This study took place at a 278 bed university-affiliated teaching hospital in in Addis Ababa, Ethiopia from May 7, 2012 to August 10, 2012. Hospital leadership was involved in project conception, design and implementation. The project was conducted in collaboration with the hospital’s Infection Control Department. The project was approved by the Institutional Review Boards (IRBs) at Emory University and St. Paul’s Millennium Medical College.
Phase 1: Baseline evaluation
The baseline evaluation phase took place over 4 weeks and included a series of direct witnessed observations of HCW hand hygiene practices. All categories of HCWs with direct patient contact were eligible for observation. All hand hygiene observations were performed by a single observer (KS), who was trained in accordance with the WHO’s hand hygiene observation method. Observations took place in all inpatient hospital wards with the exception of the pediatrics ward, which was excluded due to the small size of the ward and logistical issues including the inability to unobtrusively observe HCWs hand hygiene practices on this ward. Observations were exclusively performed during day shift for similar logistical reasons.
Opportunities for hand hygiene were adapted from the WHO’s “patient zone and health-care area” model for hand hygiene, and included (1) before patient contact and (2) after contact with a patient or patient surroundings. The 5 moments of hand hygiene were not employed in this study due to the complexity of the model and the relative infrequency of aseptic procedures in this setting. Adherence was defined as use of waterless hand sanitizer or soap and water during any instances of the above indications. Adherence was calculated by the number of times hand hygiene was performed, divided by the number of total opportunities for hand hygiene (Adherence = number of hand hygiene actions/number of opportunities for hand hygiene). The following data were recorded for each observation: date, location, professional category, indication, and if the encounter occurred on attending physician rounds (Additional file1).
A one-time facilities assessment was performed as part of the baseline evaluation. Data were collected from all inpatient hospital wards as well as from the Emergency Department. An inventory of hand hygiene resources was modified from the WHO Ward Infrastructure Survey and included information on number and functionality of sinks, the number of beds, and the availability of soap, alcohol based hand sanitizer, and drying materials.
Phase 2: Intervention
The intervention phase took place over a 6 week period and included the implementation of an abbreviated version of the WHO Multimodal Hand Hygiene Strategy. The campaign utilized a five-component approach to increase HCW hand hygiene adherence. The first component consisted of infrastructure change, which was accomplished by making soap and commercially prepared waterless hand sanitizer available, which had not previously been available in the hospital. The new commercial sanitizer was purchased from Purell, GOJO Industries, Akron, OH, USA by the study institution at a cost of approximately 1.33 USD per 112 ml bottle, for a total cost of 665 USD per month. All HCWs, including those HCWs in wards excluded from observation (e.g. night shift workers and those in pediatrics wards) received a small bottle (112 ml) of hand sanitizer for their personal use while in the hospital; refills of were available throughout the intervention and post-intervention phases. Soap was made available at all sinks throughout the hospital throughout the intervention and post-intervention period, to ensure that all HCWs had access to hand hygiene materials for the duration of the intervention and post-intervention period. All hand hygiene products that existed prior to the intervention (soap and locally produced sanitizer) were left in place for the duration of the intervention and post-intervention periods.
The second component consisted of training and education of HCWs. The initial training took place over a 6-week period and took the form of a 30 minute didactic education session that focused on the importance of hand hygiene in improving patient safety and quality of care for patients. Training materials were adapted from WHO hand hygiene training guides. Presentations were given by Ethiopian physicians and were given in both English and Amharic. Training sessions were made available to all HCWs, including those not included in study observations (e.g. night shift workers and those in pediatrics wards). Post-intervention training occurred on an ongoing basis and included informal teaching sessions given by members of the hand hygiene committee during rounds. The third component consisted of posting visual reminders for hand hygiene throughout the entire hospital. Over 250 posters were displayed throughout the hospital (Additional file2). The fourth component was development of Institutional Safety Climate, which was accomplished by the development of “hand hygiene champions” who were leaders at the hospital and served as role models and facilitators of change. Hand Hygiene Champions were primarily nurse leaders, but also included sanitation workers, physicians, and the Dean of Students. The fifth component consisted of monitoring and providing feedback on hand hygiene practices. The nurse hand hygiene champions were trained in accordance with the WHO hand hygiene observation method and performed weekly observations of their designated wards and provide feedback to HCWs on hand hygiene adherence and provided encouragement to HCWs in their areas.
Phase 3: Post-intervention evaluation
The follow up evaluation phase took place over a 4-week period, immediately following the intervention phase. During the post-intervention evaluation, additional hand hygiene observations were made to determine if hand hygiene adherence improved following the intervention period. These follow up HCW hand hygiene observations were carried out in the same wards as phase 1, using the same methodology, and by the same observer (KS) that conducted the Phase 1 (baseline) evaluations.
A final component of this study included a self-completed perceptions survey of HCWs at the teaching hospital in Addis Ababa. The survey focused on HCW acceptance of and attitudes toward the hand hygiene campaign, current hand hygiene practices, and their perceptions of the hand sanitizer (both the commercially manufactured product and the product prepared by the hospital on site using the WHO-recommended formulation). All HCWs at the hospital were eligible for the survey. The questionnaire included 26 questions and included both WHO developed items and internally developed items (Additional file3).
In order to assess HCW hand hygiene practices before and after our intervention, we sought to include 2,000 witnessed opportunities for hand hygiene (1000 at baseline and 1000 in the post-intervention post-intervention phase). The relatively large sample allowed observations in multiple departments and the ability to include multiple types of health care workers in the observations. Data from hand hygiene observations were collected on paper forms, which were subsequently entered into an Excel database. Data Analyses were performed using SAS, version 9.3 (SAS Inc., Cary, NC). Hand hygiene adherence is expressed as the proportion of predefined opportunities met by hand hygiene actions. A χ2 statistic was used to compare rates of baseline and post-intervention hand hygiene adherence rates overall and among different groups. Univariate and multivariate logistic regression analysis was used to evaluate the association of individual predictors of hand hygiene adherence. The primary predictor variable was period of observation (pre or post intervention). Other predictors and potential confounders included in the logistic regression analyses were location of hand hygiene observation, type of HCW (e.g., faculty physician, resident physician, medical student, nurse, etc.), and indication (before vs. after patient contact) observation. A p-value <0.05 was considered to be statistically significant.
Data from the perceptions survey completed by HCWs were entered into an online REDCap database and descriptive statistics were used to report survey results.