The program was reviewed, revised, and promoted annually according to the plan-do-check-act cycle [8]. The extra cost of the programme to prevent one episode of healthcare-associated infection was $163.6. An unannounced hand hygiene audit by infection control nurses was conducted of hospital wards in December 2003. Discover a faster, simpler path to publishing in a high-quality journal. Always wash your hands before putting in contacts, as being a contacts wearer increases your risk of having pink eye. The economic impact of effective hand hygiene programs on decreasing HAIs was first evaluated by Pittet et al. The authors stated that the perspective was that of the hospital. A disease-specific measure was used to examine the clinical impact of the programme on patients’ health. ... even with its limitations, that using hand sanitizer can remove the flu virus, but it took much longer than hand-washing did. The study was based on sophisticated methodology that was used to overcome some issues related to the clinical design of the study. Department of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan. The benefit-cost ratio shows that every US$1 spent on the program could result in a US$23.7 benefit. Panel A shows significant increases in percent of adherence to hand hygiene before and after patient contact for all healthcare workers in in-patient service units (p<0.001), by doctors (p<0.001), nurses (p<0.001), and other healthcare workers (p<0.001). The economic evaluation in this study produced similar results. The major barrier is poor compliance by healthcare providers, regardless of available resources [1]–[3]. We were also unable to demonstrate a reduction in HAIs caused by MSSA and E. coli. They must be supplemented with measures directed at device-associated and endogenous infections in compromised hosts, and augmented by antimicrobial stewardship. The patient population, bed occupancy rate, age, gender, severity of underlying diseases, length of hospital stay, cumulative incidence of HAI, and outcome at discharge were determined during the preintervention (January 1999 to March 2004) and intervention (April 2004 to December 2007) periods. No standard cost-effectiveness ratios were calculated as the programme was the dominant option. Citation: Chen Y-C, Sheng W-H, Wang J-T, Chang S-C, Lin H-C, Tien K-L, et al. [2], [24]. Safety glasses do not cover the whole face from chemical splashes and other hazardous materials; Psychological affect: the wearer may feel more protected than they actually are, leading to health and safety abuses The costs of implementing the program were low compared to the costs saved by reducing the HAI incidence. https://doi.org/10.1371/journal.pone.0027163.s003, https://doi.org/10.1371/journal.pone.0027163.s004. Heterogeneity factors were calculated by dividing the deviance with the degrees of freedom, and used as an indicator to assess whether an extra-Poisson variation (overdispersion) was present. The cost of personnel involved in the program (including planning, training, and auditing) was not considered in the base-case analysis (Table S2), because the program did not incur any increases in staff or manpower costs. Because of the high alcohol content of most hand sanitizing liquids, these substances are flammable, according to University of Rochester Facilities and Services. We also observed an increased use of alcohol-based hand rubs (p = .001), liquid soap (p = .03), and antiseptics (p = 0.04), as shown in Fig. This enabled us to determine the differences in HAI incidences over 4-year preintervention and postintervention periods, and conduct numerous observations while adjusting to changes in the frequency and severity of underlying diseases. Four papers failed to demonstrate an impact of hand hygiene interventions or improvement in the MDRO’s infection or colonization. Conversely, the incidences of HAIs by methicillin-susceptible S. aureus (MSSA) and Escherichia coli, which were chosen as control organisms, were relatively stable or decreased. Frequent hand-washing is standard advice for avoidance of respiratory tract infections, but the evidence for a preventive effect in a general community setting is sparse. 1A). You can tell if the sanitizer contains at least 60% alcohol by looking at the product label. Center for Infection Control, National Taiwan University Hospital, Taipei, Taiwan, Department of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan, Affiliations Six surveys were conducted during the implementation period. Infection control measures for XDRAB were intensified during June 2001 to June 2002. improved hand hygiene practices lead to a reduction of HAIs and/or transmission or colonization by MDROs. The spread of bacterial eye infections, such as trachoma, can be reduced through regular hand washing. We use a quasi-experimental, before and after, study design with prospective hospital-wide surveillance of HAIs to assess the cost effectiveness of HHPs. Finally, no significant change in the trends or levels of infections caused by MSSA and E. coli during the intervention period was observed, as shown in Fig. This result was unsurprising because of the relatively greater importance of endogenous infections in immune and structurally compromised hosts. This represented another good feature of the study. The design of the clinical study presented potential limitations as no randomisation was conducted and estimates