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https://doi.org/10.1371/journal.pone.0027163.s001. In conclusion, this study demonstrates that implementing a hospital-wide hand hygiene program is feasible. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Several studies have demonstrated a temporal relationship between improved hand hygiene practices and a reduction in HAI incidence and multidrug resistant microorganisms [2], [25]; however, few have been able to sustain a lasting impact [2], [26]. Hand sanitizer vs. soap and water: Which one should you use? We observed 8,420 opportunities for hand hygiene during the study period. The patient population, bed occupancy rate, age, gender, severity of underlying diseases, length of hospital stay, cumulative incidence of HAI, and outcome at discharge were determined during the preintervention (January 1999 to March 2004) and intervention (April 2004 to December 2007) periods. Direct observation was performed by infection control nurses (ICN) after training and consensus development [11]. 4. This study compared hand washing knowledge and practices in BRAC’s water; sanitation and hygiene (WASH) programme areas over time. Continuous emphasis on this intervention has lead to the widespread opinion that HAI rates can be greatly reduced by increased hand hygiene compliance alone. The cost categories and the source used reflected the hospital perspective reported by the authors. It was discounted at an annual rate of 3%. I will do this by analyzing the existing evidence in relation to the hierarchy of evidence. Data were collected on standardized data collection forms and inputted into the computer database manually. Accordingly, we introduced accessible alcohol-based hand rubs to improve compliance. Finally, no significant change in the trends or levels of infections caused by MSSA and E. coli during the intervention period was observed, as shown in Fig. The target hand hygiene compliance rate was determined based on the performance in the preceding year. The issue of uncertainty was partly addressed with univariate sensitivity analysis. One-way sensitivity analyses were performed to explore the influence of the uncertainty of several parameters, such as discount rates, cost of alcohol hand rub, campaign expenses, extra cost per HAI episode, and the number of averted HAIs. The spread of bacterial eye infections, such as trachoma, can be reduced through regular hand washing. Thus, evaluation of the longitudinal effect of a hospital-wide hand hygiene program is only feasible in limited healthcare settings. Instead a benefit/cost ratio was presented to show the economic benefit to the hospital of spending additional money on the programme. You can tell if the sanitizer contains at least 60% alcohol by looking at the product label. This study demonstrates that excellent compliance with hand hygiene by HCW was achieved and maintained over 4 years through an intensive hospital-wide program. There are many limitations of PPE like safety glasses and overalls, including:. values from the full and most parsimonious segmented regression models predicting monthly incidence density (episodes per 1000 patient-days) over time. Patients were followed up until hospital discharge. The costs of implementing the program were low compared to the costs saved by reducing the HAI incidence. ), you can … The site audit period was announced, though healthcare workers were not informed of the specific observation time. Hand hygiene is generally considered to be the most important measure that can be applied to prevent the spread of healthcare-associated infection (HAI). This method requires data of the continuous or counted outcome measures, summarized at regular, evenly spaced intervals. However, hand hygiene programs are only one component of hospital infection control. (A) hospital-wide (change in levels, p = 0.02; change in trends, p = 0.04); (B) intensive care units (change in levels, p = 0.26; change in trends, p<0.001); (C) hematology ward (p = 0.21, p = 0.38, respectively). where con-ditions such as hookworm or dermatological conditions of the foot may develop). Hand washing is considered as one of the most effective hygiene promotion activities for public health in developing countries. Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, No standard cost-effectiveness ratios were calculated as the programme was the dominant option. Third, the hand hygiene programs in this study focused only on HCWs. To provide consistent care and protect patient safety throughout the hospital, a hand hygiene program requires multidisciplinary efforts and encompasses all hospital units. Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, Affiliations An antimicrobial stewardship program was not conducted during the study period. In addition, not everything is dishwasher safe. Observed incidences, black solid line, —; mean, red dash line, ---; green and blue shadow, 95% confidence interval of observed incidences; yellow shadow, 95% confidence interval (CI) of predicted incidences. The authors stated that the perspective was that of the hospital. This effect was achieved and confirmed using a before and after study design combined with a prospective HAI surveillance program and hospital-wide annual promotion, which resulted in sustained effects and high-quality HH observation. Proper Method of Hand Washing. Emergency procedures were excluded. