Impact of International Nosocomial Infection Control Consortium (INICC) strategy on central line-associated bloodstream infection rates in the intensive care units of 15 developing countries

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Impact of International Nosocomial Infection Control Consortium (INICC) strategy on central line-associated bloodstream infection rates in the intensive care units of 15 developing countries
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  Major article Impact of the International Nosocomial Infection ControlConsortium multidimensional hand hygiene approach in 3 citiesin Brazil a b , c , d e , a b bc c cd d d a Hospital São Paulo, São Paulo, Brazil b Hospital General Porto Alegre, Porto Alegre, Brazil c Hospital Sao Miguel, Joaçaba, Brazil d Hospital Universitario Santa Terezinha, Joaçaba, Brazil e International Nosocomial Infection Control Consortium, Buenos Aires, ArgentinaKey Words: Hand washingHand hygieneMultidimensional approachIntensive care unitDeveloping countries  Background:  Hand hygiene (HH) is the main tool for cross-infection prevention, but adherence toguidelines is low in limited-resource countries, and there are not available published data from Brazil.  Methods:  This is an observational, prospective, interventional, before-and-after study conducted in 4intensive care units in 4 hospitals, which are members of the International Nosocomial Infection ControlConsortium (INICC), from June 2006-April 2008. The study was divided into a 3-month baseline periodand a follow-up period. A multidimensional HH approach was introduced, which included administrativesupport, supplies availability, education and training, reminders in the workplace, process surveillance,and performance feedback. Health care workers were observed for HH practices in each intensive careunit during randomly selected 30-minute periods.  Results:  We recorded 4,837 opportunities for HH, with an overall HH compliance that increasedfrom 27%-58% ( P  < .01). Multivariate analysis showed that some variables were associated with poor HHcompliance: men versus women (49% vs 38%,  P   <  .001), nurses versus doctors (55% vs 48%,  P   <  .02),among others. Conclusions:  WiththeimplementationoftheINICCapproach,adherencetoHHwassigni fi cantlyincreased.Programs should be aimed at improving HH invariables found to be predictors of poor HH compliance.Copyright    2014 by the Association for Professionals in Infection Control and Epidemiology, Inc.Published by Elsevier Inc. All rights reserved. Over more than a century ago, when the relation betweenimproved hand antisepsis and reduced mortality from puerperalsepsis was being studied by Semmelweis, 1 it was shown thatappropriate hand hygiene (HH) before patient contact was afundamental tool for infection prevention. Different studies havereported that an improved HH practice was associated with the * Address correspondence to Victor D. Rosenthal, MD, MSc, CIC, InternationalNosocomial Infection Control Consortium, Corrientes Ave #4580, Fl 12, Apt D,Buenos Aires, 1195, Argentina. E-mail address: (V.D. Rosenthal). Potential con fl icts of interest:  All authors report no con fl icts of interest relatedto this article. Funding/support:  The funding for the activities carried out at the INICCHeadquarters were provided by the corresponding author, Victor D. Rosenthal, andthe Foundation to Fight against Nosocomial Infections.  Additional information:  Every hospital ’ s institutional review board agreedto the study protocol, and patient con fi dentiality was protected by codifyingthe recorded information, making it only identi fi able to the infection controlteam.  Author contributions:  Idea, conception, and design:  Victor D. Rosenthal. Provision of study patients:  All authors.  Collection of data:  All authors.  Softwaredevelopment:  Victor D. Rosenthal.  Assembly of data:  Victor D. Rosenthal.  Analysisand interpretation of the data:  Victor D. Rosenthal.  Epidemiologic analysis:  VictorD. Rosenthal.  Statistical analysis:  Victor D. Rosenthal.  Administrative, technical,and logistic support:  Victor D. Rosenthal.  