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Interactive Interventions can Improve Hand Hygiene and Aseptic Techniques During Perioperative Care – Experience From the “Safe Hands” Project

  • Maria Frödin
    Correspondence
    Address correspondence to Maria Frödin, Sahlgrenska University Hospital, Ortopedoperation 1, Göteborgsvägen 31, SE-431 80 Göteborg, Sweden
    Affiliations
    Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Västra Götalandregionen, Sweden

    Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Västra Götalandregionen, Sweden
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  • Cecilia Rogmark
    Affiliations
    Department of Orthopedics Malmö, Lund University, Skane University Hospital, Lund, Skane, Sweden

    The Swedish Hip Arthroplasty Register, Registercentrum VGR, Gothenburg, Västra Götalandregionen, Sweden
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  • Bengt Nellgård
    Affiliations
    Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Västra Götalandregionen, Sweden
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  • Brigid M. Gillespie
    Affiliations
    NMHRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute, Griffith University, Griffith, Queensland, Australia

    Health Service, Gold Coast University Hospital and Health Service, Gold Coast, Queensland, Australia
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  • Ewa Wikström
    Affiliations
    School of Business, Economics and Law, Department of Business Administration, University of Gothenburg, Gothenburg, Västra Götalandregionen, Sweden
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  • Annette E. Andersson
    Affiliations
    Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Västra Götalandregionen, Sweden
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Open AccessPublished:October 29, 2022DOI:https://doi.org/10.1016/j.jopan.2022.07.006

      Abstract

      Purpose

      This paper evaluates a theory-driven, interactive hand hygiene (HH) intervention, the Safe Hands project, based on theories of organizational learning and culture including leadership support, dialogue and co-creation.

      Design

      This prospective quasi-experimental study used unobtrusive overt observations to evaluate adherence to HH recommendations after implementing an infection-prevention intervention.

      Methods

      The primary outcome was differences in HH practices “Before aseptic/clean procedure” (WHO moment 2), “After body fluid exposure risk” (WHO moment 3) and performance of aseptic techniques. One operating room (OR) department served as the study hospital and the other as the control hospital, both at Swedish university hospitals. Adherence to HH guidelines was measured 4 times during 2015 to 2017.

      Findings

      The intervention site displayed a significant improvement in adherence to HH guidelines and aseptic techniques. WHO 2; from 23.8% to 36.2%, (P = .014), WHO 3; from 22.2% to 42.3%, (P = .002), and aseptic techniques; from 17.5% to 31.6%, (P = .003). No changes in adherence were identified at the control site. The use of contaminated gloves decreased post intervention at the study operating department.

      Conclusions

      This study shows that implementing tailored interventions that are underpinned by theories from organizational learning and culture can improve adherence to hand hygiene in a complex setting as the OR up to 6 months post-intervention. The interprofessional co-creation of standards operating procedures addressing specific care procedures and emphasizing the importance of aseptic techniques can be an acceptable and feasible way to reduce the risks of contaminating medical devices and patients during perioperative care.

      Keywords

      As early as in the mid-19th century, Ignaz Semmelweis
      • Semmelweis WJS
      His life and his doctrine; a chapter in the history of medicine.
      ,

      Best M, Neuhauser D. Ignaz Semmelweis and the birth of infection control. Qual Safe Health Care. 2004;13:233-234. doi:10.1136%2Fqshc.2004.010918

      endorsed the importance of hand hygiene (HH). In the subsequent years, studies have continued to confirm the importance for health care workers (HCW) to adopt and adhere to HH guidelines in patient care, as one of the simplest yet most effective strategies to prevent the spread of microorganisms and health care-associated infections (HAIs).
      • Pittet D
      • Hugonnet S
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      • Willis TM
      • Wolak ES
      • Weber DJ
      • Rutala WA
      Reduction of health care-associated infections by exceeding high compliance with hand hygiene practices.
      Despite this, low adherence to HH guidelines and aseptic techniques have been identified in the operating room (OR), an environment where asepsis is a core element of clinical practice.
      • Biddle C.
      Semmelweis revisited: hand hygiene and nosocomial disease transmission in the anesthesia workstation.
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      Hand-hygiene practices in the operating theatre: An observational study.
      • Biddle C
      • Shah J.
      Quantification of anesthesia providers' hand hygiene in a busy metropolitan operating room: What would Semmelweis think?.
      • Scheithauer S
      • Rosarius A
      • Rex S
      • Post P
      • Heisel H
      • Krizanovic V.
      Improving hand hygiene compliance in the anesthesia working room work area: More than just more hand rubs.
      • Rowlands J
      • Yeager MP
      • Beach M
      • Patel HM
      • Huysman BC
      • Loftus RW.
      Video observation to map hand contact and bacterial transmission in operating rooms.

      Megeus V, Nilsson K, Eriksson B, Karlsson J, Andersson Erichsen A. Hand hygiene and aseptic techniques during routine anesthetic care - observations in the operating roomAntimicrob Resist Infect Control2015;4: doi:10.1186%2Fs13756-015-0042-y

