To evaluate the impact of an institutional hand hygiene accountability program on healthcare personnel hand hygiene adherence.

Time-series design with correlation analysis.

Tertiary care academic medical center, including outpatient clinics and procedural areas.

Medical center healthcare personnel.

A comprehensive hand hygiene initiative was implemented in 2 major phases starting in July 2009. Key facets of the initiative included extensive project planning, leadership buy-in and goal setting, financial incentives linked to performance, and use of a system-wide shared accountability model. Adherence was measured by designated hand hygiene observers. Adherence rates were compared between baseline and implementation phases, and monthly hand hygiene adherence rates were correlated with monthly rates of device-associated infection.

A total of 109,988 observations were completed during the study period, with a sustained increase in hand hygiene adherence throughout each implementation phase (P<.0001) as well as from one phase to the next (P < .0001), such that adherence greater than 85% has been achieved since January 2011. Medical center departments were able to reclaim some rebate dollars allocated through a self-insurance trust, but during the study period, departments did not achieve full reimbursement. Hand hygiene adherence rates were inversely correlated with device-associated standardized infection ratios (R2 = 0.70).

Implementation of this multifaceted, observational hand hygiene program was associated with sustained improvement in hand hygiene adherence. The principles of this program could be applied to other medical centers pursuing improved hand hygiene adherence among healthcare personnel.

In 2009, the World Health Organization (WHO) recommended “My Five Moments for Hand Hygiene” (5MHH) to optimize hand hygiene (HH). Uptake of these recommendations by healthcare workers (HCWs) remains uncertain.

We prospectively observed HCW compliance to 5MHH. After observations, eligible HCWs who consented to interviews completed surveys on factors associated with HH compliance based on constructs from the transtheoretical model of behavioral change (TTM) and the theory of planned behavior (TPB). Survey results were compared with observed HCW behaviors.

There were 968 observations among 123 HCWs, of whom 110 (89.4%) were female and 63 (51.3%) were nurses. The mean HH compliance for all 5MHH was 23.2% (95% confidence interval [CI], 18.1%-28.3%) by direct observation versus 82.4% (95% CI, 79.9%-84.9%) by self report. The HCW 5MHH compliance was associated with critical care unit encounters (P < .05), medicine unit encounters (P = 0.08, P <.001), immunocompromised patient encounters (P <. 05), and HCW prioritized patient advocacy (P <.001). Self-reported TTM stages of action or maintenance (P = .08) and the total TPB behavior score correlated with observed 5MHH (r = 0.21, P = .02) and with self-reported 5MHH compliance (r = 0.53, P < .001).

Observed HCW compliance to 5MHH was associated with the type of hospital unit, type of provider-patient encounter, and theory-based behavioral measures of 5MHH commitment.

To identify factors associated with hand hygiene compliance during a multiyear period of intervention.

Observational study.

A 719-bed tertiary care teaching hospital.

Nursing, physician, technical, and support staff.

Light-duty staff performed hand hygiene observations during the period July 2008-December 2012. Infection control implemented hospital-wide hand hygiene initiatives, including education modules; posters and table tents; feedback to units, medical directors and the executive board; and an increased number of automated alcohol hand hygiene product dispensers.

There were 161,526 unique observations; overall compliance was 83%. Significant differences in compliance were observed between physician staff (78%) and support staff (69%) compared with nursing staff (84%). Pediatric units (84%) and intensive care units (84%) had higher compliance than did medical (82%) and surgical units (81%). These findings persisted in the controlled multivariate model for noncompliance. Additional factors found to be significant in the model included greater compliance when healthcare workers were leaving patient rooms, when the patient was under contact precautions, and during the evening shift. The overall rate of compliance increased from 60% in the first year of observation to a peak of 96% in the fourth year, and it decreased to 89% in the final year, with significant improvements occurring in each of the 4 professional categories.

A multipronged hand hygiene initiative is effective in increasing compliance rates among all categories of hospital workers. We identified a variety of factors associated with increased compliance. Additionally, we note the importance of continuous interventions in maintaining high compliance rates.

