Supporting safe swallowing of care home residents with dysphagia: How does the care delivered compare with guidance from speech and language therapists?

INTRODUCTION: Dysphagia affects up to 70% of care home residents, increasing morbidity and hospital admissions. Speech and language therapists make recommendations to support safe nutrition but have limited capacity to offer ongoing guidance. This study aimed to understand if recommendations made to support safe and effective care are implemented and how these relate to the actual care delivered. METHODS: Eleven mealtimes with residents with dysphagia were observed during 2020 using a tool capturing 12 elements of expected practice. Staff actions during mealtimes were compared with adherence to residents' care plans and speech and language therapist recommendations. RESULTS: Written recommendations predominantly focused on food and fluid modification. Observations (n = 66) revealed food texture, posture, and alertness were adhered to on 90% of occasions, but alternating food and drink, prompting and ensuring swallow completed adherence was less than 60%. Thickened fluids frequently did not align with required International Dysphagia Diet Standardisation Initiative levels. Nutrition care provided in the dining room was less safe due to a lack of designated supervision. CONCLUSION: Care homes need to be supported to establish a safe swallowing culture to improve residents' safety and care experience. WHAT THIS PAPER ADDS: What is already known on this subject? Dysphagia is associated with considerable morbidity and mortality and has been identified as an independent risk factor for mortality in nursing home residents. There is evidence that compensatory swallowing strategies, safe feeding advice and dietary modifications can reduce the risk of aspiration pneumonia. Care for nursing home residents at mealtimes is often task-centred and delegated to those with limited training and who lack knowledge of useful strategies to support the nutrition and hydration needs of residents with dysphagia. What this study adds? Written advice from speech and language therapists on safe nutrition and hydration for residents with dysphagia is focused mainly on food and fluid modification. Nurses and healthcare assistants have limited understanding of International Dysphagia Diet Standardisation Initiative levels or safe swallowing strategies and recommended practices to support safe nutrition care for residents with dysphagia are inconsistently applied especially when residents are eating in dining areas. Care homes are not aware of Royal College of Speech and Language Therapists guidance on how safe nutrition care of residents with dysphagia should be supported. What are the clinical implications of this work? Care homes need to prioritise a safe swallowing culture that ensures that residents with swallowing difficulties are assisted to eat and drink in a way that enhances their mealtime experience and minimises adverse events that may result in hospital admission. Speech and language therapists could play an important role in training and supporting care home staff to understand and use safe swallowing strategies with residents with dysphagia. The Royal College of Speech and Language Therapists could provide more assistance to care homes to support and guide them in how to implement safe feeding routines. Care home staff have limited knowledge about how to implement safe feeding routines and need more guidance from speech and language specialists on how they can support residents with dysphagia to eat safely. Creating a safe swallowing culture within care homes could help to improve nutrition care and enhance patient safety.

Realist synthesis protocol for understanding which strategies are effective to prevent urinary tract infection in older people in care homes.

AIM: To identify and characterize strategies, which contribute to the prevention of urinary tract infection (UTI) in older people living in care homes. DESIGN: The realist synthesis has four iterative stages to (1) develop initial programme theory; (2) search for evidence; (3) test and refine theory supported by relevant evidence and (4) formulate recommendations. Data from research articles and other sources will be used to explore the connection between interventions and the context in which they are applied in order to understand the mechanisms, which influence the outcomes to prevent UTI. METHODS: A scoping search of the literature and workshops with stakeholders will identify initial programme theories. These theories will be tested and refined through a systematic search for evidence relating to mechanisms that trigger prevention and recognition of UTI in older people in care homes. Interviews with key stakeholders will establish practical relevance of the theories and their potential for implementation. DISCUSSION: UTI is the most commonly diagnosed infection in care home residents. Evidence on the effectiveness of strategies to prevent UTI in long-term care facilities does not address the practicality of implementing these approaches in UK care homes. The realist synthesis is designed to examine this important gap in evidence. IMPACT: Our evidence-informed programme theory will help inform programmes to improve practice to reduce the incidence of UTI in older people living in care homes and related research. Patient and public involvement will be crucial to ensuring that our findings reach carers and the public. PATIENT AND PUBLIC CONTRIBUTION: Involvement of patient and public representatives is embedded throughout the study to ensure it is underpinned by multiple perspectives of importance to care home residents. Our co-investigator representing patient and public involvement is a lay member of the team and will chair the Project Advisory Group, which has two additional lay members. This will help to ensure that our findings and resources reach carers and the public and represent their voice in our publications and presentations to professional and lay audiences.

