Hospital hand hygiene monitoring: internal audits and the role of public health residents

Background Healthcare workers (HCW) adherence to hand hygiene (HH) is the most effective infection prevention and control (IPC) measure to fight healthcare-associated infections (HAI) and is a crucial component for standard precautions, especially in a pandemic context. As suggested by the WHO and Joint Commission Network Project, evaluating adherence to HH is essential to identify deficiencies and promote improvement interventions. Methods San Raffaele Hospital in Milan, Italy, adopted internal audits to measure HCWs' adherence to HH according to WHO Guidelines. Public health (PH) residents were enrolled as auditors. They were trained with WHO technical manual for observers and handovers among residents. WHO observation form was used for collection. Process index was HH adherence, stratified by profession, unit, opportunity and indication. Results 8 PH medical residents carried out observations from January 2018 to December 2019. 434 HCWs were observed in 26 hospital units (191 nurses, 148 physicians, 83 healthcare assistants and 11 other professionals). Global adherence was 53%, calculated on 1,969 opportunities, and 2,221 indications observed, followed by 932 hands rubbing and 110 handwashing. Most observations involved nurses (adherence of 53%) and physicians (54%). Global adherence was generally higher in medicine, specialist surgery and intensive-care units while lower in general surgery and rehabilitation units. Indications with the highest adherence were “after body fluid exposure risk” (69%) and “after touching a patient” (64%). The lowest adherence (44%) was observed for “before clean/aseptic procedure” indication. The belief that gloves use may replace HH might partially explain the data. Conclusions Global HH adherence was in line with significant published data and was far better than 2016 data but slightly lower than observations in 2018 when the program started. We believe 2020 HH compliance could have changed due to HCW involvement in IPC against COVID-19. Key messages Hand hygiene (HH) audits represent a crucial tool of clinical governance and risk management: auditors’ training, monthly and annual reports, and feedbacks allowed to structure a virtuous process. If HH audits aim to improve practice we should understand when HH is most beneficial, assessing quality, improving performances through achievable targets using reproducible methods and technologies.

Application of the "immunization islands" model to improve quality, efficiency and safety of a COVID-19 mass vaccination site.

Abstract: After SARS-CoV-2 vaccines development came at an unprecedented speed, ensuring safe and efficient mass immunization, vaccine delivery be-came the major public health mandate. Although mass-vaccination sites have been identified as essential to curb COVID-19, their organization and functioning is challenging. In this paper we present the planning, implementation and evalua-tion of a massive vaccination center in Lombardy - the largest Region in Italy and the most heavily hit by the pandemic. The massive hub of Novegro (Milan), managed by the Gruppo Ospedaliero San Donato, opened in April 2021. The Novegro mass-immunization model was developed building a la-yout based on the available scientific evidence, on comparative analysis with other existing models and on the experience of COVID-19 immunization delivery of Gruppo Ospedaliero San Donato. We propose a "vaccine islands" mass-immunization model, where 4 physicians and 2 nurses operate in each island, with up to 10 islands functioning at the same time, with the capacity of providing up to 6,000 vaccinations per day. During the first week of activity a total of 37,900 doses were administered (2,700/day), most of them with Pfizer vaccine (85.8%) and first doses (70.9%). The productivity was 10.5 vaccines/hour/vaccine station. Quality, efficiency and safety were boosted by ad-hoc personnel training, quality technical infrastructure and the presence of a shock room. Constant process monitoring allowed to identify and promptly tackle process pitfalls, including vaccine refusals (0.36%, below expectations) and post-vaccinations adverse reactions (0.4%). Our innovative "vaccine islands" mass-immunization model might be scaled-up or adapted to other settings. The Authors consider that sharing best practices in immunization delivery is fundamen-tal to achieve population health during health emergencies.

Preventive and responsive plans to COVID-19 epidemic in a leading teaching hospital in Milan, Italy

Issue Following the SARS-Cov-2 outbreak in Wuhan, China, the first case of COVID-19 was reported in Codogno, Lombardy, Italy, on 20 February 2020. The ongoing epidemic has exposed the health care system to a severe stress. San Raffaele Hospital (OSR) in Milan, Italy - a leader in the emergency management, may provide a benchmarking experience useful for other countries. Description of the Problem OSR has established a task force including the health care director, the Infections Prevention and Control Committee (IPCC) and the head of ward and outpatients' facilities management area in order to assess the situation and to define a multi-step strategy. The management process has been divided in two steps. Firstly, a preventive phase was devised, in a preparedness perspective, to avoid the spread of the infection to the Healthcare Professionals (HCP). Secondly, a reorganizational phase was implemented to guarantee assistance to infected patients, especially the critical ones. Results Before the outbreak, the IPCC updated OSR's procedures, based on the WHO's, national and regional guidance, planned a lectures series and an online survey to train healthcare professionals and proposed to stack Personal Protective Equipment (PPE) to face the expected shortage. The Head of the facilities management area defined separate pathways in the Emergency Department in order to isolate patients with respiratory symptoms, set up a new ward, with 26 beds and dedicated personnel, as well as two Intensive Care Units, with 13 beds, Some wards were merged and more healthcare workers were moved to the COVID-19 units. Lessons The coordination between task force members has been crucial for translating the multi-step strategy in a quick reorganization of the whole hospital. Despite early preparations, we could not anticipate the evolution of the outbreak and its logistic impact, especially on the PPE procurement. Key messages A major Hospital was proved to be capable to respond to the changing healthcare requests. Organizational flexibility is crucial for proper emergency management.

COVID-19: knowledge and attitudes of hospital staff of a large Italian teaching hospital

Background During infectious disease emergencies, fully aware healthcare workers (HCWs) and public services staff are unique resources to keep health systems active and tackle epidemics. Aim of the study was to assess concern, general and health-related knowledge (case management and Infection Prevention and Control [IPC] measures) among hospital staff on SARS-CoV-2 in Lombardy region (Italy). Methods One week after WHO declared COVID-19 a public health emergency we developed and online administered a 7-item questionnaire to all staff of San Raffaele Hospital, a referral and teaching hospital in Milan, exploring knowledge and attitudes on COVID-19. The survey remained accessible online for 72 hours. Results A total of 2,046, including HCWs and other staff, answered the survey (response rate 25%). Among the 2,027 responders included in the analysis, 1,102 were HCWs (54%), also in training, and 924 non-HCWs (46%). 60% of responders reported being worried or extremely worried about the epidemic. Concerning knowledge, the survey asked about modes of transmission, clinical forms, preventive measures in everyday life in Italy and cough etiquette. There were uniform trends in the two groups: HCWs were more aware and answered more properly (mean of correct answers 71,6%) than non-HCWs (mean 61,2%). HCWs were asked about IPC precautions, with only 41% providing correct answers, while over 74% knew only supportive therapy is currently available against COVID-19. Conclusions We were among the first to explore hospital staff knowledge on COVID-19 reporting data from a large study population. HCWs were slightly less concerned but more knowledgeable than general staff. Last questions showed that among HCWs there is generally good knowledge on the topic. However, most of the responders missed the recommendations to adopt simultaneously standard, contact and airborne precautions plus eye protection managing suspected and confirmed cases, as proposed by national and international authorities. Key messages During the ongoing emergency, it is of utmost importance that hospital staff is adequately trained to implement the best IPC measures and limit the spread of the infection. Our data can inform planning of these preventive measures.