Annette Jeanes

Evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study

Objective To evaluate the impact of the Cleanyourhands campaign on rates of hospital procurement of alcohol hand rub and soap, report trends in selected healthcare associated infections, and investigate the association between infections and procurement. Design Prospective, ecological, interrupted time series study from 1 July 2004 to 30 June 2008. Setting 187 acute trusts in England and Wales. Intervention Installation of bedside alcohol hand rub, materials promoting hand hygiene and institutional engagement, regular hand hygiene audits, rolled out nationally from 1 December 2004. Main outcome measures Quarterly (that is, every three months) rates for each trust of hospital procurement of alcohol hand rub and liquid soap; Staphylococcus aureus bacteraemia (meticillin resistant (MRSA) and meticillin sensitive (MSSA)) and Clostridium difficile infection for each trust. Associations between procurement and infection rates assessed by mixed effect Poisson regression model (which also accounted for effect of bed occupancy, hospital type, and timing of other national interventions targeting these infections). Results Combined procurement of soap and alcohol hand rub tripled from 21.8 to 59.8 mL per patient bed day; procurement rose in association with each phase of the campaign. Rates fell for MRSA bacteraemia (1.88 to 0.91 cases per 10 000 bed days) and C difficile infection (16.75 to 9.49 cases). MSSA bacteraemia rates did not fall. Increased procurement of soap was independently associated with reduced C difficile infection throughout the study (adjusted incidence rate ratio for 1 mL increase per patient bed day 0.993, 95% confidence interval 0.990 to 0.996; P<0.0001). Increased procurement of alcohol hand rub was independently associated with reduced MRSA bacteraemia, but only in the last four quarters of the study (0.990, 0.985 to 0.995; P<0.0001). Publication of the Health Act 2006 was strongly associated with reduced MRSA bacteraemia (0.86, 0.75 to 0.98; P=0.02) and C difficile infection (0.75, 0.67 to 0.84; P<0.0001). Trust visits by Department of Health improvement teams were also associated with reduced MRSA bacteraemia (0.91, 0.83 to 0.99; P=0.03) and C difficile infection (0.80, 0.71 to 0.90; P=0.01), for at least two quarters after each visit. Conclusions The Cleanyourhands campaign was associated with sustained increases in hospital procurement of alcohol rub and soap, which the results suggest has an important role in reducing rates of some healthcare associated infections. National interventions for infection control undertaken in the context of a high profile political drive can reduce selected healthcare associated infections.

The Feedback Intervention Trial (FIT) — Improving Hand- Hygiene Compliance in UK Healthcare Workers: A Stepped Wedge Cluster Randomised Controlled Trial

Introduction Achieving a sustained improvement in hand-hygiene compliance is the WHO’s first global patient safety challenge. There is no RCT evidence showing how to do this. Systematic reviews suggest feedback is most effective and call for long term well designed RCTs, applying behavioural theory to intervention design to optimise effectiveness. Methods Three year stepped wedge cluster RCT of a feedback intervention testing hypothesis that the intervention was more effective than routine practice in 16 English/Welsh Hospitals (16 Intensive Therapy Units [ITU]; 44 Acute Care of the Elderly [ACE] wards) routinely implementing a national cleanyourhands campaign). Intervention-based on Goal & Control theories. Repeating 4 week cycle (20 mins/week) of observation, feedback and personalised action planning, recorded on forms. Computer-generated stepwise entry of all hospitals to intervention. Hospitals aware only of own allocation. Primary outcome: direct blinded hand hygiene compliance (%). Results All 16 trusts (60 wards) randomised, 33 wards implemented intervention (11 ITU, 22 ACE). Mixed effects regression analysis (all wards) accounting for confounders, temporal trends, ward type and fidelity to intervention (forms/month used). Intention to Treat Analysis Estimated odds ratio (OR) for hand hygiene compliance rose post randomisation (1.44; 95% CI 1.18, 1.76;p<0.001) in ITUs but not ACE wards, equivalent to 7–9% absolute increase in compliance. Per-Protocol Analysis for Implementing Wards OR for compliance rose for both ACE (1.67 [1.28–2.22]; p<0.001) & ITUs (2.09 [1.55–2.81];p<0.001) equating to absolute increases of 10–13% and 13–18% respectively. Fidelity to intervention closely related to compliance on ITUs (OR 1.12 [1.04, 1.20];p = 0.003 per completed form) but not ACE wards. Conclusion Despite difficulties in implementation, intention-to-treat, per-protocol and fidelity to intervention, analyses showed an intervention coupling feedback to personalised action planning produced moderate but significant sustained improvements in hand-hygiene compliance, in wards implementing a national hand-hygiene campaign. Further implementation studies are needed to maximise the intervention’s effect in different settings. Trial Registration Controlled-Trials.com ISRCTN65246961