Drinking vessel preferences in older nursing home residents: optimal design and potential for increasing fluid intake.

BACKGROUND:: residents in nursing and residential care homes are at risk of dehydration due to both resident and institutional factors. Previous studies have focused on improving fluid intakes by concentrating on types of fluids offered and assisting residents to drink. AIM:: to determine resident opinion of the optimal features of drinking vessels and evaluate the impact of improving vessel design on fluid consumption. METHODS:: residents from two units (25-bed and 21-bed) in one nursing home evaluated a range of drinking vessels. Vessels with preferred features were introduced on a 25-bed unit. The effect was tested by observing residents' fluid consumption during breakfast on three consecutive days and comparing with baseline intakes. FINDINGS:: vessels that received the highest ratings were lightweight, had large handles and held 200-300 ml of fluid. Following the introduction of the new drinking vessels, mean fluid intakes at breakfast increased from 139 ml (±84 ml) to 205 ml (±12 ml, n=65), p=0.003. CONCLUSION:: some drinking vessels used in nursing homes may be difficult for residents to handle. Making improvements to the design of drinking vessels has the potential to increase fluid intakes without increasing staff workload.

How to reduce the risk of surgical site infection.

Surgical site infections (SSIs) are an important cause of healthcare- associated infection and are associated with considerable morbidity and mortality. Although intrinsic factors in patients--such as age, underlying illness and site of the procedure--increase the risk, the quality of care delivered during the perioperative period is critical to preventing SSI. This article explores what is known about the epidemiology and pathogenesis of SSI, and practices that are effective in reducing the risk of SSI.

UK Renal Registry 16th annual report: chapter 15 epidemiology of reported infections amongst patients receiving dialysis for established renal Failure in England from May 2011 to April 2012: a joint report from Public Health England and the UK renal registry.

INTRODUCTION: Infection remains one of the leading causes of mortality in established renal failure patients receiving renal replacement therapy (RRT). Since 2007, centres providing RRT in England have been asked to provide additional data on patients with methicillin resistant Staphylococcus aureus (MRSA) bacteraemia. Since 2011, the option to provide data on methicillin sensitive Stapylococcus aureus (MSSA) and Escherichia coli bacteraemia, as well as Clostridium difficile infection has also been available. METHODS: Data were submitted to Public Health England by laboratories via HCAI-DCS including whether the patients were receiving dialysis. Individual renal centres then confirmed the record either directly via the database or after being contacted. Data were collected for the period of the 1st May 2011 to the 30th April 2012. RESULTS: There were 49 episodes of MRSA bacteraemia, an overall rate of 0.22 per 100 dialysis patients per year, representing a further year on year fall in MRSA rate. There were a higher number of MSSA episodes, 322 in total, with an overall rate of 1.15 per 100 dialysis patients per year. The number of episodes and overall rate of E. coli and C. difficile were 284 and 0.92 per 100 prevalent dialysis patients per year and 172 and 0.61 per 100 prevalent dialysis patients per year respectively. In each infection type the presence of a central venous catheter appeared to correlate with an elevated risk. CONCLUSIONS: Data are presented from one year of infections reported to PHE. The rate of MRSA bacteraemia episodes in England continues to fall. There was a higher rate of MSSA infections amongst renal dialysis patients. Findings from the first year of E. coli and C. difficile data collection are also reported. Future cycles will give us a further idea of the trend in incidences of these infections.

