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

  • M.D. van Dijk
    Correspondence
    Corresponding author. Address: Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands. Tel.: +31 10 7033510.
    Affiliations
    Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
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  • C.M. Waltmans-den Breejen
    Affiliations
    Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
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  • J.M.J.J. Vermeeren
    Affiliations
    Department of Quality and Patient Care, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
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  • S. van den Berg
    Affiliations
    Department of Anaesthesiology, Ikazia Hospital Rotterdam, Rotterdam, the Netherlands
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  • Author Footnotes
    † These authors contributed equally.
    E.F. van Beeck
    Footnotes
    † These authors contributed equally.
    Affiliations
    Department of Public Health, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
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  • Author Footnotes
    † These authors contributed equally.
    M.C. Vos
    Footnotes
    † These authors contributed equally.
    Affiliations
    Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
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  • on behalf of theCooperating Rijnmond Hospitals
  • Author Footnotes
    † These authors contributed equally.
Open AccessPublished:October 31, 2022DOI:https://doi.org/10.1016/j.jhin.2022.10.009

      Summary

      Background

      Observing hand hygiene compliance (HHC) among non-sterile healthcare workers (HCWs) in the operating theatre (OT) is challenging as there are no tailored protocols or observation tools.

      Aim

      To develop and test a hand hygiene protocol tailored to non-sterile HCWs in the OT.

      Methods

      In this prospective observational study, nine hospitals in the Rotterdam-Rijnmond region provided input on a draft protocol on hand hygiene in the OT, resulting in a new consensus protocol for the region. An observation tool based on the protocol was developed and tested. HHC rates with 95% confidence intervals (CI) were calculated by type of hospital and type of HCW.

      Findings

      The protocol has three sections: (1) written general hand hygiene rules; (2) written hand hygiene rules specific for anaesthesia and surgery; and (3) visual representation of the OT, divided into four hand hygiene areas. Hand hygiene should be applied when changing area. Average HHC of 48.0% (95% CI 45.2–61.2%) was observed in OTs across all hospitals. HHC was highest in the two specialized hospitals (64.0%, 95% CI 30.6–89.8%; 76.7%, 95% CI 62.8–84.5%) and lowest in the academic teaching hospital (23.1%, 95% CI 0.0–45.8%). In terms of type of HCW, HHC was lowest among anaesthesiologists (31.6%, 95% CI 19.2–62.4%) and highest among OT assistants (57.4%, 95% CI 50.1–78.2%).

      Conclusion

      This uniform way of observing HHC in the OT enables evaluation of the effectiveness of interventions in the OT and facilitates friendly competition. In the Rotterdam-Rijnmond region, HHC in the OT was below 50%; this needs to be addressed, particularly in teaching hospitals and among physicians.

