How can information systems provide support to nurses' hand hygiene performance? Using gamification and indoor location to improve hand hygiene awareness and reduce hospital infections

Background

Hospital-acquired infections are still amongst the major problems health systems are facing. Their occurrence can lead to higher morbidity and mortality rates, increased length of hospital stay, and higher costs for both hospital and patients. Performing hand hygiene is a simple and inexpensive prevention measure, but healthcare workers’ compliance with it is often far from ideal. To raise awareness regarding hand hygiene compliance, individual behaviour change and performance optimization, we aimed to develop a gamification solution that collects data and provides real-time feedback accurately in a fun and engaging way.

Methods

A Design Science Research Methodology (DSRM) was used to conduct this work. DSRM is useful to study the link between research and professional practices by designing, implementing and evaluating artifacts that address a specific need. It follows a development cycle (or iteration) composed by six activities. Two work iterations were performed applying gamification components, each using a different indoor location technology. Preliminary experiments, simulations and field studies were performed in an Intensive Care Unit (ICU) of a Portuguese tertiary hospital. Nurses working on this ICU were in a focus group during the research, participating in several sessions across the implementation process.

Results

Nurses enjoyed the concept and considered that it allows for a unique opportunity to receive feedback regarding their performance. Tests performed on the indoor location technology applied in the first iteration regarding distances estimation presented an unacceptable lack of accuracy. Using a proximity-based technique, it was possible to identify the sequence of positions, but beacons presented an unstable behaviour. In the second work iteration, a different indoor location technology was explored but it did not work properly, so there was no chance of testing the solution as a whole (gamification application included).

Conclusions

Combining automated monitoring systems with gamification seems to be an innovative and promising approach, based on the already achieved results. Involving nurses in the project since the beginning allowed to align the solution with their needs. Despite strong evolution through recent years, indoor location technologies are still not ready to be applied in the healthcare field with nursing wards.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-017-0410-z) contains supplementary material, which is available to authorized users.

Unit-Specific Rates of Hand Hygiene Opportunities in an Acute-Care Hospital

OBJECTIVE To explore the frequency of hand hygiene opportunities (HHOs) in multiple units of an acute-care hospital. DESIGN Prospective observational study. SETTING The adult intensive care unit (ICU), medical and surgical step-down units, medical and surgical units, and the postpartum mother-baby unit (MBU) of an academic acute-care hospital during May-August 2013, May-July 2014, and June-August 2015. PARTICIPANTS Healthcare workers (HCWs). METHODS HHOs were recorded using direct observation in 1-hour intervals following Public Health Ontario guidelines. The frequency and distribution of HHOs per patient hour were determined for each unit according to time of day, indication, and profession. RESULTS In total, 3,422 HHOs were identified during 586 hours of observation. The mean numbers of HHOs per patient hour in the ICU were similar to those in the medical and surgical step-down units during the day and night, which were higher than the rates observed in medical and surgical units and the MBU. The rate of HHOs during the night significantly decreased compared with day (P92% of HHOs on medical and surgical units, compared to 67% of HHOs on the MBU. CONCLUSIONS Assessment of hand hygiene compliance using product utilization data requires knowledge of the appropriate opportunities for hand hygiene. We have provided a detailed characterization of these estimates across a wide range of inpatient settings as well as an examination of temporal variations in HHOs. Infect Control Hosp Epidemiol 2017;38:411-416.

Automated hand hygiene auditing with and without an intervention

BACKGROUND

Daily feedback from continuous automated auditing with a peer reminder intervention was used to improve compliance. Compliance rates from covert and overt automated auditing phases with and without intervention were compared with human mandatory audits.

METHODS

An automated system was installed to covertly detect hand hygiene events with each depression of the alcohol-based handrub dispenser for 5 months. The overt phase included key clinicians trained to share daily rates with clinicians, set compliance goals, and nudge each other to comply for 6 months. During a further 6 months, the intervention continued without being refreshed. Hand Hygiene Australia (HHA) human audits were performed quarterly during the intervention in accordance with the World Health Organization guidelines. Percentage point (PP) differences between compliance rates were used to determine change.

RESULTS

HHA rates for June 2014 were 85% and 87% on the medical and surgical wards, respectively. These rates were 55 PPs and 38 PPs higher than covert automation rates for June 2014 on the medical and surgical ward at 30% and 49%, respectively. During the intervention phase, average compliance did not change on the medical ward from their covert rate, whereas the surgical ward improved compared with the covert phase by 11 PPs to 60%. On average, compliance during the intervention without being refreshed did not change on the medical ward, whereas the average rate on the surgical ward declined by 9 PPs.

CONCLUSIONS

Automation provided a unique opportunity to respond to daily rates, but compliance will return to preintervention levels once active intervention ceases or human auditors leave the ward, unless clinicians are committed to change.

The three moments of skin cream application: an evidence-based proposal for use of skin creams in the prevention of irritant contact dermatitis in the workplace

Contact dermatitis is one of the most common occupational diseases, with serious impact on quality of life, lost days at work and a condition that may be chronically relapsing. Regular prophylactic skin cream application is widely acknowledged to be an effective prevention strategy against occupational contact dermatitis; however, compliance rates remain low. To present a simple programme for skin cream application in the workplace with focus on implementation to drive down the rate of occupational irritant contact dermatitis, an expert panel of eight international dermatologists combined personal experience with extensive literature review. The recommendations are based on clinical experience as supported by evidence-based data from interventional studies. The authors identified three moments for skin cream application in the work place: (i) before starting a work period; (ii) after washing hands; and (iii) after work. Affecting behaviour change requires systematic communications, monitoring and reporting, which is proposed through Kotter's principles of organizational change management. Measurement tools are provided in the appendix. Interventional data based on application of this proposal is required to demonstrate its effectiveness.