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. There are a few disadvantages with the space saving machine though, and one of the disadvantages is that this kind of washing machine will not hold a … Time trends in the consumption of alcohol-based hand rubs, soap, and antiseptics were examined using simple linear regression. Affiliations Promotion consisted of lectures and/or web-based self-learning with a post test, reminders located near points of care, use of hand hygiene compliance as a quality indicator, observation and verbal reminders by infection control nurses, periodic audits and performance feedback provided to units and departments, and incentives of US$160.00 for an outstanding performance (unit and department level). There is no daily quota of hand washing that you have to hit in order to stay healthy. We were also unable to demonstrate a reduction in HAIs caused by MSSA and E. coli. The authors’ conclusions appear robust. Review and comments of the manuscript: SCC KST. We appreciate members of the Biostatistics Laboratory of the College of Public Health, National Taiwan University, and Dr. Grace Hui-Min Wu for their assistance and suggestions regarding the statistical analysis; they received no compensation for their contribution. Do the same with the other hand. This is particularly required by teaching hospitals where the house staff and attending physicians change periodically [25]. Nevertheless, we observed an 8.9% decrease in HAIs and a decline in the occurrence of bloodstream, methicillin-resistant Staphylococcus aureus, extensively drug-resistant Acinetobacter baumannii, and intensive care unit infections. Alcohol-based hand rubs were unavailable. Parameter estimates, standard errors and For more information about PLOS Subject Areas, click Before intervention, HAI increased gradually, and the impact of SARS and seasons were significant. With substantial support from the hospital superintendent, the hospital-wide hand hygiene promotion program began in April 2004. We found that of the 226 opportunities presented, hospital staff washed their hands for only 16.6%. The disease severity score (Charlson comorbidity index) increased (p = .002) during the intervention period. Center for Infection Control, National Taiwan University Hospital, Taipei, Taiwan, Demonstrating to hospital administrators that these programs are cost-effective, relatively inexpensive, improve patient safety, and require long-term and stable investment is essential [2], [24]. Finally, not all HAI were preventable. 2C. During the six surveys conducted during the intervention period, 8,420 opportunities to observe hand hygiene were presented, as shown in Fig. The number of expected episodes of HAI averted by the program was derived using the generalized autoregressive Poisson regression model. Other details such as the price year and discount rate were reported appropriately. PLOS ONE promises fair, rigorous peer review, Costs were in US dollars ($). Overall compliance improved from 43.3% in 2004 to 95.6% in 2007 (p<.001). Using these products can result in less skin dryness and irritation than hand-washing. Infection control measures for XDRAB were intensified during June 2001 to June 2002. Estimates were collected prospectively at the authors’ institute and were representative of that setting. No, Is the Subject Area "Epidemiology" applicable to this article? Every time hands are washed the skin loses moisture, and the protective layer is stripped away. keep the time limitations in mind. The factors considered by the model (see Text S1) include the levels and trends in the preintervention period, the changes in levels and trends during the intervention period, and autoregressive terms. e27163. We conducted a baseline evaluation in December 2003 [8]. Economic benefits from savings were estimated to have been $5,289,364 and the ratio (net benefit minus costs) was $23.7, which meant that every $1 spent on the programme resulted in a $23.7 economic benefit to the hospital. • Commercially prepared hand sanitizers contain ingredients that help prevent skin dryness. Fine china and crystal, knives, nonstick pots and pans and wooden items can be damaged in the dishwasher, meaning you have to wash them by hand. This model autocorrelates the HAI cases in successive periods by incorporating the autoregressive order j term and number of HAI cases at an earlier time t-j [17]. https://doi.org/10.1371/journal.pone.0027163.s002. Hand hygiene was identified as the core component of this strategy because it is a simple, standardized, low-cost measure based on solid scientific evidence. Base-case estimates and ranges used in sensitivity analyses of parameters. Heterogeneity factors were calculated by dividing the deviance with the degrees of freedom, and used as an indicator to assess whether an extra-Poisson variation (overdispersion) was present. The severity of underlying diseases, comprising a maximum of six diseases, was scored using the Charlson comorbidity index [13]. In the interrupted time series, the level and trend of the preintervention segment served as the controls for the postintervention segment, providing a methodologically acceptable design for measuring the intervention effect [22], [23]. Click through the PLOS taxonomy to find articles in your field. Approximately one third of the hospital's house staff on the floor are replaced each year. From a hospital perspective, the discounted additional cost of preventing one HAI episode was US$163.6. https://doi.org/10.1371/journal.pone.0027163.t002, https://doi.org/10.1371/journal.pone.0027163.t003. After implementation of the hand hygiene program, the levels and trends of HAIs changed significantly (p = .02, p = .04, respectively), as shown in Fig. However, conducting a randomized, controlled trial in such a large and complex situation is difficult. NTUH-200805033R). Contributed reagents/materials/analysis tools: LYH. The patient population characteristics during the preintervention and intervention periods are summarized in Table 1. 2B; however, no significant changes in the HAI rates of oncology and hematological wards was noted, as shown in Fig. Funding: Dr. Chen received grants (DOH96-DC-1010, DOH97-DC-1005) from the Center for Disease Control, Department of Health, and a grand (DOH99-TD-B-111-001) from the Department of Health, Taiwan. The cost-effectiveness of the program was evaluated by calculating the extra cost required to prevent one episode of HAI from a hospital perspective. The benefit was measured by subtracting the cost savings from the extra costs caused by HAIs, which was determined by a case-control study conducted in our hospital [18]. https://doi.org/10.1371/journal.pone.0027163.s003, https://doi.org/10.1371/journal.pone.0027163.s004. Frequent hand-washing is standard advice for avoidance of respiratory tract infections, but the evidence for a preventive effect in a general community setting is sparse. A positive feature of the analysis was the very large sample size and prospective collection of data. The World Health Organization launched the World Alliance for Patient Safety in October 2004 [2]. We elected to use Poisson regression analysis with an interrupted time series [22], [23] to assess the efficacy of the hospital-wide hand hygiene intervention over time, and determine whether factors other than the intervention could explain the change. 