      Keywords

      Introduction

      It is well known that hand hygiene is one of the most important measures to reduce healthcare-associated infections [
      • World Health Organization
      Evidence of hand hygiene to reduce transmission and infections by multi-drug resistant organisms in health-care settings.
      ,
      • Clancy C.
      • Delungahawatta T.
      • Dunne C.P.
      Hand-hygiene-related clinical trials reported between 2014 and 2020: a comprehensive systematic review.
      ,
      • Ojanpera H.
      • Ohtonen P.
      • Kanste O.
      • Syrjala H.
      Direct hand hygiene observations and feedback increased hand hygiene compliance among nurses and doctors in medical and surgical wards – an eight-year observational study.
      ]. Studies investigating hand hygiene compliance (HHC) are most frequently conducted on nursing wards in hospitals [
      • Erasmus V.
      • Daha T.J.
      • Brug H.
      • Richardus J.H.
      • Behrendt M.D.
      • Vos M.C.
      • et al.
      Systematic review of studies on compliance with hand hygiene guidelines in hospital care.
      ]. However, HHC in other departments (e.g. operating theatres (OTs), outpatient clinics) and in other healthcare settings (e.g. nursing homes, patients' homes) also needs improvement [
      • Paul E.T.
      • Kuszajewski M.
      • Davenport A.
      • Thompson J.A.
      • Morgan B.
      Sleep safe in clean hands: improving hand hygiene compliance in the operating room through education and increased access to hand hygiene products.
      ,
      • Pedersen L.
      • Elgin K.
      • Peace B.
      • Masroor N.
      • Doll M.
      • Sanogo K.
      • et al.
      Barriers, perceptions, and adherence: hand hygiene in the operating room and endoscopy suite.
      ,
      • Scheithauer S.
      • Rosarius A.
      • Rex S.
      • Post P.
      • Heisel H.
      • Krizanovic V.
      • et al.
      Improving hand hygiene compliance in the anesthesia working room work area: more than just more hand rubs.
      ,
      • Teesing G.R.
      • Erasmus V.
      • Nieboer D.
      • Petrignani M.
      • Koopmans M.P.G.
      • Vos M.C.
      • et al.
      Increased hand hygiene compliance in nursing homes after a multimodal intervention: a cluster randomized controlled trial (HANDSOME).
      ]. 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 university-affiliated hospital in the USA [
      • Berg H.F.
      • Maraha B.
      • van der Zee A.
      • Gielis S.K.
      • Roholl P.J.
      • Scheffer G.J.
      • et al.
      Effect of clarithromycin treatment on Chlamydia pneumoniae in vascular tissue of patients with coronary artery disease: a randomized, double-blind, placebo-controlled trial.
      ]. 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 [
      • Scheithauer S.
      • Rosarius A.
      • Rex S.
      • Post P.
      • Heisel H.
      • Krizanovic V.
      • et al.
      Improving hand hygiene compliance in the anesthesia working room work area: more than just more hand rubs.
      ,
      • Biddle C.
      • Shah J.
      Quantification of anesthesia providers' hand hygiene in a busy metropolitan operating room: what would Semmelweis think?.
      ,
      • Baier C.
      • Tinne M.
      • von Lengerke T.
      • Gosse F.
      • Ebadi E.
      Compliance with hand disinfection in the surgical area of an orthopedic university clinic: results of an observational study.
      ].
      Furthermore, regardless of the department or healthcare setting, hand hygiene observations are often performed using the World Health Organization's (WHO) Five Moments for Hand Hygiene [
      • World Health Organization
      Evidence of hand hygiene to reduce transmission and infections by multi-drug resistant organisms in health-care settings.
      ,
      • Clancy C.
      • Delungahawatta T.
      • Dunne C.P.
      Hand-hygiene-related clinical trials reported between 2014 and 2020: a comprehensive systematic review.
      ,
      • World Health Organization
      WHO guidelines on hand hygiene in health care – first global patient safety challenge: clean care is safer care.
      ]. These Five Moments are the gold standard and are, generally, easy to apply on clinical wards where there is a clear distinction between the patient zone and the healthcare zone [
      • World Health Organization
      WHO guidelines on hand hygiene in health care – first global patient safety challenge: clean care is safer care.