Wearable Sensors for eLearning of Manual Tasks: Using Forearm EMG in Hand Hygiene Training

In this paper, we propose a novel approach to eLearning that makes use of smart wearable sensors. Traditional eLearning supports the remote and mobile learning of mostly theoretical knowledge. Here we discuss the possibilities of eLearning to support the training of manual skills. We employ forearm armbands with inertial measurement units and surface electromyography sensors to detect and analyse the user’s hand motions and evaluate their performance. Hand hygiene is chosen as the example activity, as it is a highly standardized manual task that is often not properly executed. The World Health Organization guidelines on hand hygiene are taken as a model of the optimal hygiene procedure, due to their algorithmic structure. Gesture recognition procedures based on artificial neural networks and hidden Markov modeling were developed, achieving recognition rates of 98.30% (±1.26%) for individual gestures. Our approach is shown to be promising for further research and application in the mobile eLearning of manual skills.

An average hand hygiene day for nurses and physicians: The burden is not equal

BACKGROUND

To understand whether the burden of hand hygiene contributes to poor compliance we measured the daily number of hand hygiene opportunities (HHOs) by shift for nurses and physicians in 2 wards in a 850-bed university teaching hospital.

METHODS

On each ward 4 trained auditors collected the number of HHOs and compliance events for 24 hours over 7 days. Twenty-one thousand four hundred fifty HHOs were collected from a medical and a surgical ward. The proportion of alcohol-based handrub used daily, the burden of hand hygiene, and compliance rates were calculated separately for nurses and physicians.

RESULTS

The average indication for alcohol-based handrub cleansing represented 68% of all HHOs. Nurses had an average burden of 55 HHOs per 24 hours or 27 HHOs per shift, 3 times higher than the burden for physicians, who had 16 HHOs per 24 hours or 8 HHOs per shift. Overt observations of the weekly compliance identified nurses had 1.5 times higher compliance than physicians: 76% and 52% (P < .01), respectively.

CONCLUSIONS

Nurses have 3 times more HHOs than physicians, yet nurses have 1.5 times higher compliance than physicians. Hand hygiene compliance in physicians cannot be explained by burden of HHOs.

Promotion of Influenza Prevention Beliefs and Behaviors through Primary School Science Education

BACKGROUND

School-based campaigns to improve student health have demonstrated short-term success across various health topics. However, evidence of the effectiveness of programs in promoting healthy beliefs and behaviors is limited. We hypothesized that educational curricula teaching the science behind health promotion would increase student knowledge, beliefs and adherence to healthy behaviors, in this case related to influenza.

METHODS

Integrated Science Education Outreach is a successful education intervention in Rochester, Minnesota public schools that has demonstrated improvements in student learning. Within this program, we designed novel curricula and assessments to determine if gains in knowledge extended to influenza prevention. Further, we coupled InSciEd Out programming with a clinical intervention, Influenza Prevention Prescription Education (IPPE), to compare students' attitudes, intentions and healthy behaviors utilizing surveys and hand hygiene monitoring equipment.

RESULTS

95 students participated in (IPPE) in the intervention school. Talking drawings captured improvement in influenza prevention understanding related to hand washing [pre n=17(43%); post n=30(77%)] and vaccination [pre n=2(5%); post n=15(38%)]. Findings from 1024 surveys from 566 students revealed strong baseline understanding and attitudes related to hand washing and cough etiquette (74% or greater positive responses). Automated hand hygiene monitoring in school bathrooms and classrooms estimated compliance for both soap (overall median 63%, IQR 38% to 100%) and hand sanitizer use (0.04 to 0.24 uses per student per day) but did not show significant pre/ post IPPE differences.

CONCLUSIONS

Student understanding of principles of influenza prevention was reasonably high. Even with this baseline, InSciEd Out and IPPE improved students' unprompted knowledge of behaviors to prevent influenza, as reflected by talking drawings. This novel metric may be more sensitive in capturing knowledge among students than traditional assessment methods. However, IPPE did not produce further significant differences in student attitudes and behaviors regarding the flu.

Measurement of Patient Hand Hygiene in Multiorgan Transplant Units Using a Novel Technology: An Observational Study

Objective.

Healthcare worker hand hygiene is known to prevent healthcare-associated infections, but there are few data on patient hand hygiene despite the fact that nosocomial pathogens may be acquired by patients via their own unclean hands. The purpose of this study was to measure patient hand hygiene behavior in the hospital after visiting a bathroom, before eating, and on entering and leaving their rooms

Design.

Cross-sectional study.

Setting.

Acute care teaching hospital in Canada.

Patients.

Convenience sample of 279 adult patients admitted to 3 multiorgan transplant units between July 2012 and March 2013.

Methods.

Patient use of alcohol-based hand rub and soap dispensers was measured using an ultrasound-based real-time location system during visits to bathrooms, mealtimes, kitchen visits, and on entering and leaving their rooms.

Results.

Overall, patients performed hand hygiene during 29.7% of bathroom visits, 39.1% of mealtimes, 3.3% of kitchen visits, 2.9% of room entries, and 6.7% of room exits.

Conclusions.

Patients appear to perform hand hygiene infrequently, which may contribute to transmission of pathogens from the hospital environment via indirect contact or fecal-oral routes.

Infect Control Hosp Epidemiol 2014;35(11):1336–1341

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Challenges in implementing electronic hand hygiene monitoring systems

Electronic hand hygiene (HH) monitoring systems offer the exciting prospect of a more precise, less biased measure of HH performance than direct observation. However, electronic systems are challenging to implement. Selecting a system that minimizes disruption to the physical infrastructure and to clinician workflow, and that fits with the organization's culture and budget, is challenging. Getting front-line workers' buy-in and addressing concerns about the accuracy of the system and how the data will be used are also difficult challenges. Finally, ensuring information from the system reaches front-line workers and is used by them to improve HH practice is a complex challenge. We describe these challenges in detail and suggests ways to overcome them.

