Train-the-Trainers in hand hygiene facilitate the implementation of the WHO hand hygiene multimodal improvement strategy in Japan: evidence for the role of local trainers, adaptation, and sustainability.

BACKGROUND: "Train-the-Trainers in hand hygiene" (TTT) is a standardized training to train infection prevention and control (IPC) practitioners with the aim to promote hand hygiene in health care according to the World Health Organization (WHO) multimodal improvement strategy. Little is known in the literature about the sustained impact of hand hygiene and IPC trainings adapted locally. The aim of this study is to describe the impact of three TTT courses conducted annually in Japan on the adoption of the WHO multimodal improvement strategy by local IPC practitioners who became a "trainer" after their first TTT participation as a "trainee". METHODS: Three TTT courses were conducted annually from 2020 to 2022 in Japan. A team "TTT-Japan" composed of more than 20 IPC practitioners who completed their first TTT participation adapted the original TTT program to reflect the local healthcare context in Japan, and subsequently convened the 2nd and 3rd TTTs. Pre- and post-course evaluations and post-course satisfaction surveys of the course participants were conducted to assess improvement in knowledge on hand hygiene and perception towards the course, respectively. Attitude and practice surveys of the TTT-Japan trainers were conducted to assess their perception and experience in hand hygiene promotion. The Hand Hygiene Self-Assessment Framework (HHSAF), a validated tool created by WHO to monitor the capacity of hand hygiene promotion at facility level, was applied at TTT-Japan trainers' facilities to compare results before and after trainers' engagement. We applied inductive thematic analysis for qualitative analyses of open-ended survey questions of the trainers' attitude and practice surveys, and the Wilcoxon Sign Rank test for quantitive comparisons of pre- and post-data for the surveys and HHSAF. RESULTS: 158 Japanese healthcare workers participated in three TTT courses, the majority of whom (131, 82.9%) were nurses. Twenty-seven local trainers were involved in 2nd and 3rd TTTs. The scores of pre- and post-course evaluations significantly improved after the course (P < 0.001) and the improvement was consistent across all three TTTs. Post-course satisfaction survey showed that over 90% of the participants reported that the course met their expectations and that what they learned in the courses would be useful for their practice. Trainers' attitude and practice survey showed that more than three quarters (76.9%) of the trainers reported that their experience as a trainer had a positive impact on their practice at their own facilities. Qualitative analysis of the trainers' attitude and practice survey revealed that trainers appreciated continuous learning as a trainer, and group effort to promote hand hygiene as the TTT-Japan team. The HHSAF institutional climate change element at the trainers' facilities significantly improved after their engagement as a trainer (P = 0.012). CONCLUSIONS: TTTs were successfully adapted and implemented in Japan, leading to sustained hand hygiene promotion activities by local trainers over three years. Further research is warranted to assess the long-term impact on local hand hygiene promotion in different settings.

A Multimodal Cardioprotection Strategy During Cardiac Surgery: The ProCCard Study.

OBJECTIVE: The ProCCard study tested whether combining several cardioprotective interventions would reduce the myocardial and other biological and clinical damage in patients undergoing cardiac surgery. DESIGN: Prospective, randomized, controlled trial. SETTING: Multicenter tertiary care hospitals. PARTICIPANTS: 210 patients scheduled to undergo aortic valve surgery. INTERVENTIONS: A control group (standard of care) was compared to a treated group combining five perioperative cardioprotective techniques: anesthesia with sevoflurane, remote ischemic preconditioning, close intraoperative blood glucose control, moderate respiratory acidosis (pH 7.30) just before aortic unclamping (concept of the "pH paradox"), and gentle reperfusion just after aortic unclamping. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the postoperative 72-h area under the curve (AUC) for high-sensitivity cardiac troponin I (hsTnI). Secondary endpoints were biological markers and clinical events occurring during the 30 postoperative days and the prespecified subgroup analyses. The linear relationship between the 72-h AUC for hsTnI and aortic clamping time, significant in both groups (p < 0.0001), was not modified by the treatment (p = 0.57). The rate of adverse events at 30 days was identical. A non-significant reduction of the 72-h AUC for hsTnI (-24%, p = 0.15) was observed when sevoflurane was administered during cardiopulmonary bypass (46% of patients in the treated group). The incidence of postoperative renal failure was not reduced (p = 0.104). CONCLUSION: This multimodal cardioprotection has not demonstrated any biological or clinical benefit during cardiac surgery. The cardio- and reno-protective effects of sevoflurane and remote ischemic preconditioning therefore remain to be demonstrated in this context.