Drafting of the article:  Victor D.Rosenthal.  Critical revision of the article for important intellectual content:  Allauthors.  Final approval of the article:  All authors. Contents lists available at ScienceDirect American Journal of Infection Control journal homepage: American Journal of Infection Control 0196-6553/$36.00 - Copyright    2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. American Journal of Infection Control xxx (2014) 1-6 5.2.0 DTD   YMIC3264_proof  3 November 2014  7:59 pm  ce KG 123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130  Jamile Leda Spessatto MDEduardo A. Medeiros MD , Gorki Grinberg MD , Victor D. Rosenthal MD, MSc, CIC *,Daniela Bicudo Angelieri RN , Iselde Buchner Ferreira RN , Raquel Bauer Cechinel RN ,Bruna Boaria Zanandrea MD , Carolina Rohnkohl MD , Marcos Regalin MD ,, Ricardo Scopel Pasini MD , Shaline Ferla MD  reduction of antimicrobial resistance and rates of health care e associated infection (HAI). 2-4 The threat to patient safety posed by HAIs includes morbidityand mortality. 5 As shown in the mainstream scienti fi c literature,most studies addressing HAIs have been conducted in developedcountries. 6 In 2002, the International Nosocomial Infection ControlConsortium (INICC) began to apply standardized de fi nitions andmethods, contributing to systematically measuring and analyzingHAI rates worldwide. 7-11 HH serves a crucial role in preventing cross transmission of HAIs, and successful interventions to improve HH have beenreported both from developed countries 12 and limited-resourcecountries. 3,13,14 From the 1980s Q5  , investigators have analyzed theeffectiveness of interventions to improve HH, including the impactof supplies availability, 15 the use of reminders and posters at theworkplace, 16 the use of monitoring and performance feedback, 17 administrative support, 18 the introduction of alcohol-based handrub (AHR), 19 and the effectiveness of education. 20,21 In 1997, Larsonet al 18 explicitly referred to a multidimensional approach thatconsideredseveralinterventionsinastudyconductedintheUnitedStates. Likewise, Rosenthal et al implemented programs inArgentina combining administrative support, supplies availability,education and training, process surveillance, and performancefeedback, which produced a sustained improvement in HHcompliance, 14 with a reduction in HAI rates. 3 In 2002, the Centers for Disease Control and Prevention Q6 published a HH guideline. 22 With a view to promote HH from aglobal angle, in 2005 the World Health Organization (WHO)launched the program Clean Care is Safer Care. 23 In 2009, the WHOpublished its guidelines presenting a compilation of previouslypublisheddata,anewformulationforAHRproducts,amongseveralother recommendations. 4 This is the  fi rst multicentric study from Brazil that aims toestablish the baseline HH compliance rate by health care workers(HCWs) before patient contact, to analyze risk factors for pooradherence, and to implement and evaluate the impact of an INICCmultidimensional hand hygiene approach (IMHHA) in 4 intensivecare units (ICU) in 4 hospitals in 3 cities in Brazil. The approachincludes Q7  the following elements: administrative support, suppliesavailability, education and training, reminders in the workplace,process surveillance, and performance feedback. MATERIAL AND METHODS Background on the INICC  The INICC is an international, nonpro fi t, open, multicentric HAIsurveillance network with a methodology based on the Centers forDisease Control and Prevention ’ s National Healthcare SafetyNetwork in the United States. 24 The INICC is the  fi rst researchnetwork established to measure and control HAIs in hospitalsworldwide through the analysisof standardized data collected on avoluntary basis by its member hospitals. Gaining new memberssince its international inception in 2002, the INICC is nowcomposed of nearly 1,000 hospitals in 200 cities in 50 countries inLatin America, Asia, Africa, the Middle East, and Europe and hasbecome the only source of aggregate standardized internationaldata on the epidemiology of HAI worldwide. 