      ]. The patient zone includes everything that is attached to the patient or belongs to a specific patient, while everything that is not patient specific is referred to as the healthcare zone. Healthcare workers (HCWs) should apply hand hygiene when changing from the patient zone to the healthcare zone, and vice versa.
      However, the Five Moments are also used in other settings where it is more difficult to distinguish between the patient zone and the healthcare zone. This distinction is, for example, less clear for HCWs in the OT. This is because HCWs (e.g. surgeons, anaesthesiologists, anaesthesiology assistants, OT assistants) work closely together in the OT, and use and touch many different machines and equipment (e.g. instrument table, sterile covered part of the patient, anaesthesia device, patient's bed). Furthermore, some of these machines and equipment are sterile and some are not. Identifying hand hygiene moments in the OT is therefore more difficult as this depends on the type of HCW and what the HCW touches during a procedure.
      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 [
      • Paul E.T.
      • Kuszajewski M.
      • Davenport A.
      • Thompson J.A.
      • Morgan B.
      Sleep safe in clean hands: improving hand hygiene compliance in the operating room through education and increased access to hand hygiene products.
      ,
      • Scheithauer S.
      • Rosarius A.
      • Rex S.
      • Post P.
      • Heisel H.
      • Krizanovic V.
      • et al.
      Improving hand hygiene compliance in the anesthesia working room work area: more than just more hand rubs.
      ,
      • Biddle C.
      • Shah J.
      Quantification of anesthesia providers' hand hygiene in a busy metropolitan operating room: what would Semmelweis think?.
      ,
      • Baier C.
      • Tinne M.
      • von Lengerke T.
      • Gosse F.
      • Ebadi E.
      Compliance with hand disinfection in the surgical area of an orthopedic university clinic: results of an observational study.
      ,
      • Sahni N.
      • Biswal M.
      • Gandhi K.
      • Yaddanapudi S.
      Quantification of hand hygiene compliance in anesthesia providers at a tertiary care center in northern India.
      ], but in some studies, HHC has been investigated using survey data on self-reported compliance, completed by OT personnel [
      • Pedersen L.
      • Elgin K.
      • Peace B.
      • Masroor N.
      • Doll M.
      • Sanogo K.
      • et al.
      Barriers, perceptions, and adherence: hand hygiene in the operating room and endoscopy suite.
      ,
      • Ataiyero Y.
      • Dyson J.
      • Graham M.
      An observational study of hand hygiene compliance of surgical healthcare workers in a Nigerian teaching hospital.
      ]. Jeanes et al. recorded a consultant anaesthetist during normal work routines in the OT, while other studies observed HHC in the OT as part of a general infection prevention and control (IPC) observation [
      • Jeanes A.
      • Dick J.
      • Coen P.
      • Drey N.
      • Gould D.J.
      Hand hygiene compliance monitoring in anaesthetics: feasibility and validity.
      ,
      • Tartari E.
      • Mamo J.
      Pre-educational intervention survey of healthcare practitioners' compliance with infection prevention measures in cardiothoracic surgery: low compliance but internationally comparable surgical site infection rate.
      ,
      • Wall R.T.
      • Datta S.
      • Dexter F.
      • Ghyasi N.
      • Robinson A.D.M.
      • Persons D.
      • et al.
      Effectiveness and feasibility of an evidence-based intraoperative infection control program targeting improved basic measures: a post-implementation prospective case–cohort study.
      ].
      Nonetheless, adequate hand hygiene in the OT by non-sterile HCWs and surgeons (performing non-sterile actions) is of utmost importance to prevent postoperative wound infections. Considering that patients undergoing surgery are vulnerable to infection, exposure to infection risks in the OT should be kept as low as possible [
      • Biddle C.
      • Shah J.
      Quantification of anesthesia providers' hand hygiene in a busy metropolitan operating room: what would Semmelweis think?.
      ,
      • Phan H.T.
      • Zingg W.
      • Tran H.T.T.
      • Dinh A.P.P.
      • Pittet D.
      Sustained effects of a multimodal campaign aiming at hand hygiene improvement on compliance and healthcare-associated infections in a large gynaecology/obstetrics tertiary-care centre in Vietnam.
      ]. As no specific hand hygiene protocols for this group of HCWs in the OT are available to date, the authors conducted a study to develop and test a hand hygiene protocol tailored to this setting.