      • Megeus V
      • Nilsson K
      • Karlsson J
      • Eriksson BI
      • Erichsen Andersson A
      Hand contamination, cross-transmission, and risk-associated behaviors: An observational study of team members in ORs.
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      • Coen P
      • Drey N
      • Gould D.
      Hand hygiene compliance monitoring in anaesthetics: Feasibility and validity.
      • Paul ET
      • Kuszajewski M
      • Davenport A
      • Thompson JA
      • Morgan B.
      Sleep safe in clean hands: Improving hand hygiene compliance in the operating room through education and increased access to hand hygiene products.
      • Munoz-Price LS
      • Riley B
      • Banks S
      • et al.
      Frequency of interactions and hand disinfections among anesthesiologists while providing anesthesia care in the operating room: Induction versus maintenance.
      There is growing evidence that the low adoption of HH guidelines and aseptic techniques in the OR is contributing to the occurrence of postoperative infections.
      • Munoz-Price LS
      • Patel Z
      • Banks S
      • et al.
      Randomized crossover study evaluating the effect of a hand sanitizer dispenser on the frequency of hand hygiene among anesthesiology staff in the operating room.
      • Loftus RW
      • Koff MD
      • Birnbach DJ.
      The dynamics and implications of bacterial transmission events arising from the anesthesia work area.
      • Loftus RW
      Infection control in the operating room: Is it more than a clean dish?.
      • Loftus RW
      • Dexter F
      • Robinson AD.
      High-risk Staphylococcus aureus transmission in the operating room: A call for widespread improvements in perioperative hand hygiene and patient decolonization practices.
      • Munoz-Price LS
      • Bowdle A
      • Johnston BL
      • et al.
      Infection prevention in the operating room anesthesia work area.
      The most effective HH implementation strategy is yet to be established
      • Munoz-Price LS
      • Bowdle A
      • Johnston BL
      • et al.
      Infection prevention in the operating room anesthesia work area.
      ,

      Gould DJ, Moralejo D, Drey N, Chudleigh JH, Taljaard M. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev. 2017;9:doi:10.1002/14651858.CD005186.pub4

      but there is a movement towards using social science or organizational learning theories addressing behavioral change, culture and attitudes to promote a change in HCWs practice and ownership of preventing HAIs.

      Gould DJ, Moralejo D, Drey N, Chudleigh JH, Taljaard M. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev. 2017;9:doi:10.1002/14651858.CD005186.pub4

      ,
      • Gould DJ
      • Hale R
      • Waters E
      • Allen D.
      Promoting health workers' ownership of infection prevention and control: using normalization process theory as an interpretive framework.
      This paper is one in a series in the Safe Hands project (Clinical Trials. gov ID: NCT02983136), with goals of increasing awareness and understanding of infection prevention within all professional groups in the OR. The project was theory driven based on the work of Schein
      • Schein E.
      How to Offer, Give, and Receive Help.
      ,
      • Schein E.
      Organizational culture and leadership.
      and Issacs.
      • Isaacs WN.
      Creating a Shared Field of Meaning: An Action Theory of Dialogue.
      The goal was to create a shared sense of urgency through interprofessional learning to drive and support improvements, by adopting preventive measures such as HH and aseptic techniques as a means of reducing HAIs. But also, to facilitate new practices for HH where correct HH according to WHO is not fully applicable in the OR context. The implementation strategy was based on partnership and dialogue between HCWs, management and facilitators and the co-creation of improved ways of working. In previous papers,
      • Erichsen Andersson A
      • Frödin M
      • Dellenborg L
      • et al.
      Iterative co-creation for improved hand hygiene and aseptic techniques in the operating room: Experiences from the safe hands study. journal article.
      ,
      • Wikström E
      • Dellenborg L
      • Wallin L
      • Gillespie BM
      • Erichsen Andersson A
      The Safe Hands Study: Implementing aseptic techniques in the operating room: Facilitating mechanisms for contextual negotiation and collective action.
      we have described the intervention and the implementation process in detail. The aim of this study was to describe how adherence to HH guidelines and aseptic techniques changed after the Safe Hands project (ClinicalTrials.gov ID: NCT02983136), comparing baseline observations with post-intervention observations at the intervention site and the control site.

      Methods

      Design

      A prospective quasi-experimental design was used, including unobtrusive overt observations to evaluate adherence to HH recommendations before, during and after implementing an infection-prevention intervention. The study period lasted 24 months, mid-2015 to mid-2017. The primary outcome was differences in HH adherence rates in relation the World Health Organization (WHO) moments 2 and 330 and aseptic techniques (for terminology, see Supplementary Box 1).

      Setting and Participants

      Two OR departments at 2 Swedish university hospitals participated in the study. One location served as the intervention hospital (I-OR) and the other location was the control hospital (C-OR). The I-OR had 7 orthopedic ORs and the C-OR had 5. Both sites had a similar staff mix of anesthesiologists, nurse assistants, registered nurses (RNs): certified nurse anesthetists and certified OR nurses. All HCWs are instructed to follow Swedish regulations based on basic hygiene routines.

      The National Board of Health and Welfare. Basic hygiene in health care and care, SOSFS 2015:10 2015-5-10. Available at: https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/foreskrifter-och-allmanna-rad/2015-5-10-english.pdf. Accessed June 6, 2021.

      These regulations include detailed instructions on when and how to perform HH, as well as the use of work attire and personal protection equipment (Supplementary Box 2). In addition, all HCWs perform an annual, mandatory e-learning activity on hand hygiene. The HCWs in the I-OR participated in the Safe Hands intervention during 2016 to 2017.
      • Erichsen Andersson A
      • Frödin M
      • Dellenborg L
      • et al.
      Iterative co-creation for improved hand hygiene and aseptic techniques in the operating room: Experiences from the safe hands study. journal article.