Impacto de una intervención multimodal en el cumplimiento de higiene de manos en los profesionales sanitarios de un hospital de tercer nivel / Impact of a multimodal intervention on compliance with hand hygiene among health care workers of a tertiary hospital

Antecedente y objetivo: La higiene de manos (HM) es la medida más sencilla y eficaz para la prevención de la infección relacionada con la asistencia sanitaria. A pesar de ello, el cumplimiento en los profesionales sanitarios continúa siendo subóptimo. El objetivo de este estudio es evaluar el impacto de una estrategia multimodal de la Organización Mundial de la Salud (OMS) ampliada en el cumplimiento de la HM en el personal sanitario.Material y métodosSe diseñó un estudio cuasiexperimental pretest-postest, llevando a cabo durante 2018 la estrategia multimodal de la OMS ampliada y dirigida a los profesionales de un hospital de tercer nivel. En esta estrategia, aparte de aplicar los 5 pilares de la OMS, se realizó un vídeo, la administración del cuestionario de percepciones de la OMS y un incentivo al servicio/unidad con mejor cumplimiento, añadiendo a la formación una modalidad de talleres prácticos. Se compararon los porcentajes de cumplimiento del año 2017 y 2018.ResultadosEn el año 2017 se observaron 1.056 oportunidades, registrándose 631 acciones de HM, siendo el cumplimiento global del 60% (IC 95% 56,7-62,7). En el año 2018, con 1.481 oportunidades observadas y 1.111 acciones de HM, el cumplimiento fue del 75% (IC 95% 72,7-77,2) (p<0,001). Este cumplimiento se incrementó en todos los estamentos y en todas las indicaciones.ConclusionesLa aplicación de una estrategia multimodal ampliada tiene un impacto positivo en el cumplimiento de HM. Se deben dirigir estrategias a los estamentos con peor cumplimiento y de forma continuada en el tiempo. (AU)

Background and objective: Hand hygiene (HH) is the simplest and most effective measure for the prevention of infection related to healthcare. Despite this, compliance in healthcare professionals continues to be suboptimal. The aim of this study is to assess the impact of an expanded World Health Organization (WHO) multimodal strategy on HH compliance in healthcare personnel.Material and methodsA quasi-experimental before-after study was designed, carrying out the expanded WHO multimodal strategy in 2018, aimed at professionals in a tertiary hospital. In this strategy, apart from applying the 5 pillars of the WHO, a video was made, the administration of the WHO perceptions questionnaire and an incentive to the service/unit with better compliance, adding to the training a modality of practical workshops. The compliance percentages for 2017 and 2018 were compared.ResultsIn 2017, 1056 opportunities were observed, registering 631 HH actions, with global compliance of 60% (95% CI 56.7-62.7). In 2018, with 1481 opportunities observed and 1111 HH actions, compliance was 75% (95% CI 72.7-77.2) (P<.001). This compliance increased in all professional categories and in all indications.ConclusionsThe application of an expanded multimodal strategy has a positive impact on HH compliance. Strategies should be directed to the categories with the worst compliance and continuously over time. (AU)

Effect of a multimodal strategy for prevention of nosocomial influenza: a retrospective study at Grenoble Alpes University Hospital from 2014 to 2019.

BACKGROUND: A multimodal strategy to prevent nosocomial influenza was implemented in 2015-2016 in Grenoble Alpes University Hospital. Three modalities were implemented in all units: promotion of vaccination among healthcare workers, epidemiologic surveillance and communication campaigns. Units receiving a high number of patients with influenza implemented 2 additional modalities: improvement of diagnosis capacities and systematic surgical mask use. The main objective was to assess the effectiveness of the strategy for reducing the risk of nosocomial influenza. METHODS: A study was conducted retrospectively investigating 5 epidemic seasons (2014-2015 to 2018-2019) including all patients hospitalized with a positive influenza test at Grenoble Alpes University Hospital. The weekly number of nosocomial influenza cases was analyzed by Poisson regression and incidence rate ratios (IRR) were estimated. RESULTS: A total of 1540 patients, resulting in 1559 stays, were included. There was no significant difference between the 5 influenza epidemic seasons in the units implementing only 3 measures. In the units implementing the 5 measures, there was a reduction of nosocomial influenza over the seasons when the strategy was implemented compared to the 2014-2015 epidemic season (IRR = 0.56, 95% CI = 0.23-1.34 in 2015-2016; IRR = 0.39, 95% CI = 0.19-0.81 in 2016-2017; IRR = 0.50, 95% CI = 0.24-1.03 in 2017-2018; IRR = 0.48, 95% CI = 0.23-0.97 in 2018-2019). CONCLUSIONS: Our data mainly suggested that the application of the strategy with 5 modalities, including systematic surgical mask use and rapid diagnosis, seemed to reduce by half the risk of nosocomial influenza. Further data, including medico-economic studies, are necessary to determine the opportunity of extending these measures at a larger scale.

