Introduction

Hand hygiene (HH) is the single most important intervention for preventing nosocomial infection, the spread of multidrug-resistant pathogens, and mortality in a health care setting [1, 2]. Many studies have shown the overall adherence to hand-hygiene practices to be less than 50% [3]. The WHO, in 2009, developed “my five moments of hand hygiene” to reduce the burden of health care–associated infections (HAI), which include: before touching a patient, before procedures, after exposure to body fluids, after touching a patient, and after touching a patient’s surroundings [4].

The authors carried out this project based on the WHO’s five moments of hand hygiene to improve hand-hygiene compliance in their setup. The main objectives of the present project were to improve hand-hygiene compliance among the health care personnel from 69 to 85% by 4 mo, and study the impact of HH compliance upon the HAI rate in their special newborn care unit (SNCU).

Material and Methods

This was a hospital-based prospective study carried out among the health care personnel of the special newborn care unit of K. C. General Hospital, Bengaluru. The hospital caters to around 3000 deliveries annually and has around 500 SNCU admissions and another 500 admissions per year in the step-down ward. The health care personnel comprised a pediatrician, medical officers, postgraduate student, nurse-in-charge, nursing officers, a child health counselor, a data entry operator, and support staff providing 24-h services. The infant-to-nurse ratio ranged from 2–6:1 during the day shifts and 4–6:1 during the night shift.

HAI is not regularly tracked in the authors’ SNCU. To prevent HAI, the authors used the prioritization matrix to choose the hand-hygiene compliance project. Consent was obtained from all the participants. Ethical clearance was obtained. The operational team comprised a pediatrician, medical officers, postgraduate students, nurse-in-charge, and two nursing officers. Baseline hand-hygiene compliance data were collected by the team leader during March. The HH techniques performed by the health care personnel during the five moments formed the baseline value (Table 1). The barriers that led to poor compliance with hand hygiene were identified using fishbone analysis, as shown in Fig. 1. These barriers and the baseline data were discussed with the team, and measures for improvement were laid out. The consultant (pediatrician) educated the health care personnel on the proper hand-hygiene practices in accordance with the WHO’s five moments of hand hygiene. A total of three plan-do-study-act (PDSA) cycles were conducted from April to July 2021. The duration of the first two PDSA cycles was 4 wk and the last cycle was 6 wk. All the working staffs were advised to practise proper hand hygiene practices for a week prior to the start of the project. The posters depicting the five moments of hand hygiene and hand-hygiene techniques were pasted near the handwashing area and other important areas. A round-the-clock supply of nonmedicated liquid hand soap and autoclaved paper hand towels was ensured. Each bed was supplied with alcohol-based hand sanitizer. A detailed PDSA cycle intervention is depicted in Table 2. Due to the second wave of COVID-19 and lockdown restrictions, the working hours for the nursing officers were changed to two 12-h shifts for the second PDSA cycle. The strategic approach to encouraging the staffs as well as team members to improve HH compliance was changed according to the circumstances. All the working staffs responded positively during review meetings and provided appropriate feedback.

Table 1 Hand-hygiene techniques as per the WHO guidelines
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Fig. 1
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Fishbone analysis of the reasons for missed hand-hygiene opportunities. HH Hand hygiene

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Table 2 PDSA cycles
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Two team members were designated to observe the staffs who followed the five moments of HH and performed the HH techniques properly according to WHO guidelines. They collected the data in the morning and afternoon shifts, unknown to other staffs. The HH compliance rate was considered to be the primary outcome measure. It was calculated by dividing the number of observed HH moments adequately performed as per the WHO guidelines by the total number of observations for each of the moments, and the results were multiplied by 100. Sepsis data were collected by analysing the case records during the past 4 mo and also during the study period. HAI event was considered when an admitted newborn developed late-onset sepsis such as screen-positive/culture-positive/clinical sepsis and was treated with first-line antibiotic for > 5 d and/or with second- or third-line antibiotics for ≥ 5 d for the same. The HAI rate was considered a secondary outcome measure. The HAI rate was calculated for every month by recording the number of HAI events, dividing it by the patient days for that month, and multiplying the result by 1000. The data were compiled in Microsoft Excel 2019 (Microsoft Corporation, Redman, WA) and the statistical software SPSS version 28.0.1.1 (IBM, Corp. Armonk, N.Y.) was used to determine the statistical significance. The mean improvement in HH compliance among the working staffs was analysed using the t-test (paired, two-tailed). A p ≤ 0.05 was considered statistically significant. Linear regression was used to determine whether LOS was associated with average duration of stay. The HAI data obtained during the study period was compared to that of the previous 4 mo.

Results

Baseline data comprised 194 observations. Overall hand-hygiene compliance stood at 69% (16.75 ± 3.46). The HH compliance along with their respective mean ± standard deviation (SD) values for each moment is as follows: before touching a patient (80%; 10 ± 2.18), before procedures (81.82%; 2.25 ± 1.48), after exposure to body fluids (92.86%; 1.63 ± 0.48), after touching a patient (52.78%; 2.38 ± 1.41), and after touching a patient’s surroundings (18.18%; 0.5 ± 0.71).

The results of HH compliance are shown in Table 3. As per the table, there were 1617, 1073, and 2353 HH observations in the three PDSA cycles, respectively. Overall HH compliance along with the mean ± standard deviation (SD) and significance values for the three PDSA cycles are, respectively, as follows: 74.58% (43.07 ± 7.50; p = 0.043), 63.75% (24.43 ± 5.16; p = 0.083), and 84.70% (47.45 ± 10.59; p = 0.014). The t-tests were used to compare the values between the previous phases (i.e., between baseline and PDSA 1, between PDSA 1 and 2, and between PDSA 2 and 3). The sum of HH scores from the three PDSA cycles when compared to the baseline is significant (p = 0.022).

