The demographic data included the number of residents, the number of healthcare workers, number of sinks for handwashing, and number of ABHRs in private and subsidized RCHs. The data are presented in Table 1. The final sample contained 1053 (46.1%) and 1231 (53.9%) observations in private and subsidized RCHs, respectively. Hand hygiene performance, use of gloves, and respiratory protection were the most observed episodes in ICP. Other episodes of ICP, such as disinfecting used surfaces/equipment, handling of linen, handling of clinical waste, handling of sharp equipment, use of PPEs, and the likelihood of hand colonization were uncommon and difficult to record in this setting. The sampled episodes of healthcare workers included PCWs: 1474 (64.5%), HW: 349 (64.5%), nurses: 349 (18.4%), AHCPs: 36 (1.6%), and doctors: 5 (0.2%). The overall change of hand hygiene performance was minimal and steady over the observation period in both types of RCHs (Figure 1).
Table 1: Demographic data of RCHs
Demographics
|
Total
n (%)
|
Subsidized RCHs
n (%)
|
Private RCHs
n (%)
|
Number of observations
|
2284 (100)
|
1231 (53.9)
|
1053 (46.1)
|
Number of residents
|
461 (100)
|
212 (45.9)
|
249 (54.1)
|
Number of healthcare workers
- ‐ Nurses*:
- ‐ Health workers:
- Personal Care workers:
|
140 (100)
31 (22.1)
17 (12.1)
92 (65.7)
|
78 (55.7%)
15 (19.2)
9 (11.5)
54 (69.2)
|
62 (55.7)
16 (25.8)
8 (12.9)
38 (61.2)
|
Number of sinks for hand washing
|
157 (100)
|
82 (52.2)
|
75 (47.8)
|
Number of alcohol hand rubs
|
50 (100)
|
15 (30)
|
35 (70)
|
* include registered nurses and enrolled nurses
The most frequently observed ICP elements were hand hygiene, use of gloves, and respiratory practice. In this setting, other elements of ICP were seldom observed. Thus, our analysis focused on hand hygiene, use of gloves and respiratory hygiene score among healthcare workers in subsidized and private RCHs. Episodes of ICP observations among AHCPs and doctors were also seldom observed in this setting. Thus, nurses, doctors, and AHCPs were grouped as professional staff categories for further analysis (Table 2).
Table 2. Comparison between subsidized and private RCHs regarding hand hygiene, use of gloves and respiratory protection performance of different healthcare workers
|
Subsidized RCH
|
Private RCH
|
|
PCWs,
n (%)
|
HWs,
n (%)
|
Professional staffæ, n (%)
|
PCWs,
n (%)
|
HWs,
n (%)
|
Professional staffæ, n(%)
|
Hand Hygiene
|
|
|
|
|
|
|
Missing
|
742(87.6)
|
185(80.8)
|
99(63.9)
|
553(88.2)
|
112(93.3)
|
251(82)
|
Performed
|
98(11.6)
|
38(16.6)
|
47(30.3)
|
66(10.5)
|
8(6.7)
|
37(12.1)
|
Well performed
|
7(0.8)
|
6(2.6)
|
9(5.8)
|
8(1.3)
|
0(0.0)
|
18(5.9)
|
Use of gloves
|
|
|
|
|
|
|
Not applicable
|
584(68.9)
|
206(90)
|
134(86.5)
|
330(52.6)
|
53(44.2)
|
263(85.9)
|
Missing
|
3(0.4)
|
3(1.3)
|
1(0.6)
|
5(0.8)
|
0(0.0)
|
1(0.3)
|
Improperly performed
|
219(25.9)
|
11(4.8)
|
5(3.2)
|
239(38.1)
|
60(50)
|
22(7.2)
|
Properly performed
|
41(4.8)
|
9(3.9)
|
15(9.7)
|
53(8.5)
|
7(5.8)
|
20(6.5)
|
Respiratory protection
|
|
|
|
|
|
|
Missing
|
214(25.3)
|
71(31.0)
|
51(32.9)
|
273(43.5)
|
3(2.5)
|
114(37.3)
|
Improperly performed
|
8(0.9)
|
3(1.3)
|
2(1.3)
|
1(0.2)
|
0(0.0)
|
0(0.0)
|
Properly performed
|
625(73.8)
|
155(67.7)
|
102(65.8)
|
353(56.3)
|
117(97.5)
|
192(62.7)
|
n=total numbers of observed infection control practice episodes
%=percentage of compliance in each of the total number of observed infection control practice episodes
æProfessional staff include nurses, doctors, and allied health professionals
Hand hygiene performance
Healthcare workers should perform hand hygiene during the “five moments for hand hygiene.” In this study, the observation numbers of five moments showed 30.9% before touching a resident; 1.4% before a clean or aseptic procedure (e.g., before nasogastric tube feeding or changing dressing); 1.4% after blood, body fluid, secretion, excreta, wound, or mucous membrane exposure risk (e.g., after changing diaper); 50.2% after touching a resident; and 16.2% after touching contaminated items or the residents' surrounding environment.