Effectiveness and sustainability of the WHO multimodal hand hygiene improvement strategy in the University Hospital Bouaké, Republic of Côte d'Ivoire in the context of the COVID-19 pandemic.

INTRODUCTION: The most frequent adverse events in healthcare are healthcare-associated infections, whose burden is highest in resource-limited settings. In addition, low resource settings often lack Hand Hygiene (HH) knowledge and reliable supply to disinfectant, a necessity emphasized by the past West African Ebola Epidemic and the ongoing COVID-19 pandemic. PASQUALE aims to increase patient safety by introducing the WHO multimodal HH strategy in the University Hospital Bouaké, Côte d'Ivoire. METHODS: Assessment of HH knowledge, perception and compliance was performed 12 months before, right after the intervention and at a ten months interval using questionnaires for knowledge and perception and direct observation for compliance. The intervention consisted of a HH training and the introduction of local production of alcohol-based hand-rub. In the absence of a control group, the effectiveness of the intervention was assessed by a before-and-after study. RESULTS: Baseline knowledge score was 14/25, increased significantly to 17/25 (p < 0.001) upon first and decreased to 13/25 in second follow-up. Compliance showed a significant increase from 12.7% to 36.8% (p < 0.001) in first and remained at 36.4% in second follow-up. Alcohol-based hand-rub production and consumption almost doubled after first confirmed COVID-19 case in Côte d'Ivoire. CONCLUSION: The WHO HH improvement strategy is an effective and pandemic-adaptable method to increase long-term HH compliance. This study emphasizes that the implementation of the strategy to build a robust system is of utmost importance.

Impact of a multimodal intervention on compliance with hand hygiene among health care workers of a tertiary hospital. / Impacto de una intervención multimodal en el cumplimiento de higiene de manos en los profesionales sanitarios de un hospital de tercer nivel.

BACKGROUND AND OBJECTIVE: Hand hygiene (HH) is the simplest and most effective measure for the prevention of infection related to healthcare. Despite this, compliance in healthcare professionals continues to be suboptimal. The aim of this study is to assess the impact of an expanded World Health Organization (WHO) multimodal strategy on HH compliance in healthcare personnel. MATERIAL AND METHODS: A quasi-experimental before-after study was designed, carrying out the expanded WHO multimodal strategy in 2018, aimed at professionals in a tertiary hospital. In this strategy, apart from applying the 5 pillars of the WHO, a video was made, the administration of the WHO perceptions questionnaire and an incentive to the service/unit with better compliance, adding to the training a modality of practical workshops. The compliance percentages for 2017 and 2018 were compared. RESULTS: In 2017, 1056 opportunities were observed, registering 631 HH actions, with global compliance of 60% (95% CI 56.7-62.7). In 2018, with 1481 opportunities observed and 1111 HH actions, compliance was 75% (95% CI 72.7-77.2) (P<.001). This compliance increased in all professional categories and in all indications. CONCLUSIONS: The application of an expanded multimodal strategy has a positive impact on HH compliance. Strategies should be directed to the categories with the worst compliance and continuously over time.

Implementation of the Comprehensive Unit-Based Safety Program to Improve Infection Prevention and Control Practices in Four Neonatal Intensive Care Units in Pune, India.

Objective: To implement the Comprehensive Unit-based Safety Program (CUSP) in four neonatal intensive care units (NICUs) in Pune, India, to improve infection prevention and control (IPC) practices. Design: In this quasi-experimental study, we implemented CUSP in four NICUs in Pune, India, to improve IPC practices in three focus areas: hand hygiene, aseptic technique for invasive procedures, and medication and intravenous fluid preparation and administration. Sites received training in CUSP methodology, formed multidisciplinary teams, and selected interventions for each focus area. Process measures included fidelity to CUSP, hand hygiene compliance, and central line insertion checklist completion. Outcome measures included the rate of healthcare-associated bloodstream infection (HA-BSI), all-cause mortality, patient safety culture, and workload. Results: A total of 144 healthcare workers and administrators completed CUSP training. All sites conducted at least 75% of monthly meetings. Hand hygiene compliance odds increased 6% per month [odds ratio (OR) 1.06 (95% CI 1.03-1.10)]. Providers completed insertion checklists for 68% of neonates with a central line; 83% of checklists were fully completed. All-cause mortality and HA-BSI rate did not change significantly after CUSP implementation. Patient safety culture domains with greatest improvement were management support for patient safety (+7.6%), teamwork within units (+5.3%), and organizational learning-continuous improvement (+4.7%). Overall workload increased from a mean score of 46.28 ± 16.97 at baseline to 65.07 ± 19.05 at follow-up (p < 0.0001). Conclusion: CUSP implementation increased hand hygiene compliance, successful implementation of a central line insertion checklist, and improvements in safety culture in four Indian NICUs. This multimodal strategy is a promising framework for low- and middle-income country healthcare facilities to reduce HAI risk in neonates.