Removing bacteria from hospital surfaces: a laboratory comparison of ultramicrofibre and standard cloths.

We compared the ability of ultramicrofibre-woven cloths with conventional cloths moistened with water only, for their ability to remove several types of organisms relevant to hospital-acquired infections from a variety of surfaces in hospitals. We showed that ultramicrofibre cloths consistently outperformed conventional cloths in their decontamination ability, across all surfaces, and irrespective of whether the bacteria were coated on to the surfaces with phosphate-buffered saline (PBS) or PBS containing horse serum to simulate real-life soiling. The ability of the cloths to remove bacteria from surfaces was assessed by contact plating and colony formation, and by swabbing and measurement of ATP bioluminescence. The results suggest potential for use of ultramicrofibre in healthcare environments. Further studies are required, however, to define accurately how these cloths, which are designed to be used without detergent or biocides, might be capable of safe and effective deployment and recycling in the healthcare environment.

A comparison of the antibacterial efficacy and cytotoxicity to cultured human skin cells of 7 commercial hand rubs and Xgel, a new copper-based biocidal hand rub

BACKGROUND Hand cleanliness is important in hospital infection control, but skin irritation from frequent alcohol-based hand rub use reduces compliance. We have compared a new copper biocide/Aloe vera-based biocidal hand rub (Xgel) with 7 commercially available hand rubs. METHODS Hand rubs were cultured with human skin cells for 24 hours after which cytotoxicity was assessed using the sulforhodamine B assay. The EN 12054 bacterial suspension test protocol was used to assess biocidal activity of 2 of the least cytotoxic hand rubs (Xgel and Purell). RESULTS Hand rubs had 50% cytotoxic concentrations ranging from >10% to <0.1% vol/vol. In the EN12054 assay, Xgel reduced colony forming units (CFU) by >10(8) with methicillin-resistant Staphylococcus aureus (MRSA) and Acinetobacter in 1 minute, whereas Purell only reduced CFU by 10(4) and 10(5), respectively. Purell was ineffective against C difficile spores, whereas Xgel produced a 3 x 10(3) reduction in CFU. CONCLUSION The hand rubs had a wide range of cytotoxicity values for human skin cells, with Xgel being the least cytotoxic to human skin cells. In the EN 12054 bacterial suspension test, Xgel was more effective than Purell against all organisms tested. It should be noted that these in vitro results may not translate into clinical differences.

Collecting the data but missing the point: validity of hand hygiene audit data

BACKGROUND Monitoring of hand hygiene compliance (HHC) by observation has been used in healthcare for more than a decade to provide assurance of infection control practice. The validity of this information is rarely tested. AIM To examine the process and validity of collecting and reporting HHC data based on direct observation of compliance. METHODS Five years of HHC data routinely collected in one large National Health Service hospital trust were examined. The data collection process was reviewed by survey and interview of the auditors. HHC data collected for other research purposes undertaken during this period were compared with the organizational data set. FINDINGS After an initial increase, the reported HHC remained unchanged close to its intended target throughout this period. Examination of the data collection process revealed changes, including local interpretations of the data collection system, which invalidated the results. A minority of auditors had received formal training in observation and feedback of results. CONCLUSION Whereas observation of HHC is the current gold standard, unless data collection definitions and methods are unambiguous, published, carefully supervised, and regularly monitored, variations may occur which affect the validity of the data. If the purpose of HHC monitoring is to improve practice and minimize transmission of infection, then a focus on progressively improving performance rather than on achieving a target may offer greater opportunities to achieve this.

