Hand hygiene, infection prevention and antibiotic use in nursing homes

Abstract

Background: Healthcare-associated infections (HAIs) pose a major threat to patient safety. Nursing home residents are particularly vulnerable to severe consequences of infections, including hospital admission and death, due to the likelihood of reduced immunity, chronic disease, polypharmacy, and cognitive impairment. Many HAIs can be prevented, with good hand hygiene being the most cost-effective preventive measure. Infections are often treated with antibiotics, although unnecessary use can increase antimicrobial resistance, which is a global public health problem. Few studies have explored how to improve hand hygiene in nursing homes and if doing so can reduce infection and antibiotic use rates, and none in Norway.

Aims: This study sought to test new methods to achieve a long-lasting behavior change in terms of hand hygiene practices among healthcare workers in nursing homes. Thus, it explored healthcare workers’ hand hygiene practices (Paper I), infections and antibiotic use among residents (Paper II), and the effect of interventions on both hand hygiene practices and infection and antibiotic use rates (Paper III).

Method: This quasi-experimental study involved 22 nursing home wards. The wards reported on infections and antibiotic use weekly for 18 months (February 2021 to August 2022). Hand hygiene adherence was measured in February and March 2021 and September and October 2022 using the World Health Organization’s (WHO’s) validated observation tool. After six months, three wards with mean values for hand hygiene adherence and infection rates were chosen to implement interventions based on Bandura’s behavior change theory. The remaining 19 wards served as control wards and continued usual practices. The interventions were designed by three groups: education nurses and managers, “bedside” healthcare workers, and researchers collaborating with nursing students. The interventions were based on social cognitive theory and the WHO’s multimodal model, and they consisted of education, posters, ultraviolet-light boxes, and interviews.

Results:In the first study (Paper I), hand hygiene practices were investigated in 20 nursing home wards during the COVID-19 pandemic. Nursing students on clinical placement conducted the observations. A total of 7316 indications were observed, and hand hygiene was performed in 58.3% of them. Hand hygiene adherence decreased from February to March (65.8–51.4%), with large variations between wards (26.4–83.1%). In addition, there were differences between different occupations, locations where hand hygiene was conducted, and types of indications. Moreover, hand hygiene adherence was only 35.3% when gloves were used. In the second study (Paper II), infections and antibiotic use were investigated over the initial six months in 21 nursing home wards. There were 495 reported infections, 53 hospital admissions, and 11 deaths related to infections. The total infection rate was 5.37 per 1000 bed days. While the data collection was performed during the COVID-19 pandemic, urinary tract infections were the most common infection type. Of the reported infections, 97.6% were treated with antibiotics. Regression analyses revealed that the short-term wards had the highest infection rates. The final study (Paper III) included all 22 nursing home wards. Three received interventions to improve hand hygiene adherence. Adherence increased in the intervention wards from 54.7% to 60.9%, while it decreased in the control wards from 59.5% to 51.3%. The highest adherence was observed in relation to “after indications,” which also saw the greatest post-intervention increase. Hand hygiene adherence when using gloves remained low at 38.9%.

Conclusion: Hand hygiene adherence in nursing homes is too low to prevent all infections. Infection rates in Norwegian nursing homes tend toward being high compared with other countries. These findings highlight the need to improve hand hygiene among healthcare workers. Interventions based on the WHO’s multimodal model and a focus on behavior change may increase adherence.