      Data Collection

      Data was collected 4 times over a 2-year period at both study sites: at baseline, once during the intervention, once 2 weeks after and then 6 months after the intervention. The observations were carried out during daytime, for 1 week per observational period.
      All observations at the 2 sites were made by the same single observer, a certified registered nurse anesthetist with over 30 years of clinical experience and specifically trained for the study without any prior connection to either site. The observations started in the preoperative center or preparation rooms, where the first available team was observed until the patient was ready for surgery. Consecutive OR teams were then similarly observed during the day, but no observations were made during the intraoperative- or post-surgery periods.
      Monitoring of indications and opportunities for HH during anesthetic care procedures were limited to include “Before aseptic/clean procedure” WHO 2, including preparing drugs for intravenous use and handling invasive devices for patient care before and during induction whether gloves were used and, “After body fluid exposure risk” WHO 3, including HH after glove removal.
      • Sax H
      • Allegranzi B
      • Uckay I
      • Larson E
      • Boyce J
      • Pittet D.
      My five moments for hand hygiene': A user-centred design approach to understand, train, monitor and report hand hygiene.
      A HH indication was defined as the reason for why a HH action was required. A HH opportunity was defined as moments when HH was required to effectively interrupt microbial transmission during the care sequence. Aseptic techniques are vital to maintain the sterility of medical devices during insertion and were therefore also recorded along with glove use.
      The volume of hand disinfection used, and the duration of its application were not recorded. Thus, a modified version of the WHO's observational tool,
      • Sax H
      • Allegranzi B
      • Chraïti M-N
      • Boyce J
      • Larson E
      • Pittet D.
      The World Health Organization hand hygiene observation method.
      tested and adapted to the OR context,

      Megeus V, Nilsson K, Eriksson B, Karlsson J, Andersson Erichsen A. Hand hygiene and aseptic techniques during routine anesthetic care - observations in the operating roomAntimicrob Resist Infect Control2015;4: doi:10.1186%2Fs13756-015-0042-y

      was used.
      With an assumed baseline HH compliance of 10%
      • Scheithauer S
      • Rosarius A
      • Rex S
      • Post P
      • Heisel H
      • Krizanovic V.
      Improving hand hygiene compliance in the anesthesia working room work area: More than just more hand rubs.
      ,

      Megeus V, Nilsson K, Eriksson B, Karlsson J, Andersson Erichsen A. Hand hygiene and aseptic techniques during routine anesthetic care - observations in the operating roomAntimicrob Resist Infect Control2015;4: doi:10.1186%2Fs13756-015-0042-y

      and a power of 90% with an alpha level of 5% and an estimated difference before and after the intervention of 10%, the sample size was calculated to include 100 care procedures at each time point generating approximately 150 to 250 opportunities for HH per observational period and site.

      The Intervention

      Prior to the intervention, a researcher and senior expert in infection control and prevention gave the OR staff, at both sites, the same 2-hour state-of-the-art lecture on postoperative infections, their origins, incidence, and prevention. The intervention site also participated in the complete Safe Hands intervention program.
      • Erichsen Andersson A
      • Frödin M
      • Dellenborg L
      • et al.
      Iterative co-creation for improved hand hygiene and aseptic techniques in the operating room: Experiences from the safe hands study. journal article.
      ,
      • Wikström E
      • Dellenborg L
      • Wallin L
      • Gillespie BM
      • Erichsen Andersson A
      The Safe Hands Study: Implementing aseptic techniques in the operating room: Facilitating mechanisms for contextual negotiation and collective action.
      The results from the baseline observations of HH were subsequently given as feedback to staff at both study sites.
      In the intervention group, participants from the I-OR department, together with the facilitators, co-created new procedures, that is specific standard operating procedures (SOP) all addressing device-related infections, in an iterative, collaborative process. A SOP describes “step by step” how to perform a complex multistep procedure, where photographs visualized the steps. Participants decided which specific activities they wanted to improve. As a result, 4 SOPs were created during the implementation period: the insertion of an arterial catheter, neuraxial anesthesia (spinal), artificial airway access and urinary catheter insertion (Supplementary Table 1). In addition, participants identified a shortage of handy disinfection dispensers in the I-OR, and therefore fixed hand disinfection dispensers were strategically placed in the OR next to exit/entrance doors, in the preparation rooms, in the anesthesia working areas and on the ventilators.

      Ethics

      Approval was obtained from the Regional Ethical Review Board of Gothenburg, Sweden (no 166-15). The study adhered to the principles of the Helsinki Declarations.
      World Medical Association
      World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects.
      All the participants received written and oral information about the observations of compliance with hand hygiene guidelines. The observations were based on specific procedures, not personnel. Gender and professional role were not recorded to avoid the risk of identification. Each OR staff member had the option of declining observation.

      Statistical Analysis

      Hand hygiene adherence was calculated by dividing the number of HH actions by the number of opportunities for HH in relation to WHO moments 2 and 3. Adherence to aseptic techniques were calculated by dividing successful aseptic techniques by the number of opportunities for aseptic techniques. The observed care procedures were grouped as: (1) Preparation and administration of intravenous injection/infusion and handling of sterile products, (2) Insertion of peripheral venous, arterial, or central line catheters, (3) Artificial airway access, (4) Urinary catheterization and (5) Regional anesthesia. Glove use was divided into; clean, previously used (contaminated) and non-use. Glove use was also assessed as indicated or not indicated, in relation to the type of care procedure performed.
      Categorical variables are presented as numbers and percentages (%). Differences between groups were compared against those at baseline and 6 months post-intervention, at both the intervention and control sites. The χ2 test (2-sided) with Yates Continuity Correction was used to compare categorical variables at baseline with post-observations at the respective study site, to compare categorical variables at baseline between I-OR and C-OR and for the sub-analysis of grouped care procedures. If the expected frequencies were <10, Fisher's exact test (2-sided) was used. The significance level defined as a P < .05. All the data were analyzed using International Business Machines Corporation (IBM) Statistical Package for the Social Sciences (SPSS) Statistics, version 27.
      IBM SPSS Statistics for Windows, Version 27.0.

