Mental models: a basic concept for human factors design in infection prevention

Health Communication and Behavioral Change During the COVID-19 Pandemic

The COVID-19 pandemic challenged the public health system to respond to an emerging, difficult-to-understand pathogen through demanding behaviors, including staying at home, masking for long periods, and vaccinating multiple times. We discuss key challenges of the pandemic health communication efforts deployed in the United States from 2020 to 2022 and identify research priorities. One priority is communicating about uncertainty in ways that prepare the public for disagreement and likely changes in recommendations as scientific understanding advances: How can changes in understanding and recommendations foster a sense that "science works as intended" rather than "the experts are clueless" and prevent creating a void to be filled by misinformation? A second priority concerns creating a culturally fluent framework for asking people to engage in difficult and novel actions: How can health messages foster the perception that difficulties of behavior change signal that the change is important rather than that the change "is not for people like me?" A third priority entails a shift from communication strategies that focus on knowledge and attitudes to interventions that focus on norms, policy, communication about policy, and channel factors that impair behavior change: How can we move beyond educating and correcting misinformation to achieving desired actions?

Determinants of the optimal selection of vascular access devices: A systematic review underpinned by the COM-B behavioural model

BACKGROUND

Optimal selection of vascular access devices is based on multiple factors and is the first strategy to reduce vascular access device-related complications. This process is dependent on behavioural and human factors. The COM-B (Capability, Opportunity, Motivation, Behaviour) model was used as a theoretical framework to organize the findings of this systematic review.

METHODS/AIMS

To synthesize the evidence on determinants shaping the optimal selection of vascular access devices, using the COM-B behavioural model as the theoretical framework.

DESIGN

Systematic review of studies which explore decision-making at the time of selecting vascular access devices.

DATA SOURCES

The Medline, Web of Science, Scopus and EbscoHost databases were interrogated to extract manuscripts published up to 31 December 2021, in English or Spanish.

RESULTS

Among 16 studies included in the review, 8/16 (50%) focused on physical capability, 8/16 (50%) psychological capability, 15/16 (94%) physical opportunity, 12/16 (75%) social opportunity, 1/16 (6%) reflective motivation and 0/16 (0%) automatic motivation. This distribution represents a large gap in terms of interpersonal and motivational influences and cultural and social environments. Specialist teams (teams created for the insertion or maintenance of vascular access devices) are core for the optimal selection of vascular access devices (75% physical capability, 62% psychological capability, 80% physical opportunity and 100% social opportunity).

CONCLUSION

Specialist teams predominantly lead all actions undertaken towards the optimal selection of vascular access devices. These actions primarily centre on assessing opportunity and capability, often overlooking motivational influences and social environments.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

A more implementation-focused professional approach could decrease inequity among patients and complications associated with vascular access devices.

IMPACT

Optimal selection of vascular access devices is the primary strategy in mitigating complications associated with these devices. There is a significant disparity between interpersonal and motivational influences and the cultural and social environments. Furthermore, specialized teams play a pivotal role in facilitating the optimal selection of vascular access devices. The study can benefit institutions concerned about vascular access devices and their complications.

REPORTING METHOD

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution. WHAT DOES THIS ARTICLE CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Optimal selection of vascular devices remains a growing yet unresolved issue with costly clinical and patient experience impact. Interventions to improve the optimal selection of vascular devices have focused on training, education, algorithms and implementation of specialist vascular teams; alas, these approaches do not seem to have substantially addressed the problem. Specialist vascular teams should evolve and pivot towards leading the implementation of quality improvement interventions, optimizing resource use and enhancing their role.

Impact of a Serious Game (#RedPingüiNO) to Reduce Facial Self-Touches and Prevent Exposure to Pathogens Transmitted via Hands: Quasi-Experimental Intervention

BACKGROUND

After the COVID-19 pandemic, society has become more aware of the importance of some basic hygienic habits to avoid exposure to pathogens transmitted via hands. Given that a high frequency of touching mucous membranes can lead to a high risk of infection, it is essential to establish strategies to reduce this behavior as a preventive measure against contagion. This risk can be extrapolated to a multitude of health scenarios and transmission of many infectious diseases. #RedPingüiNO was designed as an intervention to prevent the transmission of SARS-CoV-2 and other pathogens through the reduction of facial self-touches by thoughtfully engaging participants in a serious game.

OBJECTIVE

Facial self-touches should be understood as behaviors of limited control and awareness, used to regulate situations of cognitive and emotional demands, or as part of nonverbal communication. The objective of this study was to ensure that participants become aware of and reduce these behaviors through a game of self-perception.

METHODS

The quasi-experimental intervention was applied to 103 healthy university students selected by convenience sampling and put into practice for 2 weeks, with 1 control group (n=24, 23.3%) and 2 experimental groups (experimental group with no additional social reinforcement interventions: n=36, 35%; experimental group with additional social reinforcement interventions: n=43, 41.7%). The objective was to improve knowledge and perception and reduce facial self-touches to prevent exposure to pathogens transmitted via hands not only in health multihazard scenarios but also in ordinary circumstances. The ad hoc instrument used to analyze the experience consisted of 43 items and was valid and reliable for the purpose of this study. The items were divided into 5 blocks extracted from the theoretical framework: sociological issues (1-5); hygiene habits (6-13); risk awareness (14-19); strategies for not touching the face (20-26); and questions after the intervention (27-42), designed as a postintervention tool assessing the game experience. Validation of the content was achieved through assessment by 12 expert referees. External validation was performed using a test-retest procedure, and reliability was verified using the Spearman correlation.

