key: cord-0828320-fwzf426z authors: Anguraj, Symphonia; Ketan, Priyadarshi; Sivaradjy, Monika; Shanmugam, Lakshmi; Jamir, Imola; Cherian, Anusha; Sankar Sastry, Apurba title: The effect of hand hygiene audit in COVID intensive care units in a tertiary care hospital in South India date: 2021-07-23 journal: Am J Infect Control DOI: 10.1016/j.ajic.2021.07.008 sha: 77f90878b97cf5bc57dd1dc569a5c401461af131 doc_id: 828320 cord_uid: fwzf426z BACKGROUND: : In the era of COVID-19 pandemic, there is an upsurge of healthcare-associated infections (HAI) in COVID intensive care units (ICUs),which can be reduced by following proper hand hygiene (HH) practice. Performing HH auditing in COVID ICU and providing timely feedback to the stake holders is crucial to reduce HAIs. METHODS: : From November 2020- April 2021, HH audit was conducted in COVID ICUs. HH complete adherence rate (HHCAR), HH partial adherence rate (HHPAR) and HH total adherence rate (HHTAR) were analyzed. Profession-specific HHTAR and moment-specific HHTAR (for each WHO moment) were also calculated. RESULTS: : HHCAR, HHPAR and HHTAR were found as 30.8%, 34.5% and 65.3% respectively. There was a significant increase in the monthly HHTAR from 26.7% to 68.4% (P<0.001).The profession-specific HHAR was found to be highest among doctors (67.5%) and nurses (66.4%) compared to ancillary staff (i.e, attenders and sweepers) (57.5%). As the HHTAR increases there is a significant decrease in device associated infection (DAI) rate from 24.7 to 11.5 per 1,000 device days. CONCLUSIONS: : Auditing HH and providing timely feedback significantly improved HH compliance. The need of the hour is to regularly conduct HH audit in COVID locations of all healthcare facilities which would contribute for the reduction of HAI infection rate among the COVID- 19 infected patients in ICUs. The COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is more than just a global health crisis; causing a significant social and economic disruption. In addition to its rapid surge in community, it has also become a major healthcare associated infection (HAI), affecting large number of healthcare workers (HCWs) and patients in hospitals [1] [2] [3] . The mode of transmission of SARS-CoV-2 is mainly through respiratory droplets, which occurs within 1 meter distance from an infected person. However, individuals who are present outside the 1 meter range of infected persons can still contract the infection via contact transmission-either direct contact (person to person contact) or indirect contact (via fomites present in the vicinity). Following contact, the virus can only be transmitted by touching a person's mouth, eye or nose with his contaminated hand 2, 4 . Therefore, frequent Hand hygiene (HH) subsequent to potential contact exposure is critical to prevent this type of transmission. HH can be performed by hand washing with either soap and water or by the use of alcohol-based hand sanitizers. The HCWs should have a HH compliance rate of more than 90% as recommended by The World Health Organization (WHO) for effective prevention of HAIs including COVID-19 5 . To break the chains of COVID-19 transmission and minimize the HAI in hospital settings, HCWs should adhere to the WHO's "My 5 Moment for HH" and strictly follow the six steps of HH technique as advised by the WHO [6] [7] [8] . WHO states that nearly 80% of people who develop symptoms, recover from the disease without requiring hospital treatment. Only 20% of individuals infected with COVID require hospitalisation, out of that 15% need oxygen and 5% requires admission in ICUs. A majority of ICU patients requires mechanical ventilation , with a mortality and morbidity of up to 80% 9 . A Meta-Analysis done by Abate SM et al revealed that globally, nearly one-third of patients with coronavirus infection were admitted to ICU and the prevalence of mortality among them was 39% 10 .The outcomes of individuals infected with COVID are very variable.The patients having increased sputum production and higher requirement of supplemental oxygen at admission, and with underlying risk factor such as diabetes or chronic kidney disease are at increased risk for severe illness and therefore are at a higher risk of being admitted to COVID ICU. Patients in COVID ICU are usually critically ill, immunocompromised and have increased vulnerability to HAIs. Respiratory failure, acute respiratory distress syndrome (ARDS), sepsis, septic shock, thromboembolism, multiorgan failure are the complications leading to death in COVID patients 9 . Although the awareness about HH among the general public and HCWs had increased