Electronic control of hand hygiene in intensive care unit and its correlation with healthcare-associated infections: a retrospective study

doi:10.21203/rs.3.rs-4110977/v1

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Electronic control of hand hygiene in intensive care unit and its correlation with healthcare-associated infections: a retrospective study

https://doi.org/10.21203/rs.3.rs-4110977/v1

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Purpose

To investigate the impact of an electronic monitoring system(EMS) on the adherence to hand hygiene༈HH༉ protocols among healthcare professionals in the intensive care unit༈ICU༉, and analyze the correlation between HH and healthcare-associated infections (HAIs) .

Methods

We implemented the EMS system to monitor the HH compliance and collected HH data throughout the year in 2020. Additionally, a retrospective analysis was conducted on the HH and infection-related indicators of medical staff in the ICU from 2016 to 2019.

Results

HH compliance rate monitored by the EMS system exhibited a noteworthy improvement at 89.44%, and the result of direct observation was 88.5%. Notably, both rates were significantly higher than those observed between 2016 and 2019 (53.0%, 60.1%, 61.11%, and 82.4%). With the enhancement of HH compliance, there was a notable reduction in HAIs’ rate in the ICU ward. Every 1% increasing results in a 5.2% decline of HAIs’ rate (Y = -5.200X + 347.2, r =-0.9991, P = 0.0186). However, HAIs did not exhibit any further decline beyond an 80% HH compliance rate. Over the past five years, no significant changes were observed in terms of average infection rates across three tubes or detection rates for four drug-resistant bacteria within the ICU ward.

Conclusion

The EMS’ efficiency is comparable to that of the direct observation method. The rate of HAIs showed a negative correlation with HH compliance until the compliance rate exceeded 80%.

hand hygiene behaviors

electronic monitoring system

healthcare–associated infections

Infection prevention

Intensive Care Unit

In 1847, Hungarian physician Ignaz Semmelweis argued that the main cause of HAIs in women was the lack of effective and standardized hand disinfection (Tyagi and Barwal, 2020). This is the first time to put forward the importance of hand cleaning, but did not cause people's attention. It wasn't until the 1980s, with the global outbreak of faecal-oral food-borne diseases, that people really began to pay attention to the importance of hand-washing. Today, HH is internationally recognized as a major measure that can effectively reduce the spread of pathogenic microorganisms and reduce the risk of HAIs (Sickbert-Bennett et al., 2016). To a certain extent, the implementation of HH reflects the level of infection prevention and control in medical institutions.

China's "Implementation Rules for the Evaluation Standards of Three-level Comprehensive Medical Institutions (2011 edition)" stipulates that the HH compliance rate should be ≥ 80%. Currently, the HH compliance rate among clinical medical personnel in China ranges from 34.26–53.32% (Chatzizacharias and Chapple, 2009, Cookson et al., 2009, Azim et al., 2016). Effective supervision plays a crucial role in enhancing HH compliance and accuracy (Whitby et al., 2006). The direct observation method, involving trained observers monitoring the HH practices during operations, is considered as the "gold standard" "(Pittet et al., 2009). While this approach provides comprehensive and detailed monitoring results, it necessitates a substantial number of personnel and may be susceptible to selection bias, Hawthorne effect, and observer bias (Haessler, 2014).

The EMS enables real-time monitoring of HH implementation, prompting medical staff to adhere to timely HH practices, and automatically generating comprehensive reports. Given the multitude of underlying diseases, compromised immune function, and frequent invasive procedures experienced by patients in the intensive care unit (ICU), this department holds significant importance for effective HH supervision (Musu et al., 2017). This study utilized the electronic HH management system developed by a technology company in Hangzhou to monitor the HH performance of ICU staff within our hospital, and to evaluate the impact of EMS system on HH. While also conducting a retrospective analysis the correlation between HH performance and HAIs.

On January 1st, 2020, our hospital (a tertiary hospital in Zhejiang, China) launched EMS to monitor the HH of ICU medical staff. A total of 63 ICU medical staff, including 17 doctors and 52 nurses, were included in the study. The average age was 34.72 ± 6.26 years old. The doctor-nurse ratio is 1:3.5. The ICU ward is equipped with a total of 23 beds, maintaining a bed-to-protection ratio of 1:2.26. Additionally, the facility possesses three mobile treatment vehicles, four hand-washing stations, and a comprehensive installation of 30 sensors.