      Methods

      This prospective observational study was performed between May 2019 and March 2020, before the coronavirus disease 2019 (COVID-19) pandemic had substantial effects in the Netherlands. The study was performed in the Rotterdam-Rijnmond region in the Netherlands, which consists of 15 municipalities with 1.2 million inhabitants. In the region, there is one academic teaching hospital, two non-academic teaching hospitals, four general hospitals, and two hospitals for care of specific categories of patients (i.e. ophthalmology and rehabilitation).

      Phase one: development protocol (May 2019–August 2019)

      A draft protocol ‘hand hygiene in the OT’ was formulated by a project team consisting of an IPC specialist, an anaesthesiology assistant and also chair of the regional OT network, a quality officer, a senior researcher and a junior researcher. In one face-to-face meeting and via e-mail correspondence, this project team reached consensus on necessary adaptations of a pre-existing protocol, which was self-developed by one of the participating hospitals in the region. The draft protocol was subsequently approved by the members (i.e. team leaders from OTs) of the regional OT network of the Cooperating Rijnmond Hospitals [in Dutch, ‘stichting Samenwerkende Rijnmond Ziekenhuizen’ (SRZ)].
      This draft protocol was sent to all the hospitals in the Rotterdam-Rijnmond region for feedback, by sending an e-mail to all 500 members of the Association for Hygiene & Infection Prevention in Healthcare [in Dutch, ‘vereniging voor hygiene & infectiepreventie in de gezondheidszorg’ (VHIG)]. The VHIG is the professional association for IPC specialists working in various fields of health care, including hospitals, nursing homes, private clinics and public health care [

      Vereniging voor Hygiëne & Infectiepreventie in de Gezondheidszorg. Over VHIG. Naarden: VHIG. Available at: https://vhig.nl/[last accessed November 2022].

      ]. IPC specialists of five hospitals provided feedback within the deadline of 2 weeks via track changes or remarks in the Word file. The draft protocol was adjusted according to their suggestions, and was converted into a shared consensus policy document for use in the Rotterdam-Rijnmond region. Based on the protocol, an observation tool was developed to observe HHC in the OT in a uniform way.
      A pilot study with the observation tool was performed at the Erasmus MC University Medical Centre Rotterdam to achieve optimal clarity of the descriptions and indications for hand hygiene observations in the OT. During this pilot study, hand hygiene was observed during four different occasions. During the first occasion, the observer attended four procedures and observed three different specialisms, where the observer focused solely on the hand hygiene of the anaesthetic staff. On the other three occasions, the observer attended four procedures and observed four different specialisms, this time focusing solely on the hand hygiene of OT assistants performing non-sterile actions. After the pilot period, no further adjustments were made.

      Phase two: hand hygiene observation in the operating theatre (January 2020–February 2020)

      The hand hygiene observations were performed in the OTs of six hospitals. The Rotterdam-Rijnmond region consists of nine hospitals, but the planned observation could not be performed in three hospitals due to the COVID-19 pandemic, which affected the Netherlands from February 2020.
      The hand hygiene observations were performed by means of an observation carousel, where OT personnel from one hospital in the region performed the observation in another hospital in the region. In this way, data were collected by independent observers. The observed non-sterile HCWs were surgeons (i.e. performing non-sterile actions such as leaving the operating complex or removing personal protective equipment), anaesthesiologists, anaesthesiology assistants and OT assistants. Furthermore, the manager of the OT was aware of the observation date, but the members of the OT team were not.
      Before a HCW could perform the hand hygiene observation in another hospital, they had to study the new OT protocol, and take and pass an exam. In this exam, 20 cases and different moments to perform or not to perform hand hygiene were discussed (Table S1, see online supplementary material). HCWs passed the exam when they answered ≥80% of the questions correctly.

      Data analysis

      Hand hygiene moments were observed during different procedures and with the involvement of different specialisms, where a distinction was made by professional category. HHC was calculated by dividing the number of correct hand hygiene moments by the total number of observed hand hygiene moments. HHC rates with 95% confidence interval (CI) were calculated by type of hospital (i.e. academic teaching hospital, non-academic teaching hospital, general hospital and specialized hospital) and professional category [i.e. physicians (surgeons, anaesthesiologists) and nurses (anaesthesiology assistants, OT assistants)]. All analyses were performed using SPSS Statistics Version 28 (IBM Corp., Armonk, NY, USA).