for the two study groups were evaluated at two different time periods, which the authors acknowledged might have introduced confounding. The authors concluded that the hand hygiene programme was feasible and reduced both healthcare-associated infection rates and hospital costs. Affiliations During the six surveys conducted during the intervention period, 8,420 opportunities to observe hand hygiene were presented, as shown in Fig. Observed incidences, black solid line, —; mean, red dash line, ---; green and blue shadow, 95% confidence interval of observed incidences; yellow shadow, 95% confidence interval (CI) of predicted incidences. These efforts resulted in only a transient reduction in the rates of infection for XDRAB and MRSA. However, hand hygiene programs are only one component of hospital infection control. No, Is the Subject Area "Nurses" applicable to this article? Before intervention, HAI increased gradually, and the impact of SARS and seasons were significant. This study was approved by the Institutional Ethics Review Board of the National Taiwan University Hospital (No. Disposable alcohol-based hand rub sanitizers (75% isopropyl alcohol in plastic hand-compressing dispensers) (So Easy liquid, PBF, Taiwan) were wall mounted between every two beds in general wards, by each bed in special units (such as intensive care units), and affixed to trolleys (including treatment trolleys and resuscitation trolleys) to ensure accessibility near or at the point of care [2]. 3A and 3B. National Taiwan University Hospital (NTUH) is a 2,200-bed major teaching hospital in Taiwan that provides both primary and tertiary medical care. Yes For people who find that soap causes skin irritation, it is useful to note that soaps can have a different pH – they may be neutral, slightly alkaline or slightly acidic, and perfumes in soap may also cause irritation. Based on conservative estimates, US$100 was saved per averted infection. This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. The economic analysis included costs of the hand hygiene programme (materials and promotional efforts) and cost-savings due to reductions in healthcare-associated infections. The study examined the cost-effectiveness of a hand hygiene programme to reduce the burden of healthcare-associated infections. However, when savings from future costs associated to healthcare-associated infection were considered the programme was dominant (more effective and less expensive). For more information about PLOS Subject Areas, click Studies Show Hand Washing May Be More Effective Than Sanitizer. The hand hygiene program was announced and promoted hospital-wide for one month every year while preparing for pandemic influenza (typically during November). We measured the overall HAI rates, HAI rates by site of infection, and HAI rates by selected pathogen to assess the effectiveness of HHP. The generalized autoregressive Poisson model. p values from the full and most parsimonious segmented regression models predicting monthly incidence density (episodes per 1000 patient-days) over time. The study results were clearly presented. Additionally, the authors are grateful to Prof. Calvin Kunin and Prof. Wei-Chuan Hsieh for their suggestions and critical review of the manuscript. There was an extensive description of the programme. All statistical tests were considered two-tailed and were significant at p<.05. Hand washing is considered as one of the most effective hygiene promotion activities for public health in developing countries. The baseline evaluation included direct observation of hand hygiene compliance by infection control nurses, a survey of knowledge and the reasons or factors affecting hand hygiene adherence using a structured, self-administered questionnaire, and suggestions to improve hand hygiene performance. The CDC advises that this process, much like hand washing, should take 20 seconds. The number of expected episodes of HAI averted by the program was derived using the generalized autoregressive Poisson regression model. After implementation of the hand hygiene program, the levels and trends of HAIs changed significantly (p = .02, p = .04, respectively), as shown in Fig. 2. Continuous emphasis on this intervention has lead to the widespread opinion that HAI rates can be greatly reduced by increased hand hygiene compliance alone. 1B. https://doi.org/10.1371/journal.pone.0027163.s002. where con-ditions such as hookworm or dermatological conditions of the foot may develop). The issue of uncertainty was partly addressed with univariate sensitivity analysis. There is no daily quota of hand washing that you have to hit in order to stay healthy. In addition, the impact of hand hygiene improvement on HAI incidence varied [31], [32]. Alcohol-based handrub is not always the recommended hand hygiene product, there are some situations when washing hands with soap and water is preferred: Bacterial spores. People must keep these sanitizers away from open flame, including candles and gas appliances. • Commercially prepared hand sanitizers contain ingredients that help prevent skin dryness. Emergency procedures were excluded. The analysis was based on a single study. In conclusion, this study demonstrates that implementing a hospital-wide hand hygiene program is feasible. It all depends on your environment and what are you doing throughout the day. This study demonstrates that excellent compliance with hand hygiene