Strengthen training on HH knowledge

In accordance with the Code of HH for Medical Personnel and the Action Plan for the Prevention and Control of HAIs, emphasis is placed on the significance, timing, and proper techniques of HH. The World Health Organization (WHO) has established five key moments for HH: prior to patient contact, following patient contact, before aseptic procedures, after exposure to bodily fluids, and subsequent to contact with patients' surroundings.

Enhance the provision of HH infrastructure.

The department should be equipped with existing hand washing facilities, rapid-drying hand sanitizer, and efficient hand drying devices. Each sink should have both hand sanitizer and paper towels readily available, while each bed and bedside treatment cart should be equipped with a designated supply of hand sanitizer. Regular monitoring by assigned personnel is necessary to ensure the proper use of hand sanitizer and timely replenishment of dry toilet paper.

The monitoring of HH implementation was conducted through direct observation

A total of six investigators, who underwent standardized training and certification, were invited to conduct direct observations of HH implementation at least 100 times per quarter. They conducted visits in a systematic manner, with a non-sequential duration of 4 hours, taking place between the hours of 8:00 a.m. and 5:00 p.m. Each observation lasted no less than 15 minutes, with a maximum of two observers present each time. The investigators utilized the World Health Organization's monitoring table for HH compliance, We conducted calibration and assessment of the observational consistency using a meticulously designed questionnaire. The observers maintained a discreet presence, ensuring minimal interference while remaining visible. Monthly statistics on medical staff's HH compliance rate were calculated using the formula: HH compliance rate = (number of observed HH implementations / number of required HH implementations) × 100%. A minimum of 100 observations were conducted monthly to assess HH practices.

Electronic monitoring system for managing HH compliance.

The HH Compliance Management Electronic System (Smalliot Technology Co., LTD., Hangzhou, China) is developed based on advanced behavior recognition technology and precise positioning technology. This comprehensive system comprises an Access Point (AP), entrance identifier, liquid bottle identifier, area identifier, smart badge, and a sophisticated background management system. In the ward, a network of six regional signal transmitters is strategically installed to effectively monitor the movements of medical personnel within various zones including entry and exit points, contaminated areas, and cleaned areas. Additionally, liquid bottle sensors are thoughtfully placed on sanitizer racks adjacent to each bed. Furthermore, comprehensive sensor systems are implemented at ward entrances and exits, mobile water washing stations, as well as underneath beds. The identification radius for bed areas can be precisely set at 50cm. Moreover, healthcare workers are equipped with electronic identification cards for seamless tracking purposes. When medical staff enter or exit the identification area, or come into contact with patients and their surroundings, the entry and exit identification device and logo are activated. The yellow indicator light on their badge illuminates to prompt timely HH measures, including using disinfectant bottles or tap water for rapid disinfection, as well as guiding proper hand washing techniques. Successful responses are uploaded to the system terminal, triggering a warning release from the badge and restoring the green light. Failure to perform required HH is recorded when the red indicator lights up. An electronic system gateway installed on the ward's ceiling aggregates all data collected through hardware equipment into the background system.

HH compliance rate as monitored by an electronic system

Computer and mobile devices were utilized for the purpose of observing and evaluating HH adherence, whereby the electronic monitoring system accurately computed the rate of HH compliance: HH compliance rate = actual instances of HH per bed day/standardized instances of HH per bed day ×100%.

Alternative observation indicators

Consumption of consumables, central venous catheter-associated infection (CRSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infection (CRUTI) were documented throughout the study period. The incidence of multi-drug resistant bacterial infections was also recorded, with test results automatically transmitted to the computer terminal of the infection management department. Furthermore, retrospective analysis was conducted on previous data pertaining to HH in our hospital's ICU from 2016 to 2019, while ensuring collection and organization of the aforementioned data.

Statistical methodology

SPSS 23.0 statistical software was utilized for conducting the statistical analysis. The measurement data were presented as mean ± standard deviation (M ± SD). T-test was employed for variables that followed a normal distribution, while non-parametric tests were applied to those that did not conform to a normal distribution. Count data underwent either rank sum test or chi-square test. A statistically significant difference was considered when P < 0.05.

The data regarding HH compliance and infection surveillance during the five-year period (2016–2020) is presented in Table 1. The EMS displays the frequency of HH monitoring, revealing an ICU medical HH compliance rate of 89.4% in 2020. Through direct observation, it was observed that HH occurred 558 times, while there were 64 instances of non-compliance with HH protocols. The resulting HH compliance rate was determined to be 88.5%, with a commendable accuracy level of 92.7%. Over the period from 2016 to 2019, the direct observation method indicated a gradual increase in ICU HH compliance rates: starting at 53.0% in 2016, then progressing to 60.1% in2017, followed by further improvement to reach a rate of 61.1% in 2018 and finally peaking at an impressive rate of 82.4% in 2019 (Fig. 1A). Notably, the introduction of electronic monitoring resulted in even higher levels of HH compliance compared to previous years.