during the COVID pandemic due to active involvement of WHO, CDC (Centers for Disease Control and Prevention), government initiatives and social media 11 , the HH compliance is found to be low among the HCWs working inside COVID care settings 12 ,which can be attributed to increased work pressure, false beliefs that continuous use of gloves obviates the need for HH, priority for patient care procedures and continuous donning of personal protective equipment (PPE) which gives a sense of discomfort 13 . As a result of this, there has been an upsurge in the cases of HAIs due to multidrug resistant organisms (MDROs) leading to increased mortality and morbidity 7, 14, 15 . More so, the data on HH compliance among HCWs in COVID care settings is lacking. Therefore, to fill the gap between theoretical knowledge about HH and practice 16 , monitoring of HH by auditing is crucial, which will eventually help in reducing HAIs among patients in COVID care settings [17] [18] [19] .So, the present study has been undertaken to determine the HH compliance rate among HCWs in COVID care settings and further evaluate the impact of HH compliance in reducing the HAIs in COVID Intensive care units(ICU) settings by auditing HH practice. This was a prospective study conducted for 6 months (November 2020-April The HH audit was conducted by direct observation method according to WHO's HH audit tool 20 and the data was collected electronically through an App (IBHAR HH audit App), which was developed in-house by the HICP unit. It has a comprehensive set of mobile enabled tools and web based analytical dashboards designed based on the WHO HH audit tool kit 20 . By using the IBHAR HH Audit tool, the auditors recorded the HH opportunities (HH moments) of multiple professionals simultaneously, marked whether the HH is followed or not (missed) for that moment and when followed they recorded the exact duration of using handrub or handwash. The HH event was marked as 'completely followed' when all the 6 WHO steps of HH were performed 8, 20, 21 , for the recommended duration (>20 sec for handrub and >40sec for handwash). When ≥ 1 WHO's HH steps were missed and/or the duration was less than recommended, such HH events were marked as 'partially followed'. The auditors also monitored and ensured the availability of consumables (e.g. handrubs, handwash, tissue papers) in the COVID ICU all the time. Immense efforts were taken to reduce all the possible bias expected to raise during the audit process and to ensure standardization and reliability of the audit. The auditors were trained prior to the audit to reduce inter-auditor variation in data collection. The auditors conducted the HH audit simultaneously along with their other routine work in COVID ICU (e.g. HAI surveillance work) so that the HCWs posted in COVID ICU would not realize that their HH practice were being monitored 20 ; thus minimizing the observational bias (i.e, Hawthorne effect). For each month, a different auditor was allotted to conduct HH audit in a month-wise rotation basis to minimize confirmation bias. The audit was carried out in a random schedule, thus obviating the confounding bias of work pressure influencing the HH compliance. The HH audit was conducted for an observation period of 20 mins/day for a period of 6 months in the COVID ICU. Thus, in total there were 123 observation periods (each conducted for 20 min) and 2887 minutes of observation were completed during the entire study period. The HH complete adherence rate (HHCAR), HH partial adherence rate (HHPAR) and HH total adherence rate (HHTAR, complete+partial) were calculated. Profession-specific HHTAR (e.g. doctors, nurses, and ancillary staff ) and moment-specific HHTAR (for each WHO moment) were also calculated [6] [7] [8] . The monthly HH audit report and the feedback were shared to the clinical team of COVID ICU and also presented in the hospital infection control committee (HICC) meeting 17 .Since, an improvement in HH compliance could lead to decrease in HAIs, which includes device associated infections (DAI), the impact of conducting the HH audit has been assessed by comparing the month-wise HHTAR with the DAI rate of COVID ICU 19 . The data on DAI rate was obtained from HAI surveillance data, which was conducted by HICP simultaneously every month based on standard operating HICP manual and the National Healthcare Safety Network guideline 22 . The collected data has been entered into Microsoft excel and analyzed using SPSS version 21 software (IBM-SPSS Inc, Armonk, NY). The month-wise HHTAR, profession-specific HHTAR, moment-specific HHTAR and DAI rates