Should automated electronic hand-hygiene monitoring systems be implemented in routine patient care? Systematic review and appraisal with Medical Research Council Framework for Complex Interventions.

Manual hand-hygiene audit is time-consuming, labour-intensive and inaccurate. Automated hand-hygiene monitoring systems (AHHMSs) offer advantages (generation of standardized data, avoidance of the Hawthorne effect). World Health Organization Guidelines for Hand Hygiene published in 2009 suggest that AHHMSs are a possible alternative. The objective of this review was to assess the current state of the literature for AHHMSs and offer recommendations for use in real-world settings. This was a systematic literature review, and publications included were from the time that PubMed commenced until 19th November 2023. Forty-three publications met the criteria. Using the Medical Research Council's Framework for Developing and Evaluating Complex Interventions, two were categorized as intervention development studies. Thirty-nine were evaluations. Two described implementation in real-world settings. Most were small scale and short duration. AHHMSs in conjunction with additional intervention (visual or auditory cue, performance feedback) could increase hand hygiene compliance in the short term. Impact on infection rates was difficult to determine. In the few publications where costs and resources were considered, time devoted to improving hand hygiene compliance increased when an AHHMS was in use. Health workers' opinions about AHHMSs were mixed. In conclusion, at present too little is known about the longer-term advantages of AHHMSs to recommend uptake in routine patient care. Until more longer-term accounts of implementation (over 12 months) become available, efforts should be made to improve direct observation of hand hygiene compliance to improve its accuracy and credibility. The Medical Research Council Framework could be used to categorize other complex interventions involving use of technology to prevent infection to help establish readiness for implementation.

What techniques are recommended to undertake procedures that require asepsis? Content and cluster analysis of information supplied in international guidance.

BACKGROUND: Health professionals frequently conduct procedures requiring asepsis but there is no definitive evidence-based guidance on how aseptic technique should be undertaken. OBJECTIVE: To undertake content and cluster analysis to compare and contrast information relating to the conduct of aseptic technique in national and international guidance. METHODS: Content and hierarchical cluster analysis. RESULTS: We identified 16 sources of information from: organizations that generate infection prevention guidelines, provide advice about infection prevention in addition to other topics, generate guidance for procedures (e.g., wound care); practice manuals; MeSH and Wikipedia. Content related to: theory underpinning aseptic technique; terminology used; how and when it should be undertaken; and equipment. The nature and amount of information varied widely. Most frequently stated information related to: environment or equipment (N = 13), followed by the absolute nature of asepsis and the importance of hand hygiene (N = 10); general personal protective equipment, the significance of pathogens, and no-touch techniques (N = 8); that it is risk-based (N = 7); the existence of key parts or sites, and that there are different types of aseptic technique (N = 6). The most comprehensive sources were a wound care organization in the USA, and a British internationally used textbook. Least information was provided in some general infection prevention guidelines. CONCLUSION: Progress with research and practice in relation to aseptic technique suffers through lack of common goals and understanding. This study is one step towards establishing what constitutes aseptic technique, how and when it should be conducted, and the equipment necessary. This is required to support practice, policy and education, and may improve sustainability of healthcare resources.

Challenges undertaking procedures requiring asepsis: a qualitative interview study with nurses.

BACKGROUND: Invasive devices and breaches to skin and mucous membranes increase susceptibility to infection. Nurses frequently undertake procedures requiring asepsis (PRAs), but report challenges and unwarranted variations in practice. OBJECTIVE: To explore nurses' experiences, perceived gaps in information and support needed to conduct PRAs. METHODS: Qualitative interviews were undertaken with 20 nurses in the UK National Health Service between September 2021 and January 2022 employing approaches to sampling and data collection adopted in grounded theory. RESULTS: Informants were employed in diverse clinical settings. They thought that outside operating theatres, attempts to maintain asepsis would inevitably be compromised, but that much could still be done to contain the risk of contaminating susceptible sites irrespective of circumstances. Suboptimal practice was reported, and informants were unclear whether asepsis was needed to perform routine procedures (e.g. dressing chronic wounds, manipulating indwelling intravascular lines). Problems were attributed to inadequacies in nursing education, poor access to continuing professional development, and carelessness of junior nurses and medical staff. Informants wanted more detailed guidelines to conduct PRAs. Senior nurses wanted procedures to be conducted in the same way regardless of circumstance. Nurses who undertook PRAs regularly suggested that guidelines should be flexible. CONCLUSION: There is a need for detailed guidelines to inform PRAs, better access to clinical updating, and improvements in pre-registration nursing education. To meet contemporary standards, guideline generation should adopt recognized methodology. Student nurses should be introduced to the knowledge and skills required to undertake and adjust PRAs according to circumstance during simulated practice before contact with real patients.