Table 3 Observational values of five moments of hand hygiene along with t-test significance
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Every one day spent by the neonate in the authors’ SNCU was considered 1 patient day. There were 178 SNCU admissions with 1534 patient days and the average duration of stay was 8.62 days during the study period with a bed occupancy rate of 104.78%. In the previous four months, there were 203 admissions with 1665 patient days and the average duration of stay was 8.20 days with the bed occupancy of 114.67%. The HAI rate was 13.81 per 1000 patient days as per records and 10.43 per 1000 patient days during the study period with p = 0.566. Four out of 8 deaths and 2 out of 20 deaths due to HAI were noted by records and during study period (p = 0.495), respectively. The HAI data are depicted in Table 4.

Table 4 HAI data with significance values
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Discussion

Newborn care has been revolutionized in order to ensure best possible outcome for all neonates delivered, regardless of maternal health status. This is leading to prolonged neonatal intensive care unit (NICU) stay thereby overburdening the health care system, hospitals, and the parents. Neonatal sepsis is a major factor contributing to neonatal mortality accounting for more than a million neonatal deaths annually around the world [5]. In India, the incidence of neonatal sepsis is 17,000/100,000 live births and its case fatality rate ranges from 25 to 65% [6]. Health care–associated infection is one of the major contributing factors to late-onset neonatal sepsis due to the advancements in therapeutic practices and increased invasive procedures [7]. Along with the advancements in protocols and management and sophisticated practices, HAI are also on the rise, requiring NICU care bundles to reduce the incidence of HAI [8]. HH remains the most effective intervention among the care bundles in reducing HAI.

The fishbone analysis revealed numerous factors that hinder appropriate HH compliance, such as improper location of the wash area, shortage of essential materials, increased workload, lack of positive role models, poor attitude leading to ineffective HH procedures, complaints of skin irritation and dryness, no HH and sepsis audits, and no formal training of new personnel. These issues are similar to those explained by Lydon et al., Purva Mathur, Erasmus et al., and Sadule-Rios et al. regarding possible barriers that lead to poor HH compliance [9,10,11,12].

The improvement in the HH compliance in the PDSA cycles 1 and 3 were noted to be statistically significant. The overall percentage of HH compliance significantly increased from 69 to 84.7% after the third PDSA cycle. van den Hoogen et al. showed that multimodal strategies can improve HH compliance [13]. In the HH project by Lam et al., it was noted that overall HH compliance increased from 40 to 53% before patient contact and from 39 to 59% after patient contact, and the rate of HAI decreased from 11.3 to 6.2 per 1000 patient days. According to Sharek et al., implementation of an evidence-based handwashing policy resulted in a statistically significant improvement in between-patient handwashing from 47.4 to 87.4% [14, 15]. Rai et al. improved HH compliance from 27.2 to 57.1% in their SNCU in three phases using multiple PDSA cycles [16]. Gopalakrishnan et al. significantly improved the HH compliance in their setup from 61.8 to 77%. They used four-phased sequential interventions that included self-directed learning, participatory learning, closed-circuit TV (CCTV) monitoring, and CCTV with feedback. Rise in HH compliance was significantly higher for after-WHO moments (12.7%) as compared to before-WHO moments (5.2%) [17].

In PDSA 2, a reduction in HH compliance was observed as compared to the previous cycle. The low compliance observed in this cycle was due to lockdown restrictions, understaffing due to COVID-19, prolonged work hours, a lack of positive role modelling, and no periodic review team meetings. Pittet et al. showed that increased workload and the high demand for strict adherence to HH are the most significant risk factors for noncompliance [18].

The percentage of HH attempts was high before touching a patient; however, it decreased for interpatient contact and after contact with the patient’s surroundings. The usage of HH after contact with the patient’s surroundings significantly improved from the baseline of 18.18–66.37% after three cycles. But the result was still low when compared to other moments of hand hygiene. In an article by FitzGerald et al., the most common hand-hygiene opportunities that were missed were after touching a patient’s surroundings, and they recommend that the health care workers be made aware of the bacterial spread that can occur even during activities of perceived low risk. Education and intervention programs should focus on the potential contamination of ward computers, case files, and door handles [19].

The present pilot project became the way to start auditing systems in the SNCU. The prioritization matrix helped the team focus on one problem rather than solving multiple problems at once. During the study period, the staffs were repeatedly exposed to the HH training, thereby improving their confidence. After the study period ended, the staff were encouraged constantly to improvise as they would be monitored during the LaQshya (Labor Room Quality Improvement Initiative) and NQAS (National Quality Assurance Standards) assessments. The mode of communication and interpersonal relationship improved during the course of the study, and feedback was appreciated from both ends. Overall positive effects were noted at the end of the study period.

The sample size was small and duration of study was short. Hand hygiene moments were not recorded during resuscitation outside the SNCU. Moments of HH were not recorded during the night shifts. There were lockdown measures and understaffing due to COVID-19 during the present study period. The total number of ventilator days, umbilical catheter days, and peripheral venous catheter days could not be recorded. The project did not involve the mothers in the hand hygiene project.

Conclusions

Hand hygiene remains the main theme in connecting various aspects of care bundles to reduce the HAI. Hand-hygiene compliance can be improved through information, education, and communication methods among the health care workers. However, these interventions need constant positive role models and monitoring. If implemented on a large scale, burden on the health care workers, hospitals, and the economy can be brought down significantly.