      Results

      Phase one: development protocol

      The new protocol has three sections: (1) written general hand hygiene rules in the operating complex (Box 1); (2) written hand hygiene rules specific for anaesthesia and surgery (Box 2); and (3) a visual representation of the OT, divided into four hand hygiene areas (Box 3, Figure 1). Hand hygiene should be applied when changing from one area to another. The complete protocol is shown in Table S2 (see online supplementary material).
      General hand hygiene rules in the operating complex.
      Specific hand hygiene rules for anaesthesia and surgery. OT, operating theatre; PACU, post-anaesthesia care unit; IC, intensive care.
      Four hand hygiene areas in the operating complex. HHA, hand hygiene area, OT, operating theatre.
      Figure 1
      Figure 1Hand hygiene areas in the operating theatre. oT, Operating theatre: HHA, hand hygiene area.
      The required conditions for performing correct hand hygiene are that hand alcohol dispensers and doors in the operating complex are operated with the elbow, and that there is sufficient soap and hand alcohol present to perform hand hygiene. Every hospital is free to choose the soap and hand alcohol brands they prefer.

      Phase two: hand hygiene observation in the operating theatre

      In total, 861 hand hygiene moments were observed during 20 procedures in six hospitals, with a median of 41 (range 15–121) hand hygiene moments per procedure. Average HHC in OTs across all hospitals was 48.0% (95% CI 45.2–61.2%) (Table I). HHC was highest in the two specialized hospitals (64.0%, 95% CI 30.6–89.8%; 76.7%, 95% CI 62.8–84.5%) and lowest in the academic teaching hospital (23.1%, 95% CI 0.0–45.8%) (Table I). Of the four types of non-sterile HCWs observed in the OTs, average HHC was lowest among anaesthesiologists (31.6%, 95% CI 19.2–62.4%) and highest among OT assistants (57.4%, 95% CI 50.1–78.2%) (Table II). Wide variation in HHC was also found by type of procedure, ranging from 22.9% in the case of a scaphoid fracture to 97.4% during a breast reduction with liposuction. These data can be found in Table S3 (see online supplementary material), and will not be discussed further in this article as too many different specialisms were observed, which resulted in groups that were too small to draw meaningful conclusions.
      Table IHand hygiene compliance by hospital
      HospitalType of hospitalNumber of correct hand hygiene momentsNumber of incorrect hand hygiene momentsTotal hand hygiene momentsCompliance (95% CI)
      AAcademic teaching hospital289312123.1% (0.0–45.8%)
      BNon-academic teaching hospital6714421131.8% (13.7–42.3%)
      CGeneral hospital437111437.7% (20.8–57.3%)
      DGeneral hospital715112258.2% (46.4–76.3%)
      ESpecialized hospital1055916464.0% (30.6–89.8%)
      FSpecialized hospital993012976.7% (62.8–84.5%)
      Total41344886148.0% (45.2–61.2%)
      CI, confidence interval.
      Table IIHand hygiene compliance by professional category
      Professional categoryNumber of correct hand hygiene momentsNumber of incorrect hand hygiene momentsTotal hand hygiene momentsCompliance (95% CI)
      Physicians9717026736.3% (32.9–59.6%)
      Surgeons
      Surgeons performing non-sterile actions, such as entering or leaving the operating complex or removing personal protective equipment.
      547713141.2% (33.0–69.7%)
      Anaesthesiologists439313631.6% (19.2–62.4%)
      Nurses31627859453.2% (50.3–69.3%)
      Anaesthesiology assistants14114828948.8% (41.7–69.6%)
      OT assistants17513030557.4% (50.1–78.2%)
      Total41344886148.0% (45.2–61.2%)
      CI, confidence interval.
      a Surgeons performing non-sterile actions, such as entering or leaving the operating complex or removing personal protective equipment.

