Abstract
Background
Hand hygiene (HH) compliance among health-care workers is important for preventing transmission of infectious diseases.
Aim
To describe health-care worker hand hygiene activity in ICU and non-ICU patients’ rooms, using an automated monitoring system (AMS), before and after the onset of the COVID-19 pandemic.
Methods
At the Intercommunal Hospital of Créteil, near Paris, France, alcohol-based hand sanitizer (ABHS) consumption in the Department of Medicine (DM) and ICU was recorded using an AMS during four periods: before, during, and after the first wave of the COVID-19 pandemic, and during its second wave.
Findings
From 1st February to 30th November 2020, in the DM, the mean number of doses per patient-day for each of the four periods was, respectively, 5.7 (±0.3), 19.4 (±1.3), 17.6 (±0.7), and 7.9 (±0.2, P < 0.0001). In contrast, ICU ABHS consumption remained relatively constant. In the DM, during the pandemic waves, ABHS consumption was higher in rooms of COVID-19 patients than in other patients’ rooms. Multivariate analysis showed ABHS consumption was associated with the period in the DM, and with the number of HCWs in the ICU.
Conclusion
An AMS allows real-time collection of ABHS consumption data that can be used to adapt training and prevention measures to specific hospital departments.
Keywords: Hand hygiene, Alcohol-based hand sanitizer, Automated monitoring system, Infection prevention, Intensive care unit, COVID-19
Introduction
The importance of promoting and monitoring hand hygiene (HH) practices has long been emphasized by the World health Organization (WHO) through its global campaign entitled “SAVE LIVES: Clean Your Hands” [1]. HH compliance significantly reduces nosocomial infections [[2], [3], [4]] and is thus crucial for infection control in health-care facilities [5]. It became even more important—for health-care workers (HCWs) and the general public—with the onset of the COVID-19 pandemic [6,7]. HH became a hot topic in the media and social networks when the COVID-19 pandemic broke out in March 2020. Preventive HH has been promoted via TV spots and online tutorials. In hospitals, staff training was also very active, especially since there were fears of contamination by SARS-CoV-2 [8]. Most COVID-19 patients have been hospitalized in ICUs and departments of medicine or infectious disease, which were consequently under the greatest pressure.
Compliance monitoring, of which several methods exist, is considered critical for an effective HH program [2,9]. Observational surveys by trained staff remain the gold standard but are time-consuming [10]. One bias of this method is the Hawthorne effect, whereby the presence of the observer alters HCW behaviour [11]. Measuring consumption of alcohol-based hand sanitizer (ABHS), expressed in litres per patient-day, within various hospital wards is a simple alternative, but the correlation between volumes of ABHS ordered and volumes actually consumed is uncertain [10]. Discreet electronic monitoring devices offer the advantage of allowing continuous evaluation of actual ABHS consumption without attracting HCW attention.
Various electronic HH monitoring systems have been developed [12]. These include automated counting systems, such as dispenser counters; video surveillance systems; and fully automated monitoring systems (AMSs). AMSs typically rely on handheld or mobile devices, record HH opportunities, and provide feedback or reminders [13].
Data collected by an AMS can also serve to identify hospital zones where HH compliance is poor and evaluate the impact of targeted interventions [12]. The collection of infection prevention data in the current context may be challenging for most health-care facilities, whose human resources are being diverted to COVID-19 patient care. AMSs allow them to quickly gather robust HH data without weighing on these resources.
COVID-19 has received significant media attention, which can increase the level of perceived personal risk [14,15]. In part, HCWs may have improved their HH to protect themselves and, indirectly, their families [14,16,17]. This study sought to describe HCW HH activity in ICU and non-ICU patients’ rooms, using an AMS, before and after the onset of the COVID-19 pandemic.
