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Role of Hand Hygiene Ambassador and Implementation of Directly Observed Hand Hygiene Among Residents in Residential Care Homes for the Elderly in Hong Kong

  • Vincent C. C. Cheng (a1) (a2), Hong Chen (a3), Shuk-Ching Wong (a2), Jonathan H. K. Chen (a1), Wing-Chun Ng (a4), Simon Y. C. So (a1), Tuen-Ching Chan (a4), Sally C. Y. Wong (a1), Pak-Leung Ho (a1), Lona Mody (a5), Felix H. W. Chan (a4), Andrew T. Y. Wong (a3) and Kwok-Yung Yuen (a1)...



Multidrug-resistant organisms (MDROs) are increasingly reported in residential care homes for the elderly (RCHEs). We assessed whether implementation of directly observed hand hygiene (DOHH) by hand hygiene ambassadors can reduce environmental contamination with MDROs.


From July to August 2017, a cluster-randomized controlled study was conducted at 10 RCHEs (5 intervention versus 5 nonintervention controls), where DOHH was performed at two-hourly intervals during daytime, before meals and medication rounds by a one trained nurse in each intervention RCHE. Environmental contamination by MRDOs, such as methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Acinetobacter species (CRA), and extended-spectrum β-lactamse (ESBL)–producing Enterobacteriaceae, was evaluated using specimens collected from communal areas at baseline, then twice weekly. The volume of alcohol-based hand rub (ABHR) consumed per resident per week was measured.


The overall environmental contamination of communal areas was culture-positive for MRSA in 33 of 100 specimens (33%), CRA in 26 of 100 specimens (26%), and ESBL-producing Enterobacteriaceae in 3 of 100 specimens (3%) in intervention and nonintervention RCHEs at baseline. Serial monitoring of environmental specimens revealed a significant reduction in MRSA (79 of 600 [13.2%] vs 197 of 600 [32.8%]; P<.001) and CRA (56 of 600 [9.3%] vs 94 of 600 [15.7%]; P=.001) contamination in the intervention arm compared with the nonintervention arm during the study period. The volume of ABHR consumed per resident per week was 3 times higher in the intervention arm compared with the baseline (59.3±12.9 mL vs 19.7±12.6 mL; P<.001) and was significantly higher than the nonintervention arm (59.3±12.9 mL vs 23.3±17.2 mL; P=.006).


The direct observation of hand hygiene of residents could reduce environmental contamination by MDROs in RCHEs.

Infect Control Hosp Epidemiol 2018;39:571–577


Corresponding author

Address correspondence to Kwok-Yung Yuen, Department of Microbiology, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China (


