Hand-hygiene practices and observed barriers in pediatric long-term care facilities in the New York metropolitan area

Objective To describe hand-hygiene practices in pediatric long-term care (pLTC) facilities and to identify observed barriers to, and potential solutions for, improved infection prevention. Design Observational study using (i) the World Health Organization's ‘5 Moments for Hand Hygiene’ validated observation tool to record indications for hand hygiene and adherence; and (ii) individual logs of subjective impressions of behavioral and/or systemic barriers witnessed during direct observation. Setting Staff in three pLTC facilities (284 beds total) were observed by two trained nurses 1 day a week for 3 weeks in February and March 2015. Participants Direct providers of health, therapeutic and rehabilitative care, and other staff responsible for social and academic activities for children with complex, chronic medical conditions. Main Outcome Measures Hand-hygiene indications, adherence and barriers. Results Hand hygiene was performed for 40% of the 847 indications observed and recorded. Adherence increased at one site and decreased in the other two sites during the study period. Adherence appeared to be influenced by individuals' knowledge, attitudes, beliefs and work setting. Conclusions Poor hand-hygiene adherence was observed overall. Specific barriers were identified, which suggest a contextual approach to the interpretation of results indicated in this uniquely challenging setting. We offer some practical suggestions for overcoming those barriers or mitigating their effect. Ultimately, an adaptation of the ‘5 Moments for Hand Hygiene’ may be necessary to improve infection prevention in pLTC.