Methods
Periods of study
In December 2019, the Intercommunal Hospital of Créteil (CHIC) installed an AMS to monitor ABHS consumption and measure the effectiveness of efforts to promote HH. The present study reports consumption between 1st February 2020 (leaving a buffer between the AMS installation date and the start of observations) and 30th November 2020. This duration may be divided into four consecutive periods: P1, from 1st February to 10th March 2020, is the baseline period. P2, from 11th March to 24th May 2020, included the lockdown, and most patients then hospitalized were positive for SARS-CoV-2. During P2, nursing and medical staff received intensive HH training, and the media stressed the importance of HH on a daily basis. P2 may be considered an intervention period. P3, from 25th May to 7th August 2020, was the interepidemic period, characterized by few COVID-19 cases. Finally, P4, from 8th August to 30th November 2020, encompassed the second wave of the pandemic, and was marked by a rise in COVID-19 cases.
Participating units and patients
CHIC is a teaching hospital near Paris, France. It has a department of infection prevention and control and a policy for the prevention of nosocomial infections. CHIC has applied the WHO multimodal HH strategy [9] since March 2018.
The CHIC hospital divisions participating in the study were the ICU and the Department of Medicine (DM). Both have received COVID-19 patients since the arrival of the pandemic in France. The ICU was able to accommodate up to 8 patients in a single-occupancy room. In the DM, 30 beds were available in 18 single- and 6 double-occupancy rooms were available in P1, but only 24 single-occupancy rooms were available after the beginning of the first wave because double rooms were no longer authorized. The ICU and DM were selected for this study because they were involved in the “SAVE LIVES: Clean Your Hands” program, welcomed patients with and without COVID-19, and were equipped with AMS units.
Automated monitoring system
The AMS deployed was manufactured by MediHandTrace, which is based at the Institut Hospitalo-Universitaire (IHU) de Marseille, in Marseille, France. In December 2019, AMS wireless units were installed inside ABHS dispensers placed in all ICU and DM rooms. There were 16 ICU and 54 DM devices in all: 2 per single room and 3 per double room. No AMS unit was installed outside of patient rooms.
Data on real-time ABHS consumption in each participating hospital unit was saved to a dedicated cloud repository using proprietary technology. The system tracks each dispenser's location, supply of ABHS, and battery level. A single dose of ABHS for proper HH is 3 mL, which corresponds to two 1.5-mL dispenser portions. Hospital staff are trained to perform two successive, closely spaced doses of ABHS at each HH opportunity. These instructions are part of the hospital's HH protocol, in accordance with the recommendations of the company marketing the dispensers. These guidelines are posted on every ABHS dispenser in the hospital. Internal audits are regularly organized by the hospital's hygiene team, including verification of the friction technique.
Professional training
Since the emergence of SARS-CoV-2, HCWs have benefited from extra training, including workshops on HH and protecting staff from COVID-19, as well videos and tutorials on the WHO's five moments for hand hygiene [18]. In March and April 2020, 575 HCWs, including 41 HCW (83.7%) in DM and 41 (75.9%) in ICU from all CHIC COVID-19 units received a total of 200 h of hygiene training.
Ethical approval
The study was approved by the hospital ethics committee (Comité d’Ethique Local du Centre Hospitalier Intercommunal de Créteil, no. 2021-10-01). No personal data were collected.
Statistics
ABHS consumption was expressed in numbers of doses (one 3-mL dose = two 1.5-mL dispenser portions) per patient-day. Daily numbers of HCWs and hospitalized patients (whether or not for COVID-19) in the ICU and DM were recorded. The presence of COVID or non-COVID patients was identified in the patient movement software with the room number. The room number is available in the SHA view software. In addition, ABHS consumption were interpreted with respect to the targets defined by the French health authority, which are 10 doses/patient-day in DM and 43 doses/patient-day in ICU (https://www.has-sante.fr/upload/docs/application/pdf/2019-04/grille_de_recueil_icsha.3_2019.pdf).
