Hand hygiene is effective to prevent transmission of pathogens and healthcare-associated infections. Despite efforts by hospitals to improve hand hygiene adherence among healthcare practitioners (HCP), adherence in neonatology wards is often limited.

Identifying determinants, i.e., facilitators and barriers, to hand hygiene adherence among frontline HCP in neonatology.

Qualitative implementation research study.

Department of Neonatology of the University Hospital Zurich, Switzerland.

Semi-structured interviews with frontline HCP and Infection Prevention and Control (IPC) experts were conducted in November 2022. Interviews were coded deductively according to the Theoretical Domains Framework (TDF) and the Capability, Opportunity, Motivation and Behavior model (COM-B), and inductively to capture nuances in the data. Determinants whose addressing was perceived to likely improve hand hygiene adherence in the current setting were rated as “high priority”.

A total of 42 interviews were conducted, 27 (64%) with nurses, six (14%) with physicians, four (10%) with other professions, and five (12%) with IPC experts. Sixteen determinants were identified, twelve of which were high-priority, four in each COM-B domain. Knowledge, attention control, planning workflows, and habits & automatisms were found in “Capability,” workload & emergencies, invisibility of germs, role models, and being observed in “Opportunity,” and bad conscience, experience consequences of (non-) adherence, self-reflection, and intention to adhere to hand hygiene in “Motivation.”

Facilitators from all COM-B domains and barriers from “Capability” and “Opportunity” influence hand hygiene behavior in neonatology settings. Our findings can now inform interventions to improving hand hygiene adherence in neonatal settings.

The preventable proportion of healthcare-associated infections (HAIs) may decrease over time as standards of care improve. We aimed to assess the proportion of HAIs prevented by multifaceted infection control interventions in different economic settings.

In this systematic review and meta-analysis, we searched OVID Medline, EMBASE, CINAHL, PubMed, and The Cochrane Library for studies published between 2005 and 2016 assessing multifaceted interventions to reduce catheter-associated urinary tract infections (CAUTIs), central-line–associated bloodstream infections (CLABSIs), surgical site infections (SSIs), ventilator-associated pneumonia (VAP), and hospital-acquired pneumonia not associated with mechanical ventilation (HAP) in acute-care or long-term care settings. For studies reporting raw rates, we extracted data and calculated the natural log of the risk ratio and variance to obtain pooled risk ratio estimates.

Of the 5,226 articles identified by our search, 144 studies were included in the final analysis. Pooled incidence rate ratios associated with multifaceted interventions were 0.543 (95% confidence interval [CI], 0.445–0.662) for CAUTI, 0.459 (95% CI, 0.381–0.554) for CLABSI, and 0.553 (95% CI, 0.465–0.657) for VAP. The pooled rate ratio was 0.461 (95% CI, 0.389–0.546) for interventions aiming at SSI reduction, and for VAP reduction initiatives, the pooled rate ratios were 0.611 (95% CI, 0.414–0.900) for before-and-after studies and 0.509 (95% CI, 0.277–0.937) for randomized controlled trials. Reductions in infection rates were independent of the economic status of the study country. The risk of bias was high in 143 of 144 studies (99.3%).

Published evidence suggests a sustained potential for the significant reduction of HAI rates in the range of 35%–55% associated with multifaceted interventions irrespective of a country’s income level.

Preventing ventilator-associated pneumonia (VAP) is an important goal for intensive care units (ICUs). We aimed to identify the optimal behavior leverage to improve VAP prevention protocol adherence.

Mixed-method study using adherence measurements to assess 4 VAP prevention measures and qualitative analysis of semi-structured focus group interviews with frontline healthcare practitioners (HCPs).

The 6 ICUs in the 900-bed University Hospital Zurich in Zurich, Switzerland.

Adherence to VAP prevention measures were assessed in patients with a device for invasive ventilation (ie, endotracheal tube, tracheostomy tube). Participants in focus group interviews included a convenience samples of ICU nurses and physicians.

Between February 2015 and July 2017, we measured adherence to 4 protocols: bed elevation showed adherence at 27% (95% confidence intervals [CI], 23%–31%); oral care at 41% (95% CI, 36%–45%); sedation interruption at 81% (95% CI, 74%–85%); and subglottic suctioning at 88% (95% CI, 83%–92%). Interviews were analyzed first inductively according a grounded theory approach then deductively against the behavior change wheel (BCW) framework. Main behavioral facilitators belonged to the BCW component ‘reflective motivation’ (ie, perceived seriousness of VAP and self-efficacy to prevent VAP). The main barriers belonged to ‘physical capability’ (ie, lack of equipment and staffing and side-effects of prevention measures). Furthermore, 2 primarily technical approaches (ie, ‘restructuring environment’ and ‘enabling HCP’) emerged as means to overcome these barriers.