by HCW was achieved and maintained over 4 years through an intensive hospital-wide program. To provide consistent care and protect patient safety throughout the hospital, a hand hygiene program requires multidisciplinary efforts and encompasses all hospital units. (A) hospital-wide (change in levels, p = 0.02; change in trends, p = 0.04); (B) intensive care units (change in levels, p = 0.26; change in trends, p<0.001); (C) hematology ward (p = 0.21, p = 0.38, respectively). Augmenting other infection control measures, such as multimodal implementation strategies (bundle care), environment cleanliness, appropriate use of antimicrobial agents, and active microbial surveillance of multidrug-resistant organisms is also necessary [33]–[38]. Well, washing your hands too much can hurt your skin, but a that can be remedied with hand lotion. Compliance with hand hygiene is the ratio of the number of performed actions using correct technique to the number of opportunities [2], [11]. There are a few disadvantages with the space saving machine though, and one of the disadvantages is that this kind of washing machine will not hold a … All economic data (resource quantities and unit costs) were taken directly from the hospital database. Wash with soap and water when visibly dirty or contaminated with proteinaceous material, or visibly soiled with blood or other body fluids, or if exposure to potential spore forming organisms is strongly suspected or proven, or after using the bathroom. The benefit was measured by subtracting the cost savings from the extra costs caused by HAIs, which was determined by a case-control study conducted in our hospital [18]. The authors’ conclusions appear robust. The impact may be even greater with full adherence to the five moments for hand hygiene. A 4-year hospital-wide HHP, with particular emphasis on using an alcohol-based hand rub, was implemented in April 2004 at a 2,200-bed teaching hospital in Taiwan. Use 1 hand to rub the back of the other hand and clean in between the fingers. The intervention had no discernable impact on HAI rates in the hematology/oncology wards. Promotion consisted of lectures and/or web-based self-learning with a post test, reminders located near points of care, use of hand hygiene compliance as a quality indicator, observation and verbal reminders by infection control nurses, periodic audits and performance feedback provided to units and departments, and incentives of US$160.00 for an outstanding performance (unit and department level). Yes However, we were unable to demonstrate a reduction in the HAIs of hematology and oncology services. Review and comments of the manuscript: SCC KST. Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, Affiliations Hand hygiene is generally considered to be the most important measure that can be applied to prevent the spread of healthcare-associated infection (HAI). We therefore set out to quantify, in a population-based adult general population cohort, the possible protection against acute respiratory tract infections (ARIs) conferred by a person’s self-perceived hand-washing frequency. Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, The authors concluded that the hand hygiene programme was feasible and reduced both healthcare-associated infection rates and hospital costs. The World Health Organization launched the World Alliance for Patient Safety in October 2004 [2]. Healthcare-associated infections (HAIs) cause significant concern regarding the safety and quality of healthcare quality worldwide [1], [2]. Chen YC, Sheng WH, Wang JT, Chang SC, Lin HC, Tien KL, Hsu LY, Tsai KS. https://doi.org/10.1371/journal.pone.0027163.t002, https://doi.org/10.1371/journal.pone.0027163.t003. Copyright: © 2011 Chen et al. Using these products can result in less skin dryness and irritation than hand-washing. No, Is the Subject Area "Taiwan" applicable to this article? Though hand sanitizer is an effective option to wash your hands, it has its own set of pros and cons. The overall improvement in hand hygiene compliance was significantly correlated with the increased consumption of alcohol-based hand rub (correlation coefficient r = 0.9399, p = .005), but less correlated with the consumption of antiseptics (r = 0.7930, p = .06) and soap (r = 0.7686, p = .07). Demonstrating to hospital administrators that these programs are cost-effective, relatively inexpensive, improve patient safety, and require long-term and stable investment is essential [2], [24]. Some costs were varied in the sensitivity analysis. Thus, evaluation of the longitudinal effect of a hospital-wide hand hygiene program is only feasible in limited healthcare settings. Department of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan, Affiliation Wrote the paper: YCC WHS JTW. The study was based on sophisticated methodology that was used to overcome some issues related to the clinical design of the study. Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, Affiliations To avoid the Hawthorne effect [12], the duration and number of opportunities for hand hygiene monitoring were increased gradually for the six surveys (Fig. Pittet and colleagues [24] estimated the program costs to be less than US$57,000 per year for a 2,600-bed hospital, an average of US$1.42 per admitted patient. broad scope, and wide readership – a perfect fit for your research every time. 2C. Studies suggest that there is a minimum RLU level that is attain-able following an effective hand wash. Hand hygiene was identified as the core component of this strategy because it is a simple, standardized, low-cost measure based on solid scientific evidence. We found that the sustained improvement of hand hygiene compliance reduces HAIs and is cost effective. To investigate the impact of the intervention on the levels and trends of cumulative HAI incidence over time, we adopted the generalized autoregressive Poisson regression analyses [15], [16]. Wet your hands with water. keep the time limitations in mind. Implementation of a HHP reduces preventable HAIs and is cost effective. Alcohol-Based Handrub Limitations Print; Alcohol-based handrub limitations. Past initiatives in Kenya have This effect was achieved and confirmed using a before and after study design combined with a prospective HAI surveillance program and hospital-wide annual promotion, which resulted in sustained effects and high-quality HH observation. A positive feature of the analysis was the very large sample size and prospective collection of data. However, the opportunity costs of personnel were considered in the sensitivity analysis by converting the number of working hours that infection control nurses spent on the program to their salary (Table S3). The analysis was further stratified by the site of infection, such as bloodstream, urinary tract, and surgical site infections, by the pathogens, such as MSSA, MRSA, Acinetobacter, XDRAB, and E. coli, and by ward units, such as ICUs, oncology wards, and hematology wards. It was discounted at an annual rate of 3%. Savings from extra costs associated with healthcare-associated infections were $5,522,408 and extra costs of the hand hygiene programme were $233,044. The costs considered in the analysis included alcohol-based hand hygiene products and promotional efforts (posters, wall displays, rewards, and other expenses) over the 4-year intervention period. Remove any hand or arm jewellery Use soap and running water Wash your hands frequently throughout the day Washing should last for at least 20 seconds, preferably a minute. Nevertheless, we observed an 8.9% decrease in HAIs and a decline in the occurrence of bloodstream, methicillin-resistant Staphylococcus aureus, extensively drug-resistant Acinetobacter baumannii, and intensive care unit infections. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Healthcare-associated infection rates by type of infection and site were estimated. PLOS ONE promises fair, rigorous peer review, The net benefit of the HHP was US$5,289,364, and the benefit-cost ratio was 23.7 with a 3% discount rate. Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, We used a quasi-experimental, before and after, study design [7] with prospective hospital-wide surveillance of HAIs to assess the effectiveness of hand hygiene. Washing hands with soap and water will remove substantially more disease causing organisms than washing hands with water alone. Yes Funding: Dr. Chen received grants (DOH96-DC-1010, DOH97-DC-1005) from the Center for Disease Control, Department of Health, and a grand (DOH99-TD-B-111-001) from the Department of Health, Taiwan. Advantages – less water usage, your clothes stay better for longer (Yes it is true, washers literally beat your clothes to death and then we put them in dryers which in all seriousness literally break the fibers in your clothes apart), you get arm muscles (this is not a joke, if you think it is…..try handwashing for a day, washing your own clothes you will also get belly and back muscles! From a hospital perspective, the discounted additional cost of preventing one HAI episode was US$163.6. Use Section 5 and Annexes 6 and 7 if you need to review basics of data collection for evaluation of handwashing promotion programmes and assistance The cost categories and the source used reflected the hospital perspective reported by the authors. https://doi.org/10.1371/journal.pone.0027163.s001. https://doi.org/10.1371/journal.pone.0027163.g001. The hand hygiene compliance rates recorded for comparison between hospital services or between years were limited to the opportunities before and after patient contact to maintain consistency during the study period. 2B; however, no significant changes in the HAI rates of oncology and hematological wards was noted, as shown in Fig. Base-case estimates and ranges used in sensitivity analyses of parameters. The number of healthcare-associated infection episodes was used as the summary benefit measure. If soap and water are not readily available, you can use an alcohol-based hand sanitizer that contains at least 60% alcohol. The results of one-way sensitivity analysis (Table S3) show that the cost of alcohol hand rub and the number of averted HAI episodes are the two factors influencing the additional cost of preventing one HAI episode; extra cost per HAI episode and the number of averted HAI episodes significantly impact the net benefit and benefit-cost ratio. The hand hygiene program was associated with an estimated reduction of 1,504 (95% confidence interval: 526 to 2,544) HAI episodes (8.9%) during the intervention period without discounting (Table 2). Center for Infection Control, National Taiwan University Hospital, Taipei, Taiwan, Alcohol-based hand rubs were unavailable. https://doi.org/10.1371/journal.pone.0027163.t001. The target hand hygiene compliance rate was determined based on the performance in the preceding