Factors Associated with Hand-Hygiene Compliance in Healthcare Settings = 병원 내 손 위생 수행률에 영향을 미치는 요인에 대한 평가

다국어 초록 (Multilingual Abstract)

Background
Hand hygiene (HH) is an important method to prevent pathogen transmission in hospital environments because the hands of healthcare workers (HCWs) can become contaminated with and subsequently transmit pathogens. The 2009 World Health Organization (WHO) guidelines recommend monitoring HH practice by direct observation to improve HH compliance. However, this approach may overestimate compliance rates due to the Hawthorne effect. Previous studies also reported that professional categories of HCWs, HH indications, and hospital workplaces affect adherence to HH practices.
In this study, we aimed to analyze the effect of the observation methods, calendar years, professional categories, HH indications, and workplaces on HH compliance rates.
Methods
A retrospective, single-center observational study was conducted over an 8-year period, from 2016 to 2023. Hospital workplaces were categorized into outpatient departments (OPD), examination facilities, wards, intensive care units (ICU), and emergency rooms (ER). Observed HCWs included personnel involved in patient care, such as nurses, the intravenous therapy and injection team (IV team), nursing assistants (NAs), paramedics, and physicians. Dedicated infection control practitioners monitored HH practices using both overt (direct) and covert (blind) observation. Observational data were recorded based on WHO recommendations (My Five Moments for Hand Hygiene): (1) before touching a patient; (2) before a clean or aseptic procedure; (3) after body fluid exposure risk; (4) after touching a patient; (5) after touching patient surroundings. HH compliance rates were defined as the ratio of HH actions performed to observed HH opportunities.

Results
In total, 75,668 HH opportunities were recorded during the study period. The overall HH compliance rates observed by overt and covert methods were 95.19% and 37.34% respectively. The compliance rate observed overtly significantly increased over time (Z = 6.54, P < 0.001), whereas the covert compliance rate remained unchanged (Z = 0.55, P = 0.58). During the coronavirus disease 2019 (COVID-19) period (February 2020 to April 2023), compliance rates were higher relative to the non-pandemic period for both observation methods, the effect was more pronounced under overt observation (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.43—1.71 for direct observation; OR 1.10, 95% CI 1.03—1.18 for covert observation). Among professional categories, physicians showed the lowest compliance rate (87.95% for overt observation and 28.20% for covert observation), whereas the IV team demonstrated the highest compliance rate (98.98% for overt observation and 66.10% for covert observation). The WHO moment with the lowest HH compliance rate was Moment 5 (after touching patient surroundings) [92.79% for overt observation and 21.92% for covert observation]). HH compliance significantly varied across workplaces; the ER showed the lowest compliance rate according to both observation methods (87.56% for overt and 26.24% for covert observation).
Conclusion
This study is the first to involve a substantial amount of HH compliance data collected over an extended period in Korea. The higher compliance rates observed during the COVID-19 pandemic period and among the IV team may be attributed to education regarding the importance of infection control and motivations for self-protection. Further research is needed to explore the reasons for low compliance rates associated with Moment 5 and in the ER. These findings provide insight into factors influencing HH practices and will inform strategies to increase HH compliance rates.

다국어 초록 (Multilingual Abstract)

Background
Hand hygiene (HH) is an important method to prevent pathogen transmission in hospital environments because the hands of healthcare workers (HCWs) can become contaminated with and subsequently transmit pathogens. The 2009 World Health Organization (WHO) guidelines recommend monitoring HH practice by direct observation to improve HH compliance. However, this approach may overestimate compliance rates due to the Hawthorne effect. Previous studies also reported that professional categories of HCWs, HH indications, and hospital workplaces affect adherence to HH practices.
In this study, we aimed to analyze the effect of the observation methods, calendar years, professional categories, HH indications, and workplaces on HH compliance rates.
Methods
A retrospective, single-center observational study was conducted over an 8-year period, from 2016 to 2023. Hospital workplaces were categorized into outpatient departments (OPD), examination facilities, wards, intensive care units (ICU), and emergency rooms (ER). Observed HCWs included personnel involved in patient care, such as nurses, the intravenous therapy and injection team (IV team), nursing assistants (NAs), paramedics, and physicians. Dedicated infection control practitioners monitored HH practices using both overt (direct) and covert (blind) observation. Observational data were recorded based on WHO recommendations (My Five Moments for Hand Hygiene): (1) before touching a patient; (2) before a clean or aseptic procedure; (3) after body fluid exposure risk; (4) after touching a patient; (5) after touching patient surroundings. HH compliance rates were defined as the ratio of HH actions performed to observed HH opportunities.

Results
In total, 75,668 HH opportunities were recorded during the study period. The overall HH compliance rates observed by overt and covert methods were 95.19% and 37.34% respectively. The compliance rate observed overtly significantly increased over time (Z = 6.54, P < 0.001), whereas the covert compliance rate remained unchanged (Z = 0.55, P = 0.58). During the coronavirus disease 2019 (COVID-19) period (February 2020 to April 2023), compliance rates were higher relative to the non-pandemic period for both observation methods, the effect was more pronounced under overt observation (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.43—1.71 for direct observation; OR 1.10, 95% CI 1.03—1.18 for covert observation). Among professional categories, physicians showed the lowest compliance rate (87.95% for overt observation and 28.20% for covert observation), whereas the IV team demonstrated the highest compliance rate (98.98% for overt observation and 66.10% for covert observation). The WHO moment with the lowest HH compliance rate was Moment 5 (after touching patient surroundings) [92.79% for overt observation and 21.92% for covert observation]). HH compliance significantly varied across workplaces; the ER showed the lowest compliance rate according to both observation methods (87.56% for overt and 26.24% for covert observation).
Conclusion
This study is the first to involve a substantial amount of HH compliance data collected over an extended period in Korea. The higher compliance rates observed during the COVID-19 pandemic period and among the IV team may be attributed to education regarding the importance of infection control and motivations for self-protection. Further research is needed to explore the reasons for low compliance rates associated with Moment 5 and in the ER. These findings provide insight into factors influencing HH practices and will inform strategies to increase HH compliance rates.