Reduction in transfer of micro-organisms between patients and staff using short-sleeved gowns and hand/arm hygiene in intensive care during the COVID-19 pandemic: A simulation-based randomised trial.

Background: Current personal protective equipment (PPE) practices in UK intensive care units involve "sessional" use of long-sleeved gowns, risking nosocomial infection transmitted via gown sleeves. Data from the first wave of the COVID19 pandemic demonstrated that these changes in infection prevention and control protocols were associated with an increase in healthcare associated bloodstream infections. We therefore explored the use of a protocol using short-sleeved gowns with hand and arm hygiene to reduce this risk. Methods: ICU staff were trained in wearing short-sleeved gowns and using a specific hand and arm washing technique between patients (experimental protocol). They then underwent simulation training, performing COVID-19 intubation and proning tasks using either experimental protocol or the standard (long-sleeved) control protocol. Fluorescent powder was used to simulate microbial contamination, detected using photographs under ultraviolet light. Teams were randomised to use control or experimental PPE first. During the simulation, staff were questioned on their feelings about personal safety, comfort and patient safety. Results: Sixty-eight staff and 17 proning volunteers were studied. Experimental PPE completely prevented staff contamination during COVID-19 intubation, whereas this occurred in 30/67 staff wearing control PPE (p = .003, McNemar). Proning volunteers were contaminated by staff in 15/17 control sessions and in 1/17 with experimental PPE (p = .023 McNemar). Staff comfort was superior with experimental PPE (p< .001, Wilcoxon). Their personal safety perception was initially higher with control PPE, but changed towards neutrality during sessions (p < .001 start, 0.068 end). Their impressions of patient safety were initially similar (p = .87), but finished strongly in favour of experimental PPE (p < .001). Conclusions: Short-sleeved gowns with hand and forearm cleansing appear superior to sessional long-sleeved gowns in preventing cross-contamination between staff and patients.

Chapter 12 Epidemiology of Staphylococcus aureus bacteraemia amongst patients receiving dialysis for established renal failure in England in 2009 to 2011: a joint report from the Health Protection Agency and the UK Renal Registry.

INTRODUCTION: Infection remains one of the leading causes of death in patients with end-stage renal failure (ESRF) receiving dialysis. Since April 2007, all centres providing renal replacement therapy in England have been required to provide additional data on patients with Methicillin Resistant Staphylococcus Aureus (MRSA) infection. From January 2011 this has also been required for patients with Methicillin Sensitive Staphylococcus Aureus (MSSA). MRSA data for 2009-2011 and the first 6 months of MSSA data are reported. METHODS: Potential bacteraemia were identified by the Health Protection Agency based on clinical details provided and the clinical setting. The records were 'shared' with the parent renal centre who then complete the additional data on the HCAI-DCS website. Centres were also contacted by phone and email as a further validation step. RESULTS: From April 2009-2010 there were 77 confirmed episodes of MRSA bacteraemia at a median rate of 0.25 per 100 prevalent dialysis patients. This number decreased to 61 episodes between April 2010-2011 at a median rate of 0 per 100 prevalent dialysis patients. Overall there has been an 82% reduction in absolute episodes since the first year of mandatory reporting in 2007. The incidence of bacteraemia in patients with a central venous catheter was approximately six fold higher than in those with an AV fistula. From 1st January to 30th June 2011 there were 160 episodes of MSSA bacteraemia with a rate of 1.06 episodes per 100 dialysis patients, again the risk was six fold higher in patients with a CVC. CONCLUSIONS: Overall rates of MRSA bacteraemia in dialysis patients continued to fall although there remained variation between renal centres. Initial data from the early days of MSSA reporting suggested high rates of infection and an even greater variation between renal centres. This requires confirmation from future data collection.

The use of behaviour change theory for infection prevention and control practices in healthcare settings: A scoping review.