RESULTS

The results of the ad hoc questionnaire, which were analyzed using the Wilcoxon signed-rank test and McNemar index to identify significant differences between test and retest for a 95% CI, showed that facial self-touches were reduced (item 20, P<.001; item 26, P=.04), and awareness of this spontaneous behavior and its triggers increased (item 15; P=.007). The results were reinforced by qualitative findings from the daily logs.

CONCLUSIONS

The intervention exhibited a greater effect from sharing the game, with interactions between people; however, in both cases, it was helpful in reducing facial self-touches. In summary, this game is suitable for reducing facial self-touches, and owing to its free availability and design, it can be adapted to various contexts.

WHO "My Five Moments for hand hygiene" in anaesthesia induction: a video-based analysis reveals novel system challenges and design opportunities

BACKGROUND

Anaesthesia induction is a fast-paced, complex activity that involves a high density of hand-to-surface exposures. Hand hygiene (HH) adherence has been reported to be low, which bears the potential for unnoticed pathogen transmission between consecutive patients. Therefore, we aimed to study the fit of the WHO's five moments of HH concept to the anaesthesia induction workflow.

METHODS

We analysed video recordings of 59 anaesthesia inductions according to the WHO HH observation method considering each hand-to-surface exposure of every involved anaesthesia provider. Binary logistic regression was used to determine risk factors for non-adherence, i.e., professional category, gender, task role, gloves, holding of objects, team size and HH moment. Additionally, we re-coded half of the videos for self-touching behaviour for quantitative and qualitative analysis.

RESULTS

Overall, 2240 HH opportunities were met by 105 HH actions (4.7%). The drug administrator role (OR=2.2), the senior physician status (OR=2.1), donning (OR=2.6) and doffing (OR=3.6) of gloves were associated with higher HH adherence. Notably, 47.2% of all HH opportunities were caused by self-touching behaviour. Provider clothes, face, and patient skin were the most frequently touched surfaces.

CONCLUSIONS

The high density of hand-to-surface exposures, a high cognitive load, prolonged glove use, carried mobile objects, self-touching, and personal behaviour patterns were potential causes for non-adherence. A purpose-designed HH concept based on these results, involving the introduction of designated objects and provider clothes to the patient zone, could mitigate HH adherence and microbiologic safety.

Hand hygiene improvement of individual healthcare workers: results of the multicentre PROHIBIT study

BACKGROUND

Traditionally, hand hygiene (HH) interventions do not identify the observed healthcare workers (HWCs) and therefore, reflect HH compliance only at population level. Intensive care units (ICUs) in seven European hospitals participating in the "Prevention of Hospital Infections by Intervention and Training" (PROHIBIT) study provided individual HH compliance levels. We analysed these to understand the determinants and dynamics of individual change in relation to the overall intervention effect.

METHODS

We included HCWs who contributed at least two observation sessions before and after intervention. Improving, non-changing, and worsening HCWs were defined with a threshold of 20% compliance change. We used multivariable linear regression and spearman's rank correlation to estimate determinants for the individual response to the intervention and correlation to overall change. Swarm graphs visualized ICU-specific patterns.

RESULTS

In total 280 HCWs contributed 17,748 HH opportunities during 2677 observation sessions. Overall, pooled HH compliance increased from 43.1 to 58.7%. The proportion of improving HCWs ranged from 33 to 95% among ICUs. The median HH increase per improving HCW ranged from 16 to 34 percentage points. ICU wide improvement correlated significantly with both the proportion of improving HCWs (ρ = 0.82 [95% CI 0.18-0.97], and their median HH increase (ρ = 0.79 [0.08-0.97]). Multilevel regression demonstrated that individual improvement was significantly associated with nurse profession, lower activity index, higher nurse-to-patient ratio, and lower baseline compliance.

CONCLUSIONS

Both the proportion of improving HCWs and their median individual improvement differed substantially among ICUs but correlated with the ICUs' overall HH improvement. With comparable overall means the range in individual HH varied considerably between some hospitals, implying different transmission risks. Greater insight into improvement dynamics might help to design more effective HH interventions in the future.