These data were described through means with standard deviations and medians with interquartile ranges. Kruskal–Wallis or paired t-tests were used for comparison, as appropriate. Multivariate analyses were carried out to identify factors associated with ABHS consumption in the two wards. Regression coefficients were calculated, taking into account study periods, numbers of HCWs, and numbers of patients hospitalized for COVID-19.P values below 0.05 were considered indications of statistical significance. Stata/SE (StataCorp, College Station, TX, USA), version 16.1, was used for statistical analysis.
Results
Between 1st February and 30th November 2020, there were 7104 DM and 2668 ICU hospital stays, defined as an admission to a full hospital bed, thus excluding programmed day hospitalizations and sessions (e.g. for chemotherapy). Total numbers of COVID-19 patients hospitalized were 204 in DM and 108 in ICU (Fig. 1 ).
Fig. 1.
Numbers of patients hospitalized for COVID-19 over course of study at the Intercommunal Hospital of Créteil (CHIC) as a whole (“total”), within its department of medicine, and within its ICU.
Over the 10 months of the study, the AMS registered 335,545 1.5-mL ABHS portions dispensed in the ICU and DM. This volume comprised 81,550 doses for the 24 DM beds and 86,222 for the 8 ICU beds (Recall that each ABHS HH dose is 3 mL, or two consecutive 1.5-mL dispenser portions.)
In the DM, relative to baseline (P1), the number of doses per patient-day increased during the lockdown (P2) and interepidemic period (P3) and then fell during the second wave (P4) (Table 1 ). In contrast, HH activity throughout the study was relatively steady in the ICU (Table 1). While the mean number of doses per patient-day in the ICU always exceeded the target of 43, the mean in the DM fell below its target of 10 during P1 and P4 (Fig. 2 ).
Table 1.
Mean number of ABHS doses per patient-day in Department of Medicine and ICU during each study period.
| Ward | Period | Mean (SD) | Median (IQR) | P valuea |
|---|---|---|---|---|
| DM | 1 | 5.7 (2.0) | 5.7 (3) | <0.001 |
| 2 | 19.4 (10) | 22.6 (18.7) | ||
| 3 | 17.6 (6) | 19.8 (10.6) | ||
| 4 | 7.9 (2.1) | 7.7 (3) | ||
| ICU | 1 | 47.7 (8.7) | 49.1 (8.8) | 0.054 |
| 2 | 47.2 (9.1) | 46.8 (6.7) | ||
| 3 | 45.5 (7.5) | 45.6 (7.1) | ||
| 4 | 45.9 (5.6) | 45.6 (7.9) |
Note: DM, Department of Medicine; IQR, interquartile range; SD, standard deviation.
Kruskal-Wallis test.
Fig. 2.
Numbers of 3-mL doses of alcohol-based hand sanitizer (ABHS) per patient-day and numbers of hospitalized patients in (A) DM and (B) ICU over course of study. Dashed red lines indicate target number of doses per patient-day in each ward, which are 10 doses per patient-day in DM and 43 in ICU, as defined by the French Health Authorities (https://www.has-sante.fr/upload/docs/application/pdf/2019-04/grille_de_recueil_icsha.3_2019.pdf).
ABHS consumption rates during the two waves, in the presence or in the absence of patients with COVID-19 patients, were compared in each ward. In the DM, ABHS consumption was higher in COVID-19 patients’ rooms during P2 (16.1 ± 17, versus 9.3 ± 10.7 in other rooms; P = 0.01) and P4 (12.7 ± 11.3, versus 7.5 ± 2.4 in other rooms; P < 0.001). A similar trend was observed in the ICU during the first wave (46 ± 18.8 in COVID-19 rooms, versus 22.7 ± 24.9 in other rooms; P < 0.001), but ABHS consumption did not differ by COVID-19 status during the second wave (46.9 ± 16.3 in COVID-19 rooms, versus 47.7 ± 12.6 in other rooms; P = 0.59) (Table 2 ).
Table 2.