국문 초록 (Abstract)

배경

손 위생은 의료 환경에서 병원체 전파를 예방하는 중요한 방법이다. 의료 종사자의 손은 병원체에 오염됨으로써 병원체 전파의 매개체가 될 수 있다. 2009년 WHO 가이드라인에서는 손 위생 수행 개선을 위해 직접 관찰 방식의 손 위생 모니터링을 권장하고 있다. 직접 관찰 방식은 호손 효과로 인한 수행률 과대 평가의 위험이 있다. 이전 연구들에서는 의료종사자의 직군, 환자 처치 및 진료 유형, 근무 부서 등이 손 위생 수행률에 영향을 미친다고 보고하였다. 본 연구에서는 손 위생 모니터링 방법, 관찰 연도, 의료 종사자의 직군, 손 위생 수행 시점 및 근무 부서가 손 위생 수행률에 미치는 영향을 분석하고자 하였다.


방법

2016년부터 2023년까지 8년 동안 단일 기관에서 획득한 손 위생 모니터링 데이터를 후향적으로 분석하였다. 병원 구역을 외래, 검사실, 병동, 중환자실, 응급실의 5개 부서로 분류하였다. 관찰 대상 의료 종사자에는 간호사, 정맥 주사 팀(IV 팀), 의사, 간호조무사, 보조의료인력 등 환자 치료에 관련된 모든 직군을 포함하였다. 감염 관리 전담 간호사가 직접 관찰과 블라인드 모니터링의 두 가지 방법으로 손 위생 모니터링을 수행하였다. 관찰 데이터는 WHO의 ‘손 위생이 필요한 5개 상황’ 등 WHO의 권장 사항에 따라 기록하였다: (1) 환자 접촉 전; (2) 청결, 무균술 전; (3) 환자 체액 접촉 위험 후; (4) 환자 접촉 후; (5) 환자 주변 환경 접촉 후. 손 위생 수행률은 ‘손 위생이 필요한 상황’ 관찰 수에 대한 손 위생 수행 수의 비율로 정의하였다.


결과

총 75,668개의 ‘손 위생이 필요한 상황’이 관찰되었다. 8년 동안 직접 관찰로 확인한 손 위생 수행률은 95.19%였고, 블라인드 모니터링에서 측정된 손 위생 수행률은 37.34%였다. 직접 관찰 시의 손 위생 수행률은 해가 지남에 따라 유의미한 증가 추세를 보였고(Z = 6.538, P < 0.001), 블라인드 모니터링 시의 수행률은 시간과 연관되어 아무 추세도 보이지 않았다(Z = 0.545, P = 0.58). 2020년 2월부터 2023년 4월까지의 COVID-19 유행 기간 동안 두 가지 관찰 방법 모두 다른 기간에 비해 손 위생 수행률이 높게 확인되었다(직접 관찰 오즈비(OR): 1.57, 95% 신뢰구간(CI): 1.43-1.71; 블라인드 모니터링 OR: 1.10, 95% CI: 1.03-1.18). 직군 중에서는 의사가 가장 낮은 수행률을 보였고(직접 관찰 87.95%, 블라인드 모니터링 28.20%), IV 팀은 가장 높은 수행률을 보였다(직접 관찰 98.98%, 블라인드 모니터링 62.60%). ‘손 위생이 필요한 상황’ 중에서는 ‘(5) 환자 주변 환경 접촉 후’의 손 위생 수행률이 가장 낮았다(직접 관찰 92.79%, 블라인드 모니터링 21.92%). 손 위생 수행률은 근무 부서에 따라 유의하게 달랐고, 응급실은 두 가지 관찰 방법 모두에서 가장 낮은 수행률을 보였다(직접 관찰 87.56%, 블라인드 모니터링 26.24%).


결론

본 연구는 국내에서 장기간 수집된 방대한 양의 손 위생 관찰 데이터를 활용한 최초의 연구이다. 직접 관찰 시의 손 위생 수행률은 블라인드 모니터링으로 확인된 손 위생 수행률에 비해 높고 연간 변동이 적었다. 이는 직접 관찰이 실제 손 위생 수행을 정확하게 반영하지 못한다는 것을 시사한다. COVID-19 유행 기간과 IV 팀에서 손 위생 수행률이 높게 확인된 것은, 감염 관리의 중요성과 자기 보호 목적성에 대한 강조와 교육이 손 위생 수행률을 높이는 요인이 될 것임을 시사한다. ‘(5) 환자 주변 환경 접촉 후’의 상황과 응급실에서 손 위생 수행률이 낮게 확인된 원인에 대해서는 추가 연구가 필요하다. 본 연구는 손 위생 수행률에 영향을 미치는 요인을 이해하고 손 위생 수행률을 높이기 위한 전략을 수립하는 데 도움이 될 것으로 기대한다.

목차 (Table of Contents)

• Chapter 1. Introduction 1
• 1.1. Study Background 1
• 1.2. Purpose of Research 3
• Chapter 2. Body 4
• 2.1. Methods 4
• 2.2. Results 6
• Chapter 3. Conclusion 10
• 3.1. Discussion 10
• 3.2. Conclusion 15
• Bibliography 16
• Abstract in Korean 23
• Tables 26
• Table1 26-27
• Table2 28
• Table3 29
• Table4 30
• Table5 31
• Table6 32
• Figures 33
• Figure1 33
• Figure2 34
• Figure3 35