Electronic hand hygiene monitoring systems can be well-tolerated by health workers: Findings of a qualitative study.

BACKGROUND: Electronic hand hygiene monitoring overcomes limitations associated with manual audit but acceptability to health workers varies and may depend on culture of the ward and the nature of the system. OBJECTIVES: Evaluate the acceptability of a new fifth type electronic monitoring system to frontline health workers in a National Health Service trust in the UK. METHODS: Qualitative interviews with 11 informants following 12 months experience using an electronic monitoring system. RESULTS: Informants recognised the importance of hand hygiene and embraced technology to improve adherence. Barriers to hand hygiene adherence included heavy workload, dealing with emergencies and ergonomic factors related to placement of alcohol dispensers. Opinions about the validity of the automated readings were conflicting. Some health workers thought they were accurate. Others reported problems associated with differences in the intelligence of the system and their own clinical decisions. Opinions about feedback were diverse. Some health workers thought the system increased personal accountability for hand hygiene. Others ignored feedback on suboptimal performance or ignored the data altogether. It was hard for health workers to understand why the system registered some instances of poor performance because feedback did not allow omissions in hand hygiene to be related to the context of care. CONCLUSION: Electronic monitoring can be very well tolerated despite some limitations. Further research needs to explore different reactions to feedback and how often clinical emergencies arise. Electronic and manual audit have complementary strengths.

The Hawthorne effect on adherence to hand hygiene in patient care.

Numerous studies demonstrate that the Hawthorne effect (behaviour change caused by awareness of being observed) increases health workers' hand hygiene adherence but it is not clear whether they are methodologically robust, what the magnitude of the effect is, how long it persists or whether it is the same across clinical settings. The objective of this review was to determine the rigour of the methods used to assess the Hawthorne effect on hand hygiene, effect size estimation, variations between clinical settings and persistence. To this end, a systematic literature review with meta-analysis was conducted. Nine studies met the criteria for the review. Methodological quality was variable. The Hawthorne effect ranged from -6.9% to 65.3%. It was 4.2% in one study conducted in intensive care and 16.4% in transplant units. It was most marked when data were collected across an entire hospital and in a group of general hospitals. Differences between wards in the same hospital were apparent. In the two studies where duration was estimated, the Hawthorne effect appeared transient. Despite methodological shortcomings, the review indicates clear evidence of a Hawthorne effect on general wards. There is evidence that it may vary between clinical speciality and across departments. The review identifies a need for standardized methodologies to measure the Hawthorne effect to overcome the dilemma of reporting the potentially inflated rates of adherence obtained through overt audit. Occasional covert audit could give a better estimation of true hand hygiene adherence but its acceptability and feasibility to health workers need to be explored.

Changing the paradigm: messages for hand hygiene education and audit from cluster analysis.

