To our knowledge, this prospective longitudinal observational quality improvement project is the largest sample size and longest investigation related to HHC. In this study, we found that using KCM can systematically change the understanding of HH among medical staff and improve the HHC of medical staff consistently. Therefore, it contributed to the stable low level of the incidence of CAUTI and CLABSI under the premise of increasing medical business and medical technology.
KCM was a method that can systematically and continuously improve HHC and was a comprehensive and systematic long-term intervention measure starting from awareness, motivation, and behavior, from the cultivation of HH awareness of medical staff, the establishment of the cooperative team, the establishment of vision and objectives, the implementation of reward mechanism to the strengthening of behavior change.
In the previous literature, many investigators have reported the intervention measures to improve HHC, which have improved to varying levels [15–17]. However, despite those improvements, health care providers were easy to form slack and declined in the later stage because they were often a single approach or short-term intervention measures. Therefore, the improvement of HHC strongly depended on the culture and atmosphere created by medical institutions for a long time [18]. At the same time, it also needs to cooperate with multiple members for continuous improvement. KCM method provided a better clinical practice thought to achieve this goal. Long-term systematic improvement can create HH culture and atmosphere, help form stable HHC, and reduce individual differences among medical staff [19].
At the same time, we also found that during the implementation of the KCM project, the HHC at different stages has certain changes. In the first stage, the improvement of HHC was very obvious in creating a sense of urgency, forming a guiding coalition, and creating a vision. The possible reason is that medical staff have a consistent sense of urgency and have a shared vision in the initial stage of project implementation. Hence, the improvement rate was high [20]. In the second stage, the HHC among medical staff repeatedly fluctuated or even decreased in communicating and empowering others to act on the vision and creating quick wins. We speculate that the possible reason is that the implementation of some reward and punishment measures for HH will make medical personnel feel uncomfortable. As a result, medical staff could have also been burnout [21]. Finally, in the third stage, building on change and institutionalizing it, the HHC reached a relatively stable state and fluctuated normally, indicating that the medical staff had passed the "labor pain period" and the culture, atmosphere, and consciousness were gradually formed and stable.
As we all know, it is an ideal state for medical institutions to achieve 100% HHC at all times. Therefore, our goal should focus on high and stable HHC in medical institutions and pay more attention to the compliance of different HH opportunities [22, 23]. This study found that after the KCM project, the most significant improvement was after patient contacts. The smallest gain was after contacting the patient's surrounding environment, likely because it was high at the baseline. The HHC, after contact with patients' body fluids, blood and secretions, fluctuated in the KCM implementation process, which was an improvement indication worthy of special attention in the future. In addition, an important finding in this study is that physicians' HHC increased greatly, while nurses' HHC tended to decrease. As we all know, physicians have always had lower HHC than nurses, and KCM has greatly improved physicians' HHC by creating a safe atmosphere and continuous consolidation of objectives [24, 25].
The ultimate goal of HH in ICU is to reduce the incidence of HAIs, especially CLABSI and CAUTI, which are directly related to HH. In our study, although there was no significant improvement in CLABSI and CAUTI from March 2018 to August 2021 with quarterly incidence data, the incidence of CAUTI and CLABSI remained stable at a low level under the background of the number of cases and the treatment complexities of the patients increasing year by year, which also illustrate the role of KCM on maintaining a consistently high level of HHC to a certain degree. However, there was a significant increase in the incidence of CLABSI from the second quarter to the third quarter of 2020, primarily due to the COVID-19 outbreak in Wuhan. Although we lacked the HHC data for that period in our study, from the relevant literature, we noticed the HHC during the early stage of COVID-19 epidemic was very low [26–28], which can explain why the increase of nosocomial infection accompanied by low HHC. With the improvement of the epidemic situation and the re-implementation of KCM, we noted a gradual decrease in CLABSI as of the fourth quarter of 2020.
This study also has some limitations. Firstly, although KCM is a very effective method to improve HHC systematically, it still needs to be continuous and stable monitored and systematic planned, which is easy to be terminated by various influencing factors in clinical practice, especially in some areas with limited resources; Secondly, COVID-19 outbreak began in the global pandemic. Therefore, the promotion of HHC did not exclude the impact of the COVID-19 pandemic. Nevertheless, despite the limitations of the above research, the research still showed that KCM was very suitable as a fundamental method to improve HHC.