A multifaceted approach to education, observation, and feedback in a successful hand hygiene campaign.

BACKGROUND: Prevention of health care-associated infections starts with scrupulous hand hygiene (HH). Improving HH compliance is a major target for the World Health Organization Patient Safety Challenge and is one of The Joint Commission's National Patient Safety Goals. Yet, adherence to HH protocols is generally poor for health care professionals, despite interventions designed to improve compliance. At Tufts Medical Center (Boston), HH compliance rates were consistently low despite the presence of a traditional HH campaign that used communication and education. METHODS: A comprehensive program incorporated strong commitment by hospital leadership-who were actively involved in responsibilities previously only performed by infection preventionists and quality and patient safety staff-dedication of financial resources, including securing a grant; collaborating with a private advertising firm in a marketing campaign; and employing a multifaceted approach to education, observation, and feedback. RESULTS: This campaign resulted in a rapid and sustained improvement in HH compliance: Compared with the mean HH compliance rate for the six months before the campaign (72%), postcampaign HH compliance (mean = 94%) was significantly greater (p < .0001). Factors contributing to the success of the campaign included the development of the marketing campaign to fit this academic medical center's particular culture, strong support from the medical center leadership, a multifaceted educational approach, and monthly feedback on HH compliance. CONCLUSIONS: A comprehensive campaign resulted in rapid and sustained improvement in HH compliance at an academic medical center after traditional communication and education strategies failed to improve HH performance.

Antibiotic exposure and room contamination among patients colonized with vancomycin-resistant enterococci.

OBJECTIVE: To determine whether total and antianaerobic antibiotic exposure increases the risk of room contamination among vancomycin-resistant enterococci (VRE)-colonized patients. DESIGN AND SETTING: A 14-month study in 2 intensive care units at an academic tertiary care hospital in Boston, Massachusetts. PATIENTS: All patients who acquired VRE or were VRE-colonized on admission and who had environmental cultures performed. METHODS: We performed weekly environmental cultures (2 sites per room) and considered a room to be contaminated if there was a VRE-positive environmental culture during the patient's stay. We determined risk factors for room contamination by use of the Cox proportional hazards model. RESULTS: Of 142 VRE-colonized patients, 35 (25%) had an associated VRE-positive environmental culture. Patients who contaminated their rooms were more likely to have diarrhea than those who did not contaminate their rooms (23 [66%] of 35 vs 41 [38%] of 107; P = .005) and more likely to have received antibiotics while VRE colonized (33 [94%] of 35 vs 86 [80%] of 107; P = .02). There was no significant difference in room contamination rates between patients exposed to antianaerobic regimens and patients exposed to nonantianaerobic regimens or between patients with and patients without diarrhea, but patients without any antibiotic exposure were unlikely to contaminate their rooms. Diarrhea and antibiotic use were strongly confounded; although two-thirds of room contamination occurred in rooms of patients with diarrhea, nearly all of these patients received antibiotics. In multivariable analysis, higher mean colonization pressure in the ICU increased the risk of room contamination (adjusted hazard ratio per 10% increase, 1.44 [95% confidence interval, 1.04-2.04]), whereas no antibiotic use during VRE colonization was protective (adjusted hazard ratio, 0.21 [95% confidence interval, 0.05-0.89]). CONCLUSIONS: Room contamination with VRE was associated with increased mean colonization pressure in the ICU and diarrhea in the VRE-colonized patient, whereas no use of any antibiotics during VRE colonization was protective.

Prior environmental contamination increases the risk of acquisition of vancomycin-resistant enterococci.

BACKGROUND: Patients colonized with vancomycin-resistant enterococci (VRE) frequently contaminate their environment, but the environmental role of VRE transmission remains controversial. METHODS: During a 14-month study in 2 intensive care units, weekly environmental and twice-weekly patient surveillance cultures were obtained. VRE acquisition was defined as a positive culture result >48 h after admission. To determine risk factors for VRE acquisition, Cox proportional hazards models using time-dependent covariates for colonization pressure and antibiotic exposure were examined. RESULTS: Of 1330 intensive care unit admissions, 638 patients were at risk for acquisition, and 50 patients (8%) acquired VRE. Factors associated with VRE acquisition included average colonization pressure (hazard ratio [HR], 1.4 per 10% increase; 95% confidence interval [CI], 1.2-1.8), mean number of antibiotics (HR, 1.7 per additional antibiotic; 95% CI, 1.2-2.5), leukemia (HR, 3.1; 95% CI, 1.2-7.8), a VRE-colonized prior room occupant (HR, 3.1; 95% CI, 1.6-5.8), any VRE-colonized room occupants within the previous 2 weeks (HR, 2.5; 95% CI, 1.3-4.8), and previous positive room culture results (HR, 3.4; 95% CI, 1.2-9.6). In separate multivariable analyses, a VRE-colonized prior room occupant (HR, 3.8; 95% CI, 2.0-7.4), any VRE-colonized room occupants within the previous 2 weeks (HR, 2.7; 95% CI, 1.4-5.3), and previous positive room culture results (HR, 4.4; 95% CI, 1.5-12.8) remained independent predictors of VRE acquisition, adjusted for colonization pressure and antibiotic exposure. CONCLUSIONS: We found that prior room contamination, whether measured via environmental cultures or prior room occupancy by VRE-colonized patients, was highly predictive of VRE acquisition. Increased attention to environmental disinfection is warranted.