Hand hygiene compliance: bridging the awareness-practice gap in sub-Saharan Africa.

This review provides an exploratory overview of hand hygiene compliance in sub-Saharan Africa and examines strategies to bridge the compliance gap. While there is increasing awareness on hand hygiene, empirical evidence suggests that there is no concurrent increase in correct hand hygiene practice among key populations in sub-Saharan Africa. Children, adolescents and even healthcare providers (HCPs) in sub-Saharan Africa consistently assume poor hand hygiene compliance levels resulting in negative health consequences. Faecal-oral diseases remain common among schoolchildren, leading to school absenteeism and disease-specific morbidity. Additionally, the incidence of nosocomial infections in health facilities in sub-Saharan Africa remains high, as many HCPs do not adopt good hand hygiene practice. Increased disease burden, high healthcare costs and eroding public confidence in the healthcare system are a few implications of HCPs' poor compliance with hand hygiene. These trends underscore the inadequacies of educational approaches (cognition model) to hand hygiene promotion commonly adopted in sub-Saharan Africa. It was therefore recommended that the governments of sub-Saharan Africa should focus on promoting skill-based hygiene education which will help schoolchildren develop good hand hygiene practice as a lifelong skill. In addition, efforts should be made to implement a multimodal hand hygiene strategy in healthcare facilities in order to increase compliance by healthcare providers.

Implementation of the WHO hand hygiene strategy in Faranah regional hospital, Guinea.

BACKGROUND: Healthcare-associated infections are the most frequent adverse events in healthcare worldwide, with limited available evidence suggesting highest burden in resource-limited settings. Recent Ebola epidemics emphasize the disastrous impact that spread of infectious agents within healthcare facilities can have, accentuating the need for improvement of infection control practices. Hand hygiene (HH) measures are considered to be the most effective tool to prevent healthcare-associated infections. However, HH knowledge and compliance are low, especially in vulnerable settings such as Guinea. The aim of PASQUALE (Partnership to Improve Patient Safety and Quality of Care) was to assess knowledge and compliance with HH and improve HH by incorporating the WHO HH Strategy within the Faranah Regional Hospital (FRH), Guinea. METHODS: In a participatory approach, a team of FRH staff and leadership was invited to identify priorities of the hospital prior to the start of PASQUALE. The local hygiene committee was empowered to increase its activities and take ownership of the HH improvement strategy. A baseline assessment of knowledge, perception and compliance was performed months before the intervention. The main intervention consisted of local alcohol-based-hand-rub (ABHR) production, with final product efficacy testing, in conjunction with a training adapted to the needs identified in the baseline assessment. A follow-up assessment was conducted directly after the training. Effectiveness of the intervention was assessed via uncontrolled before-and-after comparison. RESULTS: Baseline knowledge score (13.0/25) showed a significant increase to 19.0/25 in follow-up. Baseline-Compliance was 23.7% and increased significantly to 71.5% in follow-up. Compliance rose significantly across all professional groups except for midwifes and in all indications for HH, with the largest in the indication "Before aseptic tasks". The increase in compliance was associated with the intervention and remained significant after adjusting for confounders. The local pharmacy successfully supplies the entire hospital. The local supply resulted in a ten-fold increase of monthly hospital disinfectant consumption. CONCLUSION: The WHO HH strategy is an adaptable and effective method to improve HH knowledge and compliance in a resource-limited setting. Local production is a feasible method for providing self-sufficient supply of ABHR to regional hospitals like the FRH. Participatory approaches like hygiene committee ownership builds confidence of sustainability.

Assessment of hand hygiene facilities and staff compliance in a large tertiary health care facility in northern Nigeria: a cross sectional study.