Impact of Situational Environmental Education on Tourist Behavior-A Case Study of Water Culture Ecological Park in China

With the increasing number of travelling people, the behavior of tourists is having an increasing impact on the environment. Situational environmental education will influence the tourists' responsible environmental behavior, which positively or negatively affects the environment. The purpose of this study is to explore the impact of situational environmental education on tourists' responsible environmental behavior through a field study of Changchun Water Culture Ecological Park, combined with a survey and Zaltman metaphor elicitation technique (ZMET) interview method. There are 527 questionnaires, 89 pre-questionnaires, and 15 interview records collected. The results showed that: (1) All interviewees were impressed with the situational environmental education in the park. It can be concluded that the situational environmental education is easily accepted. The reason may be that, among the theme park users, 42.69% were aged 21-30 year's old, and 62.8% of the population have a college degree or above. (2) The standardized path coefficient of situational environmental education in tourist destinations for tourists' behavioral intention is 0.74, and the standardized path coefficient for responsible environmental behavior is 0.78, which is much higher than the standard value of 0.4. Therefore, situational environmental education has positive influences on the tourists' behavioral intention and responsible environmental behavior. (3) The sensitive analysis the tourists' behavioral intention has a positive relationship with attitudes toward environmental behaviors (0.66), subjective norm (0.53), and perceptual behavior control (0.52). The results of this study can provide a scientific basis for the planning and design of urban parks.

Healthcare worker mental models of patient care tasks in the context of infection prevention and control

OBJECTIVE

Understanding the cognitive determinants of healthcare worker (HCW) behavior is important for improving the use of infection prevention and control (IPC) practices. Given a patient requiring only standard precautions, we examined the dimensions along which different populations of HCWs cognitively organize patient care tasks (ie, their mental models).

DESIGN

HCWs read a description of a patient and then rated the similarities of 25 patient care tasks from an infection prevention perspective. Using multidimensional scaling, we identified the dimensions (ie, characteristics of tasks) underlying these ratings and the salience of each dimension to HCWs.

SETTING

Adult inpatient hospitals across an academic hospital network.

PARTICIPANTS

In total, 40 HCWs, comprising infection preventionists and nurses from intensive care units, emergency departments, and medical-surgical floors rated the similarity of tasks. To identify the meaning of each dimension, another 6 nurses rated each task in terms of specific characteristics of tasks.

RESULTS

Each HCW population perceived patient care tasks to vary along 3 common dimensions; most salient was the perceived magnitude of infection risk to the patient in a task, followed by the perceived dirtiness and risk of HCW exposure to body fluids, and lastly, the relative importance of a task for preventing versus controlling an infection in a patient.

CONCLUSIONS

For a patient requiring only standard precautions, different populations of HCWs have similar mental models of how various patient care tasks relate to IPC. Techniques for eliciting mental models open new avenues for understanding and ultimately modifying the cognitive determinants of IPC behaviors.

Surgeons' mental models of surgical site infection: Insights into adherence with complex prevention bundles

Of 10 surgeons interviewed in a descriptive qualitative study, 6 believed that surgical site infections are inevitable. Bundle adherence was felt to be more likely with strong evidence-based measures developed by surgical leaders. The intrinsic desire to excel was viewed as the main adherence motivator, rather than "pay-for-performance" models.

Cognitive Predictors of Precautionary Behavior During the COVID-19 Pandemic

The attempts to mitigate the unprecedented health, economic, and social disruptions caused by the COVID-19 pandemic are largely dependent on establishing compliance to behavioral guidelines and rules that reduce the risk of infection. Here, by conducting an online survey that tested participants' knowledge about the disease and measured demographic, attitudinal, and cognitive variables, we identify predictors of self-reported social distancing and hygiene behavior. To investigate the cognitive processes underlying health-prevention behavior in the pandemic, we co-opted the dual-process model of thinking to measure participants' propensities for automatic and intuitive thinking vs. controlled and reflective thinking. Self-reports of 17 precautionary behaviors, including regular hand washing, social distancing, and wearing a face mask, served as a dependent measure. The results of hierarchical regressions showed that age, risk-taking propensity, and concern about the pandemic predicted adoption of precautionary behavior. Variance in cognitive processes also predicted precautionary behavior: participants with higher scores for controlled thinking (measured with the Cognitive Reflection Test) reported less adherence to specific guidelines, as did respondents with a poor understanding of the infection and transmission mechanism of the COVID-19 virus. The predictive power of this model was comparable to an approach (Theory of Planned Behavior) based on attitudes to health behavior. Given these results, we propose the inclusion of measures of cognitive reflection and mental model variables in predictive models of compliance, and future studies of precautionary behavior to establish how cognitive variables are linked with people's information processing and social norms.

Identifying the World Health Organization's fifth moment for hand hygiene: Infection prevention in the operating room

Background

The World Health Organization have designed the fifth of their '5 moments' for hand hygiene to account for microbial transfer from patients to equipment in a narrow area around that patient, known as the patient zone. The study was prompted by emerging local confusion about application of the patient zone in the operating room (OR).

Aim/Objectives

In two phases, we aimed to create a '5 moments' style poster displaying an OR patient zone: phase 1, quantify equipment, in direct contact with the patient and, touched by non-scrubbed staff immediately after touching the patient; and phase 2, categorise equipment identified in phase 1 into patient zone and healthcare zone. An objective is to produce a '5 moments' poster for the OR.

Methods

The first phase used non-participant direct overt observation. In phase 2, phase 1 data were collaboratively assigned to patient zone or healthcare zone. Photography and graphic design were used to produce the OR '5 moments' poster.