      Findings

      During 320 study hours, we observed a total number of 1,592 clean/aseptic care procedures, resulting in 2,693 opportunities for HH, in relation to WHO moments 2 and 3. From baseline to 6 months post-intervention, we found a significant improvement in adherence to HH guidelines and aseptic techniques at the I-OR. In contrast, no changes in HH or aseptic techniques were detected at the C-OR. (Table 1).
      Table 1Adherence to Hand Hygiene in Relation to WHO Moments 2 and 3, Maintained Aseptic Techniques, at Intervention-OR and Control-OR
      Baseline, September 2015During Intervention May 2016Post-intervention I, December 2016Post-intervention II May 2017P-value
      Baseline vs post-observation II, 6 months post-intervention, Chi2 with Yates Continuity Correction (2-sided).
      P-value
      I-ORC-OR,I-ORC-OR,I-OR,C-OR,I-OR,C-OR,I-OR,C-OR,I-OR vs
      StudyControlStudyControlStudyControlStudyControlStudyControlC-OR at Baseline
      WHO 2
      WHO moment 2, before clean/aseptic procedures.
      39 (23.8)63 (42.3)88 (43.1)82 (39.2)85 (41.5)87 (41.4)76 (36.2)87 (36.7)0.014.324.001
      n=164n=149n=204n=209n=205n=210n=210n=237
      WHO 3
      WHO moment 3, after risk for body fluid exposure.
      22 (22.2)48 (47.5)55 (49.5)62 (49.2)84 (45.9)72 (39.5)61 (42.3)79 (49.6)0.002.832.001
      n=99n=101n=111n=126n=183n=182n=144n=159
      Aseptic techniques28 (17.5)42 (29.4)65 (33.2)53 (25.6)69 (33.5)60 (28.6)66 (31.6)73 (30.8)0.003.858.021
      n=160n=143n=196n=207n=206n=210n=209n=237
      OR, operating room.
      low asterisk WHO moment 2, before clean/aseptic procedures.
      WHO moment 3, after risk for body fluid exposure.
      Baseline vs post-observation II, 6 months post-intervention, Chi2 with Yates Continuity Correction (2-sided).
      We found significantly improved adherence to HH at the I-OR for both WHO moments 2 and 3 when comparing baseline with post-intervention, for inserting venous, arterial and central line catheters (Tables 2 and 3). A significant increase in the use of HH was also observed after IV injections/infusions and handling sterile products (for the latter HH is not indicated) (Table 3). In the I-OR successful aseptic techniques improved for inserting venous-, arterial- and central-line catheters, as well as for injections/infusions and handling sterile products (Table 4). No significant improvements were observed at the C-OR.
      Table 2Adherence to WHO Moment 2 in Relation to Care Procedures, Intervention-OR (I-OR) n = 783, Control-OR (C-OR) n = 805, [N = 1592]
      Type of Indication, n (%)Baseline,During InterventionPost-intervention I,Post-intervention IIP-value
      Baseline vs post-observation II, 6 months post-intervention.
      September 2015May 2016December 2016May 2017
      I-ORC-OR,I-ORC-OR,I-OR,C-OR,I-OR,C-OR,I-OR,C-OR,
      StudyControlStudyControlStudyControlStudyControlStudyControl
      Preparing and giving IV medication or handling sterile products16 (17.0)29 (34.5)49 (38.0)41 (34.7)35 (29.2)36 (30.0)33 (24.8)42 (32.6)0.214
      Yates Continuity Correction (2-sided).
      0.882
      Yates Continuity Correction (2-sided).
      n = 94n = 84n = 129n = 118n = 120n = 120n = 133n =129
      Inserting peripheral venous catheter, arterial catheter or central line catheter7 (21.2)15 (48.4)14 (53.8)13 (32.5)20 (64.5)22 (48.9)20 (58.8)23 (39.7)0.004
      Yates Continuity Correction (2-sided).
      0.570
      Yates Continuity Correction (2-sided).
      n = 33n = 31n = 26n = 40n = 31n = 45n = 34n = 58
      Artificial airway access2 (25.0)13 (56.5)4 (23.5)10 (43.5)6 (66.7)13 (59.1)9 (45.0)9 (29.0)0.419
      Fisher's Exact Test (2-sided).
      0.080
      Yates Continuity Correction (2-sided).
      n = 8n = 23n = 17n = 23n = 9n = 22n = 20n = 31
      Indwelling urinary catheter or intermittent catheterization5 (55.6)3 (50.0)9 (75.0)9 (75.0)8 (72.7)7 (63.6)10 (76.0)9 (81.8)0.376
      Fisher's Exact Test (2-sided).
      0.280
      Fisher's Exact Test (2-sided).
      n = 9n = 6n = 12n = 12n = 11n = 11n = 13n = 11
      Regional anesthesia9 (45.0)3 (60.0)12 (60.0)9 (56.3)16 (47.1)9 (75.0)4 (40.0)4 (50.0)1.000
      Fisher's Exact Test (2-sided).
      1.000
      Fisher's Exact Test (2-sided).
      n = 20n = 5n = 20n = 16n = 34n = 12n = 10n = 8
      Total care procedures, NN = 164N = 149N = 204N = 209N = 205N = 210N = 210N = 237
      IV, intravenous; OR, operating room.
      low asterisk Baseline vs post-observation II, 6 months post-intervention.
      Yates Continuity Correction (2-sided).
      Fisher's Exact Test (2-sided).
      Table 3Adherence to WHO Moment 3, Care Procedures, Intervention-OR (I-OR) n = 537, Control-OR (C-OR) n = 568, [N = 1105]
      Type of Indication, n (%)Baseline,During InterventionPost- intervention I,Post-intervention IIP-value
      Baseline vs post-observation II, 6 months post-intervention.
      September 2015May 2016December 2016May 2017
      I-ORC-OR,I-ORC-OR,I-OR,C-OR,I-OR,C-OR,I-OR,C-OR,
      StudyControlStudyControlStudyControlStudyControlStudyControl
      Preparing and giving IV. medication or handling sterile products3 (8.1)17 (37.0)15 (31.9)18 (36.0)29 (28.7)22 (23.9)22 (29.3)19 (35.2).022
      Yates Continuity Correction (2-sided).
      1.000
      Yates Continuity Correction (2-sided).
      n = 37n = 461n = 47n = 50n = 101n = 92n = 75n = 54
      Inserting peripheral venous7 (24.1)14 (56.0)16 (66.7)14 (48.3)23 (74.2)18 (40.0)16 (57.1)29 (51.8)0.023
