title: Workload even affects hand hygiene in a highly trained and well-staffed setting: a prospective 365/7/24 observational study.
abstract: BACKGROUND
  Compliance with hand hygiene (HH) has often not proved satisfactory; high workload is a commonly self-reported reason. Previous studies comparing workload and compliance have not measured workload precisely and have focused on certain times of day. This study aimed to investigate the association between HH compliance and workload, both electronically defined 365/7/24 (primary endpoint). In addition, the quality of commonly used compliance defining methods (hand disinfectant usage, direct observation) was investigated (secondary endpoint).
  
  
  METHODS
  Correlation of electronically measured HH compliance (hand-rub activities (HRA)/HH opportunities) with electronically determined workload (nursing time output/nursing time input) was undertaken over one year at a stem cell transplant unit at University Hospital Basel, Switzerland. HRA and procedures requiring HRA according to the five World Health Organization indications were recorded continuously (365/7/24) using electronic dispensers and electronic documentation, and compliance was calculated accordingly. Hand disinfectant usage was calculated using spending records for one year; direct observation was performed for approximately 1800 HH opportunities.
  
  
  RESULTS
  During the investigation, 208,184 HRA, translating into 57 [standard deviation (SD) 10] HRA/patient-day (PD), were performed. Electronically determined compliance ranged from 24% to 66% [mean 42.39% (SD 8%)]. The higher the workload, the lower the compliance (R=-0.411; P<0.001). HRA/PD (r=-0.037), hand disinfectant usage (mean 160mL/PD) and observed compliance (95%; 1734 HRA/1813 HH opportunities) were not found to be associated with workload.
  
  
  CONCLUSIONS
  Calculated compliance was inversely associated with nurses' workload. HRA/PD, observer-determined compliance and amount of disinfectant dispensed were used as surrogates for compliance, but did not correlate with actual compliance and thus should be used with caution.
authors.affiliation: Infection Control and Infectious Diseases, University Medicine Goettingen, University Goettingen, Germany; Infectious Diseases, Basel University Hospital, Basel, Switzerland. Electronic address: simone.scheithauer@med.uni-goettingen.de.
authors.forename: S
authors.initials: S
authors.lastname: Scheithauer
authors.affiliation: Infectious Diseases, Basel University Hospital, Basel, Switzerland.
authors.forename: B
authors.initials: B
authors.lastname: Batzer
authors.affiliation: Infectious Diseases, Basel University Hospital, Basel, Switzerland.
authors.forename: M
authors.initials: M
authors.lastname: Dangel
authors.affiliation: Clinic for Haematology, Basel University Hospital, Basel, Switzerland.
authors.forename: J
authors.initials: J
authors.lastname: Passweg
authors.affiliation: Infectious Diseases, Basel University Hospital, Basel, Switzerland.
authors.forename: A
authors.initials: A
authors.lastname: Widmer
mesh_terms: D003428:Cross Infection / Q000517:prevention & control*; D019983:Guideline Adherence; D006235:Hand Disinfection / Q000379:methods*; D006785:Hospitals, University; D006801:Humans; D009726:Nurses; D011446:Prospective Studies; D033581:Stem Cell Transplantation; D013557:Switzerland; D016526:Workload
keywords: Cross-transmission; Hand disinfection; Hospital-acquired infection; Quality management; Surveillance