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1. Smith, PW, Bennett, G, Bradley, S, et al. SHEA/APIC guideline: infection prevention and control in the long-term care facility, July 2008. Infect Control Hosp Epidemiol 2008;29:785814.
2. Cheng, VC, Tai, JW, Wong, ZS, et al. Transmission of methicillin-resistant Staphylococcus aureus in the long term care facilities in Hong Kong. BMC Infect Dis 2013;13:205.
3. Stine, OC, Burrowes, S, David, S, Johnson, JK, Roghmann, MC. Transmission clusters of methicillin-resistant Staphylococcus aureus in long-term care facilities based on whole-genome sequencing. Infect Control Hosp Epidemiol 2016;37:685691.
4. Hocine, MN, Temime, L. Impact of hand hygiene on the infectious risk in nursing home residents: a systematic review. Am J Infect Control 2015;43:e47e52.
5. Schweon, SJ, Edmonds, SL, Kirk, J, Rowland, DY, Acosta, C. Effectiveness of a comprehensive hand hygiene program for reduction of infection rates in a long-term care facility. Am J Infect Control 2013;41:3944.
6. Ho, ML, Seto, WH, Wong, LC, Wong, TY. Effectiveness of multifaceted hand hygiene interventions in long-term care facilities in Hong Kong: a cluster-randomized controlled trial. Infect Control Hosp Epidemiol 2012;33:761767.
7. Cheng, VC, Chen, JH, Ng, WC, et al. Emergence of carbapenem-resistant Acinetobacter baumannii in nursing homes with high background rates of MRSA colonization. Infect Control Hosp Epidemiol 2016;37:983986.
8. Chan, TC, Luk, JK, Chu, LW, Chan, FH. Low education level of nursing home staff in Chinese nursing homes. J Am Med Dir Assoc 2013;14:849850.
9. Cheng, VC, Tai, JW, Li, WS, et al. Implementation of directly observed patient hand hygiene for hospitalized patients by hand hygiene ambassadors in Hong Kong. Am J Infect Control 2016;44:621624.
10. Cheng, VC, Tai, JW, Chau, PH, et al. Successful control of emerging vancomycin-resistant enterococci by territory-wide implementation of directly observed hand hygiene in patients in Hong Kong. Am J Infect Control 2016;44:11681171.
11. Cheng, VC, Chen, JH, Poon, RW, et al. Control of hospital endemicity of multiple-drug-resistant Acinetobacter baumannii ST457 with directly observed hand hygiene. Eur J Clin Microbiol Infect Dis 2015;34:713718.
12. Patel, PK, Mantey, J, Mody, L. Patient hand colonization with MDROs is associated with environmental contamination in post-acute care. Infect Control Hosp Epidemiol 2017;38:11101113.
13. Hardy, KJ, Oppenheim, BA, Gossain, S, Gao, F, Hawkey, PM. A study of the relationship between environmental contamination with methicillin-resistant Staphylococcus aureus (MRSA) and patients’ acquisition of MRSA. Infect Control Hosp Epidemiol 2006;27:127132.
14. Drees, M, Snydman, DR, Schmid, CH, et al. Prior environmental contamination increases the risk of acquisition of vancomycin-resistant enterococci. Clin Infect Dis 2008;46:678685.
15. Cheng, VCC, Wong, SC, Chen, JHK, et al. Control of multidrug-resistant Acinetobacter baumannii in Hong Kong: role of environmental surveillance in communal areas after a hospital outbreak. Am J Infect Control 2018;46:6066.
16. Cheng, VC, Li, IW, Wu, AK, et al. Effect of antibiotics on the bacterial load of meticillin-resistant Staphylococcus aureus colonisation in anterior nares. J Hosp Infect 2008;70:2734.
17. Cheng, VCC, Chen, JHK, Wong, SCY, et al. Hospital outbreak of pulmonary and cutaneous zygomycosis due to contaminated linen items from substandard laundry. Clin Infect Dis 2016;62:714721.
18. Cheng, VCC, Wong, SC, Wong, IWY, et al. The challenge of patient empowerment in hand hygiene promotion in health care facilities in Hong Kong. Am J Infect Control 2017;45:562565.
19. Cheng, VC, Chan, JF, Lau, EH, et al. Studying the transmission dynamics of meticillin-resistant Staphylococcus aureus in Hong Kong using spa typing. J Hosp Infect 2011;79:206210.
20. Cheng, VC, Chen, JH, So, SY, et al. A novel risk factor associated with colonization by carbapenemase-producing Enterobacteriaceae: use of proton pump inhibitors in addition to antimicrobial treatment. Infect Control Hosp Epidemiol 2016;37:14181425.
21. Aschbacher, R, Pagani, E, Confalonieri, M, et al. Review on colonization of residents and staff in Italian long-term care facilities by multidrug-resistant bacteria compared with other European countries. Antimicrob Resist Infect Control 2016;5:33.
22. Cassone, M, Mody, L. Colonization with multi-drug resistant organisms in nursing homes: scope, importance, and management. Curr Geriatr Rep 2015;4:8795.
23. Murphy, CR, Eells, SJ, Quan, V, et al. Methicillin-resistant Staphylococcus aureus burden in nursing homes associated with environmental contamination of common areas. J Am Geriatr Soc 2012;60:10121018.
24. Kahvecioglu, D, Ramiah, K, McMaughan, D, et al. Multidrug-resistant organism infections in US nursing homes: a national study of prevalence, onset, and transmission across care settings, October 1, 2010–December 31, 2011. Infect Control Hosp Epidemiol 2014;35(Suppl 3):S48S55.
25. Rollnik, JD, Bertram, M, Bucka, C, et al. Outcome of neurological early rehabilitation patients carrying multi-drug resistant bacteria: results from a German multi-center study. BMC Neurol 2017;17:53.
26. Cheng, VC, Tai, JW, Chen, JH, et al. Proactive infection control measures to prevent nosocomial transmission of vancomycin-resistant enterococci in Hong Kong. J Formos Med Assoc 2014;113:734741.
27. Cheng, VC, Chan, JF, Wong, SC, et al. Proactive infection control measures to prevent nosocomial transmission of carbapenem-resistant Enterobacteriaceae in a non-endemic area. Chin Med J (Engl) 2013;126:45044509.
28. Cheng, VC, Tai, JW, Wong, LM, et al. Effect of proactive infection control measures on benchmarked rate of hospital outbreaks: an analysis of public hospitals in Hong Kong over 5 years. Am J Infect Control 2015;43:965970.
29. Cheng, VC, Wong, SC, Ho, PL, Yuen, KY. Strategic measures for the control of surging antimicrobial resistance in Hong Kong and mainland of China. Emerg Microbe Infect 2015;4:e8.
30. Adams, CE, Smith, J, Watson, V, Robertson, C, Dancer, SJ. Examining the association between surface bioburden and frequently touched sites in intensive care. J Hosp Infect 2017;95:7680.
31. Kampf, G, Kramer, A. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clin Microbiol Rev 2004;17:863893.
32. Kramer, A, Schwebke, I, Kampf, G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis 2006;6:130.
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