Although catheter-associated urinary tract infection (CAUTI) and catheter-associated asymptomatic bacteriuria (CAABU) are clinically distinct conditions, most literature describing the risks of bacteriuria does not distinguish between them. We studied the relationship between catheter-associated bacteriuria and bacteremia from a urinary source in CAUTI relative to that in CAABU. Second, we investigated whether the presence or absence of urinary symptoms in catheterized patients with bacteriuria was associated with bacteremia from any source or mortality. Finally, we explored the effect of antimicrobial treatment of bacteriuria on subsequent bacteremia from any source and mortality.

We performed a retrospective cohort study with 30 days of follow-up after an initial positive urine culture. CAUTI and CAABU were defined by Infectious Diseases Society of America guidelines.

A large tertiary care facility.

All inpatients with a urinary catheter (external or indwelling) and a positive urine culture between October 2010 and June 2011.

We captured 444 episodes of catheter-associated bacteriuria in 308 patients; 128 (41.6%) patients had CAUTI, and 180 (58.4%) had CAABU. Three episodes of bacteriuria were followed by bacteremia from a urinary source (0.7%). CAUTI, rather than CAABU, was associated with bacteremia from any source, but neither CAUTI nor CAABU predicted subsequent mortality. Use of antimicrobial agents to treat bacteriuria was not associated with either bacteremia from any source or mortality.

Bacteremia from a urinary source was infrequent, and there was no evidence of an association of mortality with symptomatic versus asymptomatic bacteriuria in this population. Antibiotic treatment of bacteriuria did not affect outcomes.

Describe the epidemiology of central line-associated bloodstream infections (CLABSIs) in neonatal intensive care units (NICUs) participating in a standardized and mandatory CLABSI surveillance program.

Retrospective cohort.

We included patients admitted (April 2007-March 2011) to 7 level II/III NICUs who developed a CLABSI (as defined by the National Healthcare Safety Network).

. CLABSIs/1,000 central line–days and device utilization ratio were calculated; x2 test, Student t test, Kruskal-Wallis, and Poisson regression were used.

Overall, 191 patients had 202 CLABSI episodes for a pooled mean rate of 4.0 CLABSIs/1,000 central line-days and a device utilization ratio of 0.20. Annual pooled mean CLABSI rates increased from 3.6 in 2007-2008 to 5.1 CLABSIs/1,000 central line-days in 2010-2011 (P = .01). The all-cause 30-day case fatality proportion was 8.9% (n = 17) and occurred a median of 8 days after CLABSI. Coagulase-negative Staphylococcus was identified in 112 (50.5%) cases. Staphylococcus aureus was identified in 22 cases, and 3 (13.6%) were resistant to methicillin. An underlying intra-abdominal pathology was found in 20% (40/202) of CLABSI cases, 50% of which were reported in the last year of study. When adjusted for mean birth weight, annual CLABSI incidence rates were independently associated with the proportion of intra-abdominal pathology (P = .007) and the proportion of pulmonary pathology (P = .016) reported.

The increase in CLABSI rates in Quebec NICUs seems to be associated with an increased proportion of cases with underlying intra-abdominal and pulmonary pathologies, which needs further investigation.

To determine whether retractable intravenous devices produced blood splatter and whether blood splatter frequency differed between visual and microscopy detection methods.

In this laboratory-based experiment, 105 venipunctures were performed in a simulated brachial vein containing mock venous blood. The retraction mechanism was activated in a testing chamber with precut fabric filters, placed at 3 different locations, to capture blood splatter. Differences in filter mass, visual inspection, and microscopic analysis for presence of blood on filters were the units of analysis. Descriptive statistics, paired Student t tests, and k statistics were used for data analysis.

Blood splatter was detected visually and microscopically as follows: filter A, 70% and 71%, respectively; filter B, 12% and 9%, respectively; and filter C, 13% and 10%, respectively. A statistically significant difference was observed in the mean mass of filter A between before and after activation when confirmed by the naked eye (P = .014) and microscopically (P = .0092). Substantial agreement between methods was observed for filter A (k = 0.78 [95% confidence interval, 0.64-0.92]), filter B (k = 0.73 [95% confidence interval, 0.51-0.95]), and filter C (k = 0.75 [95% confidence interval, 0.55-0.96]). However, blood was detected by microscopy and not by the naked eye in 7 instances (7%).