Background: Infection prevention and control (IPC) practices performed by healthcare workers are key to the prevention and management of infections. Compliance with IPC practices is often low, they are therefore commonly the focus of improvement interventions. Designing interventions that are based on behaviour change theories may help to improve compliance to practice. The aim of this review is to synthesise the evidence on the application of behaviour change theories to interventions to improve IPC practice in healthcare settings. Methods: A scoping review was conducted following the Joanna Briggs Institute methodological framework. The theories of focus were the Theoretical Domains Framework (TDF), Capability, Opportunity, Motivation, Behaviour (COM-B) and Behaviour Change Wheel (BCW). Studies which applied these theories to any IPC practice were included. Results: Eleven studies were identified which met the inclusion criteria. The IPC behaviours investigated were hand hygiene (7), antimicrobial stewardship (3), and MRSA screening (1). Nine studies explored barriers and facilitators to existing IPC practice; three used their findings to design a behaviour change intervention or tool. Domains of 'beliefs about consequences', 'environmental context/resources', and 'social/professional role and identity' were identified as key across all three IPC behaviours. Discussion: This review has demonstrated the use of behavioural theories to understand determinants of behaviour related to IPC practice. Currently, there are few published examples of interventions to improve IPC practice that have been underpinned by behavioural theory. Practitioners in IPC should consider the use of these methods to enhance the efficacy of strategies to change healthcare worker behaviour.

Using a multimodal strategy to improve patient hand hygiene.

OBJECTIVE: The role of health care worker hand hygiene in preventing health care associated infections (HCAI) is well-established. There is less emphasis on the hand hygiene (HH) of hospitalized patients; in the context of COVID-19 mechanisms to support it are particularly important. The purpose of this study was to establish if providing patient hand wipes, and a defined protocol for encouraging their use, was effective in improving the frequency of patient HH (PHH). DESIGN: Before and after study. SETTIN: General Hospital, United Kingdom. PARTICIPANTS: All adult patients admitted to 6 acute elderly care/rehabilitation hospital wards between July and October 2018. METHODS: Baseline audit of PHH opportunities conducted over 6 weeks. Focus group with staff and survey of the public informed the development of a PHH bundle. Effect of bundle on PHH monitored by structured observation of HH opportunities over 12 weeks. RESULTS: During baseline 303 opportunities for PHH were observed; compliance with PHH was 13.2% (40/303; 95% confidence interval 9.9-7.5). In the evaluation of PHH bundle, 526 PHH opportunities were observed with HH occurring in 58.9% (310/526); an increase of 45.7% versus baseline (95% confidence interval 39.7%-51.0%; P < .001). CONCLUSION: Providing patients with multiwipe packs of handwipes is a simple, cost-effective approach to increasing PHH and reducing the risk of HCAI in hospital. Health care workers play an essential role in encouraging PHH.

UK Renal Registry 12th Annual Report (December 2009): chapter 12: epidemiology of methicillin resistant Staphylococcus aureus bacteraemia amongst patients receiving dialysis for established renal failure in England in 2008: a joint report from the UK Renal Registry and the Health Protection Agency.

BACKGROUND: From April 2007, all centres providing renal replacement therapy in England were asked to provide additional data on patients with Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia using a secure web based system established to capture data for the mandatory surveillance of MRSA bacteremia. RESULTS: From April 2008 until March 2009 171 discrete episodes of MRSA bacteraemia were identified from the Health Protection Agency database as being potentially associated with patients in established renal failure (ERF) requiring dialysis. Of 171 records, 18 records were rejected by renal centres as not being associated with patients on dialysis or as being duplicates of other records. Following data validation by centres, 139 patients had vascular access documented (no episodes of bacteraemia were recorded amongst patients receiving peritoneal dialysis). Of these patients, 30.2% were utilising an arteriovenous fistula or graft and 69.8% were dialysing on a nontunnelled or tunnelled venous catheter. Two of the patients on arteriovenous fistulae had used venous catheters in the prior 28 days. Eleven patients had more than one episode in the year and accounted for 30 (20%) of the episodes of MRSA bacteraemia. Overall there was a reduction of 22% in episodes from the previous year. The median centre-specific rate of MRSA bacteraemia was 0.64 (range 0-3.49) episodes per 100 haemodialysis patients per year, and 0.55 (range 0-2.89) episodes per 100 dialysis (haemodialysis and peritoneal dialysis combined) patients per year. CONCLUSIONS: The rate of MRSA bacteraemia in patients requiring long term dialysis continues to fall within the prevalent dialysis population in England, but there is still marked variation in centrespecific rates.