were reported as percentages and the association between the above mentioned parameters were done using chi-square test and chi-square for trend . A P-value of <0.05 was considered as statistically significant. Table 1 , 2,232 opportunities were recorded during the entire study period. The HHTAR, HHCAR and HHPAR for the study period were found to be 65.3% (1458 out of 2232), 30 .8% (688 out of 2232) and 34.5% (770 out of 2232) respectively. It was also observed that monthly HHTAR increased progressively during the study period from 26.7% in November 2020 to 68.4% in April 2021. To determine whether this monthly increase in HHTAR is statistically significant, we have proceeded with the chi-square for trend analysis and reported a P-value of <0.001. The highest HHTAR was documented in the month of March 2021 (79.8%). The profession-specific HHTAR was depicted in Table 2 , which was found to be highest among doctors (67.5%; 702 out of 1040) and nurses (66.4%; 505 out of 761) compared to ancillary staff (57.5%; 218 out of 379). Even though, the HHTAR kept fluctuating, there was a progressive increase in the HH compliance towards the end of the study period among doctors, nurses and ancillary staff. With the chi-square for trend analysis, we found that there was an increase in trend in the monthly HHTAR among doctors(P <0.001 ), nurses (P <0.001) and ancillary staff (P <0.001 ). The moment-specific HH adherence was shown in Figure 1 , which explains that WHO's moments 2 and 3 have shown to `have highest HH compliance (83.3% and 93.1%, respectively) as compared with WHO's moments 1, 4, and 5 (61.6%, 75.1% and 54.6%, respectively) [6] [7] [8] . The improvement in monthly HH compliance during the study period for moments 1, 4 and 5 showed an increase in trend in the monthly HHTAR with the chi-square for trend analysis with a P-value of <0.001 for moment 1, moment 4 and moment 5 each. The comparison of month-wise trends of HHTAR and DAI rates was depicted in Figure 2 . It was observed that HHTAR inversely correlates with DAI rates. As the HHTAR increases, there was a decrease in DAI rate from 24.7 to 11.5 per 1,000 device days 19. We have made an effort to analyze HHTAR(complete and partial) in this study, even though WHO does not recommend to monitor partial compliance. This attempt was taken in order to encourage the HCWs in a hope that their partial HH adherence will be converted to complete adherence in the subsequent audits. In the present study, the month-wise trend analysis showed that there was a significant improvement of HHTAR (27% to 68%), HHCAR (4% to 25 %) and HHPAR (22% to 43%) from November 2020 to April 2021 (Table 1 ). This signifies that providing feedback of HH performance to the HCWs on a daily basis and displaying HH audit report in HICC monthly meetings immensely helps in improving the compliance. Even though the HHCAR improved from 4% to 25%, this is very less when compared to WHO's recommended HH compliance rate (90%) 5 . The reason of poor HH compliance may be attributed to the false sense of security because of wearing gloves continuously in COVID ICU. Further strategies may be needed to improve compliance such as augmented educational intervention, displaying individual specific HH compliance with punish-reward mechanism, and avoiding frequent rotation of HCWs posted in the staff in ICU. A mega study conducted at the same facility in 14 different non-COVID ICUs documented a significant improvement in HHCAR from 37.5% to 51.8% 16 . Another extensive study conducted at the same facility showed a significant increase of HHCAR from 3% to 70% following a multi modal intervention 25 . In the last month of the study, there was a slight decrease in HHTAR. The possible reason could be due to the increased workload of the HCWs posted in COVID ICU as there was an acute surge of COVID cases in April 2021 in our locality leading to increased bed occupancy. There was also an increase in the proportion of sick patients admitted in our COVID ICU, which resulted in HCW's increased concern over patient care procedures like intubation, cardiopulmonary resuscitation etc., directly affecting the compliance 24 . As depicted in Month-wise comparison of HHTAR and device associated infection (DAI) rates was depicted in Figure 2 . A good HH compliance directly reflects in reduction in HAIs and eventually results in effective healthcare system. It was also observed in our study that the HHTAR inversely correlated with DAI rates. With the corresponding increase in the HHTAR, there was a significant decrease in DAI rate from 24.7 to 11.5 per 1,000 device days. This