Results

In 11 full-length surgeries, 20 pieces of equipment were in direct contact with the patient and 57 pieces of equipment were touched. In phase 2, a '5 moments' poster showing an OR patient zone was designed.

Discussion

Content of the patient zone was identified and displayed in a novel resource. Having shared understanding of the patient zone has potential to sustain hand hygiene compliance and equipment cleaning in the OR.

Conclusion

Limitations in methods were balanced by collaboration with frontline staff. The study has been used as a teaching tool in the OR and similar settings.

Understanding nurses' workflow: Batching care and potential opportunities for transmission of infectious organisms, a pilot study

BACKGROUND

Caring for patients in contact precautions can be challenging. In this pilot study, we sought to understand, using qualitative and visual methods, how nurses provide care for patients in contact precaution rooms and to identify potential breakdowns in practice that could increase risk of disease transmission.

METHODS

Qualitative data were collected while shadowing 4 nurses on 2 medical/surgical units at a university medical center between September and October 2016. Observers documented nurses' movements in handwritten fieldnotes. Fieldnote data were analyzed using a descriptive approach with visual depiction to map care delivery in precaution and non-precaution rooms.

RESULTS

Nurses moved between non-precaution rooms, completing 1-4 tasks per room entry, over the course of several brief room entries and exits. In contrast, nurses rarely entered contact precaution rooms to complete only a few tasks, generally completing ≥10 tasks per room entry. Although hand hygiene on room entry/exit was consistently performed, a breakdown in practice occurred in precaution rooms as nurses tended to move between tasks and contact with the environment without performing hand hygiene.

CONCLUSIONS

Differences in how nurses structure their work in contact precaution rooms may contribute to risk of infectious disease transmission. Understanding and addressing the challenges specific to how nurses work is a critical part of infection prevention in today's hospital environment.

Effect of an Intervention Package and Teamwork Training to Prevent Healthcare Personnel Self-contamination During Personal Protective Equipment Doffing

BACKGROUND

More than 28 000 people were infected with Ebola virus during the 2014-2015 West African outbreak, resulting in more than 11 000 deaths. Better methods are needed to reduce the risk of self-contamination while doffing personal protective equipment (PPE) to prevent pathogen transmission.

METHODS

A set of interventions based on previously identified failure modes was designed to mitigate the risk of self- contamination during PPE doffing. These interventions were tested in a randomized controlled trial of 48 participants with no prior experience doffing enhanced PPE. Contamination was simulated using a fluorescent tracer slurry and fluorescent polystyrene latex spheres (PLSs). Self-contamination of scrubs and skin was measured using ultraviolet light visualization and swabbing followed by microscopy, respectively. Doffing sessions were videotaped and reviewed to score standardized teamwork behaviors.

RESULTS

Participants in the intervention group contaminated significantly fewer body sites than those in the control group (median [interquartile range], 6 [3-8] vs 11 [6-13], P = .002). The median contamination score was lower for the intervention group than the control group when measured by ultraviolet light visualization (23.15 vs 64.45, P = .004) and PLS swabbing (72.4 vs 144.8, P = .001). The mean teamwork score was greater in the intervention group (42.2 vs 27.5, P < .001).

CONCLUSIONS

An intervention package addressing the PPE doffing task, tools, environment, and teamwork skills significantly reduced the amount of self-contamination by study participants. These elements can be incorporated into PPE guidance and training to reduce the risk of pathogen transmission.

Exploring healthcare providers' mental models of the infection prevention "patient zone" - a concept mapping study

Background

Pathogen transmission plays a major role in the development of healthcare-associated infections. The “patient zone” concept developed as part of the World Health Organization’s “Five moments of hand hygiene” aims to distinguish surfaces primarily contaminated by flora of a single patient, i.e. inside the patient zone, from those outside the patient zone containing foreign and potentially harmful microorganisms. Discrepancies in healthcare provider (HCP) internal conceptual representations (i.e. mental models) of the patient zone may lead to missed infection prevention measures that could result in patient harm. We explored HCPs’ mental models of the patient zone that shape how they interact with the work environment.

Methods

We conducted individual concept mapping interviews supported by a card-sorting technique to examine HCPs’ mental models of the patient zone and compared these to IPC expert models. Ten participants (five nurses, five physicians) without IPC specialization and two IPC experts provided definitions of the patient zone and allocated 32 items to “inside” or “outside” the patient zone while verbalizing their thought processes. We calculated similarity as percent agreement among participants and accuracy as percent allocated consistently with expert consensus. A content analysis of interview recordings served to identify mental models underlying the allocation decisions.

Results

Our study revealed limited similarity among participants, with seven of 32 items allocated consistently among all participants. Overall, 68% of items were sorted accurately according to expert consensus. Identified mental models were categorized as follows: “Patient contact”, the patient zone defined according to objects having patient contact; “Sectors”, the patient zone as a defined physical space; “Disinfection”, the patient zone deduced based on need to disinfect hands and objects; and “Context-dependency”, the patient zone defined depending on the context of an object’s use.