      Discussion

      This study described the development and use of a novel hand hygiene protocol tailored to non-sterile HCWs in the OT. HHC observed in the OT, using the protocol, was below 50%. Furthermore, this study found indications that specialized hospitals had higher HHC than the academic teaching hospital, and that there were differences in HHC by type of HCW.
      In this study, hand hygiene observations based on the new uniform protocol showed an overall HHC of 48%. HHC in this study was higher than that reported in other studies on HHC in the OT. However, HHC reported in these studies varies widely from 1.4% to 55%, and is difficult to interpret or compare due to the lack of a good uniform observation method [
      • Paul E.T.
      • Kuszajewski M.
      • Davenport A.
      • Thompson J.A.
      • Morgan B.
      Sleep safe in clean hands: improving hand hygiene compliance in the operating room through education and increased access to hand hygiene products.
      ,
      • Scheithauer S.
      • Rosarius A.
      • Rex S.
      • Post P.
      • Heisel H.
      • Krizanovic V.
      • et al.
      Improving hand hygiene compliance in the anesthesia working room work area: more than just more hand rubs.
      ,
      • Biddle C.
      • Shah J.
      Quantification of anesthesia providers' hand hygiene in a busy metropolitan operating room: what would Semmelweis think?.
      ,
      • Baier C.
      • Tinne M.
      • von Lengerke T.
      • Gosse F.
      • Ebadi E.
      Compliance with hand disinfection in the surgical area of an orthopedic university clinic: results of an observational study.
      ,
      • Megeus V.
      • Nilsson K.
      • Karlsson J.
      • Eriksson B.I.
      • Andersson A.E.
      Hand hygiene and aseptic techniques during routine anesthetic care – observations in the operating room.
      ,
      • Megeus V.
      • Nilsson K.
      • Karlsson J.
      • Eriksson B.I.
      • Andersson A.E.
      Hand contamination, cross-transmission, and risk-associated behaviors: an observational study of team members in ORs.
      ,
      • Krediet A.C.
      • Kalkman C.J.
      • Bonten M.J.
      • Gigengack A.C.
      • Barach P.
      Hand-hygiene practices in the operating theatre: an observational study.
      ,
      • Zomer T.P.
      • Erasmus V.
      • van Beeck E.F.
      • Tjon-A-Tsien A.
      • Richardus J.H.
      • Voeten H.A.C.M.
      Hand hygiene compliance and environmental determinants in child day care centers: an observational study.
      ].
      In contrast to WHO's Five Moments [
      • World Health Organization
      WHO guidelines on hand hygiene in health care – first global patient safety challenge: clean care is safer care.
      ], which are often used to observe HHC in the OT, the specific work routines of the different HCWs in the OT were included in this study. This resulted in a tailor-made hand hygiene observation method for use in the OT. Moreover, as the specific working routines were included in the protocol, it was possible to compare the HHC of different professional groups in the OT. Megeus et al. showed that the working conditions of HCWs in the OT are often complex, stressful, and change rapidly with production pressure [
      • Megeus V.
      • Nilsson K.
      • Karlsson J.
      • Eriksson B.I.
      • Andersson A.E.
      Hand hygiene and aseptic techniques during routine anesthetic care – observations in the operating room.
      ]. These working conditions and the HCWs' perception of limited time for preventive measures can lead to non-compliance [
      • Scheithauer S.
      • Rosarius A.
      • Rex S.
      • Post P.
      • Heisel H.
      • Krizanovic V.
      • et al.
      Improving hand hygiene compliance in the anesthesia working room work area: more than just more hand rubs.
      ]. Therefore, one-to-one translation of WHO's Five Moments to the OT is not ideal, and a tailor-made protocol could be useful to improve HHC in this setting.