The impact of gown-use requirement on hand hygiene compliance.

BACKGROUND: Hand hygiene compliance remains low, despite its effectiveness in preventing infections. Gowns are routinely used to reduce dissemination of organisms within hospitals. Use of gowns is time consuming and costly, and their effectiveness, compared with that of hand hygiene alone, is debated. Among the arguments supporting a gown-use requirement is the potential to boost awareness of infection control, leading to improved hand hygiene compliance. METHODS: Hand hygiene compliance was recorded in a 14-month crossover trial comparing compliance at 2 intensive care units during periods with and without a gown-use requirement. RESULTS: During 170 h of observation, 1619 hand hygiene opportunities were recorded. Compliance was 10% before care was given and 36% after care was given. Compliance with glove and gown use was 62% and 63%, respectively. After-care hand hygiene compliance for nurses, physicians, and therapists was 40%, 38%, and 22%, respectively. Compliance after patient contact, body fluid contact, and other in-room activity was 42%, 48%, and 22%, respectively. For periods with and without a gown-use requirement, overall after-care compliance (37% vs. 34%) and rates by personnel and activity type were similar. In the subgroup of patients on contact precautions, hand hygiene compliance during the period with a gown-use requirement versus the period without a gown-use requirement was 11% versus 10% (P=.85) before care was given and 45% versus 39% (P=.09) after care was given. In this subgroup, after adjustment for type of in-room activity, medical personnel, intensive care unit, and observer, the predicted after-care hand hygiene compliance during periods with and without a gown-use requirement was 48% versus 41% (P=.02). CONCLUSIONS: The hypothesis that a gown-use requirement might improve hand hygiene compliance in the intensive care unit could not be confirmed. In the subgroup of patients on contact precautions, improvement in hand hygiene compliance associated with the gown-use requirement was small and did not affect precare rates.

Role of environmental contamination as a risk factor for acquisition of vancomycin-resistant enterococci in patients treated in a medical intensive care unit.

BACKGROUND: Colonization pressure, proximity to another case, exposure to a nurse who cares for another case, enteral feeding, and the use of sucralfate, vancomycin hydrochloride, cephalosporins, or antibiotics are among the defined risk factors for acquisition of vancomycin-resistant enterococci (VRE) in the intensive care unit (ICU) setting. However, the role of rooms with contaminated environmental surfaces has not been well delineated. METHODS: Retrospective case-control study conducted on patients admitted to the medical ICU (MICU) of a tertiary-care, university-affiliated medical center during a 9-month period. Patients who acquired VRE (cases) were matched with 2 randomly selected control subjects who did not acquire VRE and had been in the MICU for at least the same number of days. RESULTS: Thirty cases were matched with 60 appropriate controls. Cases were more likely to have been in the hospital for longer than 7 days before MICU admission (P =.009); to have occupied a specific room with persisting contaminated surfaces (P =.06); to have had a central venous catheter (P =.05); to have received vancomycin (P =.02), cephalosporins (P =.03), and quinolones (P =.006) before MICU admission; and to have received vancomycin (P =.02) and metronidazole sodium phosphate (P =.03) after MICU admission. Multivariate analysis showed that a hospital stay of longer than 1 week before MICU admission (P =.04), use of vancomycin before or after MICU admission (P =.03), use of quinolones before MICU admission (P =.03), and placement in a contaminated room (P =.02) were the best predictors of VRE acquisition. CONCLUSIONS: Among all other factors associated with VRE transmission, VRE acquisition may depend on room contamination, even after extensive cleaning. This study underscores the need for better cleaning and the role of the environment in transmission of VRE.