Conclusions

Our study revealed ambiguity surrounding the patient zone concept as evidenced by low similarity between participants and important discrepancies between participant and expert mental models. Such ambiguity may lead to inconsistent application of the patient zone concept and represents a patient safety risk. Initiatives to improve understanding and application of the patient zone concept should focus on establishing consistent, theoretically founded mental models.

Human Factors Engineering Contributions to Infection Prevention and Control

OBJECTIVE

This article provides a review of areas that present significant challenges in infection prevention and control and describes human factors engineering (HFE) approaches that have been applied successfully to these areas. In addition, implications and recommendations for HFE use in future research are discussed.

BACKGROUND

Infection prevention and control aims to prevent patients and health care personnel from acquiring preventable infections in healthcare. Effective infection control practices of healthcare-associated infections have recently become even more critical with the emergence of life-threatening infections. HFE could benefit infection prevention and control in addressing older and more recent challenges, but uptake has been limited.

METHOD/RESULTS

This literature review is an integration and synthesis of recently published research that describes HFE-based approaches in infection prevention and control to address the challenges for three specific topics. The results of the review suggests that HFE is in a position to support work in infection prevention and control and improve overall healthcare safety.

CONCLUSION

HFE provides conceptual frameworks and methods that have significant potential to improve infection prevention and control.

APPLICATION

The work reviewed can provide potential solutions for current infection prevention and control challenges by applying HFE based recommendations.

Preventing healthcare-associated infections through human factors engineering

PURPOSE OF REVIEW

Human factors engineering (HFE) approaches are increasingly being used in healthcare, but have been applied in relatively limited ways to infection prevention and control (IPC). Previous studies have focused on using selected HFE tools, but newer literature supports a system-based HFE approach to IPC.

RECENT FINDINGS

Cross-contamination and the existence of workarounds suggest that healthcare workers need better support to reduce and simplify steps in delivering care. Simplifying workflow can lead to better understanding of why a process fails and allow for improvements to reduce errors and increase efficiency. Hand hygiene can be improved using visual cues and nudges based on room layout. Using personal protective equipment appropriately appears simple, but exists in a complex interaction with workload, behavior, emotion, and environmental variables including product placement. HFE can help prevent the pathogen transmission through improving environmental cleaning and appropriate use of medical devices.

SUMMARY

Emerging evidence suggests that HFE can be applied in IPC to reduce healthcare-associated infections. HFE and IPC collaboration can help improve many of the basic best practices including use of hand hygiene and personal protective equipment by healthcare workers during patient care.

Likelihood of Infectious Outcomes Following Infectious Risk Moments During Patient Care-An International Expert Consensus Study and Quantitative Risk Index

OBJECTIVE To elicit expert consensus on the likelihood of infectious outcomes (patient colonization or infection) following a broad range of infectious risk moments (IRMs) from observations in acute care. DESIGN Expert consensus study using modified Delphi technique. PARTICIPANTS Panel of 40 international experts including nurses, physicians and microbiologists specialized in infectious diseases and infection prevention and control (IPC). METHODS The modified Delphi process consisted of 3 online survey rounds, with feedback of mean ratings and expert comments between rounds. The Delphi survey comprised 52 care scenarios representing observed IRMs organized into 6 sections: hands, gloves, medical devices, mobile objects, invasive procedures, and additional moments. For each scenario, experts indicated the likelihood of both patient colonization and infection on a scale from 0 to 5 (high). Expert ratings were plotted against frequencies of IRMs observed during actual patient care resulting in a risk index. RESULTS Following 3 rounds, consensus was achieved for 92 of 104 items (88.5%). The mean ratings across all scenarios for likelihood of colonization and infection were 2.68 and 2.02, respectively. The likelihood of colonization was rated higher than infection for 48 of 52 scenarios. Ratings were significantly higher for colonization (P=.001) and infection (P<.0005) when the scenario involved transfer of pathogens to critical patient sites. CONCLUSIONS The design of effective IPC strategies requires the selection of behaviors according to their impact on patient outcomes. The IRM index reported here provides a basis for standardizing and prioritizing targets for quality improvement initiatives, training, and future research in acute health care. Infect Control Hosp Epidemiol 2018;39:280-289.

Frequency and Nature of Infectious Risk Moments During Acute Care Based on the INFORM Structured Classification Taxonomy