11 Study setting  This study was conducted in 4 adult ICUs in 4 Q8 INICC memberhospitals from Brazil, which were successively incorporated intothe study over a period of 3 years.Eachhospitalhas aninfectioncontrol team (ICT)composed ofatleast 1 infection control practitioner and 1 physician. The HCW inchargeofprocesssurveillanceateachhospitalhasatleast2yearsof infection control experience.The study protocol was approved by the institutional reviewboard at each hospital. Study design An observational, prospective, cohort, interventional, before-and-after, multicentric study was conducted from June2006-April 2008. The study was divided into 2 periods: a baselineperiod and a follow-up period. The baseline period for HHcompliance included episodes documented at each hospital duringtheir  fi rst 3 months of participation, and the follow-up periodincluded episodes following the fourth month of participation.Each ICU started to participate in the study at different times andtherefore have different lengths of follow-up (5-24 months).For comparison of compliance rates, the ICUs were alignedindependently of the date at which they started its participation inthe study. IMHHA The IMHHA is implemented at each hospital from thebeginningof theirparticipationintheINICC.Theapproachincludesthe following 6 components  Q9 : administrative support, suppliesavailability, education and training, reminders in the workplace,process surveillance, and performance feedback. Although thecomponents are presented individually, they are interactiveelements that must concur for the effective implementation of anymultidimensional approach.  Administrative support  Hospital administrators of the participating hospitals agreedand committed tothe study, attended infection control meetings todiscuss study  fi ndings, and allocated supplies of HH products. Supplies availability Duringthestudyperiod,AHRsbottleswereavailableattheICUs ’ entrances, nursing stations, and near the site of patient care(individual patient room entrances, at bedside tables, and on thefeet of patient beds). Sinks with water supply, soap, and papertowels were available at the ICUs ’  entrances, nursing stations, andcommon areas of the ICUs. Education and training  In the ICUs, the ICT members provided 30-minute educationsessions to HCWs in each work shift, at the beginning of the studyperiod and periodically (every month, every 2 months, and every6 months, depending on the ICU) during the follow-up period.Education included basic information about indications of HH andthe correct procedures and technique for HH. Reminders in the workplace Posterremindersweredisplayedallaroundthehospitalsettings(ie, hospital entrance, corridors, ICT of  fi ce, ICU entrances, nursingstations, beside each sink, and beside each AHR bottle). Theyincluded simple instructions on HH performance, in line with thecontents of the education and training program. Process surveillance ProcesssurveillanceofHHpracticesconsistedoftheregistrationof potential opportunities for HH 4 and the actual number of HHepisodes, either with water and soap or AHR. HCWs ’  HH practice E.A. Medeiros et al. / American Journal of Infection Control xxx (2014) 1-6  2 5.2.0 DTD   YMIC3264_proof  3 November 2014  7:59 pm  ce KG 131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259260  was directly monitored by a member of the ICT following astandardized protocol and included completing HH processsurveillance INICC forms that included a questionnaire. 7 Themonitoring included HH compliance before patient contact andbefore an aseptic task and also included use of HH products overtime.WedidnotmonitorallMy5MomentsforHHaccordingtotheWHO recommendations because we started this approach severalyearsbeforethelaunchingoftheWHOHHprogramadvisingonthe5 moments. 