Reducing health care-associated infections by implementing a novel all hands on deck approach for hand hygiene compliance

Hand hygiene is a key intervention for preventing health care-associated infections; however, maintaining high compliance is a challenge, and accurate measurement of compliance can be difficult. A novel program that engaged all health care personnel to measure compliance and provide real-time interventions overcame many barriers for compliance measurement and proved effective for sustaining high compliance and reducing health care-associated infections.

Successful development of a direct observation program to measure health care worker hand hygiene using multiple trained volunteers

BACKGROUND

Direct observation of health care worker (HCW) hand hygiene (HH) remains the gold standard, but implementation is challenging. Our objective was to develop an accurate HH observation program using multiple HCW volunteers.

METHODS

HH compliance was defined as correct HH performed before and after contact with a patient or a patient's environment. HCW volunteers from each unit at our children's hospital were trained by infection preventionists to covertly collect HH observations during routine care using an electronic tool. Questionnaires sent to observers in February and December 2014 recorded demographic characteristics, observation time, and scenarios assessing accuracy. HCWs were surveyed regarding their awareness that their HH behavior was being recorded.

RESULTS

There were 146 HH observers. The majority of observers reported making 1-2 observations per shift (65%) and taking ≤10 minutes recording an observation (85%). Between January 2012 and December 2014 there were 22,484 HH observations (average, 622 per month), including nurses (46%), physicians (21%), and other HCWs (33%). Observers correctly recorded HH behavior more than 90% of the time in 5 of the 6 scenarios. Most HCWs (86%) were unaware they were being observed.

CONCLUSION

A direct observation program staffed by multiple HCW volunteers can inexpensively and accurately collect HCW HH data.

Handrub Consumption Mirrors Hand Hygiene Compliance

We assessed handrub consumption as a surrogate marker for hand hygiene compliance from 2007 to 2014. Handrub consumption varied substantially between departments but correlated in a mixed effects regression model with the number of patient-days and the observed hand hygiene compliance. Handrub consumption may supplement traditional hand hygiene observations. Infect Control Hosp Epidemiol 2016;37:707-710.

Using Computer Vision and Depth Sensing to Measure Healthcare Worker-Patient Contacts and Personal Protective Equipment Adherence Within Hospital Rooms

This prospective study of cellulitis identified β-hemolytic streptococci as the dominating cause in all investigated subgroups. Group C/G streptococci were more frequently detected than group A streptococci. No single clinical feature substantially increased the probability of confirmed streptococcal etiology.

Background. We determined the feasibility of using computer vision and depth sensing to detect healthcare worker (HCW)-patient contacts to estimate both hand hygiene (HH) opportunities and personal protective equipment (PPE) adherence.

Methods. We used multiple Microsoft Kinects to track the 3-dimensional movement of HCWs and their hands within hospital rooms. We applied computer vision techniques to recognize and determine the position of fiducial markers attached to the patient's bed to determine the location of the HCW's hands with respect to the bed.

To measure our system's ability to detect HCW-patient contacts, we counted each time a HCW's hands entered a virtual rectangular box aligned with a patient bed. To measure PPE adherence, we identified the hands, torso, and face of each HCW on room entry, determined the color of each body area, and compared it with the color of gloves, gowns, and face masks. We independently examined a ground truth video recording and compared it with our system's results.

Results. Overall, for touch detection, the sensitivity was 99.7%, with a positive predictive value of 98.7%. For gowned entrances, sensitivity was 100.0% and specificity was 98.15%. For masked entrances, sensitivity was 100.0% and specificity was 98.75%; for gloved entrances, the sensitivity was 86.21% and specificity was 98.28%.

Conclusions. Using computer vision and depth sensing, we can estimate potential HH opportunities at the bedside and also estimate adherence to PPE. Our fine-grained estimates of how and how often HCWs interact directly with patients can inform a wide range of patient-safety research.

Enhancing the evaluation of pathogen transmission risk in a hospital by merging hand-hygiene compliance and contact data: a proof-of-concept study

Background

Hand-hygiene compliance and contacts of health-care workers largely determine the potential paths of pathogen transmission in hospital wards. We explored how the combination of data collected by two automated infrastructures based on wearable sensors and recording (1) use of hydro-alcoholic solution and (2) contacts of health-care workers provide an enhanced view of the risk of transmission events in the ward.

Methods

We perform a proof-of-concept observational study. Detailed data on contact patterns and hand-hygiene compliance of health-care workers were collected by wearable sensors over 12 days in an infectious disease unit of a hospital in Marseilles, France.

Results

10,837 contact events among 10 doctors, 4 nurses, 4 nurses’ aids and 4 housekeeping staff were recorded during the study. Most contacts took place among medical doctors. Aggregate contact durations were highly heterogeneous and the resulting contact network was highly structured. 510 visits of health-care workers to patients’ rooms were recorded, with a low rate of hand-hygiene compliance. Both data sets were used to construct histories and statistics of contacts informed by the use of hydro-alcoholic solution, or lack thereof, of the involved health-care workers.

Conclusions

Hand-hygiene compliance data strongly enrich the information concerning contacts among health-care workers, by assigning a ‘safe’ or ‘at-risk’ value to each contact. The global contact network can thus be divided into ‘at-risk’ and ‘safe’ contact networks. The combined data could be of high relevance for outbreak investigation and to inform data-driven models of nosocomial disease spread.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1409-0) contains supplementary material, which is available to authorized users.

Back to basics: hand hygiene and isolation

Purpose of review

Hand hygiene and isolation are basic, but very effective, means of preventing the spread of pathogens in healthcare. Although the principle may be straightforward, this review highlights some of the controversies regarding the implementation and efficacy of these interventions.