      This study showed that HHC in the OT was lowest in the academic teaching hospital (i.e. 23.1%). To the authors' knowledge, there are no other studies on HHC in the OT where a clear distinction or comparison is made between clinical settings (e.g. teaching hospital, general hospital etc.). This makes it difficult to compare the found results. However, HHC of 23.1% in an academic teaching hospital could be of concern, and may indicate that academic teaching hospitals are currently not the best environment to instruct medical students about proper hand hygiene behaviour. Erasmus et al. showed the importance of good role models for final year medical students in order to teach them the right patient safety behaviours and habits, such as hand hygiene [
      • Erasmus V.
      • Otto S.
      • De Roos E.
      • van Eijsden R.
      • Vos M.C.
      • Burdorf A.
      • et al.
      Assessment of correlates of hand hygiene compliance among final year medical students: a cross-sectional study in the Netherlands.
      ]. The low HHC in academic teaching hospitals may also be a result of frequent changes within OT teams. As medical students often attend a specific ward for a short period of time, it may be difficult to create a good safety culture where poor HHC is addressed.
      Furthermore, this study showed that the HHC of physicians was lower than that of nurses, which is in line with previous studies in both OTs and on clinical wards [
      • Ojanpera H.
      • Ohtonen P.
      • Kanste O.
      • Syrjala H.
      Direct hand hygiene observations and feedback increased hand hygiene compliance among nurses and doctors in medical and surgical wards – an eight-year observational study.
      ,
      • Erasmus V.
      • Daha T.J.
      • Brug H.
      • Richardus J.H.
      • Behrendt M.D.
      • Vos M.C.
      • et al.
      Systematic review of studies on compliance with hand hygiene guidelines in hospital care.
      ,
      • Lambe K.A.
      • Lydon S.
      • Madden C.
      • Vellinga A.
      • Hehir A.
      • Walsh M.
      • et al.
      Hand hygiene compliance in the ICU: a systematic review.
      ,
      • Kingston L.M.
      • Slevin B.L.
      • O'Connell N.H.
      • Dunne C.P.
      Attitudes and practices of Irish hospital-based physicians towards hand hygiene and hand rubbing using alcohol-based hand rub: a comparison between 2007 and 2015.
      ]. More attention to IPC, including hand hygiene behaviour, in the curriculum of medical students could be an opportunity to close the gap between physicians and nurses. Megeus et al. stratified HHC in the OT by profession, and reported that HHC was lowest among surgeons/instrument nurses (4.3%) and highest among nursing assistants (8.6%) [
      • Megeus V.
      • Nilsson K.
      • Karlsson J.
      • Eriksson B.I.
      • Andersson A.E.
      Hand hygiene and aseptic techniques during routine anesthetic care – observations in the operating room.
      ]. Although surgeons showed low HHC in the present study, it was still considerably higher (41.2%) compared with the study of Megeus et al. [
      • Megeus V.
      • Nilsson K.
      • Karlsson J.
      • Eriksson B.I.
      • Andersson A.E.
      Hand hygiene and aseptic techniques during routine anesthetic care – observations in the operating room.
      ]. However, Megeus et al. did not include Moments 1, 3 and 4 in the reported HHC per professional category [
      • Megeus V.
      • Nilsson K.
      • Karlsson J.
      • Eriksson B.I.
      • Andersson A.E.
      Hand hygiene and aseptic techniques during routine anesthetic care – observations in the operating room.
      ]. On the other hand, Baier et al. [
      • Baier C.
      • Tinne M.
      • von Lengerke T.
      • Gosse F.
      • Ebadi E.
      Compliance with hand disinfection in the surgical area of an orthopedic university clinic: results of an observational study.
      ] reported HHC of 38.5% for physicians, which is more in line with the 36.3% found in the present study. As for nurses, Baier et al. [
      • Baier C.
      • Tinne M.
      • von Lengerke T.
      • Gosse F.
      • Ebadi E.
      Compliance with hand disinfection in the surgical area of an orthopedic university clinic: results of an observational study.
      ] reported HHC of 42.9%, compared with a HHC of 53.2% in the present study.