4 Observations were conducted unobtrusively at speci fi c timeperiodsdistributedatrandomin3workshifts(morning,afternoon,evening). HCWs were not aware of the schedule of the monitoringperiod. Potential confounders of HH included type of ICU,professional category, sex, work shift, and type of contact. Performance feedback Every month, the INICC Headquarters team prepares and sendsto each participating ICU a  fi nal month-by-month report oncompliance with HH. These charts contain a running tally of HHcompliance by HCWs of the ICUs and compliance comparingseveral variables (eg, sex, HCW professional status, ICU type,contact type, work shift). Those charts were reviewed at monthlyICT meetings and also posted in the ICUs to give performancefeedback to the HCWs of the participating ICUs. 7 The performancefeedback process started in the third month of participation. 7 Training of the ICT for process surveillance The ICT member investigators were self-trained with aprocedure manual sent from the INICC Headquarters in BuenosAires specifying how to carry out the HH process surveillanceand how to  fi ll in the INICC forms. 7 ICT members had continuoustelephone or e-mail access to a support team at the INICCHeadquarters. Data collection and processing  Completed INICC process surveillance forms of HH were sentmonthly by ICT members from each participating ICU to the INICCHeadquarters. The team at the INICC Headquarters uploaded thedata into a database, analyzed and sent a report of HH complianceto ICT members of each participating ICU, showing HH complianceby month, sex, HCW profession, ICU, work shift, and type of contact. 7 Statistical methodsUnivariate analysis of variables associated with poor HH and impact of the HH approach The aggregated independent variables (sex of HCWs, professionof HCWs, type of ICU, type of contact, etc) of all observed HHopportunitiesandHHcomplianceduringthestudyandcomparisonof HH compliance during the baseline period and follow-up periodwere compared using Fisher exact test for dichotomous variablesandunmatchedStudent t  testforcontinuousvariables.Relativeriskratios were calculated for comparisons of analyzed variablesassociated with HH using Epi Info version 6. The 95% con fi denceintervals were calculated using VCStat (Castiglia).  P   values < .05 by2-tailed tests were considered signi fi cant. Multivariate analysis of variables associated with poor HH  The aggregated described independent variables of allobserved HH opportunities and HH compliance during the studywere compared using logistic regression for dichotomous andcontinuous variables. Odds ratios with 95% con fi dence intervalswere calculated for comparisons of analyzed variables associatedwith HH using PASW Statistics 18.  P   values  < .05 by 2-tailed testswere considered signi fi cant. Multivariate analysis of impact of the INICC HH multidimensionalapproach HH opportunities and compliance during baseline and follow-up were explored for changes in HH compliance rates followingan ICU joining the INICC. We looked at the follow-up periodstrati fi ed by 3-month periods over the  fi rst year and yearly forsecondyear.Wepresenttheresultsofalogisticregressionmodeltoconsider change in HH compliance in the INICC participating ICUsover time since the beginning of the HH surveillance. Odds ratiosare presented, comparing each time period since the start of thesurveillance with the baseline of 3 months. This is a large data set,with 4,837 observations; therefore, we were able to adjust for theeffect of each ICU on HH compliance as a categorical variable in theanalysis. Because of the different length of follow-up of each ICU(1 month-2 years), for each time period, only ICUs with follow-upin that time period were included in the baseline period used forcalculating the odds ratio of HH compliance for that period. RESULTS From June 2006-April 2008, we recorded a total of 4,837opportunitiesforHHbeforepatientcontactandbeforeaseptictask. Predictors of poor HH compliance Table1presentsthecharacteristicsoftheparticipatinghospitalsand ICUs.We observed 1,068 procedures in men and 3,769 in women.There were 738 in nurses, 572 in physicians, and 3,527 in ancillarystaff. There were 3,653 prior to noninvasive patient contact and1,184 prior to invasive procedures. All 4,837 were in adult ICUs.There were 1,604 during the morning, 1,579 during the afternoon,and 1,654 during the night shift.Table 2 shows HH compliance according to each variable (typeof hospital, sex, profession of HCW, type of procedure, type of unit,and work shift) and association with poor HH, analyzed withunivariate and multivariate statistical methods, respectively. Components of the IMHHA During the follow-up period, the 6 components of the IMHHAwere applied simultaneously: 100% counted on administrativesupport and available supplies for HH and AHR; 100% educatedHCWs (50% of them every month, 25% every 2 months, and 25%every year); 100% posted reminders (100% of them at ICU entrance,100%incommonICUareas);processsurveillancewasconductedby100%; and 75% provided performance feedback (50% of them everymonth, and 25% every 2 months).  