Motivation and job satisfaction of cleaning staff in the NHS: a pilot study:

Fourteen NHS hospital ward cleaning staff were interviewed about their background, job satisfaction and motivation as part of the evaluation of a new cleaning system. Four (28%) staff had attended university, five (35%) had no qualifications and the remainder had a range of educational attainments. Nine (64%) did the job to earn money, three (22%) because they liked it and two (14%) because there were no other opportunities. Repetitive tasks were undertaken routinely with tight control of method and order of working. The work was tiring and ad hoc requests increased the burden. Although all staff knew what was expected of them in their job, nine (62%) reported they “knew themselves” if they had done a good job as feedback was frequently absent or belated. Opportunities including access to the internet were limited and long hours doing extra work reduced free time. This pilot study highlights the potential of these healthcare cleaning professionals to contribute and develop given the opportunities.

Effect of the dried residues of two hand gels on the survival of meticillin-resistant Staphylococcus aureus and Acinetobacter calcoaceticus-baumannii

We assessed the ability of the residues of an alcohol-based hand gel (hand gel A) and an Aloe vera-based CuAL42 copper biocide-containing hand gel (hand gel B), to support the survival of meticillin-resistant Staphylococcus aureus (MRSA) and Acinetobacter calcoaceticus-baumannii (ACCB). One-millilitre samples of hand gels A and B were spread over marked 20 cm2 areas and dried overnight. MRSA or ACCB (1 × 104 CFU) were spread onto the dried residue and contact plated at various times. MRSA and ACCB survived for 8 hours on hand gel A residue, whilst MRSA did not survive on hand gel B residue and ACCB survived less than 30 min. Low concentrations of hand gel A facilitate the growth of ACCB, but this is not the case for hand gel B. Hand gel A is extensively used in UK hospitals and its residue left on high-touch surfaces may support the survival of bacteria that cause healthcare-acquired infections.

A UK district general hospital cleaning study: a comparison of the performance of ultramicrofibre technology with or without addition of a novel copper-based biocide with standard hypochlorite-based cleaning

We compared the performance of an ultramicrofibre (UMF)-based system with or without a novel copper-based biocide (CuWB50) with standard cleaning using Actichlor Plus in four hospital wards in a crossover study design, and analysed our results using univariate and multivariate statistics. We measured total viable counts (TVCs) and ATP levels in 10 near-patient sites three times weekly, one hour before and after cleaning. Standard cleaning reduced TVCs further than UMF cleaning with water, but UMF cleaning with CuWB50 produced equivalent TVC reduction. Furthermore we identified a ‘residual effect’ with UMF + CuWB50, conferring TVC suppression for up to a week after application. ATP results did not correlate with TVCs. We conclude that UMF-based cleaning with CuWB50 results in TVC reductions equivalent to hypochlorite-based standard cleaning, with the added advantages of a residual effect that keeps TVCs lower between cleaning rounds.

Rapid molecular screening for meticillin-sensitive Staphylococcus aureus (MSSA) carriage: an economic evaluation:

Aim: To establish the cost-effectiveness of screen-A ing and treating meticillin-sensitive Staphylococcus aureus (MSSA) carriers, potentially reducing both financial and clinical burdens of managing healthcare-acquired infections. Methods: A decision health economic model analysed the impact of a ‘screen and treat’ strategy for Hospital inpatients from the perspective of the UK National Health Service. Results: Cost savings in excess of £600k and around 840 potential infections could be avoided in a 70,000 patient cohort, at a nasal carriage prevalence of 30%. For 2000 high infection risk cardiothoracic surgery patients, cost savings could reach £8,636 per annum. The dominance of the ‘screen and treat’ strategy holds for plausible variations in the model parameter values and simple modelling of secondary transmission. Conclusion: Adopting rapid screening and treating MSSA nasal carriers should be clinically and financially advantageous, compared to current strategies of not screening, even under conservative assumptions for costs and probabilities of managing infections.

Estimating the Hospital Burden of Norovirus-Associated Gastroenteritis in England and Its Opportunity Costs for Nonadmitted Patients

Since the introduction of rotavirus vaccination in England in July 2013, norovirus has become the second-largest contributor of inpatient gastroenteritis, preventing 57800 patients from being admitted annually. Economic costs amount to £297.7 million, which translates into 6300 quality-adjusted life years.