A prevalence survey of patients with indwelling urinary catheters on district nursing caseloads in the United Kingdom: The Community Urinary Catheter Management (CCaMa) Study.

BACKGROUND: Catheter-associated urinary tract infection (CAUTI) is common in both hospitals and the community. AIM: To investigate the prevalence of indwelling urinary catheters on district nursing caseloads in the UK. METHODS: Participants were recruited through the Infection Prevention Society (IPS). An electronic survey was undertaken on a single day between November 2017 and January 2018. Data were analysed using descriptive statistics. FINDINGS: A total of 49,575 patients were included in the survey, of whom 5352 had an indwelling urinary catheter. This gave a point prevalence of 10.8% (95% confidence interval [CI] = 10.53-11.07), which varied between organisations, ranging from 2.36% (95% CI = 2.05-2.73) to 22.02% (95% CI = 20.12-24.05). Of catheters, 5% were newly placed (within four weeks). Of these, most (77%) had a documented indication for insertion. Only half of patients with a newly placed catheter had a plan for its removal. This varied between organisations in the range of 20%-96%. Only 13% of patients had a patient-held management plan or 'catheter passport' but these patients were significantly more likely to also have an active removal plan (28/36 [78%] vs. 106/231 [46%]; P < 0.0001). Alternative bladder management strategies had been considered for 70/267 (26%) patients. DISCUSSION: The management of patients with an indwelling urinary catheter represents a significant component of district nursing caseloads. Given the high proportion of newly catheterised patients without an active management plan for removal of the catheter, the establishment of an optimal management pathway should be the focus of future prevention efforts.

Cost-benefit analysis of surveillance for surgical site infection following caesarean section.

OBJECTIVE: To estimate the economic burden to the health service of surgical site infection following caesarean section and to identify potential savings achievable through implementation of a surveillance programme. DESIGN: Economic model to evaluate the costs and benefits of surveillance from community and hospital healthcare providers' perspective. SETTING: England. PARTICIPANTS: Women undergoing caesarean section in National Health Service hospitals. MAIN OUTCOME MEASURE: Costs attributable to treatment and management of surgical site infection following caesarean section. RESULTS: The costs (2010) for a hospital carrying out 800 caesarean sections a year based on infection risk of 9.6% were estimated at £18 914 (95% CI 11 521 to 29 499) with 28% accounted for by community care (£5370). With inflation to 2019 prices, this equates to an estimated cost of £5.0 m for all caesarean sections performed annually in England 2018-2019, approximately £1866 and £93 per infection managed in hospital and community, respectively. The cost of surveillance for a hospital for one calendar quarter was estimated as £3747 (2010 costs). Modelling a decrease in risk of infection of 30%, 20% or 10% between successive surveillance periods indicated that a variable intermittent surveillance strategy achieved higher or similar net savings than continuous surveillance. Breakeven was reached sooner with the variable surveillance strategy than continuous surveillance when the baseline risk of infection was 10% or 15% and smaller loses with a baseline risk of 5%. CONCLUSION: Surveillance of surgical site infections after caesarean section with feedback of data to surgical teams offers a potentially effective means to reduce infection risk, improve patient experience and save money for the health service.

UK Renal Registry 11th Annual Report (December 2008): Chapter 12 Epidemiology of Methicillin Resistant Staphylococcus aureus bacteraemia amongst patients receiving Renal Replacement Therapy in England in 2007.