The HWs had poor hand hygiene performance before patient contact (98% failed to perform) and after coming into contact with the patients' surrounding (97% failed to perform). In comparison, they showed better hand hygiene after body fluid exposure risk (only 54% failed to perform).
The hand hygiene performance of the professional staff and HWs is better than that of PCWs (Table 2). The best and worst hand hygiene practices were observed among the professional staff and the PCWs, respectively. The professional staff (well-performed: 5.8%, performed: 30.3%) and HWs (well-performed: 2.6%, performed: 16.6%) in subsidized RCHs performed better than the professional staff (well-performed: 5.9%, performed: 12.1%) and HWs (well performed: 0%, performed: 6.7%) in private homes (Table 2). Post-hoc analysis using the Bonferroni multiple comparison also indicated that the hand hygiene of professional staff was significantly different from those of HWs and PCWs (F=27.54, p<0.001) (Table 3), wherein the professional staff performed better than HWs and PCWs.
Table 3. Compliance with infection control guidelines among healthcare workers (HCWs)
|
Professional staff æ, n (%)
|
HWs,
n (%)
|
PCWs,
n (%)
|
ANOVA test,
p-value
|
Hand hygiene
|
|
|
|
F=27.54, p<0.001
|
Missing
|
350(75.92)
|
297(85.1)
|
1295(87.86)
|
|
Performed
|
84(18.22)
|
46(13.18)
|
164(11.13)
|
|
Well performed
|
27(5.86)
|
6(1.72)
|
15(1.02)
|
|
Use of gloves
|
|
|
|
F=40.13, p<0.001
|
Missing
|
2(3.13)
|
3(3.33)
|
8(1.43)
|
|
Improperly performed
|
27(42.19)
|
71(78.89)
|
458(81.79)
|
|
Properly performed
|
35(54.69)
|
16(17.78)
|
94(16.79)
|
|
Respiratory protection
|
|
|
|
F=11.08, p<0.001
|
Missing
|
165(35.79)
|
74(21.2)
|
487(33.04)
|
|
Improperly performed
|
2(0.43)
|
3(0.86)
|
9(0.61)
|
|
Properly performed
|
294(63.77)
|
272(77.94)
|
978(66.35)
|
|
n=total numbers of observed infection control practice episodes
%=percentage of compliance in each of the total number of observed infection control practice episodes
æProfessional staff include nurses, doctors, and allied health professionals
Overall hand hygiene performance among healthcare workers was inadequate in RCHs. The missing rate in private RCHs (87%) was slightly higher than that in subsidized RCHs (83%) (Table 4). The use of soap and water to wash hands (82%) was obviously higher than using ABHR (18%) among healthcare workers. However, the use of ABHR was more frequent among the professional staff (8%) than HWs (4%) and PCWs (1%) (Table 5). T-test results showed there was no significant difference in hand hygiene performance between private and subsidized RCHs (t=1.65, p=0.1) and between common areas and bedroom areas (t=0.74, p=0.92) (Table 4).