      Yates Continuity Correction (2-sided).
      .912
      Yates Continuity Correction (2-sided).
      catheter, arterial- catheter or central line cathetern = 29n = 25n = 24n = 29n = 31n = 45n = 28n = 56
      Artificial airway access2 (25.0) n = 88 (42.1) n = 199 (64.3) n = 149 (47.4) n = 197 (77.8) n = 913 (59.1) n = 229 (50.0) n = 1818 (60.0) n = 300.395
      Fisher's Exact Test (2-sided).
      .353
      Yates Continuity Correction (2-sided).
      Indwelling urinary catheter or intermittent catheterization5 (55.6) n = 96 (100) n = 68 (66.7) n = 1211 (91.7) n = 129 (81.8) n = 119 (81.8) n = 119 (69.2) n = 139 (81.8) n = 110.662
      Fisher's Exact Test (2-sided).
      .515
      Fisher's Exact Test (2-sided).
      Regional anesthesia5 (31.3) n = 163 (60.0) n = 57 (50.0) n = 1410 (62.5) n = 1616 (51.6) n = 3110 (83.3) n = 125 (50.0) n = 104 (50.0) n = 80.425
      Fisher's Exact Test (2-sided).
      1.000
      Fisher's Exact Test (2-sided).
      Total care procedures, N++N = 99N = 101N = 111N = 126N = 183N = 182N = 144N = 159
      IV, intravenous; OR, operating room.
      low asterisk Baseline vs post-observation II, 6 months post-intervention.
      Yates Continuity Correction (2-sided).
      Fisher's Exact Test (2-sided).
      Table 4Successful Aseptic Technique per Targeted (Grouped) Care Procedures, Intervention-OR n = 771, Control-OR n = 797, [N = 1568]
      Type of IndicationBaseline,During InterventionPost-intervention I,Post-intervention IIP-value
      Baseline vs 6 months post-intervention.
      September 2015May 2016December 2016May 2017
      I-ORC-OR,I-ORC-OR,I-OR,C-OR,I-OR,C-OR,I-OR,C-OR,
      StudyControlStudyControlStudyControlStudyControlStudyControl
      Preparing and giving IV. medication or handling sterile products11 (12.0)21 (25.6)35 (28.2)23 (19.7)23 (19.2)24 (20.0)32 (24.1)38 (29.5)0.036
      Chi2 with Yates Continuity Correction (2-sided).
      0.653
      Chi2 with Yates Continuity Correction (2-sided).
      n = 92n = 82n = 124n = 117n = 120n = 120n = 133n = 129
      Inserting peripheral venous catheter, arterial catheter or central line catheter4 (12.5)12 (40.0)11 (44.0)8 (20.5)18 (56.3)13 (28.9)15 (45.5)15 (25.9)0.008
      Chi2 with Yates Continuity Correction (2-sided).
      0.263
      Chi2 with Yates Continuity Correction (2-sided).
      n = 32n = 30n = 25n = 39n = 32n = 45n = 33n = 58
      Artificial airway2 (25.0)4 (18.2)4 (22.2)6 (26.1)6 (66.7)9 (40.9)7 (35.0)8 (25.8)1.000
      Fisher's Exact Test (2-sided).
      0.740
      Chi2 with Yates Continuity Correction (2-sided).
      n = 8n = 22n = 18n = 23n = 9n = 22n = 20n = 31
      Indwelling urinary catheter or intermittent catheterization4 (44.4)3 (75.0)7 (58.3)9 (75.0)7 (63.6)6 (54.5)8 (61.5)8 (72.7)0.666
      Fisher's Exact Test (2-sided).
      1.000
      Fisher's Exact Test (2-sided).
      n = 9n = 4n = 12n = 12n = 11n = 11n = 13n = 11
      Regional anesthesia7 (36.8)2 (40.0)8 (47.1)7 (43.8)15 (44.1)8 (66.7)4 (40.0)4 (50.0)1.000
      Fisher's Exact Test (2-sided).
      1.000
      Fisher's Exact Test (2-sided).
      n = 19n = 5n = 17n = 16n = 34n = 12n = 10n = 8
      Total care procedures, NN = 160N = 143N = 196N = 207N = 206N = 210N = 209N = 237
      IV, intravenous, OR, operating room.
      low asterisk Baseline vs 6 months post-intervention.
      Chi2 with Yates Continuity Correction (2-sided).
      Fisher's Exact Test (2-sided).
      Overall glove uses at the I-OR decreased between baseline and 6 months post-intervention: (68,9%, n = 113%-47,2%, n = 94, P =.0001), The largest reductions in glove use were seen for injections/infusions and handling sterile products (46,8%, n = 94%-73,4%, n = 124), P =.0001.
      In contrast, an increase of glove use was observed at the C-OR, (35.5%, n = 99%-64.5%, n = 180, P =.056). In addition, there was a significant increase in the use of contaminated gloves at the C-OR for IV injections/infusions and handling sterile products (30%, n = 40%-53,8%, n = 80, P =.023).
      At baseline in the I-OR, 164 care procedures were observed for glove use, 77 were clean before use, 36 were contaminated and in 51 cases no gloves were use. Of the clean gloves used (34%) were used without indication. Of the contaminated gloves, 66% were used without indication. For the 51 cases where no gloves were used, gloves were not required. At baseline in the C-OR, 149 care procedures were observed for glove use, 74 were clean before use, 25 contaminated and in 50 cases no gloves were used. Of the clean gloves used 33% were used without indication. For the contaminated gloves, 45% were used without indication. In 33% of the cases, no gloves were used and not required.
      At post-intervention II in the I-OR, 199 care-procedures were observed for glove use, 74 were clean before use, 20 contaminated and in 105 no gloves were used. Of all clean glove used 27% were used without indication. Of the contaminated gloves 55% were used without indication. For no-glove use, in 1 case, glove use was indicated. At post-intervention II the C-OR, of the 237 care procedures observed for glove use, 113 were clean, 67 contaminated and in 57 cases no gloves were used. Of the clean gloves used 33% were used without indication. Of the contaminated gloves 64% were used without indication. In the cases where no gloves were used, in 1 case glove use was required.

