Compliance with hand disinfection in the surgical area of an orthopedic university clinic: results of an observational study

Abstract

Background Hand hygiene using alcoholic hand rub solution is essential for the prevention of surgical site infections. There are several opportunities for hygienic hand disinfection (termed “hand hygiene” in the following) during immediate pre-, intra- and postoperative orthopedic patient care. However, the level of hand hygiene compliance among surgical and anesthesia staff in this context is unclear. Therefore, we conducted an observational study in operating theatres of an orthopedic university clinic in northern Germany during July and August 2020. Methods One trained person directly and comprehensively observed hand hygiene compliance of surgical and anesthesia staff according to the WHO “My 5 moments for hand hygiene” model (WHO-5). In addition to cross-tabulations with Chi2 tests, multiple logistic regression models were used to study associations between occupational group, medical specialty, and compliance (both overall and for each WHO-5 indication). Models were adjusted for hand hygiene opportunities being associated with female or male healthcare workers, being located within or outside the operation room, and occurring in adult or pediatric surgery. Results In total, 1145 hand hygiene opportunities during 16 surgeries were observed. The overall compliance was 40.8% (95% CI 37.9–43.6%), with a larger difference between surgical versus anesthesia staff (28.4% vs. 46.1%, p < 0.001) than between physicians versus nurses (38.5% vs. 42.9%, p = 0.13). Adjusting for sex, place of observation, and adult versus pediatric operation theatre, logistic regression analyses revealed a significant interaction between medical specialty and occupational group (p < 0.001). In particular, the odds for compliance were higher for anesthesiologists (47.9%) than for surgeons (19.6%) (OR = 4.8, 95% CI 3.0–7.6). In addition, compliance was higher in pediatric surgery (OR = 1.9, 95% CI 1.4–2.6). In general, WHO-5-stratified results were in line with these overall patterns. Conclusions Hygienic hand disinfection compliance was approximately 41%. Notably, surgeons performed worse than anesthesiologists did. These results indicate that hand hygiene compliance in orthopedic surgery needs to be improved. Tailored interventions promise to be an appropriate way to address each occupational group’s specific needs.

Do task and item difficulty affect overestimation of one’s hand hygiene compliance? A cross-sectional survey of physicians and nurses in surgical clinics of six hospitals in Germany

“…While that study involved university students in different disciplines rather than health care workers, it does support the importance of further research to elucidate whether physicians' overestimation of their hand hygiene is truly a question of motivated social desirability and impression management, or not, more simply, an indication that they may not be aware of what they do in this regard. The fact that explorative analyses revealed that the contrast between the singleitem-based results and the WHO-5-based results was confined to orthopedic/trauma surgeons is consistent with earlier research [34], but further scrutiny regarding differences related to physicians' specialties is needed.…”

“…This is lower than the global average response rate of 53% reported for surgical doctors [35]). However, indirect approaches such as that used in the present survey (i.e., distributing a written questionnaire from the WACH team to the survey respondents via the in-house IPC-teams) were not reviewed in [34]. It is probable that the lack of monetary or similar incentives, lack of personalization of the questionnaire, and the relative length of the questionnaire [36] affected the response rate in the WACH-survey.…”

“…Due to evidence of especially low hand hygiene compliance among orthopedic surgeons [34], explorative analyses were conducted at the individual level for the single-item overestimation effect among physicians. First, neither sex nor age were associated with a difference between the single-item and the WHO-5-based overall compliance rate, but specialty was (see Table 4(a)).…”

Compliance with a novel hand hygiene protocol tailored to non-sterile healthcare workers in the operating theatre

“…Regarding HHC in the OT, Paul et al reported HHC of 1.4% pre-implementation and 37.9% 60 days post-implementation of an intervention in a universityaffiliated hospital in the USA [9]. In comparison, baseline HHC of 10% was observed at a university hospital in Aachen, HHC of 40.8% was reported in a university hospital in Germany, and overall HHC of 18% was reported in a large academic centre in Virginia [7,10,11].…”

“…Previous studies have described different methods to observe HHC in the OT as consensus-based protocols have not been published to date in the international literature. Most studies still use WHO's Five Moments [5,7,10,11,13], but in some studies, HHC has been investigated using survey data on self-reported compliance, completed by OT personnel [6,14]. Nonetheless, adequate hand hygiene in the OT by nonsterile HCWs and surgeons (performing non-sterile actions) is of utmost importance to prevent postoperative wound infections.…”