BACKGROUND: The burden of healthcare-associated infection (HAI) is 2 to 18 times higher in developing countries. However, few data are available regarding infection prevention and control (IPC) process indicators in these countries. We evaluated hand hygiene (HH) facilities and compliance amongst healthcare workers (HCW) in a 600-bed healthcare facility in Northcentral Nigeria providing tertiary care service for a catchment population of about 20 million. METHODS: An in-house facility assessment tool and the World Health Organization (WHO) direct observation method were used to assess the HH facilities and compliance, respectively. Factors associated with good compliance were determined by multivariate analysis. RESULTS: The facility survey was carried out in all 46 clinical units of the hospital. 72% of the units had no poster or written policy on HH; 87% did not have alcohol-based hand rubs; 98% had at least one handwash sink; 28% had flowing tap water all day while 72% utilized cup and bucket; and 58% had no hand drying facilities. A total of 406 HH opportunities were observed among 175 HCWs. The overall compliance was 31%, ranging from 18% among ward attendants to 82% among medical students. Based on WHO "5 moments" for HH, average compliance was 21% before patient contact, 23% before aseptic procedure, 63% after body fluid exposure risk, 41% after patient contact and 40% after contact with patients' surrounding. Being a medical student was independently associated with high HH compliance, adjusted odds ratio: 13.87 (1.70-112.88). CONCLUSIONS: Availability of HH facilities and HCW compliance in a large tertiary hospital in Nigeria is poor. Our findings confirm that HCWs seem more sensitized to their risk of exposure to potential pathogens than to the prevention of HAI cross-transmission. Inadequate HH facilities probably contributed to the poor compliance. Specific measures such as improved facilities, training and monitoring are needed to improve HH compliance.

Impact of implementation of a modified World Health Organization multimodal hand hygiene strategy in a university teaching hospital.

BACKGROUND: Although educational programs could enhance knowledge, practices, and compliance with hand hygiene (HH) for health care workers, the researches focusing on effective methods for educating and increasing the compliance with HH practices are scanty. Consequently, the researchers conducted the present study to assess HH-related knowledge, attitude, and compliance rate after the implementation of a modified version of the World Health Organization (WHO) multimodal strategy was written in the background. METHODS: A pretest-posttest quasiexperimental study was conducted in a university hospital in Cairo among 84 nurses. The study consisted of 4 phases: baseline assessment, intervention, postintervention assessment, and follow-up phase. The intervention (HH-campaign) consisted of 4 components: infrastructure change, training/education of health care workers, posting visual reminders, and development of institutional safety climate "hand hygiene champions." RESULTS: HH compliance rate significantly increased from 28% before the intervention to 50% after the intervention and 58% after the follow-up period (P < .001). The knowledge score and the attitude score significantly improved before and after the intervention (P < .001). The use of alcohol handrub significantly increased from 9.5% before the intervention to 65% after the intervention and 76% after the follow-up period. CONCLUSIONS: Implementation of a modified version of the World Health Organization multimodal strategy successfully doubled HH compliance rates. Tackling a social way of thinking together with regular frequent training and follow-up are essential to sustain adherence to safe HH practices.

Hand hygiene - social network analysis of peer-identified and management-selected change agents.

Background: Hand hygiene compliance can be improved by strategies fostering collaborative efforts among healthcare workers (HCWs) through change agents. However, there is limited information about how change agents shape the social networks of work teams, and how this relates to organisational culture. The objectives of this study were to describe the influence of peer-identified change agents (PICAs) and management-selected change agents (MSCAs) on hand hygiene, perception of their leadership style by peers, and the role of the organisational culture in the process of hand hygiene promotion. Methods: This study, stratified in pre-, during, and post-intervention periods, was conducted between February 2017 and March 2018 in two wards at a tertiary care hospital in Malaysia. Hand hygiene promotion was facilitated either by PICAs (study arm 1) or MSCAs (study arm 2), and the two wards were randomly allocated to one of the two interventions. Outcomes were: 1) perceived leadership styles of PICAs and MSCAs by staff, vocalised during question and answer sessions; 2) the social network connectedness and communication patterns between HCWs and change agents by applying social network analysis; and 3) hand hygiene leadership attributes obtained from HCWs in the post-intervention period by questionnaires. Results: Hand hygiene compliance in study arm 1 and study arm 2 improved by from 48% (95% CI: 44-53%) to 66% (63-69%), and from 50% (44-55%) to 65% (60-69%), respectively. There was no significant difference between the two arms. Healthcare workers perceived that PICAs lead by example, while MSCAs applied an authoritarian top-down leadership style. The organisational culture of both wards was hierarchical, with little social interaction, but strong team cohesion. Position and networks of both PICAs and MSCAs were similar and generally weaker compared to the leaders who were nominated by HCWs in the post-intervention period. Healthcare workers on both wards perceived authoritative leadership to be the most desirable attribute for hand hygiene improvement. Conclusion: Despite experiencing successful hand hygiene improvement from PICAs, HCWs expressed a preference for the existing top-down leadership structure. This highlights the limits of applying leadership models that are not supported by the local organisational culture.

Multimodal cardioprotective strategy in cardiac surgery (the ProCCard trial): Study protocol for a multicenter randomized controlled trial.