OBJECTIVE In this study, we sought to establish a comprehensive inventory of infectious risk moments (IRMs), defined as seemingly innocuous yet frequently occurring care manipulations potentially resulting in transfer of pathogens to patients. We also aimed to develop and employ an observational taxonomy to quantify the frequency and nature of IRMs in acute-care settings. DESIGN Prospective observational study and establishment of observational taxonomy. SETTING Intensive care unit, general medical ward, and emergency ward of a university-affiliated hospital. PARTICIPANTS Healthcare workers (HCWs) METHODS Exploratory observations were conducted to identify IRMs, which were coded based on the surfaces involved in the transmission pathway to establish a structured taxonomy. Structured observations were performed using this taxonomy to quantify IRMs in all 3 settings. RESULTS Following 129.17 hours of exploratory observations, identified IRMs involved HCW hands, gloves, care devices, mobile objects, and HCW clothing and accessories. A structured taxonomy called INFORM (INFectiOus Risk Moment) was established to classify each IRM according to the source, vector, and endpoint of potential pathogen transfer. We observed 1,138 IRMs during 53.77 hours of structured observations (31.25 active care hours) for an average foundation of 42.8 IRMs per active care hour overall, and average densities of 34.9, 36.8, and 56.3 IRMs in the intensive care, medical, and emergency wards, respectively. CONCLUSIONS Hands and gloves remain among the most important contributors to the transfer of pathogens within the healthcare setting, but medical devices, mobile objects, invasive devices, and HCW clothing and accessories may also contribute to patient colonization and/or infection. The INFORM observational taxonomy and IRM inventory presented may benefit clinical risk assessment, training and education, and future research. Infect Control Hosp Epidemiol 2018;39:272-279.

Human factors-based risk analysis to improve the safety of doffing enhanced personal protective equipment

OBJECTIVE

To systematically assess enhanced personal protective equipment (PPE) doffing safety risks.

DESIGN

We employed a 3-part approach to this study: (1) hierarchical task analysis (HTA) of the PPE doffing process; (2) human factors-informed failure modes and effects analysis (FMEA); and (3) focus group sessions with a convenience sample of infection prevention (IP) subject matter experts.

SETTING

A large academic US hospital with a regional Special Pathogens Treatment Center and enhanced PPE doffing protocol experience.ParticipantsEight IP experts.

METHODS

The HTA was conducted jointly by 2 human-factors experts based on the Centers for Disease Control and Prevention PPE guidelines. The findings were used as a guide in 7 focus group sessions with IP experts to assess PPE doffing safety risks. For each HTA task step, IP experts identified failure mode(s), assigned priority risk scores, identified contributing factors and potential consequences, and identified potential risk mitigation strategies. Data were recorded in a tabular format during the sessions.

RESULTS

Of 103 identified failure modes, the highest priority scores were associated with team members moving between clean and contaminated areas, glove removal, apron removal, and self-inspection while preparing to doff. Contributing factors related to the individual (eg, technical/ teamwork competency), task (eg, undetected PPE contamination), tools/technology (eg, PPE design characteristics), environment (eg, inadequate space), and organizational aspects (eg, training) were identified. Participants identified 86 types of risk mitigation strategies targeting the failure modes.

CONCLUSIONS

Despite detailed guidelines, our study revealed 103 enhanced PPE doffing failure modes. Analysis of the failure modes suggests potential mitigation strategies to decrease self-contamination risk during enhanced PPE doffing.

Human factors considerations in designing for infection prevention and control in neonatal care - findings from a pre-design inquiry

Qualitative data collection methods drawn from the early stages of human-centred design frameworks combined with thematic analysis were used to develop an understanding of infection prevention practice within an existing neonatal intensive care unit. Findings were used to generate a framework of understanding which in turn helped inform a baseline approach for future research and design development. The study revealed that a lack of clarity between infection transmission zones and a lack of design attributes needed to uphold infection prevention measures may be undermining healthcare workers' understanding and application of good practice. The issue may be further complicated by well-intentioned behavioural attitudes to meeting work objectives; undue influences from spatial constraints; the influence of inadvertent and excessive touch-based interactions; physical and/or cognitive exertion to maintain transmission barriers; and the impact of expanding job design and increased workload to supplement for lack of effective barriers. Practitioner Summary: Despite high hand hygiene compliance within a neonatal intensive care unit, healthcare workers expressed concerns about the unit design and infection prevention practice. Early inquiry methods from human-centred design and thematic analysis helped develop a framework to understand how design can be used to aid infection prevention.

"First-person view" of pathogen transmission and hand hygiene - use of a new head-mounted video capture and coding tool

Background

Healthcare workers' hands are the foremost means of pathogen transmission in healthcare, but detailed hand trajectories have been insufficiently researched so far. We developed and applied a new method to systematically document hand-to-surface exposures (HSE) to delineate true hand transmission pathways in real-life healthcare settings.

Methods

A head-mounted camera and commercial coding software were used to capture ten active care episodes by eight nurses and two physicians and code HSE type and duration using a hierarchical coding scheme. We identified HSE sequences of particular relevance to infectious risks for patients based on the WHO 'Five Moments for Hand Hygiene'. The study took place in a trauma intensive care unit in a 900-bed university hospital in Switzerland.

Results

Overall, the ten videos totaled 296.5 min and featured eight nurses and two physicians. A total of 4222 HSE were identified (1 HSE every 4.2 s), which concerned bare (79%) and gloved (21%) hands. The HSE inside the patient zone (n = 1775; 42%) included mobile objects (33%), immobile surfaces (5%), and patient intact skin (4%), while HSE outside the patient zone (n = 1953; 46%) included HCW's own body (10%), mobile objects (28%), and immobile surfaces (8%). A further 494 (12%) events involved patient critical sites. Sequential analysis revealed 291 HSE transitions from outside to inside patient zone, i.e. "colonization events", and 217 from any surface to critical sites, i.e. "infection events". Hand hygiene occurred 97 times, 14 (5% adherence) times at colonization events and three (1% adherence) times at infection events. On average, hand rubbing lasted 13 ± 9 s.