Recent findings

Hand hygiene compliance is an accepted measure of quality and safety in many countries. The evidence for the efficacy of hand hygiene in directly reducing rates of hospital-acquired infections has strengthened in recent years, particularly in terms of reduced rates of staphylococcal sepsis. Defining the key components of effective implementation strategies and the ideal method(s) of assessing hand hygiene compliance are dependent on a range of factors associated with the healthcare system. Although patient isolation continues to be an important strategy, particularly in outbreaks, it also has some limitations and can be associated with negative effects. Recent detailed molecular epidemiology studies of key healthcare-acquired pathogens have questioned the true efficacy of isolation, alone as an effective method for the routine prevention of disease transmission.

Summary

Hand hygiene and isolation are key components of basic infection control. Recent insights into the benefits, limitations and even adverse effects of these interventions are important for their optimal implementation.

A Prospective Controlled Trial of an Electronic Hand Hygiene Reminder System

Background.  The use of electronic hand hygiene reminder systems has been proposed as an approach to improve hand hygiene compliance among healthcare workers, although information on efficacy is limited. We prospectively assessed whether hand hygiene activities among healthcare workers could be increased using an electronic hand hygiene monitoring and reminder system. Methods.  A prospective controlled clinical trial was conducted in 2 medical intensive care units (ICUs) at an academic medical center with comparable patient populations, healthcare staff, and physical layout. Hand hygiene activity was monitored concurrently in both ICUs, and the reminder system was installed in the test ICU. The reminder system was tested during 3 administered phases including: room entry/exit chimes, display of real-time hand hygiene activity, and a combination of the 2. Results.  In the test ICU, the mean number of hand hygiene events increased from 1538 per day at baseline to 1911 per day (24% increase) with the use of a combination of room entry/exit chimes, real-time displays of hand hygiene activity, and manager reports (P < .001); in addition, the ratio of hand hygiene to room entry/exit events also increased from 26.1% to 36.6% (40% increase, P < .001). The performance returned to baseline (1473 hand hygiene events per day) during the follow-up phase. There was no significant change in hand hygiene activity in the control ICU during the course of the trial. Conclusions.  In an ICU setting, an electronic hand hygiene reminder system that provided real-time feedback on overall unit-wide hand hygiene performance significantly increased hand hygiene activity.

Over-Reporting in Handwashing Self-Reports: Potential Explanatory Factors and Alternative Measurements

Handwashing interventions are a priority in development and emergency aid programs. Evaluation of these interventions is essential to assess the effectiveness of programs; however, measuring handwashing is quite difficult. Although observations are considered valid, they are time-consuming and cost-ineffective; self-reports are highly efficient but considered invalid because desirable behaviour tends to be over-reported. Socially desirable responding has been claimed to be the main cause of inflated self-reports, but its underlying factors and mechanisms are understudied. The present study investigated socially desirable responding and additional potential explanatory factors for over-reported handwashing to identify indications for measures which mitigate over-reporting. Additionally, a script-based covert recall, an alternative interview question intended to mitigate recall errors and socially desirable responding, was developed and tested. Cross-sectional data collection was conducted in the Borena Zone, Ethiopia, through 2.5-hour observations and 1-hour interviews with the primary caregivers in households. A total sample of N = 554 was surveyed. Data were analysed with correlation and multiple regression analyses and dependent t-tests. Over-reporting of handwashing was associated with factors assumed to be involved in (1) socially desirable responding, (2) encoding and recall of information, and (3) dissonance processes. The latter two factor groups explained over-reported handwashing beyond socially desirable responding. The alternative interview question—script-based covert recall—reduced over-reporting compared to conventional self-reports. Although the difficulties involved in measuring handwashing by self-reports and observations are widely known, the present study is the first to investigate the factors which explain over-reporting of handwashing. This research contributes to the limited evidence base on a highly important subject: how to evaluate handwashing interventions efficiently and accurately.

Strategies to prevent healthcare-associated infections through hand hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Quantifying the Hawthorne Effect in Hand Hygiene Compliance Through Comparing Direct Observation With Automated Hand Hygiene Monitoring

OBJECTIVE

To quantify the Hawthorne effect of hand hygiene performance among healthcare workers using direct observation.

DESIGN

Prospective observational study.

SETTING

Intensive care unit, university hospital.

METHODS

Direct observation of hand hygiene compliance over 48 audits of 2 hours each. Simultaneously, hand hygiene events (HHEs) were recorded using electronic alcohol-based handrub dispensers. Directly observed and electronically recorded HHEs during the 2 hours of direct observation were compared using Spearman correlations and Bland-Altman plots. To quantify the Hawthorne effect, we compared the number of electronically recorded HHEs during the direct observation periods with the re-scaled electronically recorded HHEs in the 6 remaining hours of the 8-hour working shift.

RESULTS

A total of 3,978 opportunities for hand hygiene were observed during the 96 hours of direct observation. Hand hygiene compliance was 51% (95% CI, 49%–53%). There was a strong positive correlation between directly observed compliance and electronically recorded HHEs (ρ=0.68 [95% CI, 0.49–0.81], P<.0001). In the 384 hours under surveillance, 4,180 HHEs were recorded by the electronic dispensers. Of those, 2,029 HHEs were recorded during the 96 hours in which direct observation was also performed, and 2,151 HHEs were performed in the remaining 288 hours of the same working shift that were not under direct observation. Healthcare workers performed 8 HHEs per hour when not under observation compared with 21 HHEs per hour during observation.

CONCLUSIONS

Directly and electronically observed HHEs were in agreement. We observed a marked influence of the Hawthorne effect on hand hygiene performance.

Infect Control Hosp Epidemiol 2015;36(8):957–962

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Overcoming Patient Barriers to Discussing Physician Hand Hygiene: Do Patients Prefer Electronic Reminders to Other Methods?