3C. The price year was 2007. PLoS ONE 6(11): The hand hygiene compliance rates recorded for comparison between hospital services or between years were limited to the opportunities before and after patient contact to maintain consistency during the study period. Savings from extra costs associated with healthcare-associated infections were $5,522,408 and extra costs of the hand hygiene programme were $233,044. (2011) Effectiveness and Limitations of Hand Hygiene Promotion on Decreasing Healthcare–Associated Infections. Performed the experiments: KLT. 5. A disease-specific measure was used to examine the clinical impact of the programme on patients’ health. The study examined the cost-effectiveness of a hand hygiene programme to reduce the burden of healthcare-associated infections. You should wash your hands for the amount of time it takes to sing "Happy Birthday" twice (around 20 seconds): 1. Center for Infection Control, National Taiwan University Hospital, Taipei, Taiwan, We followed the principles expressed in the Declaration of Helsinki. No, Is the Subject Area "Nurses" applicable to this article? Extensively drug-resistant A. baumannii (XDRAB) was defined as isolates that were resistant to five or more classes of antibacterial agents [6]. The number of healthcare-associated infection episodes was 16,032 without the programme and 14,608 with the programme. The program was associated with significant decreasing trends for all HAIs and HAIs caused by MRSA and XDRAB, and was cost effective. We used a quasi-experimental, before and after, study design [7] with prospective hospital-wide surveillance of HAIs to assess the effectiveness of hand hygiene. 1A). No significant changes in the respiratory tract and gastrointestinal tract infection rates were observed during the intervention. Our recent survey demonstrated that the HH rate for 5 moments was only approximately 60%; whereas the HH rate for two moments exceeded 90% (unpublished data). Some costs were varied in the sensitivity analysis. Several potentially confounding factors are relevant to this study. A 4-year hospital-wide HHP, with particular emphasis on using an alcohol-based hand rub, was implemented in April 2004 at a 2,200-bed teaching hospital in Taiwan. It cannot also protect you against from droplet and airborne diseases, … According to a recent, comprehensive review of literature published as a Cochrane Review [21], the quality of intervention studies intended to increase hand hygiene compliance remains disappointing. However, when savings from future costs associated to healthcare-associated infection were considered the programme was dominant (more effective and less expensive). The predicted monthly cumulative incidence of HAI using the full and most parsimonious segmented regression models are shown in Table S1. Use Section 5 and Annexes 6 and 7 if you need to review basics of data collection for evaluation of handwashing promotion programmes and assistance The baseline evaluation included direct observation of hand hygiene compliance by infection control nurses, a survey of knowledge and the reasons or factors affecting hand hygiene adherence using a structured, self-administered questionnaire, and suggestions to improve hand hygiene performance. For more information about PLOS Subject Areas, click Compliance improved significantly for all professional categories of HCW (p<.001), in both general wards and intensive care units (p<.001). Alcohol-Based Handrub Limitations Print; Alcohol-based handrub limitations. Advantages – less water usage, your clothes stay better for longer (Yes it is true, washers literally beat your clothes to death and then we put them in dryers which in all seriousness literally break the fibers in your clothes apart), you get arm muscles (this is not a joke, if you think it is…..try handwashing for a day, washing your own clothes you will also get belly and back muscles! Because the SARS epidemic occurred during the later part of the preintervention period (April 2003 to July 2003), an additional variable was added to the model to assess the effect of SARS. At that time, hands-free washing facilities with unmedicated liquid soap (not refilled) and paper towels were located in every room of the wards and by every intensive care unit (ICU) bed. The authors’ conclusions appear robust. Citation: Chen Y-C, Sheng W-H, Wang J-T, Chang S-C, Lin H-C, Tien K-L, et al. However, the opportunity costs of personnel were considered in the sensitivity analysis by converting the number of working hours that infection control nurses spent on the program to their salary (Table S3). The number of healthcare-associated infections was the main endpoint of the analysis. A fine of US$3.00 for compliance failures (individual level) was implemented in 2007 in highly specific situations, that is, individuals not modify their behavior even after face-to-face communication. Analyzed the data: YCC WHS LYH. Endogenous infection may be reduced through improvements in host immunity. The intervention had no discernable impact on HAI rates in the hematology/oncology wards. However, alcohol-based hand rubs were unavailable. Although evidence exists that improved adherence to hand hygiene is linked to reduced infection rates [24]–[26], other studies failed to report these effects [27]–[30]. Because of the high alcohol content of most hand sanitizing liquids, these substances are flammable, according to University of Rochester Facilities and Services. Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, The overall improvement in hand hygiene compliance was significantly correlated with the increased consumption of alcohol-based hand rub (correlation coefficient r = 0.9399, p = .005), but less correlated with the consumption of antiseptics (r = 0.7930, p = .06) and soap (r = 0.7686, p = .07). The cumulative incidence of HAIs was defined as episodes per 1,000 patient-days. Healthcare-associated infection rates by type of infection and site were estimated. 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