      Discussion

      In this study, we have described improvements in HH and aseptic techniques over time after implementing an infection-prevention intervention, based on knowledge from theories on organizational learning and culture,
      • Schein E.
      Organizational culture and leadership.
      ,
      • Isaacs WN.
      Creating a Shared Field of Meaning: An Action Theory of Dialogue.
      including leadership support and interprofessional co-creation of SOPs for the insertion of medical devices.

      Hand Hygiene, Aseptic Techniques, and Glove Use

      Significant and sustained improvements in HH were identified for WHO moments 2, 3 and aseptic techniques at the intervention site, while remaining unchanged at the control site. The improvements in HH and aseptic techniques are encouraging, as these moments are crucial in preventing HAIs.
      • Sax H
      • Allegranzi B
      • Uckay I
      • Larson E
      • Boyce J
      • Pittet D.
      My five moments for hand hygiene': A user-centred design approach to understand, train, monitor and report hand hygiene.
      However, correctly performed WHO moments 2 and 3 do not necessarily mean that the aseptic techniques are maintained, as the devices can be contaminated during insertion.
      • Biddle C
      • Shah J.
      Quantification of anesthesia providers' hand hygiene in a busy metropolitan operating room: What would Semmelweis think?.
      ,
      • Bennett SN
      • McNeil MM
      • Bland LA
      • Arduino MJ
      • Villarino ME
      • Perrotta DM.
      Postoperative infections traced to contamination of an intravenous anesthetic, propofol.
      • Pittet D
      • Allegranzi B
      • Sax H
      • et al.
      Evidence-based model for hand transmission during patient care and the role of improved practices.
      • Koff MD
      • Loftus RW
      • Burchman CC
      • et al.
      Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device.
      So, even though we identified an overall improvement in aseptic techniques at the I-OR, asepsis was still only maintained in one third of the observed moments. Further, we found greater adherence to WHO moment 3 and poorer adherence to WHO moment 2, in line with previous research in the OR.
      • Scheithauer S
      • Rosarius A
      • Rex S
      • Post P
      • Heisel H
      • Krizanovic V.
      Improving hand hygiene compliance in the anesthesia working room work area: More than just more hand rubs.
      • Rowlands J
      • Yeager MP
      • Beach M
      • Patel HM
      • Huysman BC
      • Loftus RW.
      Video observation to map hand contact and bacterial transmission in operating rooms.

      Megeus V, Nilsson K, Eriksson B, Karlsson J, Andersson Erichsen A. Hand hygiene and aseptic techniques during routine anesthetic care - observations in the operating roomAntimicrob Resist Infect Control2015;4: doi:10.1186%2Fs13756-015-0042-y