Conclusions

The abundance of HSE underscores the central role of hands in the spread of potential pathogens while hand hygiene occurred rarely at potential colonization and infection events. Our approach produced a valid video and coding instrument for in-depth analysis of hand trajectories during active patient care that may help to design more efficient prevention schemes.

Evaluation of a visual tool co-developed for training hospital staff on the prevention and control of the spread of healthcare associated infections

BACKGROUND

Staff training in infection prevention and control (IPC) across hospital settings has a crucial role in reducing the incidence of healthcare associated infections (HAIs). However the application of dynamic visualisation approaches in this context is under-developed, with very few in-depth evaluation studies of related processes and impacts.

METHODS

A prototype training tablet app for hospital staff, using interactive visuals was developed and evaluated. To demonstrate different pathogen behaviour, dynamic visualisations of norovirus, Clostridium difficile, and MRSA were developed in relation to location, survival and transmission within a virtual hospital ward model using evidence-based microbiological and staff behavioural data. A three-stage evaluation process was designed, involving a mixed sample of UK National Health Service staff (doctors, nurses and domestic staff, n = 150).

RESULTS

Participants reported improved awareness and understanding of the pathogens responsible for HAI, the types of information relevant for different staff cohorts, those aspects of the visualisations which worked well and those which were prone to cause misunderstandings, and suggestions for further development and improvement. The tool appeared to offer staff a new perspective on pathogens, being able to 'see' them contextualised in the virtual ward, making them seem more real.

CONCLUSION

Results showed the benefits of a detailed co-development process and a more contextualised understanding of the potential for visual apps to be used in IPC training.

Similarity and accuracy of mental models formed during nursing handovers: A concept mapping approach

BACKGROUND

Shared mental models are crucial for constructing mutual understanding of the patient's condition during a clinical handover. Yet, scant research, if any, has empirically explored mental models of the parties involved in a clinical handover.

OBJECTIVES

This study aimed to examine the similarities among mental models of incoming and outgoing nurses, and to test their accuracy by comparing them with mental models of expert nurses.

DESIGN

A cross-sectional study, exploring nurses' mental models via the concept mapping technique.

PARTICIPANTS

40 clinical handovers.

DATA COLLECTION

Data were collected via concept mapping of the incoming, outgoing, and expert nurses' mental models (total of 120 concept maps). Similarity and accuracy for concepts and associations indexes were calculated to compare the different maps.

RESULTS

About one fifth of the concepts emerged in both outgoing and incoming nurses' concept maps (concept similarity=23%±10.6). Concept accuracy indexes were 35%±18.8 for incoming and 62%±19.6 for outgoing nurses' maps. Although incoming nurses absorbed fewer number of concepts and associations (23% and 12%, respectively), they partially closed the gap (35% and 22%, respectively) relative to expert nurses' maps. The correlations between concept similarities, and incoming as well as outgoing nurses' concept accuracy, were significant (r=0.43, p<0.01; r=0.68 p<0.01, respectively). Finally, in 90% of the maps, outgoing nurses added information concerning the processes enacted during the shift, beyond the expert nurses' gold standard.

DISCUSSION AND CONCLUSIONS

Two seemingly contradicting processes in the handover were identified. "Information loss", captured by the low similarity indexes among the mental models of incoming and outgoing nurses; and "information restoration", based on accuracy measures indexes among the mental models of the incoming nurses. Based on mental model theory, we propose possible explanations for these processes and derive implications for how to improve a clinical handover.

Role of Human Factors Engineering in Infection Prevention: Gaps and Opportunities

Human factors engineering (HFE), with its focus on studying how humans interact with systems, including their physical and organizational environment, the tools and technologies they use, and the tasks they perform, provides principles, tools, and techniques for systematically identifying important factors, for analyzing and evaluating how these factors interact to increase or decrease the risk of Healthcare-associated infections (HAI), and for identifying and implementing effective preventive measures. We reviewed the literature on HFE and infection prevention and control and identified major themes to document how researchers and infection prevention staff have used HFE methods to prevent HAIs and to identify gaps in our knowledge about the role of HFE in HAI prevention and control. Our literature review found that most studies in the healthcare domain explicitly applying (HFE) principles and methods addressed patient safety issues not infection prevention and control issues. In addition, most investigators who applied human factors principles and methods to infection prevention issues assessed only one human factors element such as training, technology evaluations, or physical environment design. The most significant gap pertains to the limited use and application of formal HFE tools and methods. Every infection prevention study need not assess all components in a system, but investigators must assess the interaction of critical system components if they want to address latent and deep-rooted human factors problems.

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.