BACKGROUND: Hand hygiene is considered to be the foremost infection prevention measure. How healthcare workers accept and make sense of the hand hygiene message is likely to contribute to the success and sustainability of initiatives to improve performance, which is often poor. METHODS: A survey of nurses in critical care units in three National Health Service trusts in England was undertaken to explore opinions about hand hygiene, use of alcohol hand rubs, audit with performance feedback, and other key hand-hygiene-related issues. Data were analysed descriptively and subjected to cluster analysis. RESULTS: Three main clusters of opinion were visualized, each forming a significant group: positive attitudes, pragmatism and scepticism. A smaller cluster suggested possible guilt about ability to perform hand hygiene. CONCLUSION: Cluster analysis identified previously unsuspected constellations of beliefs about hand hygiene that offer a plausible explanation for behaviour. Healthcare workers might respond to education and audit differently according to these beliefs. Those holding predominantly positive opinions might comply with hand hygiene policy and perform well as infection prevention link nurses and champions. Those holding pragmatic attitudes are likely to respond favourably to the need for professional behaviour and need to protect themselves from infection. Greater persuasion may be needed to encourage those who are sceptical about the importance of hand hygiene to comply with guidelines. Interventions to increase compliance should be sufficiently broad in scope to tackle different beliefs. Alternatively, cluster analysis of hand hygiene beliefs could be used to identify the most effective educational and monitoring strategies for a particular clinical setting.

Cyclooxygenase inhibitors inhibit antibody response through interference with MAPK/ERK pathways and BLIMP-1 inhibition.

Fever is a common symptom of illness in children, and although not harmful in itself, fever and its associated symptoms are often treated with antipyretic drugs. A number of national and other guidelines now recommend against their routine use; a conclusion that was initially supported by a study showing that the prophylactic use of paracetamol might reduce antibody response to some vaccine antigens, although data from booster vaccinations are more equivocal. Although in vivo data on the cause of this inhibition are scarce, in vitro data suggests that the cause may be due to inhibition of the mitogen activated protein kinase/extracellular regulated protein kinase pathways, and a subsequent reduction in the process of plasma cell differentiation at the beginning of the antibody response. This suggests that in high-risk patients these drugs could be avoided in the early part of an infection when plasma-cell differentiation is occurring. More data are needed to define this period; until then existing data support the recommendation against the routine use of these drugs.

Physical treatment of fever.

Fever is a common symptom of childhood illness, and much time and effort is spent in the pursuit of reducing high temperature. Although antipyretic drugs are the main form of treatment, this report considers the part that physical treatments might play in reducing the temperature of febrile children. Such treatments include tepid sponging, removing clothing, and cooling the environment. Of these treatments, tepid sponging has been studied most extensively, as an addition to paracetamol, but seems to offer little advantage over paracetamol alone. It is likely that other methods might be equally ineffective because they all rely on similar methods of heat loss.

The use of antipyretic medications in the prevention of febrile convulsions in children.

Febrile convulsions are a relatively common outcome in paediatric febrile illness, although it is not known why some children suffer these. Antipyretic medications may form the basis for some treatment regimens, although they are not recommended in published guidelines. There is little evidence that the prophylactic use of antipyretics has any effect in reducing the incidence of febrile convulsions. Consequently, educational interventions aimed at reducing parental fear and helping them to care for their children during febrile illnesses may be more efficacious.

The diagnosis, transmission and prevention of HIV-1 in the infant under 18 months of age: implications for nursing practice.

Vertical transmission of HIV from mother-to-child is a significant problem around the world. This paper examines the main issues that confront those caring for pregnant women who may transmit HIV-1 to their babies with reference to the impact upon clinical practice. Nursing practice should accommodate research from a number of disciplines including medical and scientific researchers. A number of risk factors for vertical transmission have been identified, including immunological status of the mother, premature birth, method of delivery and breast feeding. The use of prophylactic zidovudine has also been shown to reduce the rate of transmission of the virus, although it is not clear at what point in pregnancy and delivery it exerts this protection. Although this paper considers recent advances in the prevention of vertical transmission, this is a rapidly developing area and readers are provided with Internet addresses where the most up to date information may be found.

Preventing nosocomial infection in paediatric wards.

Nosocomial infection is potentially a major problem in paediatric wards. However, there are methodological difficulties which hinder researchers in identifying the true extent of nosocomial infection. Respiratory infections pose the greatest challenge, with the respiratory syncytial virus (RSV) being particularly problematic. However, RSV can be contained by strict implementation of isolation procedures. Other major pathogens such as enteric bacteria and viruses can similarly be controlled through vigorous attention to hand-washing and isolation. Health-care staff are implicated in the nosocomial spread of many other infectious agents, and should pay particular care to personal practice.