is in concordance with several other studies such as A.S. Sastry et al, Roshan et al and Lohiya et al 16, 18, 19 . HH is one of the most essential component of care bundle practices which need to be followed for the prevention of DAI rates 30 . The limitations of this study include-HH compliance based on shift variation, gender variation, diurnal variation and experience specific variation were not studied. The observation periods were based on convenience sampling, but not randomized. The duration of the study was also short. The HHCAR was found to be very low compared to the WHO's recommended HH compliance of 90% 5 . With a multimodal and strong administrative intervention conducted for longer duration, the HH compliance can further be improved with a significant decrease in HAI rates. In our future research, we will focus on these areas. This was one of the first study on HH audit conducted inside COVID ICU, with an objective of improving HH compliance. We conclude that by conducting HH audit and providing timely feedback to the stakeholders has a significant influence on HH compliance in COVID ICU. Therefore we urge the infection control departments of the healthcare facilities to regularly conduct HH audit in their COVID locations, which is the need of the hour. More emphasis needs to be given to improve the HHCAR by following all the WHO steps and for the recommended duration. A behavioral change is warranted to achieve a higher standard of HH compliance, which is sustainable in-spite of the increased work pressure. Prevention and control of health care-associated infections through improved HH. Indian journal of medical microbiology A review of coronavirus disease-2019 (COVID-19). The indian journal of pediatrics World Health Organization COVID-19: A review on the novel coronavirus disease evolution, transmission, detection, control and prevention HH and the novel coronavirus pandemic: the role of healthcare workers. The Journal of hospital infection HH: back to the basics of infection control. The Indian journal of medical research World Health Organization. Recommendations to Member States to improve HH practices to help prevent the transmission of the COVID-19 virus: interim guidance World Health Organization World Health Organi ation. Coronavirus disease ( CO -19) Rate of Intensive Care Unit admission and outcomes among patients with coronavirus: A systematic review and Meta-analysis The impact of COVID-19 pandemic on HH performance in hospitals HH and the novel coronavirus pandemic: the role of healthcare workers. The Journal of hospital infection Rational Use of Personal Protective Equipment for Coronavirus Disease (COVID-19): Interim Guidance The impact of the COVID-19 pandemic on healthcare acquired infections with multidrug resistant organisms The impact of universal face masking and enhanced HH for COVID-19 disease prevention on the incidence of hospitalacquired infections in a Taiwanese hospital Impact of a HH audit on HH compliance in a tertiary care public sector teaching hospital in South India Infection control with limited resources: Why and how to make it possible?. Indian journal of medical microbiology Journal of the Pediatrics Association of India Rigorous HH practices among health care workers reduce hospital-associated infections during the COVID-19 pandemic WHO HH audit tool kit. World Health Organization. WHO guidelines on HH in health care: first global patient safety challenge clean care is safer care. World Health Organization The WHO Clean Care is Safer Care programme: field-testing to enhance sustainability and spread of HH improvements National Healthcare Safety Network (NHSN) Overview Bridging the gap between guidelines and practice in the management of emerging infectious diseases: a qualitative study of emergency nurses World Health Organization. COVID-19 Weekly Epidemiological Update A multimodal intervention to improve HH compliance in a tertiary care center Mind the mind: Results of a hand-hygiene research in a state-of-the-art cancer hospital A multimodal intervention to improve HH in ICUs Improving HH compliance among healthcare workers in intensive care unit: an interventional study Compliance of healthcare workers with HH practices in neonatal and pediatric intensive care units: overt observation. Interdisciplinary perspectives on infectious diseases Care bundle approach to reduce device-associated infections in a tertiary care teaching hospital, South India The authors thank Dr L.N. Dorairajan, medical superintendent, Jawaharlal Revathy and for her contributions during data entry and statistical analysis.