Table 1 Characteristics of the participating hospitals (June 2006-April 2008)Data ICUs and hospitals ICU HH observationsType of ICUMedical surgical 4 (100) 4,837Type of hospitalAcademic teaching 2 (50) 1,330Private 2 (50) 3,507All hospitals 4 (100) 4,837NOTE. Values are n or n (%). HH  , hand hygiene;  ICU  , intensive care unit. E.A. Medeiros et al. / American Journal of Infection Control xxx (2014) 1-6   3 5.2.0 DTD   YMIC3264_proof  3 November 2014  7:59 pm  ce KG 261262263264265266267268269270271272273274275276277278279280281282283284285286287288289290291292293294295296297298299300301302303304305306307308309310311312313314315316317318319320321322323324325326327328329330331332333334335336337338339340341342343344345346347348349350351352353354355356357358359360361362363364365366367368369370371372373374375376377378379380381382383384385386387388389390  Impact of the IMHHA on HH compliance InTable3wepresenttheresultsofalogisticregressionmodeltoconsider change in HH compliance in the INICC participating ICUsover the whole study period. The baseline period of the INICC ICUswas 3 months, and their average follow-up period was 9.7 months(range, 4-21 months). Use of HH products over time Common soap for HH was at 31% in 2004; it roseto72% in 2005.It was gradually reduced to 0% by 2007. AHR use started in 2007,with a sharp rise to 100% in 2008 (Fig 1). DISCUSSION Baseline HH compliance (27%) of HCWs at the INICC ICUs wassimilar to that shown in previous studies, where HH compliancerates ranged from9%-75%. 4 In astudy byHoferet al, 25 conducted ina Brazilian hospital, it was reported that appropriate performanceHH was observed in only 35% of opportunities for HH.In this study, we have shown that implementing the previouslydescribed 6 measures of the IMHHA in each ICU was followed byvery substantial improvements in HH practices in 4 ICUs from 4hospitals in Brazil.One unanticipated  fi nding was that there was highercompliance in men than women, which is contrary to other  fi nd-ings unrelated to health care, such as the  fi ndings of Guinan et al 26 showing higher compliance by female students. Compliance washigher among nurses as shown in a study by Rosenthal et al, 3 inwhich compliance was lower among physicians and ancillary staff than nurses. Morning and afternoon shifts were signi fi cantlyassociated with lower HH compliance than night shift. This can beexplained bythe fact that during dayshifts, ICUs are morecrowdedand busy than night shifts. In 1982, Haley et al 27 showed thatovercrowdingandunderstaf  fi nghinderedHCWs ’ effortstoperformHH. In regard to noninvasive and invasive procedures, we did not fi nd any difference in HH compliance; this differs with the  fi ndingsofLipsettetal, 28 whoshowedthatlowerHHcompliancewasfoundin low-risk situations.Use of HH products changed, showing an increase in AHR useand a reduction in common soap use, which could be related toincreasingly wider promotion of AHR by the WHO, which wasincluded in the IMHHA, and therefore support by hospitaladministrators. 4 Ourapproach included administrative support. Rosenthal etal 14 showed that higher HH adherence was associated with adminis-trative support. Additionally, ICUs had availability of supplies.Bischoff et al 29 showed that easily accessible dispensers of AHR revealed the more dispensers per bed, the higher HH compliance.In addition, we included education and training, which were otherbasic independent interventions identi fi ed to foster adequate HHperformance. As shown by Santana et al, 20 alcohol-based hand geland an educational program on HH improved adherence amongHCWs in an ICU of a Brazilian hospital. 