The importance and effectiveness of HH to prevent healthcare associated infections has been documented in several studies [17, 20]. However, compliance remains an ongoing challenge. Not only do factors such as workload, visibility and location of ABHR-Ds contribute to HH compliance, but also a good skin tolerance of the product, and the instruction of the healthcare workers [9, 12, 13, 21]. To our knowledge, this is the first study published to assess the number and location of ABHR-Ds in a national survey.
Up to now, only the RKI issued recommendations on the number of ABHR-Ds, namely one ABHR-D per bed in intensive care units and 0.5 ABHR-D per bed in general wards as minimum requirement [2]. Our data suggests that the current number in Switzerland is 2–4 times higher with a mean of 2.4 ABHR-Ds per patient bed in large acute care hospitals. One small study also suggested two dispensers per patient bed, and higher number did not result in improved compliance regarding the use of handrub [8]. Therefore, 0.5 dispenser per patient bed as standard –suggested by the German public health service RKI—appears to be too low as minimal standard given the higher number of ABHR-Ds in Switzerland. Importantly, these wall-mounted dispensers are provided in addition to the pocket dispensers in most hospitals. Surprisingly, the introduction of wearable pocket-sized dispensers failed to increase HH compliance or ABHR consumption in an emergency department already well equipped with mounted dispensers [22]. Therefore, hospitals may not improve compliance by additionally offering pocket-size dispenser, if sufficient number and optimized location of ABHR-Ds are available.
Wall-mounted dispensers were the dominant type of ABHR dispensers in 75% (n = 82) of hospitals compared to 25% where pocket-sized dispensers are mainly offered. However, 97% (n = 107) hospitals provide pocket-sized dispensers as an additional tool to wall-mounted dispensers to facilitate access to handrub. Overall, the reported mean number was two ABHR-Ds per patient room (mean: 1.83, range 1–4). Out of 110 hospitals, 91 (83%) provided detailed data on the total number of beds and dispensers within the building, not only in patient rooms, resulting in a higher mean of 2.4 (range 0.4–22.1) ABHR-Ds per hospital bed. Therefore, the number of ABHR-Ds per bed is higher than the number of ABHR-Ds per room since fixed mounted dispsenser e.g., on mobile care trolleys were also included. Data regarding the availability of disinfectant dispensers in European countries was published in 2015. It showed that accessibility to dispensers varied greatly between countries, and there was also a variance between ICU, medical and surgical wards. It should be noted that in this study, 100% availability was achieved in all departments in Switzerland [6].
In contrast to several other studies that highlight the importance of the positioning of ABHR-Ds at the point-of-care to improve HH compliance [4, 5, 13, 15, 17, 23], our study revealed that ABHR-Ds are frequently located at the entrance of the patients’ room and near the sink. Hence, these locations reflect the workflow in a patient room, which plays an important role in HH compliance [15]. As demonstrated in former trials, the visibility of ABHR-Ds is another important factor for HH compliance [3, 4, 18]. This fact is taken into account, reflected by ABHR-Ds located within one-meter radius form the bed in 28% of hospitals and at the bedside in 24%, respectively. Along with the wide usage of pocket dispensers, at least one ABHR-D is available at the point of care in the majority of patient beds. This finding is consistent with the observation in the PROHIBIT study, where a correlation between availability of ABHR and consumption was observed [6].
Small hospitals reported more frequently to have bed-mounted ABHR-Ds, whereas large hospitals tend to prefer a location within one-meter radius from the bed probably due to organizational reasons. Our data demonstrates a positive correlation between number of ABHR-Ds per bed and handrub consumption, statistically significant in hospitals with more than 500 beds. Similar results were seen in two European studies, suggesting that there are more HH opportunities in larger hospitals or possibly, monitoring of compliance is more accurate [6, 7]. Most large hospitals are staffed with board-certified trained infection control practitioners, while smaller hospitals commonly have a dedicated nurse without federally regulated formal training. Therefore, we hypothesized that data quality may be lower in smaller hospitals.
Our study has several limitations. As our survey was conducted anonymously, reported data could not be validated on site. However, most individuals asked to respond were participants in the network Swissnoso for more than 5 years. Out of 110 hospitals, only 91 (83%) were able to respond on the detailed number of dispensers in their hospital, which may lead to an over- or underestimation of the mean ABHR-Ds per patient bed. We found a statistically significant correlation between handrub consumption and the number of dispensers per patient bed only in hospitals with more than 500 beds. In the PROHIBIT study [6] the authors report that “higher AHR consumption in University hospitals may be due to both having an academic attitude towards patient safety, and having a larger budget compared with general hospitals”. Smaller hospitals patients generally suffer from few comorbidities, fewer immunocompromised patients and fewer ICU beds, all partly explain the lower number of opportunities for hand hygiene.
The type of hospitals—large versus small, paediatric versus adult—have not been evaluatated in detail, but influences the study results as observed in the PROHIBIT study [6]. However, the quality of data from larger hospitals in Switzerland commonly excels those from smaller hospitals, since the latter still do not use electronic patient charts, or similar computer-based data: Such analyses are very difficult, since there is commonly a collinearity between size of hospitals, number of infection control staff, quality improvement programs and other factors [6]. Paediatric beds are below 5% of all Swissnoso hospitals, and therefore, do not seriously influence the main results: However, a similar study should be done focusing on paediatric institutions where results might differ from this study in adult hospitals.