From April 2007, all centres providing Renal Replacement Therapy in England were asked to provide additional data on patients with Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia using a secure web-based system. Data were recorded on modality of treatment and the type of vascular access in use at diagnosis and in the previous 28 days. From April 2007 until March 2008, 188 discrete episodes of MRSA bacteraemia were reported in patients receiving dialysis for established renal failure. Over the same period 4,448 MRSA bacteraemias were reported in England, indicating that 4.2% of all cases occurred in dialysis patients. Of the 188 episodes, additional data from the renal centres were available in 92 cases (49%). All patients with completed records were on haemodialysis at the time of the bacteraemia. Of those, 65/92 (70.7%) were using venous catheters, the majority tunnelled lines (n = 55, 59.8%), and 2 other cases had used venous catheters in the previous 28 days. The relative risk of MRSA bacteraemia was about 100 fold higher for a dialysis patient in comparison to the general population and 8 fold higher for a patient using a catheter in comparison to a fistula. The mean rate for all patients was 0.92 +/- 0.85 episodes/100 prevalent dialysis patients/year but the rate varied between renal centres with a range of 0-3.28. Using just haemodialysis patients as the denominator, the mean was 1.14 +/- 0.95 episodes/100 patients/year with a range of 0-3.93. Compared to previous Registry reports, absolute numbers of reported MRSA bacteraemias has fallen by approximately 62% from 2004. Many centres have substantially reduced the numbers of cases. Dialysis patients are at increased risk of MRSA bacteraemia; this is closely associated with the use of venous catheters. The rate of MRSA bacteraemia is falling substantially within the prevalent dialysis population, but with variation in performance between centres.

Improving hydration of care home residents by increasing choice and opportunity to drink: A quality improvement study.

BACKGROUND & AIMS: Dehydration is recognised as an important problem among care home residents and can be associated with severe consequences. Insufficient provision of fluids to meet resident preferences and lack of assistance to drink have been identified as key factors driving under-hydration of care home residents. Using targeted interventions, this study aimed to optimise hydration care for frail older people in a care home setting. METHODS: The study used quality improvement methods to develop and test interventions to extend drinking opportunities and choice in two care homes. Changes were made and evaluated using Plan-Do-Study-Act (PDSA) cycles. Data were captured on the amount of fluids served and consumed, and staff and resident feedback. The long-term impact of the interventions was assessed by measuring daily laxative and antibiotic consumption, weekly incidence of adverse health events, and average fluid intake of a random sample of six residents captured monthly. RESULTS: The interventions were associated with an increase in the amount and range of fluids consumed, in one home mean fluid intakes exceeded 1500 ml for three consecutive months. Laxative use decreased significantly in both homes. A number of practical and organisational barriers affected the sustainability of interventions. CONCLUSIONS: Interventions to optimise the hydration of care home residents can be effective. Plan-Do-Study-Act cycles provide an effective methodology to implement new interventions into existing practice in care homes. Sustainable change requires strong leadership, organisational support and teamwork.

I-Hydrate training intervention for staff working in a care home setting: An observational study.

BACKGROUND: Dehydration is a complex and well-recognised problem for older people residing in care homes. Within the social care sector support staff provide the majority of direct care for residents, and yet receive minimal training. OBJECTIVES: To design, deliver and evaluate a hydration specific training session for care home staff to develop their knowledge and skills in supporting the hydration of care home residents. DESIGN: An observational study comprising a pre-test post-test survey of staff knowledge following a training intervention. PARTICIPANTS AND SETTINGS: Training of care home staff took place in two care homes in North West London. METHODS: An interactive training session was developed and delivered, with content informed by observations of hydration care within the two homes and evaluated using CIRO model. Participant self-evaluation forms were used to collect data after the session regarding satisfaction and usefulness of the session, and pre and post levels of self-reported knowledge across six facets of hydration care. Training facilitators captured qualitative data in the form of field notes. Observations of hydration care explored the impact of training on practice. RESULTS: Eighteen training sessions were delivered. A total of 161 participant evaluation forms were returned. There was a significant increase in self-reported knowledge across all six facets of hydration care (p = 0.000). The majority of participants found the training enjoyable and useful, and expressed an expected change in their practice. Participants enjoyed the interactive components of the training. A lack of reflective practice skills meant participants were unable to reflect realistically about the hydration care provided in the home. CONCLUSION: Focused training on hydration in the care home environment benefits from being interactive and experiential. Although such training can be effective in increasing staff knowledge, inclusion of skills in reflective practice is required if this knowledge is to be translated into practice.