BACKGROUND: Myocardial damage in patients undergoing cardiac surgery increases both morbidity and mortality. Different protective strategies dealing with either preconditioning or postconditioning or assessing a single aspect of cardioprotection have shown conflicting results. We tested the hypothesis that a multimodal approach would improve cardioprotection and limit myocardial damage following cardiac surgery with cardiopulmonary bypass. METHODS: This study is a pragmatic multicenter (six French institutions), prospective, randomized, single-blinded, controlled trial. The randomization is stratified by centers. In the study, 210 patients scheduled for aortic valve surgery with or without coronary artery bypass grafting will be assigned to a control or a treatment group (105 patients in each group). In the control group, patients receive total intravenous anesthesia with propofol and liberal intraoperative blood glucose management (initiation of insulin infusion when blood glucose, measured every 60 min, is greater than 180 mg/dl), as a standard of care. The treatment group receives a bundle of care combining five techniques of cardioprotection: (1) remote ischemic preconditioning applied before aortic cross-clamping; (2) maintenance of anesthesia with sevoflurane; (3) tight intraoperative blood glucose management (initiation of insulin infusion when blood glucose, measured every 30 min, is greater than 140 mg/dl); (4) moderate respiratory acidosis (pH 7.30) at the end of cardiopulmonary bypass; and (5) a gentle reperfusion protocol following aortic unclamping. The primary outcome is myocardial damage measured by postoperative 72-h area under the curve of high-sensitivity cardiac troponin I. DISCUSSION: The ProCCard study will be the first multicenter randomized controlled trial aiming to assess the role of a bundle of care combining several cardioprotective strategies to reduce myocardial damage in patients undergoing cardiac surgery with cardiopulmonary bypass. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03230136 . Registered on July 26, 2017. Last updated on April 17, 2019.

Effectiveness over time of a multimodal intervention to improve compliance with standard hygiene precautions in an intensive care unit of a large teaching hospital.

Background: Standard hygiene precautions are an effective way of controlling healthcare-associated infections. Nevertheless, compliance with hand hygiene (HH) guidelines among healthcare workers (HCWs) is often poor, and evidence regarding appropriate use of gloves and gowns is limited and not encouraging. In this study, we evaluated the ability over time of a multimodal intervention to improve HCWs compliance with standard hygiene precautions. Methods: Trend analysis of direct observations of compliance with HH guidelines and proper glove or gown use was conducted in the medical/surgical intensive care unit (ICU) of Umberto I Teaching Hospital of Sapienza University of Rome. The study consisted of two phases: a six-month baseline phase and a 12-month post-intervention phase. The multimodal intervention was based on the World Health Organization strategy and included education and training of HCWs, together with performance feedback. Results: A total of 12,853 observations were collected from November 2016 to April 2018. Overall compliance significantly improved from 41.9% at baseline to 62.1% (p < 0.001) after the intervention and this improvement was sustained over the following trimesters. Despite variability across job categories and over the study period, a similar trend was observed for most investigations. The main determinants of compliance were job category (with nurses having the highest compliance rates), being a member of ICU staff and whether delivering routine, as opposed to emergency, care. HH compliance was modified by glove use; unnecessary gloving negatively affected HH behaviour while appropriate gloving positively influenced it. Conclusions: The multimodal intervention resulted in a significant improvement in compliance with standard hygiene precautions. However, regular educational reinforcement and feedback is essential to maintain a high and uniform level of compliance.

Train-the-Trainers in hand hygiene: a standardized approach to guide education in infection prevention and control.

BACKGROUND: Harmonization in hand hygiene training for infection prevention and control (IPC) professionals is lacking. We describe a standardized approach to training, using a "Train-the-Trainers" (TTT) concept for IPC professionals and assess its impact on hand hygiene knowledge in six countries. METHODS: We developed a three-day simulation-based TTT course based on the World Health Organization (WHO) Multimodal Hand Hygiene Improvement Strategy. To evaluate its impact, we have performed a pre-and post-course knowledge questionnaire. The Wilcoxon signed-rank test was used to compare the results before and after training. RESULTS: Between June 2016 and January 2018 we conducted seven TTT courses in six countries: Iran, Malaysia, Mexico, South Africa, Spain and Thailand. A total of 305 IPC professionals completed the programme. Participants included nurses (n = 196; 64.2%), physicians (n = 53; 17.3%) and other health professionals (n = 56; 18.3%). In total, participants from more than 20 countries were trained. A significant (p < 0.05) improvement in knowledge between the pre- and post-TTT training phases was observed in all countries. Puebla (Mexico) had the highest improvement (22.3%; p < 0.001), followed by Malaysia (21.2%; p < 0.001), Jalisco (Mexico; 20.2%; p < 0.001), Thailand (18.8%; p < 0.001), South Africa (18.3%; p < 0.001), Iran (17.5%; p < 0.001) and Spain (9.7%; p = 0.047). Spain had the highest overall test scores, while Thailand had the lowest pre- and post-scores. Positive aspects reported included: unique learning environment, sharing experiences, hands-on practices on a secure environment and networking among IPC professionals. Sustainability was assessed through follow-up evaluations conducted in three original TTT course sites in Mexico (Jalisco and Puebla) and in Spain: improvement was sustained in the last follow-up phase when assessed 5 months, 1 year and 2 years after the first TTT course, respectively. CONCLUSIONS: The TTT in hand hygiene model proved to be effective in enhancing participant's knowledge, sharing experiences and networking. IPC professionals can use this reference training method worldwide to further disseminate knowledge to other health care workers.