Background.

Despite agreement that handwashing decreases hospital-acquired infections (HAIs), physician hand hygiene remains suboptimal. Interventions to empower patients to discuss handwashing have had variable success.

Objective.

To understand patient perceived barriers to discussing physician hand hygiene and to determine whether patients prefer electronic alerts over printed information as an intervention to discuss physician handwashing.

Design.

Cross-sectional study of 250 medical/surgical patients at an academic medical center.

Results.

Ninety-six percent of patients had heard of HAIs. Ninety-six percent of patients thought it was important for physicians to clean their hands before touching anything in a patient's room. The majority of patients (78%) believed patients should remind physicians to clean their hands. Thirty-two percent of patients observed physician hand hygiene noncompliance. In multivariate analysis, predictors of not speaking up regarding physician hand hygiene included never having worked in health care (odds ratio [OR], 2.8 [95% confidence interval (CI), 1.5-5.1]), not observing a physician clean hands before touching the patient (OR, 2.4 [95% CI, 1.3-4.4]), and not thinking patients should have to remind physicians to clean hands (OR, 5.5 [95% CI, 2.4-12.7]). Ninety-three percent of patients favored electronic device reminders over printed information as an intervention to encourage patients to discuss hand hygiene with their doctors.

Conclusions.

The strongest predictor of not challenging a doctor to clean their hands was not believing it was the patient's role to do so. Patients prefer electronic device reminders to printed information as an aid in overcoming barriers to discussing hand hygiene with physicians.

Quicker, Easier, and Cheaper? The Promise of Automated Hand Hygiene Monitoring

There are several reasons why surveillance of hand hygiene performance is a crucial part of successful promotion strategies. These can be conceptualized according to the end-user of the data: infection control professionals; healthcare workers (HCWs); researchers; and external stakeholders, such as governmental and nongovernmental accreditation and benchmarking bodies and the general public. Each of these groups comes to hand hygiene performance data with different expectations and preconceptions and will use it for different purposes. Thus, one of the challenges of collecting such data is to do it in such a way that it satisfies the specifications of all interested parties as much as possible.

Boyce provides a thorough and balanced overview of the current state of hand hygiene monitoring. At a time when the field of hand hygiene promotion is maturing rapidly and infection control professionals are facing a vast range of options for monitoring performance in their hospital, this review comes as a timely and welcome summary and answers many common questions in addition to demystifying some newer technologies.

Comparison of hand hygiene monitoring using the 5 Moments for Hand Hygiene method versus a wash in-wash out method

BACKGROUND

One strategy to promote improved hand hygiene is to monitor health care workers' adherence to recommended practices and give feedback. For feasibility of monitoring, many health care facilities assess hand hygiene practices on room entry and exit (wash in-wash out). It is not known if the wash in-wash out method is comparable with a more comprehensive approach, such as the World Health Organization's My 5 Moments for Hand Hygiene method.

METHODS

During a 1-month period, a surreptitious observer monitored hand hygiene compliance simultaneously using the wash in-wash out and My 5 Moments for Hand Hygiene methods.

RESULTS

For 283 health care worker room entries, the methods resulted in similar rates of hand hygiene compliance (70% vs 72%, respectively). The wash in-wash out method required 148 hand hygiene events not required by the My 5 Moments for Hand Hygiene method (ie, before and after room entry with no patient or environmental contact) while not providing monitoring for 89 hand hygiene opportunities in patient rooms.

CONCLUSION

The monitoring methods resulted in similar overall rates of hand hygiene compliance. Use of the wash in-wash out method should include ongoing education and intermittent assessment of hand hygiene before clean procedures and after body fluid exposure in patient rooms.

The role of the healthcare environment in the spread of multidrug-resistant organisms: update on current best practices for containment

The role of the environment in harboring and transmitting multidrug-resistant organisms has become clearer due to a series of publications linking environmental contamination with increased risk of hospital-associated infections. The incidence of antimicrobial resistance is also increasing, leading to higher morbidity and mortality associated with hospital-associated infections. The purpose of this review is to evaluate the evidence supporting the existing methods of environmental control of organisms: environmental disinfection, contact precautions, and hand hygiene. These methods have been routinely employed, but transmission of multidrug-resistant organisms continues to occur in healthcare facilities throughout the country and worldwide. Several new technologies have entered the healthcare market that have the potential to close this gap and enhance the containment of multidrug-resistant organisms: improved chemical disinfection, environmental monitoring, molecular epidemiology, self-cleaning surfaces, and automated disinfection systems. A review of the existing literature regarding these interventions is provided. Overall, the role of the environment is still underestimated and new techniques may be required to mitigate the role that environmental transmission plays in acquisition of multidrug-resistant organisms.

Comparison of human and electronic observation for the measurement of compliance with hand hygiene

BACKGROUND

Monitoring of hand hygiene is an important part of the improvement of hospital quality indicators.

METHODS

This study was prospectively performed over a 14-week (electronic observer) period from December 3, 2013-March 9, 2014, to evaluate hand hygiene compliance in an adult step-down unit. We compared electronic handwash counters with the application of radiofrequency identification (RFID - ZigBee; i-Healthsys, São Carlos, Brazil) (electronic observer), which counts each activation of the alcohol gel dispenser to direct observation (human observer) using the iScrub application.

RESULTS

For the overall time period of simultaneous electronic and human observation, we found that the electronic observer identified 414 hand hygiene episodes, whereas the human observers identified 448 episodes. Therefore, we found 92% (95% confidence interval [CI], 90%-95%) overall concordance (414/448), with an intraclass correlation coefficient of .87 (95% CI, 0.77-0.92).

CONCLUSION

Our RFID (ZigBee) system showed good accuracy (92%) and is a useful method to monitor hand hygiene compliance.