Our findings suggest that technical, rather than education-based, solutions should be promoted to improve VAP prevention. This theory-informed mixed-method approach is an effective means of guiding infection prevention efforts.

The transfer of pathogens may spread antimicrobial resistance and lead to healthcare-acquired infections. We performed a systematic literature review to generate estimates of pathogen transfer in relation to healthcare provider (HCP) activities.

For this systematic review and meta-analysis, Medline/Ovid, EMBASE, and the Cochrane Library were searched for studies published before July 7, 2017. We reviewed the literature, examining transfer of pathogens associated with HCP activities. We included studies that (1) quantified transfer of pathogens from a defined origin to a defined destination surface; (2) reported a microbiological sampling technique; and (3) described the associated activity leading to transfer. For studies reporting transfer frequencies, we extracted data and calculated the estimated proportion using Freeman-Tukey double arcsine transformation and the DerSimonian-Laird random-effects model.

Of 13,121 identified articles, 32 were included. Most articles (n=27, 84%) examined transfer from patients and their environment to HCP hands, gloves, and gowns, with an estimated proportion for transfer frequency of 33% (95% confidence interval [CI], 12%–57%), 30% (95% CI, 23%–38%) and 10% (95% CI, 6%–14%), respectively. Other articles addressed transfer involving the hospital environment and medical devices. Risk factor analyses in 12 studies suggested higher transfer frequencies after contact with moist body sites (n=7), longer duration of care (n=5), and care of patients with an invasive device (n=3).

Recognizing the heterogeneity in study designs, the available evidence suggests that pathogen transfer to HCPs occurs frequently. More systematic research is urgently warranted to support targeted and economic prevention policies and interventions.

In this study, we sought to establish a comprehensive inventory of infectious risk moments (IRMs), defined as seemingly innocuous yet frequently occurring care manipulations potentially resulting in transfer of pathogens to patients. We also aimed to develop and employ an observational taxonomy to quantify the frequency and nature of IRMs in acute-care settings.

Prospective observational study and establishment of observational taxonomy.

Intensive care unit, general medical ward, and emergency ward of a university-affiliated hospital.

Healthcare workers (HCWs)

Exploratory observations were conducted to identify IRMs, which were coded based on the surfaces involved in the transmission pathway to establish a structured taxonomy. Structured observations were performed using this taxonomy to quantify IRMs in all 3 settings.

Following 129.17 hours of exploratory observations, identified IRMs involved HCW hands, gloves, care devices, mobile objects, and HCW clothing and accessories. A structured taxonomy called INFORM (INFectiOus Risk Moment) was established to classify each IRM according to the source, vector, and endpoint of potential pathogen transfer. We observed 1,138 IRMs during 53.77 hours of structured observations (31.25 active care hours) for an average foundation of 42.8 IRMs per active care hour overall, and average densities of 34.9, 36.8, and 56.3 IRMs in the intensive care, medical, and emergency wards, respectively.

Hands and gloves remain among the most important contributors to the transfer of pathogens within the healthcare setting, but medical devices, mobile objects, invasive devices, and HCW clothing and accessories may also contribute to patient colonization and/or infection. The INFORM observational taxonomy and IRM inventory presented may benefit clinical risk assessment, training and education, and future research.

Infect Control Hosp Epidemiol 2018;39:272–279

To elicit expert consensus on the likelihood of infectious outcomes (patient colonization or infection) following a broad range of infectious risk moments (IRMs) from observations in acute care.

Expert consensus study using modified Delphi technique.

Panel of 40 international experts including nurses, physicians and microbiologists specialized in infectious diseases and infection prevention and control (IPC).

The modified Delphi process consisted of 3 online survey rounds, with feedback of mean ratings and expert comments between rounds. The Delphi survey comprised 52 care scenarios representing observed IRMs organized into 6 sections: hands, gloves, medical devices, mobile objects, invasive procedures, and additional moments. For each scenario, experts indicated the likelihood of both patient colonization and infection on a scale from 0 to 5 (high). Expert ratings were plotted against frequencies of IRMs observed during actual patient care resulting in a risk index.

Following 3 rounds, consensus was achieved for 92 of 104 items (88.5%). The mean ratings across all scenarios for likelihood of colonization and infection were 2.68 and 2.02, respectively. The likelihood of colonization was rated higher than infection for 48 of 52 scenarios. Ratings were significantly higher for colonization (P=.001) and infection (P<.0005) when the scenario involved transfer of pathogens to critical patient sites.

The design of effective IPC strategies requires the selection of behaviors according to their impact on patient outcomes. The IRM index reported here provides a basis for standardizing and prioritizing targets for quality improvement initiatives, training, and future research in acute health care.

Infect Control Hosp Epidemiol 2018;39:280–289