Mean number of ABHS doses per patient day by COVID status in Department of Medicine and ICU in periods 2 and 4.
| Ward | Period | Number of daysa | Covid status | Mean (SD) | P valueb |
|---|---|---|---|---|---|
| DM | 2 | 62 | Positive | 16.1 (17.0) | 0.01 |
| Negative | 9.3 (10.7) | ||||
| 4 | 102 | Positive | 12.7 (11.3) | <0.001 | |
| Negative | 7.5 (2.4) | ||||
| ICU | 2 | 62 | Positive | 46.0 (18.8) | <0.001 |
| Negative | 22.7 (24.9) | ||||
| 4 | 115 | Positive | 46.9 (16.3) | 0.59 | |
| Negative | 45.7 (12.6) |
Note: DM, Department of Medicine; SD, standard deviation.
Days when both covid and non-covid patients were present on the units were considered.
Paired t-tests.
Factors found to be associated with ABHS consumption were period, in the DM, and number of HCWs present, in the ICU (Table 3 ).
Table 3.
Multiple linear regression analysis of factors associated with number of ABHS doses per patient-day in Department of Medicine and ICU.
| Ward | Variable | Coefficient | 95% CI | SE | P value | Overall P value | |
|---|---|---|---|---|---|---|---|
| DM, N = 278 days | Period | 1 (baseline) | <0.001 | ||||
| 2 | 13.7 | 11.1–16.3 | 1.3 | <0.001 | |||
| 3 | 11.9 | 10.4–13.4 | 0.7 | <0.001 | |||
| 4 | 2.3 | 1.5–3.0 | 0.4 | <0.001 | |||
| Constant | 5.7 | 5.1–6.3 | 0.3 | <0.001 | |||
| ICU, N = 291 days | Number of HCWs | 0.4 | 0.1–0.7 | 0.1 | 0.004 | 0.03 | |
| Constant | 38.9 | 34.2–43.7 | 2.40 | <0.001 |
Note: CI, confidence interval; DM, Department of Medicine; HCW, health-care worker; SE, standard error.
Discussion
In March 2020, the rapid spread of SARS-CoV-2 within the French population and the resulting health emergency led to the wide promotion of HH both inside and, through the media and social networks, outside of the hospital [19]. In the DM, the pandemic waves greatly increased ABHS consumption in COVID-19 patients' rooms, though overall HH compliance gradually fell from its P2 peak. In contrast, within the ICU, while ABHS consumption was higher in COVID-19 patients’ rooms during the first wave, overall HH compliance was nearly constant throughout the study period.
This shows that high HH levels can be achieved within certain contexts such as epidemics, and that HH promotion must be adapted to each ward. During the 2009H1N1 influenza epidemic, Boyce et al. [20] found increased HH compliance in two hospital units. The authors used electronic counting devices to assess the number of HH events per patient-day. Their data for the H1N1 outbreak (surgical ICU: 36.1–46.7 [HH events]; general medical ward: 12.4–14.2) were similar to our own for the first wave of the COVID-19 pandemic in France (ICU: 47.2; DM: 19.4).
Other studies have reported greater HCW HH compliance at the start of the pandemic, i.e., during the first quarter of 2020 [14,18,21,22]. Two of them, which also used AMSs, observed a later decrease in HH compliance—i.e., after COVID-19-related school closures, which were milestone events of the pandemic—as we did in the present study in DM [14,22]. It is likely that, after their initial fear of contracting the disease and contaminating other patients and their relatives subsided, HCWs gradually resumed their pre–COVID-19 habits.
CHIC is the second site in France—the IHU de Marseille being the first [22]—to have implemented an AMS for continuous monitoring of staff ABHS consumption as a surrogate for HH compliance, and the only one to have used it in an ICU. Contrary to recently published studies, we observed a mostly constant level of HH compliance among ICU staff. This is likely due to greater HH awareness within this ICU, which has for 16 straight years been a member of the French Réa-Raisin national network for monitoring of adult ICU acquired infections [23]. The CHIC ICU has also, since 2015, adopted a number of nursing and HH practices aimed at preventing ventilator-associated pneumonia and central line–associated bacteraemia. Furthermore, an intensivist and two advanced practice nurses within the CHIC ICU are tasked with coaching other ICU staff members, and HCWs in the unit benefit from training programs offered each year.