Our findings demonstrate that splatter, which can potentially expose healthcare workers (HCWs) to bloodborne pathogens, is associated with the activation of intravascular catheters with retraction mechanisms. HCWs may not detect this splatter when it occurs and may not report a splash to mucous membranes or nonintact skin. The need to wear personal protective equipment when using such devices is reinforced.

Minimizing healthcare worker exposure to airborne infectious pathogens is an important infection control practice. This study utilized mathematical modeling to evaluate the trajectories and subsequent concentrations of particles following a simulated release in a patient care room.

Observational study.

Biocontainment unit patient care room at a university-affiliated tertiary care medical center.

. Quantitative mathematical modeling of airflow in a patient care room was achieved using a computational fluid dynamics software package. Models were created on the basis of a release of particles from various locations in the room. Computerized particle trajectories were presented in time-lapse fashion over a blueprint of the room. A series of smoke tests were conducted to visually validate the model.

Most particles released from the head of the bed initially rose to the ceiling and then spread across the ceiling and throughout the room. The highest particle concentrations were observed at the head of the bed nearest to the air return vent, and the lowest concentrations were observed at the foot of the bed.

Mathematical modeling provides clinically relevant data on the potential exposure risk in patient care rooms and is applicable in multiple healthcare delivery settings. The information obtained through mathematical modeling could potentially serve as an infection control modality to enhance the protection of healthcare workers.

Stethoscopes are contaminated with pathogenic bacteria and pose a risk for transmission of infections, but few clinicians disinfect their stethoscope after every use. We sought to improve stethoscope disinfection rates among pediatric healthcare providers by providing access to disinfection materials and visual reminders to disinfect stethoscopes.

Prospective intervention study.

Inpatient units and emergency department of a major pediatric hospital.

Physicians and nurses with high anticipated stethoscope use.

Baskets filled with alcohol prep pads and a sticker reminding providers to regularly disinfect stethoscopes were installed outside of patient rooms. Healthcare providers' stethoscope disinfection behaviors were directly observed before and after the intervention. Multivariable logistic regression models were created to identify independent predictors of stethoscope disinfection.

Two hundred twenty-six observations were made in the preintervention period and 261 in the postintervention period (83% were of physicians). Stethoscope disinfection compliance increased significantly from a baseline of 34% to 59% postintervention (P < .001). In adjusted analyses, the postintervention period was associated with improved disinfection among both physicians (odds ratio [OR], 2.3 [95% confidence interval (CI), 1.4-3.5]) and nurses (OR, 14.3 [95% CI, 4.6-44.6]). Additional factors independently associated with disinfection included subspecialty unit (vs general pediatrics; OR, 0.5 [95% CI, 0.3-0.8]) and contact precautions (OR, 2.3 [95% CI, 1.2-4.1]).

Providing stethoscope disinfection supplies and visible reminders outside of patient rooms significantly increased stethoscope disinfection rates among physicians and nurses at a children's hospital. This simple intervention could be replicated at other healthcare facilities. Future research should assess the impact on patient infections.

Although mandatory vaccination programs have been effective in improving the vaccination rate among healthcare workers, implementing this type of program can be challenging because of varied reasons for vaccine refusal. The purpose of our study is to measure improvement in the influenza vaccination rate from a multifaceted intervention at a Japanese tertiary care center where implementing a mandatory vaccination program is difficult.

Before-and-after trial.

Healthcare workers at a 550-bed, tertiary care, academic medical center in Sapporo, Japan.

We performed a multifaceted intervention including (1) use of a declination form, (2) free vaccination, (3) hospital-wide announcements during the vaccination period, (4) prospective audit and real-time telephone interview for healthcare workers who did not receive the vaccine, (5) medical interview with the hospital executive for noncompliant (no vaccine, no declination form) healthcare workers during the vaccination period, and (6) mandatory submission of a vaccination document if vaccinated outside of the study institution.

With the new multifaceted intervention, the vaccination rate in the 2012-2013 season increased substantially, up to 97%. This rate is similar to that reported in studies with a mandatory vaccination program. Improved vaccination acceptance, particularly among physicians, likely contributed to the overall increase in the vaccination rate reported in the study.

Implementation of comprehensive strategies with strong leadership can lead to substantial improvements in vaccine uptake among healthcare workers even without a mandatory vaccination policy. The concept is especially important for institutions where implementing mandatory vaccination programs is challenging.