Review of technologies available to improve hand hygiene compliance - are they fit for purpose?

Hand hygiene has been empirically proven to prevent cross-transmission of infection, which has led to the development of global guidelines such as the World Health Organization's 'My 5 Moments for Hand Hygiene.' Because of the relatively recent launch of these guidelines (2009) technology designed to assist in measuring hand hygiene compliance appears not to fully acknowledge the influence of the WHO 5 Moments for hand hygiene Consequently, they may not be fit for purpose (FFP). This paper uses a review of the literature on current hand hygiene technology to assess the extent to which these are FFP based on these global guidelines. The results show that there are a variety of technologies available to assist with the monitoring and measurement of hand hygiene levels. However, none appear to explicitly achieve detection of all WHO 5 Moments for hand hygiene, limiting their effectiveness. The authors conclude that a systems approach offers a potential aid for developers aspiring to meet domain specific FFP requirements. Human factors may help guide such developments to meet user and context specific needs.

Disentangling quality and safety indicator data: a longitudinal, comparative study of hand hygiene compliance and accreditation outcomes in 96 Australian hospitals

OBJECTIVES

The study aims are twofold. First, to investigate the suitability of hand hygiene as an indicator of accreditation outcomes and, second, to test the hypothesis that hospitals with better accreditation outcomes achieve higher hand hygiene compliance rates.

DESIGN

A retrospective, longitudinal, multisite comparative survey.

SETTING

Acute public hospitals in New South Wales, Australia.

PARTICIPANTS

96 acute hospitals with accreditation survey results from two surveys during 2009-2012 and submitted data for more than four hand hygiene audits between 2010 and 2013.

OUTCOMES

Our primary outcome comprised observational hand hygiene compliance data from eight audits during 2010-2013. The explanatory variables in our multilevel regression model included: accreditation outcomes and scores for the infection control standard; timing of the surveys; and hospital size and activity.

RESULTS

Average hand hygiene compliance rates increased from 67.7% to 80.3% during the study period (2010-2013), with 46.7% of hospitals achieving target compliance rates of 70% in audit 1, versus 92.3% in audit 8. Average hand hygiene rates at small hospitals were 7.8 percentage points (pp) higher than those at the largest hospitals (p<0.05). The association between hand hygiene rates, accreditation outcomes and infection control scores is less clear.

CONCLUSIONS

Our results indicate that accreditation outcomes and hand hygiene audit data are measuring different parts of the quality and safety spectrum. Understanding what is being measured when selecting indicators to assess the impact of accreditation is critical as focusing on accreditation results would discount successful hand hygiene implementation by smaller hospitals. Conversely, relying on hand hygiene results would discount the infection control related research and leadership investment by larger hospitals. Our hypothesis appears to be confounded by an accreditation programme that makes it more difficult for smaller hospitals to achieve high infection control scores.

Hand-hygiene compliance does not predict rates of resistant infections in critically ill surgical patients

BACKGROUND

Our institution had a major outbreak of multi-drug-resistant Acinetobacter (MDRA) in its general surgical and trauma intensive care units (ICUs) in 2011, requiring implementation of an aggressive infection-control response. We hypothesized that poor hand-hygiene compliance (HHC) may have contributed to the outbreak of MDRA. A response to the outbreak including aggressive environmental cleaning, cohorting, and increased hand hygiene compliance monitoring may have led to an increase in HHC after the outbreak and to a consequent decrease in the rates of infection by the nosocomial pathogens methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridium difficile.

METHODS

Hand-hygiene compliance, tracked in monthly audits by trained and anonymous observers, was abstracted from an infection control database. The incidences of nosocomial MRSA, VRE, and C. difficile were calculated from a separate prospectively collected data base for 6 mo before and 12 mo after the 2011 outbreak of MDRA in the institution's general surgical and trauma ICUs, and data collected prospectively from two unaffected ICUs (the thoracic surgical ICU and medical intensive care unit [MICU]). We created a composite endpoint of "any resistant pathogen," defined as MRSA, VRE, or C. difficile, and compared incidence rates over time, using the Wilcoxon signed rank test and Pearson product-moment correlation coefficient to measure the correlations among these rates.

RESULTS

Rates of HHC before and after the outbreak of MDRA were consistently high in both the general surgical (median rates: 100% before and 97.6% after the outbreak, p=0.93) and trauma ICUs (median rates: 90% before and 96.75% after the outbreak, p=0.14). In none of the ICUs included in the study did the rates of HHC increase in response to the outbreak of MDRA. The incidence of "any resistant pathogen" decreased in the general surgical ICU after the outbreak (from 6.7/1,000 patient-days before the outbreak to 2.7/1,000 patient-days after the outbreak, p=0.04), but this decrease did not correlate with HHC (trauma ICU: Pearson correlation [ρ]=-0.34, p=0.28; general surgical ICU: ρ=0.52, p=0.08).

CONCLUSIONS

The 2011 outbreak of MDRA at our institution occurred despite high rates of HHC. Notwithstanding stable rates of HHC, the rates of infection with MRSA, VRE and C. difficile decreased in the general surgical ICU after the outbreak. This suggests that infection control tactics other than HHC play a crucial role in preventing the transmission of nosocomial pathogens, especially when rates of HHC have been maximized.

Common infection control practices in the emergency department: a literature review

BACKGROUND

Health care-associated infections (HAIs) are a major health concern, despite being largely avoidable. The emergency department (ED) is an essential component of the health care system and subject to workflow challenges, which may hinder ED personnel adherence to guideline-based infection prevention practices.