[Prevention of suicide of the elderly in France. To a multimodal strategy against depression and isolation: CQFDi]. / Prévention du suicide des personnes âgées en France. Vers une stratégie multimodale de lutte contre la dépression et l'isolement : CQFDi.

ISSUE: Suicide is a major problem of public health around the world, and if suicidal mortality rates have declined in recent years, the elderly remain a category of the world's population at major risk of suicide. Seventeen percent of deaths by suicide across the world are individuals over the age of 65. The existence of suicidal ideas for an individual in this age group increases the risk of suicide attempt in the year by 34. In France, about a little less than a quarter of suicides belong to persons over 60-years-old. More risk factors found in the international literature are in the foreground of mental disorders and in particular the major depression episode, then secondarily addictions, neuro-degenerative disorders as well as pain and other diseases. Depression is found in 60% to 90% of suicides. We notice also that older people privileged the general practitioner as interlocutor to discuss their problems and worries much more than psychiatrists or psychologists. In fact, two-thirds of the elderly who committed suicide had consulted their general practioner in the month prior to suicide and half in the 10 last days. That raises the question of the identification of depression and the evaluation of suicidal risk. On the other side, there is an abundant literature about psychosocial risk factors especially on the influence of isolation and lack of social support as well as on conflicts and family losses. In France, more than 4 million of the elderly live alone. So, while the world population is increasing and life expectancy lengthens, it is important to already act for elderly suicide prevention. PERSPECTIVES: Suicide prevention actions whose efficacity have been demonstrated around the world are designed as part of multimodal strategies combining several levers of action. The consensual recommendations for prevention of elderly suicide recommend the association of actions on the reduction of depression and combating social isolation in connection with the training of front-line actors such as general practitioners. As a result of these experiments and recommendations, the first francophone multimodal strategy was developed to act both on depression and social isolation: the Coopération Québec France sur la dépression et l'isolement (CQFDi) program which will be implemented in France and Quebec in 2019. CONCLUSION: It has been proven that multimodal suicide prevention strategies allow a reduction in the number of suicides. The CQFDi program focuses on at risk of suicide population and aims to reduce the suicide rate of elderly people in France.

Impact of a multifaceted prevention program on ventilator-associated pneumonia including selective oropharyngeal decontamination.

PURPOSE: We describe the impact of a multifaceted program for decreasing ventilator-associated pneumonia (VAP) after implementing nine preventive measures, including selective oropharyngeal decontamination (SOD). METHODS: We compared VAP rates during an 8-month pre-intervention period, a 12-month intervention period, and an 11-month post-intervention period in a cohort of patients who received mechanical ventilation (MV) for > 48 h. The primary objective was to assess the effect on first VAP occurrence, using a Cox cause-specific proportional hazards model. Secondary objectives included the impact on emergence of antimicrobial resistance, antibiotic consumption, duration of MV, and ICU mortality. RESULTS: Pre-intervention, intervention and post-intervention VAP rates were 24.0, 11.0 and 3.9 VAP episodes per 1000 ventilation-days, respectively. VAP rates decreased by 56% [hazard ratio (HR) 0.44, 95% CI 0.29-0.65; P < 0.001] in the intervention and by 85% (HR 0.15, 95% CI 0.08-0.27; P < 0.001) in the post-intervention periods. During the intervention period, VAP rates decreased by 42% (HR 0.58, 95% CI 0.38-0.87; P < 0.001) after implementation of eight preventive measures without SOD, and by 70% after adding SOD (HR 0.30, 95% CI 0.13-0.72; P < 0.001) compared to the pre-intervention period. The incidence density of intrinsically resistant bacteria (to colistin or tobramycin) did not increase. We documented a significant reduction of days of therapy per 1000 patient-days of broad-spectrum antibiotic used to treat lower respiratory tract infection (P < 0.028), median duration of MV (from 7.1 to 6.4 days; P < 0.003) and ICU mortality (from 16.2 to 13.5%; P < 0.049) for patients ventilated > 48 h between the pre- and post-intervention periods. CONCLUSIONS: Our preventive program produced a sustained decrease in VAP incidence. SOD provides an additive value.

[How to increase the health staff adherence to the hands hygiene protocol?] / ¿Cómo incrementar la adhesión del personal sanitario al protocolo de higiene de manos?