Relationship between hospital ward design and healthcare associated infection rates: what does the evidence really tell us? Comment on Stiller et al. 2016.

The systematic review published by Stiller et al. in Antimicrobial Resistance & Infection Control in November 2016 concludes that single-patient bedrooms confer a significant benefit for protecting patients from healthcare associated infection and colonization. This conclusion is not substantiated by the evidence included in their review which has been largely drawn from uncontrolled before and after studies in the absence of a transparent assessment of the risk of bias. There are also errors in the analysis of supporting data. Evaluating the specific impact of single rooms on preventing transmission from a sound epidemiological perspective is essential to assure safe and effective care and a clear evidence-base for infection prevention and control advice.

Applying human factors and ergonomics to the misuse of nonsterile clinical gloves in acute care.

BACKGROUND: Health care workers (HCWs) are recommended to wear nonsterile clinical gloves (NSCG) for direct contact with blood and body fluids. However, there is evidence of extensive inappropriate NSCG use. METHODS: A mixed-methods study comprising observation of NSCG use in 2 acute hospitals and semistructured HCW interviews. Qualitative data were categorized using thematic analysis. Findings were mapped to the Systems Engineering Initiative for Patient Safety model and used to develop a strategy for improving NSCG use. RESULTS: Two hundred seventy-eight procedures performed in 178 episodes of care involved the use of NSCG. NSCG were inappropriate for 59% of procedures (165 out of 278). Risk of cross-contamination occurred in 49% (87 out of 178) episodes. Twenty-six HCWs were interviewed; emotion and socialization were key factors influencing decisions to use NSCG. Data from observation and thematic analysis were mapped to 6 interacting components of the Systems Engineering Initiative for Patient Safety work system. Interventions targeting each component informed quality improvement strategies CONCLUSIONS: Despite intense promotion of hand hygiene as the key measure to protect patients from health care-associated infection, NSCG dominate routine clinical practice and potential cross-contamination occurs in 50% of care episodes. Such practice is associated with significant environmental and financial costs and adversely affects patient safety. The application of human factors and ergonomics to the complex drivers of inappropriate NSCG behavior may be more effective than conventional approaches of education and policy in achieving the goal of preventing health care-associated infection and improving patient safety.

Public perceptions of the use of gloves by healthcare workers and comparison with perceptions of student nurses.

INTRODUCTION: There is evidence that non-sterile clinical gloves (NSCG) are over-used by healthcare workers (HCWs) and are associated with cross-contamination. This study aimed to determine attitudes of student nurses and members of the public to the use of NSCG. METHODS: Third-year student nurses completed a questionnaire indicating tasks for which they would wear NSCG and influences on their decision. Correlations between tasks were identified using exploratory factor analysis. An online survey of the public was conducted using snowball sampling method. RESULTS: Sixty-seven students completed the questionnaire; they indicated use of NSCG for low-risk tasks and reported their own judgement as the main influence on their decision to wear them. Correlated tasks included 'perceived to be risky' or 'definitive indication for gloves/no gloves' and 'related to personal hygiene'. A total of 142 respondents completed the public survey. They reported being uncomfortable with HCW wearing gloves for some personal tasks, e.g. assisting to toilet and dressing, but 94% preferred their use for washing 'private parts'; 29% had observed inappropriate glove use by HCWs during recent contact with healthcare. CONCLUSION: Student nurses reported using NSCG routinely for tasks for which they are neither required nor recommended. The public observe inappropriate glove use and are uncomfortable with their use for some personal tasks.