year. No, Is the Subject Area "Acinetobacter infections" applicable to this article? Is the Subject Area "Hygiene" applicable to this article? The authors’ conclusions appear robust. The cumulative incidence of HAIs caused by MRSA, Acinetobacter, and XDRAB decreased substantially during the intervention period, as shown in Figs. Click through the PLOS taxonomy to find articles in your field. Yes Approximately one third of the hospital's house staff on the floor are replaced each year. Compliance was measured by direct observation and the use of hand rub products. This finding led us to introduce alcohol-based hand rubs, and implement a hospital-wide program promoting hand hygiene through using alcohol-based hand rubs. However, conducting a randomized, controlled trial in such a large and complex situation is difficult. The annual consumption of liquid soap, antiseptics, and alcohol hand rub (product volume use per 1,000 patient-days) was used as a surrogate marker of hand hygiene over time. The program was associated with significant decreasing trends for all HAIs and HAIs caused by MRSA and XDRAB, and was cost effective. 3. Bloodstream (p<.001), urinary tract (trend, p = .03), and skin and soft tissue infections (trend, p<.001) decreased significantly. Apply enough soap to cover your hands. Conceived and designed the experiments: YCC WHS JTW HCL. The numbers of patients and patient-days were 290,056 and 648,305 ± 32,109 in the pre-intervention period (January 1999 to March 2004) and 262,090 and 720,564 ± 9,543 in the intervention period (April 2004 to December 2007). Handwashing will remove all types of germs from your hands, but hand sanitizers are not able to kill all types of germs or remove harmful chemicals like pesticides and heavy metals. Proper Method of Hand Washing. We observed 8,420 opportunities for hand hygiene during the study period. In order to achieve greater public health benefits associated with good hand-washing practices, WASH actors need to identify and apply collaborative and However, the net benefit of the hand hygiene program is US$5,289,364, which indicates that the benefits from savings to the additional costs of HAI could outweigh the program costs. Observed incidences, black solid line, —; mean, red dash line, ---; green and blue shadow, 95% confidence interval of observed incidences; yellow shadow, 95% confidence interval (CI) of predicted incidences. Hand sanitizers also should not be used when cooking on a barbecue grill. Yes A multidisciplinary approach involving cognition, equipment, and behavior was designed based on literature, the baseline evaluation, and the concept of total quality improvement [9]. Indications for Hand Hygiene. Competing interests: None of the authors declared a conflict of interest. washing hands and can potentially violate ‘do no harm’ principles (i.e. This type of washing machine is up to 24 inches in width making it great for small spaces such as in a small condo or apartment. Poisson regression analyses were employed to evaluate the densities and trends of HAIs during the preintervention (January 1999 to March 2004) and intervention (April 2004 to December 2007) periods. Panel B shows significant increases in the annual consumption of alcohol-based hand rub (p = 0.001), antiseptics (p = 0.04), and liquid soap (p = 0.03). The site audit period was announced, though healthcare workers were not informed of the specific observation time. Facing an increase in overall HAIs and infections caused by multidrug-resistant organisms [6], the goal of this initiative was to decrease HAIs by blocking the transmission of microorganisms via the hands of healthcare workers (HCW). Following the SARS epidemic in 2003, we reviewed the strengths and weaknesses of infection control strategies at the National Taiwan University Hospital in anticipation of other infectious diseases emerging [4], [5]. Several studies have demonstrated a temporal relationship between improved hand hygiene practices and a reduction in HAI incidence and multidrug resistant microorganisms [2], [25]; however, few have been able to sustain a lasting impact [2], [26]. Extensive statistical analyses were carried out to identify the potential impact of confounders and isolate the effect of the intervention from other factors (such as historical trends or changes in epidemiological/organisational variables). Every time hands are washed the skin loses moisture, and the protective layer is stripped away. The limitations of hand washing Although hand washing can help to protect people from the bacteria and diseases transmitted through direct physical contact, it cannot kill all of the germs out there. Time trends in the consumption of alcohol-based hand rubs, soap, and antiseptics were examined using simple linear regression. Our data failed to support the effects of HHP on decreasing HAIs among hemato-oncology patients and patients with infections caused by MSSA and E. coli. We conducted a baseline evaluation in December 2003 [8]. Contributed reagents/materials/analysis tools: LYH. The disease severity score (Charlson comorbidity index) increased (p = .002) during the intervention period. The vertical dashed lines (- - -) separate the preintervention and intervention periods. The study examined the cost-effectiveness of a hand hygiene programme to reduce the burden of healthcare-associated infections. 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