      ,
      • Paul ET
      • Kuszajewski M
      • Davenport A
      • Thompson JA
      • Morgan B.
      Sleep safe in clean hands: Improving hand hygiene compliance in the operating room through education and increased access to hand hygiene products.
      ,
      • Andersson AE
      • Bergh I
      • Karlsson J
      • Eriksson BI
      • Nilsson K.
      The application of evidence-based measures to reduce surgical site infections during orthopedic surgery - report of a single-center experience in Sweden.
      As identified in larger health care settings,
      • Grayson ML
      • Stewardson AJ
      • Russo PL
      • et al.
      Effects of the Australian national hand hygiene initiative after 8 years on infection control practices, health care worker education, and clinical outcomes: a longitudinal study.
      • Moghnieh R
      • Soboh R
      • Abdallah D
      • et al.
      Health care workers' compliance to the My 5 moments for hand hygiene: comparison of 2 interventional methods.
      • Arntz PRH
      • Hopman J
      • Nillesen M
      • et al.
      Effectiveness of a multimodal hand hygiene improvement strategy in the emergency department.
      this result may be related to the internalized and socially driven behavior of cleaning one's hands after doing anything that is defined as “dirty.”
      • Whitby M
      • Pessoa-Silva CL
      • McLaws ML
      • et al.
      Behavioural considerations for hand hygiene practices: the basic building blocks.
      In contrast, disinfecting the hands prior to a clean aseptic procedure making it necessary to incorporate new ways of both thinking and acting on risks.
      Incorrect glove use has been associated with the failure or inhibition of HH.
      • Girou E
      • Chai SHT
      • Oppein F
      • et al.
      Misuse of gloves: The foundation for poor compliance with hand hygiene and potential for microbial transmission?.
      • Fuller C
      • Savage J
      • Besser S
      • Hayward A
      • Cookson B
      • Cooper B.
      The dirty hand in the latex glove”: A study of hand hygiene compliance when gloves are worn.
      • Picheansathian W
      • Chotibang J.
      Glove utilization in the prevention of cross transmission: A systematic review.
      Misuse and failure to change or remove contaminated gloves has shown to be a major factor in poor compliance to HH.
      • Fuller C
      • Savage J
      • Besser S
      • Hayward A
      • Cookson B
      • Cooper B.
      The dirty hand in the latex glove”: A study of hand hygiene compliance when gloves are worn.
      ,
      • Picheansanthian W
      • Chotibang J.
      Glove utilization in the prevention of cross transmission: A systematic review.
      It does not only increase the risk of cross-contamination
      • Fuller C
      • Savage J
      • Besser S
      • Hayward A
      • Cookson B
      • Cooper B.
      The dirty hand in the latex glove”: A study of hand hygiene compliance when gloves are worn.
      ,
      • Picheansanthian W
      • Chotibang J.
      Glove utilization in the prevention of cross transmission: A systematic review.
      but it also represents a waste of health care equipment. It has been pointed out that correct glove use is a vital part of HH interventions.
      • Fuller C
      • Savage J
      • Besser S
      • Hayward A
      • Cookson B
      • Cooper B.
      The dirty hand in the latex glove”: A study of hand hygiene compliance when gloves are worn.
      ,
      • Picheansanthian W
      • Chotibang J.
      Glove utilization in the prevention of cross transmission: A systematic review.
      We identified a reduction in glove use and the use of contaminated gloves at the I-OR, along with increased adherence to HH at the I-OR, and a cautious interpretation is that gloves were replaced by HH, as reported in other studies.
      • Scheithauer S
      • Rosarius A
      • Rex S
      • Post P
      • Heisel H
      • Krizanovic V.
      Improving hand hygiene compliance in the anesthesia working room work area: More than just more hand rubs.
      ,
      • Paul ET
      • Kuszajewski M
      • Davenport A
      • Thompson JA
      • Morgan B.
      Sleep safe in clean hands: Improving hand hygiene compliance in the operating room through education and increased access to hand hygiene products.
      We were unable to identify any significant change in adherence to HH in relation to the specifically developed SOPs, because of the à priori set study protocol. However, the urinary catheter SOP has been fully adopted at the interventional hospital on all wards. Moreover, in a recently published study we observed a substantial and significant reduction in urinary catheter-associated infections from 18.5% at baseline to 4.2% post-intervention.
      • Frödin M
      • Ahlstrom L
      • Gillespie BM
      • et al.
      Effectiveness of implementing a preventive urinary catheter care bundle in hip fracture patients.
      Adhering to HH guidelines can be difficult in the OR setting, especially during critical moments such as induction, even where assistance from colleagues can facilitate appropriate HH. However, a prerequisite for this is that HCWs possess the knowledge and the intention to give and receive aid. The SOPs that were co-created facilitated this collaboration

      The Intervention

      The Safe Hands project used a theory-based approach to tailor interventions to reflect the OR context,
      • Schein E.
      Organizational culture and leadership.
      • Isaacs WN.
      Creating a Shared Field of Meaning: An Action Theory of Dialogue.
      as a means of embedding and implementing improved best practice with the emphasis on HH and aseptic techniques to enhance HAI prevention.
      • Erichsen Andersson A
      • Frödin M
      • Dellenborg L
      • et al.
      Iterative co-creation for improved hand hygiene and aseptic techniques in the operating room: Experiences from the safe hands study. journal article.
      ,
      • Wikström E
      • Dellenborg L
      • Wallin L
      • Gillespie BM
      • Erichsen Andersson A
      The Safe Hands Study: Implementing aseptic techniques in the operating room: Facilitating mechanisms for contextual negotiation and collective action.
      We used leadership support, involved the whole OR team and created a safe place for learning with a no-blame and shame culture, which has been identified as an important factor in HAI prevention practices.
      • Gould DJ
      • Hale R
      • Waters E
      • Allen D.
      Promoting health workers' ownership of infection prevention and control: using normalization process theory as an interpretive framework.
      ,
      • Greene MT
      • Gilmartin HM
      • Saint S.
      Psychological safety and infection prevention practices: Results from a national survey.
      A collaborative culture within a work unit, related to teamwork with shared responsibility, has also been associated with greater adherence to HH
      • Huis A
      • Schoonhoven L
      • Grol R
      • Donders R
      • Hulscher M
      • Achterberg T.
      Impact of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: A cluster randomised trial.
      ,
      • Bernard L
      • Biron A
      • Lavigne G
      • et al.
      An exploratory study of safety culture, biological risk management and hand hygiene of health care professionals.
      and increases in perceived safety climate.
      • Daugherty EL
      • Paine LA
      • Maragakis LL
      • Sexton JB
      • Rand CS.
      Safety culture and hand hygiene: linking attitudes to behavior.
      Further, applied patient safety science that interlinks technical skills and non-technical skills may facilitate a shared understanding of the complex performance in the OR and improve the procedural practices.
      • Gillespie BM
      • Gwinner K
      • Chaboyer W
      • Fairweather N.
      Team communications in surgery creating a culture of safety.
      Creating shared understandings among team members was also one of the goals of SOP development in our study.
      Very few interventional studies have previously addressed HH deficits in the OR.
      • Scheithauer S
      • Rosarius A
      • Rex S
      • Post P
      • Heisel H
      • Krizanovic V.
      Improving hand hygiene compliance in the anesthesia working room work area: More than just more hand rubs.
      ,
      • Paul ET
      • Kuszajewski M
      • Davenport A
      • Thompson JA
      • Morgan B.
      Sleep safe in clean hands: Improving hand hygiene compliance in the operating room through education and increased access to hand hygiene products.
      ,
      • Munoz-Price LS
      • Patel Z
      • Banks S
      • et al.
      Randomized crossover study evaluating the effect of a hand sanitizer dispenser on the frequency of hand hygiene among anesthesiology staff in the operating room.
      All have included easy access to HH products, Scheithauer et al
      • Scheithauer S
      • Rosarius A
      • Rex S
      • Post P
      • Heisel H
      • Krizanovic V.
      Improving hand hygiene compliance in the anesthesia working room work area: More than just more hand rubs.
      also included SOP developments and audit and feedback, and Paul et al
      • Paul ET
      • Kuszajewski M
      • Davenport A
      • Thompson JA
      • Morgan B.
      Sleep safe in clean hands: Improving hand hygiene compliance in the operating room through education and increased access to hand hygiene products.
      included motivational and educational components. Scheithauer et al
      • Scheithauer S
      • Rosarius A
      • Rex S
      • Post P
      • Heisel H
      • Krizanovic V.
      Improving hand hygiene compliance in the anesthesia working room work area: More than just more hand rubs.
      study was undertaken over 1 year and Paul et al
      • Paul ET
      • Kuszajewski M
      • Davenport A
      • Thompson JA
      • Morgan B.
      Sleep safe in clean hands: Improving hand hygiene compliance in the operating room through education and increased access to hand hygiene products.
      had a 60 days post intervention follow up. Observing behavioral changes over time is important, as almost all interventions appear to have an initial positive improvement, followed by difficulty creating sustained improvements or loss to follow-up making it difficult to assess sustainability.