30 Likewise, Rosenthal et al 14 showed HCWs ’  education improved HH adherence and complianceincreased further if performance feedback was also implemented.We also included reminders at the workplace. Conly et al 16 showedthe importance of reminders to raise HCWs ’  awareness of therelation between correct HH performance and HAI reduction.We measured 4,837 opportunities for HH. Every month, the ICTteam provided performance feedback to HCWs of each ICU. This isthe most motivating aspect of the IMHHA for HCWs. Awareness of the outcome of their efforts re fl ected by the measurement of their  Table 2 HH compliance by type of variable Q16Q17 VariableUnivariate analysis Multivariate analysis% (no. of HH/no. of opportunities) ComparisonRelativerisk 95% CI  P   valueAdjustedOR 95% CIOR  P   valueType of hospitalAcademic 42 (911/2,159) Academic vs private .94 0.87-1.01 .041 1.0Private 40 (1,061/2,678) 0.9 0.8-1.0 .07SexFemale 38 (1,451/3,769) Female vs male .80 0.7-0.9 .0001 0.72 0.62-0.84 .0001Male 49 (521/1,068) 1.0HCWsNurses 55 (406/738) Q18 Nurses vs physicians .86 0.76-0.98 .02 1.0Physicians 48 (272/572) Nurses vs ancillary staff .70 0.6-0.76 .0001 0.64 0.51-0.8 .0001Ancillary staff 37 (1,294/3,527) Physicians vs ancillary staff .77 0.7-0.9 .0005 0.5 0.4-0.6 .0001ProcedureNoninvasive 41 (1,491/3,653) Noninvasive vs invasive .99 0.94-1.1 .90 1.0Invasive 41 (481/1,184) 0.99 0.94-1.1 .90Work shiftMorning 48 (764/1,604) Morning work shift vs afternoon work shift .76 0.7-0.83 .0001 1.0Afternoon 36 (570/1,579) Morning work shift vs night work shift .81 0.74-0.9 .0001 0.65 0.6-0.75 .0001Night 39 (638/1,654) Afternoon work shift vs night work shift .94 0.85-1.0 .16 0.73 0.63-0.84 .0001 CI  , con fi dence interval;  HCW  , health care worker;  HH  , hand hygiene;  OR , odds ratio.  Table 3 HH improvement by year of participationYears since joining the INICC HH observations No. of ICUs included No. of hospitals included HH (%) Adjusted OR (95% CI)  P   valueFirst 3 months (baseline) 1,594 4 4 27 1.0 NASecond 3 months 1,001 4 4 36 1.23 (1.0-1.5) .03Third 3 months 767 2 2 43 1.5 (0.2-1.8) .002Fourth 3 months 730 2 2 57 2.6 (2.0-3.3) .0001Second year 745 2 2 58 2.9 (2.3-3.6) .0001 CI  , con fi dence interval;  HH  , hand hygiene;  ICU  , intensive care unit;  INICC  , International Nosocomial Infection Control Consortium;  NA , not applicable;  OR , odds ratio. E.A. Medeiros et al. / American Journal of Infection Control xxx (2014) 1-6  4 5.2.0 DTD   YMIC3264_proof  3 November 2014  7:59 pm  ce KG 391392393394395396397398399400401402403404405406407408409410411412413414415416417418419420421422423424425426427428429430431432433434435436437438439440441442443444445446447448449450451452453454455456457458459460461462463464465466467468469470471472473474475476477478479480481482483484485486487488489490491492493494495496497498499500501502503504505506507508509510511512513514515516517518519520  practices and HAI incidence is a conscious-raising factor to ensurethe IMHHA ’ s effectiveness. From 1998 in Argentina, 3,14 and 2002internationally, 7-11 the INICC has introduced process surveillanceand performance feedback as a means to improve quality in healthcare to a new level, monitoring and providing continuous feedbacknot only of outcome data (rates of HAI) but also of the results of process surveillance (rates of HH compliance and other simple buthighly effective, evidence-based infection control practices) andshown that combining educationwith feedback of surveillance canbring quantum reductions in the risk of life-threatening HAIs inICUs. 3,14 Through the last decade, the INICC has undertaken a globaleffort in Latin America, Asia, Africa, the Middle East, and Europe torespond to the burden of HAIs and has achieved successful resultsby increasing HH compliance, improving compliance with otherinfection control interventions, as described in several INICCpublications, and consequently reducing the rates of HAI andmortality. Since 2002, in adult ICUs in 15 countries, the INICC hasreducedtherateofCLABby54%, 31 catheter-associatedurinarytractinfection by 37%, 32 ventilator-associated pneumonia (VAP) by56%, 33 and mortality by 58%. 