The quantity of HH consumables (hand sanitizer and hand sanitizer) in the ICU in 2020 amounted to 100,7570ml, indicating a significant increase of 26.6% compared to the previous year 2019. Moreover, the average daily consumption of HH consumables per patient bed rose from 94.81mL in 2019 to 120.02mL in 2020 (Fig. 1B). Notably, there has been a consistent annual growth in the volume of HH consumables since 2016. As depicted in Fig. 2, Pearson correlation analysis revealed a robust linear association between the compliance rate of HH and amount of consumables utilized (r = 0.9390, P = 0.018) (Fig. 1C). The HAI rate for the year 2020 stood at an encouragingly low level of only 31.4%, reflecting a notable decrease by 10.7% compared to that observed in 2019. Intriguingly, in the period spanning from 2016 to 2018, the HAI rate exhibited a downward trajectory concurrent with an increase in HH compliance (r=-0.9996, P = 0.019) (Fig. 1D). However, it is noteworthy that despite achieving a commendable HH compliance rate exceeding 80% in 2019, the incidence of HAIs did not witness any reduction.

Central line-associated bloodstream infection (CLABSI) was 3.8‰, ventilator-associated pneumonia (VAP) was 2.5‰, and catheter-associated urinary tract infection (CAUTI) was 0.8‰ (Fig. 2A). The mean infection rate of the three tubes in 2020 did not exhibit a statistically significant difference compared to that observed in 2019. From 2016 to 2018, the three-tube infection rate showed a downward trend with the increase of HH compliance rate, but there was no statistical significance (p = 0.30). When the HH compliance rate reached more than 80%, the three-tube infection rate did not decrease.

The investigation focused on the detection rate of four drug-resistant bacteria in the ICU, taking into account factors such as hospitalization number, specimen type, and pathogen name while eliminating repeated detections. The overall detection rate for Acinetobacter baumannii, Klebsiella pneumoniae, Staphylococcus aureus and Pseudomonas aeruginosa was found to be 22.7%, with a key bacteria detection rate of 48.9%. No significant difference was observed compared to the data from 2020, and there was no correlation with increased compliance in HH practices (Fig. 2B).

During the study period, HH performance was continuously monitored through direct observation in general wards, excluding ICU wards. The compliance rate of HH in general wards during 2020 (66.9%) exhibited a lower level compared to that observed in ICU wards (89.4%). This persistent gap of 22.5% has been evident since 2016 and continued throughout the years until 2019 with rates of 10.1%, 13.6%, 12.47%, and 20.9% respectively, further widening in the year under investigation. Simultaneously, there was a decrease in infection rates within general wards from 3.6% in 2019 to a reduced level of 2.6%, indicating a decline of approximately 22.1%. Conversely, the infection rate within ICU wards experienced a lesser reduction at only about10.8% when compared to ordinary ward statistics. In terms of HH consumables usage, it was noted that ordinary wards witnessed an increase from the previous year by approximately 61.5%, reaching an amount of 12 .24 ml/bed for the year 2020.The increase ratio for HH consumables within ICU wards stood at 26.6% which is significantly lower than that observed within ordinary ward settings.

After the implementation of the electronic management system in this study, the compliance rate for hand hygiene (HH) reached 89.4%, which was slightly higher than that achieved through direct observation method (88.5%). Both rates exceeded the minimum requirement of achieving a compliance rate ≥ 80% as stated in the Implementation Rules for the Evaluation Standards of China's Tertiary Comprehensive Medical Institutions (2011 edition). Previous research has demonstrated that the electronic management system significantly enhances hospital HH compliance (Makhni et al., 2021). However, with the outbreak of COVID-19 in early 2020, medical staff have heightened their awareness regarding hand-washing practices, leading to improved monitoring results through direct observation. Consequently, similar outcomes were observed between both groups (Makhni et al., 2021).

In this study conducted in 2020 and 2019, compared to the year 2018, there was an observed increase in the consumption of HH consumables as well as an improvement in HH compliance rate. However, no significant changes were noted in the infection rate, detection rate and discovery rate of key bacteria, or the proportion of "three tubes" infection. Some experts suggest that these findings may be attributed to the rise in seasonal pneumonia cases, increased frequency of ventilator usage, and a higher incidence of multidrug-resistant bacterial infections (Xu et al., 2021). This study is based on year, and there is no seasonal difference. At the same time, the outbreak of COVID-19 in early 2020 further strengthened the control of HAIs, and the bacterial culture and examination rate increased (Graveto et al., 2018). However, as the ICU ward of our hospital did not participate in the treatment of COVID-19 patients, the situation of patients admitted was not significantly worse than before, so the COVID-19 epidemic had no significant impact on HAIs in ICU wards.