      Gould DJ, Moralejo D, Drey N, Chudleigh JH, Taljaard M. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev. 2017;9:doi:10.1002/14651858.CD005186.pub4

      Thus, our study ran for 2 years. However, it is difficult to directly compare these studies to ours due to differences in HH monitoring, interventional components and strategies and differences in baseline HH adherence. The aforementioned studies
      • Scheithauer S
      • Rosarius A
      • Rex S
      • Post P
      • Heisel H
      • Krizanovic V.
      Improving hand hygiene compliance in the anesthesia working room work area: More than just more hand rubs.
      ,
      • Paul ET
      • Kuszajewski M
      • Davenport A
      • Thompson JA
      • Morgan B.
      Sleep safe in clean hands: Improving hand hygiene compliance in the operating room through education and increased access to hand hygiene products.
      already had substantially lower baseline adherence rates than those identified in the I-OR in our study and particularly the C-OR, who had higher adherence rates over all 4 measurement points. The C-OR also differed from the I-OR in relation to contextual factors. In contrast to the I-OR, the C-OR had a stable organization and staff had worked together for a long time with low turnover rates.

      Methodological Considerations

      We acknowledge this study's strengths and limitations. We restricted the observations to include “Before aseptic/clean procedure” WHO 2 before and “After body fluid exposure risk” WHO 3, thereby omitting “Before patient contact” WHO 1, “After patient contact” WHO 4, “After contact with patient surroundings” WHO 5. The limitations and modifications applied were based on the premise that the work in the OR differs substantially from that on general wards in relation to tasks and task intensity.
      • Jeanes A
      • Dick J
      • Coen P
      • Drey N
      • Gould D.
      Hand hygiene compliance monitoring in anaesthetics: Feasibility and validity.
      ,
      • Munoz-Price LS
      • Bowdle A
      • Johnston BL
      • et al.
      Infection prevention in the operating room anesthesia work area.
      ,
      • Gillespie BM
      • Gwinner K
      • Chaboyer W
      • Fairweather N.
      Team communications in surgery creating a culture of safety.
      ,
      • Reason J.
      Safety in the operating theatre - Part 2: Human error and organizational failure.
      Direct observation for adherence to HH guidelines is widely acknowledged as the gold standard, performed either covertly or overtly.
      • Haas JP
      • Larson EL.
      Measurement of compliance with hand hygiene.
      ,
      • Ellingson K
      • Haas JP
      • Aiello AE
      • et al.
      Strategies to prevent health care-associated infections through hand hygiene.
      However, participant reactivity may lead to HCWs improving their behavior when they are observed.
      • Purssell E
      • Drey N
      • Chudleigh J
      • Creedon S
      • Gould DJ.
      The Hawthorne effect on adherence to hand hygiene in patient care.
      To overcome this limitation, the same trained observer undertook all observations in concordance with the study protocol, which eliminated the risk of inter-rater-related discrepancies. Moreover, the observations at both sites were made within a fortnight which reduced the impact of external confounding factors. There were no other HH campaigns performed at either site during the study period. Further, the observations were only made during daytime.
      To avoid selection bias, the observation strategy was stated à priori and predefined according to the well-known infection-prone procedures without singling out a particular OR personnel, and also not targeting the specific co-created SOPs. In hindsight, it would have been useful to have observed adherence directed towards the selected SOPs. However, this was not possible, as the co-development of specific SOPs was undertaken by study participants during the intervention, after the first time point measurement and changing the protocol during the ongoing study was not an option.

      Conclusion

      This study shows that implementing tailored interventions that are underpinned by theories from organizational learning and culture can improve adherence to hand hygiene in a complex setting as the OR up to 6 months post-intervention. The interprofessional co-creation of SOPs addressing specific care procedures and stressing the importance of aseptic techniques seems to be an acceptable and feasible way to reduce the risks of contaminating medical devices and patients.

      Availability of data and materials

      The data can be shared in response to reasonable requests.

      Acknowledgments

      We thank Lisbeth Sjöstedt for performing the observations in this study, and all the HCWs at the 2 OR departments participating in the Safe Hands project.

      Appendix. Supplementary materials

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