METHODS

The purpose of this review was to examine published literature regarding adherence rates among ED personnel to selected infection control practices, including hand hygiene (HH) and aseptic technique during the placement of central venous catheters and urinary catheters. We also reviewed studies reporting rates of ED equipment contamination. PubMed was searched for studies that included adherence rates among ED personnel to HH during routine patient care, aseptic technique during the placement of central venous catheters and urinary catheters, and rates of equipment contamination.

RESULTS

In total, 853 studies was screened, and 589 abstracts were reviewed. The full texts of 36 papers were examined, and 23 articles were identified as meeting inclusion criteria. Eight studies used various scales to measure HH compliance, which ranged from 7.7% to 89.7%. Seven articles examined central venous catheters inserted in the ED or by emergency medicine residents. Detail of aseptic technique practices during urinary catheterization was lacking. Four papers described equipment contamination in the ED.

CONCLUSION

Standardized methods and definitions of compliance monitoring are needed to compare results across settings.

Success of a multimodal program to improve hand hygiene compliance

The purpose of this article was to describe the successful implementation of a quality improvement initiative focusing on a hand hygiene program that used the multimodal interventions of tailored education, monthly feedback, and reminders. Compliance rates improved from July 2011 to December 2012 by 57.4%. Efforts are continuing to ensure program sustainability.

A pre- and post-intervention study of infection control in equine hospitals in Sweden

Background

Detection of nosocomial methicillin-resistant Staphylococcus aureus infections in horses in Sweden has increased attention on infection control (IC) in equine hospitals. This study established baseline data on IC programmes within such settings, evaluated compliance with some IC procedures before and after an education intervention, and examined barriers to compliance.

The study was carried out between 2008 and 2011 in four Swedish equine hospitals. Data on current IC of each hospital, purchase data on hand sanitisers and disposable gloves per patient, and direct observations of compliance with procedures were monitored pre- and post-intervention. The intervention comprised a lecture on common IC and a review of each hospital’s current procedures. For comparison, retrospective purchase data were reviewed. A questionnaire on individual compliance, experiences and opinions of IC was issued to employees.

Results

Three hospitals completed the study, while the fourth reported its IC procedures and completed the questionnaire. Actual numbers of procedures, content and level of documentation differed among the hospitals. Similarities were poor or absent IC implementation strategy, lack of active surveillance of compliance with procedures and no monitoring of such as nosocomial infections. Among the hospitals which completed the study, two reported pre-intervention observation of compliance, while all three reported post-intervention observations. The purchase data showed trends for changes over time, although not uniformly related to the intervention. One hospital demonstrated a significant post-intervention increase in compliance with glove procedures, accompanied by a non-significant post-intervention increase in purchases figures. Compliance with dress code and personal appearance was high in all three hospitals (92-100%), while compliance with hand hygiene procedures was generally poorer. Barriers to compliance cited in the questionnaire (data from four hospitals) included insufficient supplies of hygiene products, lack of readily accessible places for cleaning, insufficient knowledge and high workload.

Conclusions

Potential for easily attainable improvements in IC, such as traceability of documents, implementation strategies and surveillance of efficacy, was revealed. Attention to hand hygiene implementation and improvement of logistics appeared important. Data on purchases per patient were readily available and therefore applicable for intra-hospital surveillance of IC trends over time.

Influence of signal colored hand disinfectant dispensers on hand hygiene compliance at a medical intensive care unit

To assess the influence of signal colors on hand disinfectant dispenser activities, health care workers (HCWs) at a medical intensive care unit were analyzed for a total of 20 weeks with 8 weeks before and 12 weeks after exchange to signal color. No significant increase in hand rubs (HRs) per patient day (PD) was observed (about 40 HRs/PD); however, HCW-adjusted compliance showed a 6% increase with signal colored devices. Therefore, colored devices may help to improve hand hygiene compliance.

Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study

Background

The Hawthorne effect, or behaviour change due to awareness of being observed, is assumed to inflate hand hygiene compliance rates as measured by direct observation but there are limited data to support this.

Objective

To determine whether the presence of hand hygiene auditors was associated with an increase in hand hygiene events as measured by a real-time location system (RTLS).

Methods

The RTLS recorded all uses of alcohol-based hand rub and soap for 8 months in two units in an academic acute care hospital. The RTLS also tracked the movement of hospital hand hygiene auditors. Rates of hand hygiene events per dispenser per hour as measured by the RTLS were compared for dispensers within sight of auditors and those not exposed to auditors.

Results

The hand hygiene event rate in dispensers visible to auditors (3.75/dispenser/h) was significantly higher than in dispensers not visible to the auditors at the same time (1.48; p=0.001) and in the same dispensers during the week prior (1.07; p<0.001). The rate increased significantly when auditors were present compared with 1–5 min prior to the auditors’ arrival (1.50; p=0.009). There were no significant changes inside patient rooms.

Conclusions

Hand hygiene event rates were approximately threefold higher in hallways within eyesight of an auditor compared with when no auditor was visible and the increase occurred after the auditors’ arrival. This is consistent with the existence of a Hawthorne effect localised to areas where the auditor is visible and calls into question the accuracy of publicly reported hospital hand hygiene compliance rates.

Estimation of hand hygiene opportunities on an adult medical ward using 24-hour camera surveillance: validation of the HOW2 Benchmark Study

BACKGROUND

We previously published a formula to estimate the number of hand hygiene opportunities (HHOs) per patient-day using the World Health Organization's "Five Moments for Hand Hygiene" methodology (HOW2 Benchmark Study). HHOs can be used as a denominator for calculating hand hygiene compliance rates when product utilization data are available. This study validates the previously derived HHO estimate using 24-hour video surveillance of health care worker hand hygiene activity.

METHODS

The validation study utilized 24-hour video surveillance recordings of 26 patients' hospital stays to measure the actual number of HHOs per patient-day on a medicine ward in a large teaching hospital. Statistical methods were used to compare these results to those obtained by episodic observation of patient activity in the original derivation study.