      Strengths and limitations

      This study has a number of strengths and limitations. First, the protocol enables uniform hand hygiene observations across different hospitals, tailored to non-sterile HCWs in the OT. This will give insight into HHC in the OT, and also makes it clear which non-sterile HCWs or specialisms in the OT need extra attention from the IPC department. Furthermore, using a uniform protocol in the region enables comparison of HHC between hospitals, which could lead to friendly competition. Van Dijk et al. showed that friendly competition could lead to an increase in HHC on clinical wards, which could promise a comparable effect in the OT [
      • van Dijk M.D.
      • Mulder S.A.
      • Erasmus V.
      • van Beeck A.H.E.
      • Vermeeren J.
      • Liu X.
      • et al.
      A multimodal regional intervention strategy framed as friendly competition to improve hand hygiene compliance.
      ]. Secondly, Moghri et al. reported that HCWs often work in more than one hospital [
      • Moghri J.
      • Rashidian A.
      • Arab M.
      • Akbari Sari A.
      Implications of dual practice among health workers: a systematic review.
      ]. A disadvantage of working in multiple hospitals is that hospitals could have different IPC policies. Not remembering the specific IPC guidelines of a hospital could possibly result in non-compliance with hand hygiene guidelines [
      • Pedersen L.
      • Elgin K.
      • Peace B.
      • Masroor N.
      • Doll M.
      • Sanogo K.
      • et al.
      Barriers, perceptions, and adherence: hand hygiene in the operating room and endoscopy suite.
      ]. As the uniform HHC protocol has been approved and implemented by all hospitals in the Rotterdam-Rijnmond region, this overcomes the above-mentioned issue. A third strength of this study is that HCWs had to pass an exam before they were allowed to perform the observations in another hospital. This ensured the quality and reliability of the observations. Also, as HCWs did not perform the observations in their own hospitals, and as the observations were unannounced, the independent nature of the observation was ensured.
      A major limitation of this study was the influence of COVID-19. First, in January and February 2020, hospitals were already paying extra attention to IPC due to the possible threat of COVID-19. This, and the possibility of the Hawthorne effect, could have influenced the hand hygiene behaviour of HCWs, and may have resulted in overestimation of actual HHC in the OT. Secondly, due to COVID-19, it was not possible to include three hospitals in this study, which reduced the number of hand hygiene moments observed and the power of the study. A third limitation is that both the consensus period for the development of the protocol, and the actual hand hygiene observations were only performed in one region in one country. This could make translation of the protocol to other regions and countries challenging. However, as almost all observations in OTs nowadays are still performed using WHO's Five Moments for Hand Hygiene, the authors believe that their protocol and observation tool could be a valuable addition to the existing literature. Finally, due to COVID-19, it was not possible to perform a second hand hygiene observation after the new protocol was implemented in all online learning systems of the participating hospitals. As the authors chose to not present pre-protocol data, due to non-uniform observation methods in the hospitals, it is difficult to show the actual effect of the new protocol on HHC in the OT. However, as overall HHC in the OT was low (48%), there is room for improvement.
      In this study, a new hand hygiene protocol, tailored to non-sterile HCWs in the OT, was developed and tested. The new protocol was used successfully during hand hygiene observations in the OT. These observations showed that, in general, HHC in the OT can be improved, and that there were indications of differences between types of hospitals and types of HCWs. The use of a shared uniform protocol to perform hand hygiene observations facilitates the comparison of HHC of different hospitals, and enables friendly competition to stimulate improvements.

      Acknowledgements

      The authors wish to thank all hospitals in the Rotterdam-Rijnmond region that contributed in any way to the realization of the new ‘hand hygiene in the OT’ protocol, particularly the SRZ hospitals. Furthermore, the authors wish to thank the OT personnel who performed the hand hygiene observations, as well as the hospitals who were observed. In addition, the authors wish to thank the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) for financial support by assigning the 31st ECCMID 2021 Travel Grant. This grant covered the registration costs of the 31st ECCMID, which was held online on 9–12 July 2021.

      Appendix ASupplementary data

      The following is the Supplementary data to this article:

      Conflict of interest statement

      None declared.

      Funding sources

      This study is part of ongoing surveillance programmes supported and funded by SRZ. However, the Board of Directors of SRZ were in no way involved in the data management, data analysis or writing of the manuscript.

      Ethical approval

      In the Netherlands, it is not necessary to collect informed consent from HCWs before observing their behaviour, although all participating hospitals were informed about and approved the study prior to commencement.

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