Electronic systems often fail to effectively monitor proper hand-washing procedures, thereby increasing the risk of infection rates (Novak et al., 2020). Since 2011, our hospital's Department of Sensory Hygiene has been actively promoting a comprehensive HH supervision system. This initiative involves the establishment of dedicated sensory control teams in each department, ensuring timely and routine observation as well as key supervision. Furthermore, we have encouraged active participation from young employees in the prevention and control of hospital-acquired infections while incorporating HH supervision into performance assessments. By 2019, the compliance rate of HH had exceeded 80% through direct observation. However, electronic monitoring of the transport process is hindered by the relatively unfixed nature of transport workers and cleaning personnel as well as high installation costs, resulting in dead angles. These limitations also apply to direct observation methods.

During the study period, there was a higher consumption of HH consumables in the general ward compared to the ICU ward. However, no significant difference was observed in the rate of increase in HH compliance between these two wards. The direct observation method was consistently employed in general wards, resulting in a greater surge in HH consumption as opposed to ICU wards. This discrepancy may be attributed to an evident rise in overall hospital-wide HH practices amidst the backdrop of the epidemic.

Between 2016 and 2018, there was a notable decrease in nosocomial infection rates as HH compliance increased. Specifically, for every 1% increase in HH compliance, there was a corresponding decrease of approximately 1.7% in infection rates. However, despite the continuous improvement in HH compliance during the years 2019 and 2020, no further reduction in infection rates was observed. This analysis suggests that while low HH compliance is an important contributing factor to HAIs, other potential factors such as patient's physical condition, instrument operation, surgical incision and wound conditions may also contribute to the increased infection rate. Therefore, it is imperative for modern hospitals to comprehensively monitor suspicious sensitization data and develop optimized personalized programs as part of their management strategies.

In summary, the effect of electronic monitoring is no less than that of direct observation. The prerequisite for the implementation of electronic monitoring is to improve cognition and assessment, improve HH facilities, and effective supervision (Salmon et al., 2020). The outbreak of COVID-19 further accelerates the process of improving HH. The integration of electronic medical monitoring systems signifies a progressive trend in the advancement of hospital information management. However, it inevitably entails economic burdens such as installation costs for equipment, maintenance expenses, and personalized system customization charges that necessitate financial support. Moreover, accurately quantifying the economic benefits derived from implementing such a system remains challenging. Once hand hygiene has reached a certain level, its impact on relevant infection indicators diminishes, prompting further exploration into alternative sources of infection.

Acknowledgements

We would like to express our gratitude to all participants who voluntarily participated in our project. We are also grateful to all staff who cooperated with us during the investigation.

Conflict of interest

The authors declare that there is no conflict of interest.

Ethics approval and consent to participate

The study was approved by the Ethics Committee of the Zhejiang Hospital of Traditional Chinese Medicine (approval number: 2021-KL-138-01). The requirement of informed consent was exempted after review by the Ethics Committee.

Data availability

The data and materials used to support the findings of this study are available from the corresponding author upon request.

Author Contribution

B.G. and Y.G. conceived and designed the project. H.Y., H.T. and M. W. recruited and trained volunteers. Y.Z. and Y.G. aggregated and managed data. B.G. and Y.Z. analyzed the data. B.G. and Y.G. wrote the manuscript with input from all the co-authors. All authors read and approved the final manuscript.

Funding

This work was supported by the Research Project of Zhejiang Provincial Department of Education project (grant no. Y202046195) and Zhejiang Traditional Chinese Medicine Health Administration project (grant no. 2021ZB117).

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Table 1 Compliance rates of HH performance and infection surveillance during 2016 to 2020

No competing interests reported.

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Version 1

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You are reading this latest preprint version

Electronic control of hand hygiene in intensive care unit and its correlation with healthcare-associated infections: a retrospective study

Status:

Version 1

Abstract

Purpose

Methods

Results

Conclusion

Figures

Introduction

Methods

Strengthen training on HH knowledge

The monitoring of HH implementation was conducted through direct observation

HH compliance rate as monitored by an electronic system

Alternative observation indicators

Statistical methodology

Result

Discussion

Declarations

References

Table 1

Additional Declarations

Status:

Version 1