Table 4. Compliance with infection control guidelines in type of RCHs (subsidized and private RCHs) and location (common area and bedroom area)
|
Overall, n(%)
|
Subsidized RCHs, n(%)
|
Private RCHs, n(%)
|
t-test, p value
|
Common areas, n(%)
|
Bedroom areas, n(%)
|
t-test, p value
|
Hand hygiene
|
|
|
|
t=1.65, p=0.10
|
|
|
t=0.74, p=0.92
|
Missing
|
1942(85.03)
|
1026(83.35)
|
916(86.99)
|
|
881(84.87)
|
1061(85.5)
|
|
Performed
|
294(12.87)
|
183(4.87)
|
111(10.54)
|
|
136(13.1)
|
158(12.68)
|
|
Well performed
|
48(2.10)
|
22(1.79)
|
26(2.47)
|
|
21(2.02)
|
27(2.70)
|
|
Use of gloves
|
|
|
|
t=-6.81, p<0.001
|
|
|
t=-3.84, p<0.001
|
Missing
|
13(1.82)
|
6(1.95)
|
5(1.23)
|
|
3(1.05)
|
10(2.34)
|
|
Improperly performed
|
556(77.87)
|
235(76.55)
|
321(78.87)
|
|
240(83.62)
|
316(74.00)
|
|
Properly performed
|
145(20.31)
|
66(21.5)
|
81(19.9)
|
|
44(15.33)
|
101(23.65)
|
|
Respiratory protection
|
|
|
|
t=4.74,
p<0.001
|
|
|
t= -1.841.84,
p=0.06
|
Missing
|
726(31.79)
|
338(27.46)
|
390(37.04)
|
|
351(33.82)
|
375(30.1)
|
|
Improperly performed
|
14(0.61)
|
13(1.06)
|
1(0.09)
|
|
5(0.48)
|
9(0.72)
|
|
Properly performed
|
1544(67.6)
|
880(71.49)
|
662(62.87)
|
|
682(65.7)
|
862(69.8)
|
|
n=total numbers of observed infection control practice episodes
%=percentage of compliance in each of the total number of observed infection control practice episodes
Table 5: Use of handrub and handwashing among healthcare workers
|
Occupations
|
|
PCWs,
n (%)
|
HWs,
n (%)
|
Professional staff, n (%)
|
Alcohol-based handrub
|
11 (1)
|
14 (4)
|
38(8)
|
Handwashing using soap and water
|
168(11)
|
38(11)
|
73(16)
|
Hand hygiene missing
|
1295(88)
|
297(85)
|
350(76)
|
Use of gloves
There was a low number of observations before aseptic task (1.4%) and after body fluid exposure risk (1.4%) moments. About 67% were presented as not applicable among the use of gloves observations. However, the observations showed that 77.9% improperly performed this practice. Most of the healthcare workers did not even change gloves between patient contacts.
The observations for the proper use of gloves were 77.3% in nurses, 12.4% in HWs, and 10.2% in professional staff. A significant difference was found in the performance score of using gloves via the ANOVA test (F=40.13, p<0.001) (Table 3). Post-hoc analyses showed that the professional staff performed significantly better than PCWs (p<0.001) and HWs (p<0.01) (Table 3).
On the one hand, there was a slightly higher frequency of improper use of gloves in private (79%) than in subsidized (77%) RCHs (Table 4). On the other hand, there were 6% and 5% who failed to use gloves in subsidized and private RCHs, respectively. A significant difference in the proper use of gloves between subsidized and private RCHs (t=–6.81, p<0.001) and between common areas and bedroom areas (t=–3.84, p<0.001) was found (Table 4).
Respiratory Protection
Around 31.8% failed to wear the mask as needed. However, most of them knew how to wear the required mask properly. Moreover, HWs performed better respiratory protection (77% performed properly) than the professional staff (65%) and PCWs (66%). A significant difference in respiratory protection among occupations was found (F=11.08, p<0.001) (Table 3).
The practice of respiratory protection was better in subsidized (72%) than in private RCHs (63%). A significant difference was found in the practice of respiratory protection between subsidized and private RCHs (t=4.74, p<0.001). However, there was no significant difference of such a practice between common areas and bedroom areas (t=-1.84, p=0.06) (Table 4).
Association between hand hygiene performance and use of gloves
There was a negative correlation between the proper use of gloves and hand hygiene performance (r=–0.239, p<0.001).