31 In pediatric ICUs in 5 countries, theINICC has reduced the rate of CLAB by 52%, 34 catheter-associatedurinary tract infection by 57%, 35 VAP by 31%, 36 and mortality by31%. 34 In neonatal ICUs in 10 countries, the INICC has reduced therate of VAP by 33%. 37 This study has some limitations. First, we did not measure My 5Moments for HH as described recently by the WHO in 2009. This isbecause the INICC program started the IMHHA in 1998 inArgentina 3,14 and in 2002 internationally, 7 that is, several yearsbefore the WHO published its recommendation in 2009. However,since 2009, the INICC has included the WHO ’ s My 5 Moments forHH in its process surveillance forms and manuals. 4 Additionally, itshould be noted that this study applied an observational, before-after methodology, which implies less strength of evidence thanother study designs. A Hawthorne effect is typical of directobservations of adherence. In addition, direct observationsrepresent only a sample of all opportunities and there are inherentweaknesses, including assuring interobserver reliability. Finally, isit highly complex to capture the quality of HH techniques, and wewerenotable toinclude many details in this study (eg, informationregarding HAI and mortality rates) because there are several INICCpublications that focus on these topics in relation to HH. CONCLUSIONS As demonstrated, the IMHHA improved HH compliance in 4ICUs in 4 hospitals in 3 cities in Brazil, probably contributing to theHAIratesandmortalityrates. 31-37 ItistheINICC ’ sprimaryobjectiveto foster infection control practices by freely facilitating elementaland inexpensive resourceful tools to tackle this problem effectivelyand systematically, leading to greater and steady adherence toinfection control programs and guidelines (eg, HH compliance) andto the correlated reduction of HAIs and their consequences (eg,mortality, extra cost).  Acknowledgments We thank the many health care professionals at each memberhospital who assisted with surveillance in their hospital; MarianoVilar and Débora López Burgardt, who work at the INICCHeadquarters in Buenos Aires; the INICC country coordinators andsecretaries (Altaf Ahmed, Carlos A. Álvarez-Moreno, AnuchaApisarnthanarak, Luis E. Cuéllar, Bijie Hu, Namita Jaggi, HakanLeblebicioglu, Montri Luxsuwong, Eduardo A. Medeiros, YatinMehta, Ziad Memish, Toshihiro Mitsuda, and Lul Raka); and theINICCAdvisoryBoard (CarlaJ.Alvarado, NicholasGraves,William R. Jarvis, Patricia Lynch, Dennis Maki, Gerald McDonnell, ToshihiroMitsuda, Cat Murphy, Russell N. Olmsted, Didier Pittet, WilliamRutala, Syed Sattar, and Wing Hong Seto), who have so generouslysupported this unique international infection control network. References 1. Raju TN. Ignac Semmelweis and the etiology of fetal and neonatal sepsis. J Perinatol 1999;19:307-10.2. Simmons B, Bryant J, Neiman K, Spencer L, Arheart K. The role of handwashingin prevention of endemic intensive care unit infections. Infect Control HospEpidemiol 1990;11:589-94.3. Rosenthal VD, Guzman S, Safdar N. Reduction in nosocomial infection withimproved hand hygiene in intensive care units of a tertiary care hospital inArgentina. Am J Infect Control 2005;33:392-7.4. 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Am J Infect Control 1989;17:330-9.     p    r     i    n     t      &    w    e      b     4      C           =       F      P      O Fig 1.  Type of product used in HH over the years of participation.  HH  , hand hygiene. E.A. Medeiros et al. / American Journal of Infection Control xxx (2014) 1-6   5 5.2.0 DTD   YMIC3264_proof  3 November 2014  7:59 pm  ce KG 521522523524525526527528529530531532533534535536537538539540541542543544545546547548549550551552553554555556557558559560561562563564565566567568569570571572573574575576577578579580581582583584585586587588589590591592593594595596597598599600601602603604605606607608609610611612613614615616617618619620621622623624625626627628629630631632633634635636637638639640641642643644645646647648649650
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