MDRA were consistently high in both the general surgical (median rates: 100% before and 97.6% after the outbreak, p=0.93) and trauma ICUs (median rates: 90% before and 96.75% after the outbreak, p=0.14). In none of the ICUs included in the study did the rates of HHC increase in response to the outbreak of MDRA. The incidence of "any resistant pathogen" decreased in the general surgical ICU after the outbreak (from 6.7/1,000 patient-days before the outbreak to 2.7/1,000 patient-days after the outbreak, p=0.04), but this decrease did not correlate with HHC (trauma ICU: Pearson correlation [ρ]=-0.34, p=0.28; general surgical ICU: ρ=0.52, p=0.08). CONCLUSIONS: The 2011 outbreak of MDRA at our institution occurred despite high rates of HHC. Notwithstanding stable rates of HHC, the rates of infection with MRSA, VRE and C. difficile decreased in the general surgical ICU after the outbreak. This suggests that infection control tactics other than HHC play a crucial role in preventing the transmission of nosocomial pathogens, especially when rates of HHC have been maximized.