OBJECTIVE: Nosocomial infection is a frequent adverse event in health care. Hand hygiene (HH) reduces cross-transmission, but staff adherence is not always adequate. The objectives of this work were evaluating the effectiveness of the HH technique applied in the workplace and monitoring the adherence of the healthcare staff of a Hospital of Medium-Long Stay to the HH protocol. METHODS: Two cross sectional studies were carried out (2010-2012), to determine the prevalence of colonization of the hands of the staff by pathogenic microorganisms, a cross-sectional study (2015), to evaluate their knowledge of the HH technique and two cross-sectional studies (2015-2016), to evaluate the compliance of the protocol in the healthcare practice. The WHO Self-Assessment Framework was applied annually. The hydroalcoholic solution consumption was monitored as a process indicator. RESULTS: The prevalence of colonization of the staff hands went from 28.3% to 21.2%. Compliance with hand hygiene went from 39.5% to 72% and the results of the WHO Self-Assessment Framework went from an intermediate level with 287.5 points to an advanced level with 432.5 points. The consumption of hydroalcoholic solution went from 3.9 to 19.3 liters/1000 stays. CONCLUSIONS: Staff adherence to the HH protocol has increased, having significantly improved the compliance with the recommendations, the hydroalcoholic solution consumption and the HH level assigned to the hospital. The most effective measures to improve the results have been the development of specific improvement plans, having been decisive, the involvement of managers and the use of direct observation as a regular method of work.

OBJETIVO: La infección nosocomial es un evento adverso frecuente en la atención sanitaria. La higiene de manos (HM) reduce la transmisión cruzada, pero la adhesión del personal no siempre es adecuada. Los objetivos de este trabajo fueron evaluar la efectividad de la técnica de HM aplicada en el lugar de trabajo y monitorizar la adhesión del personal sanitario de un Hospital de Media-Larga Estancia al protocolo de HM. METODOS: Se realizaron dos cortes transversales (2010-2012), para conocer la prevalencia de colonización de las manos del personal por microorganismos patógenos, un estudio transversal (2015), para evaluar sus conocimientos sobre la técnica de HM y dos estudios observacionales (2015-2016) para evaluar el cumplimiento del protocolo en la práctica asistencial. Se aplicó anualmente el Marco de Autoevaluación de la OMS. Como indicador de proceso se monitorizó el consumo de solución hidroalcohólica. El análisis estadístico se realizó con el programa SPSS, versión 19.0. RESULTADOS: La prevalencia de colonización pasó del 28,3% al 21,2%. El cumplimiento de la HM pasó del 39,5% al 72%. Aplicando el Marco de Autoevaluación de la OMS se pasó de un nivel intermedio con 287,5 puntos a un nivel avanzado con 432,5 puntos. El consumo de solución hidroalcohólica pasó de 3,9 a 19,3 litros/1000 estancias. CONCLUSIONES: La adhesión al protocolo ha aumentado, habiendo mejorado significativamente el cumplimiento de las recomendaciones, el consumo de solución hidroalcohólica y el Nivel de HM asignado al hospital. Las medidas más eficaces para mejorar los resultados han sido la elaboración de planes de mejora específicos, habiendo sido decisiva la implicación de los directivos y el uso de la observación directa como método habitual de trabajo.

Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections.

PURPOSE: To test the effectiveness of a central venous catheter (CVC) insertion strategy and a hand hygiene (HH) improvement strategy to prevent central venous catheter-related bloodstream infections (CRBSI) in European intensive care units (ICUs), measuring both process and outcome indicators. METHODS: Adult ICUs from 14 hospitals in 11 European countries participated in this stepped-wedge cluster randomised controlled multicentre intervention study. After a 6 month baseline, three hospitals were randomised to one of three interventions every quarter: (1) CVC insertion strategy (CVCi); (2) HH promotion strategy (HHi); and (3) both interventions combined (COMBi). Primary outcome was prospective CRBSI incidence density. Secondary outcomes were a CVC insertion score and HH compliance. RESULTS: Overall 25,348 patients with 35,831 CVCs were included. CRBSI incidence density decreased from 2.4/1000 CVC-days at baseline to 0.9/1000 (p < 0.0001). When adjusted for patient and CVC characteristics all three interventions significantly reduced CRBSI incidence density. When additionally adjusted for the baseline decreasing trend, the HHi and COMBi arms were still effective. CVC insertion scores and HH compliance increased significantly with all three interventions. CONCLUSIONS: This study demonstrates that multimodal prevention strategies aiming at improving CVC insertion practice and HH reduce CRBSI in diverse European ICUs. Compliance explained CRBSI reduction and future quality improvement studies should encourage measuring process indicators.