RESULTS

Total hours of data collection were 81.3 and 1,510.8, resulting in 1,740 and 4,522 HHOs in the derivation and validation studies, respectively. Comparisons of the mean and median HHOs per 24-hour period did not differ significantly. HHOs were 71.6 (95% confidence interval: 64.9-78.3) and 73.9 (95% confidence interval: 69.1-84.1), respectively.

CONCLUSION

This study validates the HOW2 Benchmark Study and confirms that expected numbers of HHOs can be estimated from the unit's patient census and patient-to-nurse ratio. These data can be used as denominators in calculations of hand hygiene compliance rates from electronic monitoring using the "Five Moments for Hand Hygiene" methodology.

The use of real-time feedback via wireless technology to improve hand hygiene compliance

BACKGROUND

Hand hygiene (HH) is widely regarded as the most effective preventive measure for health care-associated infection. However, there is little robust evidence on the best interventions to improve HH compliance or whether a sustained increase in compliance can reduce rates of health care-associated infection.

METHODS

To evaluate the effectiveness of a real-time feedback to improve HH compliance in the inpatient setting, we used a quasiexperimental study comparing the effect of real-time feedback using wireless technology on compliance with HH. The study was conducted in two 20-bed step-down units at a private tertiary care hospital. Phase 1 was a 3-month baseline period in which HH counts were performed by electronic handwash counters. After a 1-month washout period, a 7-month intervention was performed in one step-down unit while the other unit served as a control.

RESULTS

HH, as measured by dispensing episodes, was significantly higher in the intervention unit (90.1 vs 73.1 dispensing episodes/patient-day, respectively, P = .001). When the intervention unit was compared with itself before and after implementation of the wireless technology, there was also a significant increase in HH after implementation (74.5 vs 90.1 episodes/patient-day, respectively, P = .01). There was also an increase in mean alcohol-based handrub consumption between the 2 phases (68.9 vs 103.1 mL/patient-day, respectively, P = .04) in the intervention unit.

CONCLUSION

We demonstrated an improvement in alcohol gel usage via implementation of real-time feedback via wireless technology.

The evolving landscape of healthcare-associated infections: recent advances in prevention and a road map for research

This white paper identifies knowledge gaps and new challenges in healthcare epidemiology research, assesses the progress made toward addressing research priorities, provides the Society for Healthcare Epidemiology of America (SHEA) Research Committee's recommendations for high-priority research topics, and proposes a road map for making progress toward these goals. It updates the 2010 SHEA Research Committee document, "Charting the Course for the Future of Science in Healthcare Epidemiology: Results of a Survey of the Membership of SHEA," which called for a national approach to healthcare-associated infections (HAIs) and a prioritized research agenda. This paper highlights recent studies that have advanced our understanding of HAIs, the establishment of the SHEA Research Network as a collaborative infrastructure to address research questions, prevention initiatives at state and national levels, changes in reporting and payment requirements, and new patterns in antimicrobial resistance.

Automated and electronically assisted hand hygiene monitoring systems: a systematic review

BACKGROUND

Hand hygiene is one of the most effective ways to prevent transmission of health care-associated infections. Electronic systems and tools are being developed to enhance hand hygiene compliance monitoring. Our systematic review assesses the existing evidence surrounding the adoption and accuracy of automated systems or electronically enhanced direct observations and also reviews the effectiveness of such systems in health care settings.

METHODS

We systematically reviewed PubMed for articles published between January 1, 2000, and March 31, 2013, containing the terms hand AND hygiene or hand AND disinfection or handwashing. Resulting articles were reviewed to determine if an electronic system was used.

RESULTS

We identified 42 articles for inclusion. Four types of systems were identified: electronically assisted/enhanced direct observation, video-monitored direct observation systems, electronic dispenser counters, and automated hand hygiene monitoring networks. Fewer than 20% of articles identified included calculations for efficiency or accuracy.

CONCLUSIONS

Limited data are currently available to recommend adoption of specific automatic or electronically assisted hand hygiene surveillance systems. Future studies should be undertaken that assess the accuracy, effectiveness, and cost-effectiveness of such systems. Given the restricted clinical and infection prevention budgets of most facilities, cost-effectiveness analysis of specific systems will be required before these systems are widely adopted.

Development and psychometric testing of ventilator bundle questionnaire and observation schedule

BACKGROUND

There is a current lack of valid and reliable instruments that can be used to examine critical care nurses' knowledge and skills in adhering to ventilator bundles. The aim of this study was to develop and psychometrically test a ventilator bundle questionnaire (VBQ) and ventilator bundle observation schedule (VBOS).

METHODS

The VBQ and VBOS consisted of a list of pharmacologic and nonpharmacologic nurse-led interventions taken from the literature and supported by various levels of evidence. After content validation, stability and equivalence reliabilities of the VBOS were determined in a randomly selected sample of critical care nurses from a single academic center in Finland.

RESULTS

The final VBQ contained 49 multiple-choice questions, and the VBOS had 86 dichotomous items, whose overall content validity ranged from 0.99 to 1.0. The overall intraclass correlation coefficient of the VBOS ranged from 0.93 to 1.0.

CONCLUSIONS

The VBQ and VBOS have acceptable psychometric properties and could be used to objectively assess whether evidence-based guidelines regarding ventilator bundles are being used in clinical practice. Further testing with diverse samples is needed to strengthen the validity and reliability of these instruments.

Patients' hand hygiene at home predicts their hand hygiene practices in the hospital

We examine factors associated with hand hygiene practices of hospital patients. Hygiene in the hospital decreased compared to that at home, and home practices were strongly associated with hospital practices. Understanding and leveraging the intrinsic value some patients associate with hand hygiene may be important for improving overall hospital hygiene and decreasing healthcare-associated infections.