In Italy, Ragusa et al. [24] conducted HH compliance audits—using the WHO method [9]—of caregivers in a 400-bed teaching hospital for 6 consecutive years (January 2015 to December 2020). Only in the ICU did compliance increase significantly between 2019 (57%) and 2020 (73%). No significant difference was observed in the departments of medicine (67% vs. 69%) and surgery (57% vs. 59%). The authors suggested that the presence of a nurse from the hospital's infection control team in the ICU may explain the increase in HH compliance there. This difference in levels of compliance between the ICU and the Department of Medicine is similar to that observed in the current study.
Numerous HH compliance studies were conducted before and during the COVID-19 pandemic [21,22,[24], [25], [26], [27]]; however, few [25,26] deployed an AMS within an ICU. In the multicentre study involving 20 ICUs at 12 acute care hospitals in Ontario [25], the rate of HH compliance was 80% during the first wave of the COVID-19 pandemic but dropped down to its initial level within 3 months of the epidemic peak. Casaroto et al. [26] noted no significant improvement in HH compliance during the COVID-19 pandemic at a 40-bed medical-surgical ICU equipped with an AMS linked to ABHS dispensers. Thus, our study is the only one to date reporting a significant improvement in HH compliance sustained throughout the COVID-19 pandemic.
Our AMS allowed us to monitor daily ABHS consumption for the entire health-care team. We also considered actual bed occupancy in reporting compliance, but we weren't able to distinguish the WHO's five moments for hand hygiene [9], which could be assessed by direct observation. However, Hagel et al., in a large study on almost 4000 opportunities showed a good correlation between directly observed compliance and AMS [11]. An AMS is less intrusive and wearisome for HCWs than badge or bracelet systems that generate compliance alerts [28]. A further advantage is that it obviates the need for direct observation, which is especially resource-intensive during pandemics, when staff are mobilized for patient care.
Conclusions
The initial weeks of a pandemic such as the COVID-19 outbreak demand quick adaptation of the health-care system. Our single-centre study showed that ABHS consumption changed rapidly in the DM during the first wave, but consumption patterns diverged thereafter. On the contrary, ABHS consumption in ICU was relatively steady. During a pandemic, an AMS can greatly reduce the burden on staff, by eliminating the need for human observation; ensure continuous monitoring, covering many more HH opportunities than observations or surveys can; and avoid the Hawthorne effect [29]. It can also be used to assess the impact of HH prevention measures and plan corrective actions by infection control staff alongside HCW teams.
Ethics
The study was approved by the hospital ethics committee (Comité d’Ethique Local du Centre Hospitalier Intercommunal de Créteil, no. 2021-10-01). No personal data were collected.
Authorship statement
AS and CJ designed the study; VG, CL, FS, AC recruited patients; OC and PB collected the data; FL and AE installed the system; CJ analysed the data; AS, CJ, MB, and YJ interpreted the data; CJ and AS wrote the manuscript; AS, OC, PB, VG, CL, FS, AC, FL, AE, SP and CJ critically reviewed the manuscript.
Conflicts of interest
All authors report no conflicts of interest relevant to this article.
Source of funding
This study was funded by CHIC without any specific grant from agencies in the public, commercial, or not-for-profit sectors.
Provenance and peer review
Not commissioned; externally peer reviewed.
Acknowledgements
The authors thank Valentin Simon (CHIC), Elisabeth Deletang (CHIC), Jean-Baptiste Excoffier (Kaduceo), Stéphane Pardoux (CHIC), and Jason Miller (SQUID Translation) for their contributions.
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