Mental models of a water management system in a green building

This intergroup case study compared users' mental models with an expert design model of a water management system in a green building. The system incorporates a constructed wetland component and a rainwater collection pond that together recycle water for re-use in the building and its surroundings. The sample consisted of five building occupants and the cleaner (6 users) and two experts who were involved with the design of the water management system. Users' mental model descriptions and the experts' design model were derived from in-depth interviews combined with self-constructed (and verified) diagrams. Findings from the study suggest that there is considerable variability in the user mental models that could impact the efficient functioning of the water management system. Recommendations for improvements are discussed.

Patient engagement in clinical communication: an exploratory study

AIM

Existing practice strategies for actively involving patients in care during hospitalisation are poorly understood. The aim of this study was to explore how healthcare professionals engaged patients in communication associated with care transitions.

METHOD

An instrumental, collective case study approach was used to generate empirical data about patient transitions in care. A purposive sample of key stakeholders representing (i) patients and their families; (ii) hospital discharge planning team members; and (iii) healthcare professionals was recruited in five Australian health services. Individual and group semi-structured interviews were conducted to elicit detailed explanations of patient engagement in transition planning. Interviews lasted between 30 and 60 minutes and were digitally recorded and transcribed verbatim. Data collection and analysis were conducted simultaneously and continued until saturation was achieved. Thematic analysis was undertaken.

RESULTS

Five themes emerged as follows: (i) organisational commitment to patient engagement; (ii) the influence of hierarchical culture and professional norms on patient engagement; (iii) condoning individual healthcare professionals' orientations and actions; (iv) understanding and negotiating patient preferences; and (v) enacting information sharing and communication strategies. Most themes illustrated how patient engagement was enabled; however, barriers also existed.

CONCLUSION

Our findings show that strong organisational and professional commitment to patient-centred care throughout the organisation was a consistent feature of health services that actively engaged patients in clinical communication. Understanding patients' needs and preferences and having both formal and informal strategies to engage patients in clinical communication were important in how this involvement occurred.

An automated hand hygiene training system improves hand hygiene technique but not compliance

INTRODUCTION

The hand hygiene technique that the World Health Organization recommends for cleansing hands with soap and water or alcohol-based handrub consists of 7 poses. We used an automated training system to improve clinicians' hand hygiene technique and test whether this affected hospitalwide hand hygiene compliance.

METHODS

Seven hundred eighty-nine medical and nursing staff volunteered to participate in a self-directed training session using the automated training system. The proportion of successful first attempts was reported for each of the 7 poses. Hand hygiene compliance was collected according to the national requirement and rates for 2011-2014 were used to determine the effect of the training system on compliance.

RESULTS

The highest pass rate was for pose 1 (palm to palm) at 77% (606 out of 789), whereas pose 6 (clean thumbs) had the lowest pass rate at 27% (216 out of 789). One hundred volunteers provided feedback to 8 items related to satisfaction with the automated training system and most (86%) expressed a high degree of satisfaction and all reported that this method was time-efficient. There was no significant change in compliance rates after the introduction of the automated training system. Observed compliance during the posttraining period declined but increased to 82% in response to other strategies.

CONCLUSIONS

Technology for training clinicians in the 7 poses played an important education role but did not affect compliance rates.

The 'My five moments for hand hygiene' concept for the overcrowded setting in resource-limited healthcare systems

Hand hygiene is a core activity of patient safety for the prevention of healthcare-associated infections (HCAIs). To standardize hand hygiene practices globally the World Health Organization (WHO) released Guidelines on Hand Hygiene in Health Care and introduced the 'My five moments for hand hygiene' concept to define indications for hand hygiene rooted in an evidence-based model for transmission of micro-organisms by healthcare workers' (HCWs) hands. Central to the concept is the division of the healthcare environment into two geographical care zones, the patient zone and the healthcare zone, that requires the HCW to comply with specific hand hygiene moments. In resource-limited, overcrowded healthcare settings inadequate or no spatial separation between beds occurs frequently. These conditions challenge the HCW's ability to visualize and delineate patient zones. The 'My five moments for hand hygiene' concept has been adapted for these conditions with the aim of assisting hand hygiene educators, auditors, and HCWs to minimize ambiguity regarding shared patient zones and achieve the ultimate goal set by the WHO Guidelines--the reduction of infectious risks.

Reflections on HIS 2014: In praise of enthusiasts

Medical conferences have had a bad press recently. They have been accused of leaving nothing but indifferent research and an enormous carbon footprint. They are also likely to contribute to 'intervention bias' in healthcare, in that the speakers tend to be selected from among the more enthusiastic interventionists and charismatic optimists. But this weakness is arguably also an important strength, for they can be the vehicle by which participants are inspired to innovate and evaluate. It is difficult to predict the outcome of interventions aimed at prevention and control of infection because they involve interactions between people and complex systems, not to mention the invisible agents of infection. Progress therefore depends largely on the empirical approach - trial and error. In this context we need both enthusiasts to inspire trial and sceptics to expose error. Conferences deserve support for encouraging debate between enthusiasts and sceptics, for providing a forum for cross-fertilization between sub-specialties, and for inspiring trainees as well as practitioners. The papers presented in this issue of JHI illustrate the wide range of contemporary challenges in healthcare-associated infection, and summarize the 'state of the art' of infection prevention and control.