The Efficacy of Visual Cues to Improve Hand Hygiene Compliance

A helping hand: Applying behavioural science and co-design methodology to improve hand hygiene compliance in the hospital setting

Compliance with hand hygiene is an effective way of reducing the incidence of healthcare acquired infections (HCAI). At one London National Health Service (NHS) Trust, improving hand hygiene compliance (HHC) was a patient safety priority in response to non-compliance and ongoing occurrences of HCAI. The objective of this study was to co-design a behavioural science informed intervention to improve HHC. To obtain a baseline level of HHC and understand associated behaviours, 18 hours of observation were undertaken on three inpatient wards. These focused upon Moment 1 and 5 of the World Health Organisation's moments for hand hygiene. The intervention was co-designed with clinical staff and took the form of "visual primes". Three different stickers designed to create a motivational "nudge" were placed at key points where HHC had been observed to fail. Following implementation, a further 18 hours of observation took place. A Chi-squared statistical analysis compared proportions of HHC pre- and post-intervention. Our intervention led to an 11% increase in HHC across the three study wards for both Moments (X2 (1, N = 1,285) = 13.711, p = <0.001) in the six weeks following the intervention. The intervention had a more marked effect on Moment 1, (with an increase of 15%, X2 (1, N = 667) = 17.091, p = <0.001 when compared to the change in compliance with Moment 5 (11%, X2 (1, N = 652) = 7.449, p = 0.06). This study demonstrated that utilising behavioural science in the co-design and placement of visual motivational nudges can significantly improve compliance with hand hygiene practices. We highlight the benefit of co-design when designing interventions-both in terms of engagement with and efficacy of the intervention.

The Effect of Simulation-Based Training on the Hand Hygiene Knowledge and Practices of Palliative Caregivers: A Double-Blind, Randomized, Controlled Single-Center Study

This study aimed to investigate the effect of simulation-based training on hand hygiene knowledge and practices among palliative caregivers. The study was conducted with 60 caregivers in a palliative care clinic between December 2022 and September 2023. The participants were divided into two groups by simple randomization. The intervention and control groups received the same hand hygiene theoretical education and demonstration. The intervention group also received additional simulation-based hand hygiene practices recommended by the World Health Organization. A pretest-posttest design was used to assess hand hygiene knowledge and practices. Data were collected with personal information, hand hygiene knowledge, and hand hygiene practice forms. Analysis of covariance was performed to compare posttest scores between the groups. Simulation-based hand hygiene training programs offer an effective and feasible strategy to improve the hand hygiene knowledge and practices of caregivers. It should be integrated into clinical areas to increase palliative caregivers' hand hygiene knowledge and practices. Evidence-based practices can be improved by increasing randomized controlled studies on the effectiveness of simulation-based hand hygiene training for caregivers. Trial Registration: The study was registered at ClinicalTrials.gov with registration number NCT05848596.

Visibility and Accessibility of Hand Hygiene Stations and Fatigue Among Nurses Working in Long-Term Care (LTC) During the COVID-19 Pandemic

OBJECTIVES

Evaluate the relationship between nurses' perception of the long-term care (LTC) environment, specifically having visible and accessible hand hygiene stations (HHS), and nurses' fatigue during the COVID-19 pandemic.

BACKGROUND

LTC nurses experience not only heavy workloads and fatigue but also a high risk of infection during the COVID-19 pandemic. Few studies have evaluated the relationship between safety measures such as having visible and accessible HHS and nurses' fatigue.

METHODS

The cross-sectional COVID-19 Impact on Nurses Study (COINS) was an online survey distributed to members of the American Association of Post-Acute Care Nursing through the REDCap survey platform, between June 1, 2020, and January 31, 2021. Logistic regression modeling was conducted to identify the relationship between nurses' perception of having visible and accessible HHS and fatigue among LTC nurses.

RESULTS

The majority of LTC nurse respondents (78.35%) reported having moderate to very severe fatigue. Nurses who reported not having enough visible and accessible HHS in their work environment have statistically significantly higher odds (odds ratio [OR] = 0.37, 95% confidence interval [CI] [0.20, 0.70], p = .002) of reporting experiencing moderate to very severe fatigue compared to nurses who perceived there was adequate HHS. The logistic regression is significant while controlling for sociodemographic differences, guilt for family and patients, support from work, and confidence in the future of LTC.

CONCLUSIONS

This study reveals the LTC environment that incorporates better considerations of more visible and accessible HHS might mitigate nurses' fatigue during the pandemic. A conceptual framework has been proposed for future studies.

A nudge intervention to improve hand hygiene compliance in the hospital

Hand hygiene among professionals plays a crucial role in preventing healthcare-associated infections, yet poor compliance in hospital settings remains a lasting reason for concern. Nudge theory is an innovative approach to behavioral change first developed in economics and cognitive psychology, and recently spread and discussed in clinical medicine. To assess a combined nudge intervention (localized dispensers, visual reminders, and gain-framed posters) to promote hand hygiene compliance among hospital personnel. A quasi-experimental study including a pre-intervention phase and a post-intervention phase (9 + 9 consecutive months) with 117 professionals overall from three wards in a 350-bed general city hospital. Hand hygiene compliance was measured using direct observations by trained personnel and measurement of alcohol-based hand-rub consumption. Levels of hand hygiene compliance were low in the pre-intervention phase: 11.44% of hand hygiene opportunities prescribed were fulfilled overall. We observed a statistically significant effect of the nudge intervention with an increase to 18.71% (p < 0.001) in the post-intervention phase. Improvement was observed in all experimental settings (the three hospital wards). A statistical comparison across three subsequent periods of the post-intervention phase revealed no significant decay of the effect. An assessment of the collected data on alcohol-based hand-rub consumption indirectly confirms the main result in all experimental settings. Behavioral outcomes concerning hand hygiene in the hospital are indeed affected by contextual, nudging factors to a significant extent. If properly devised, nudging measures can provide a sustainable contribution to increase hand hygiene compliance in a hospital setting.

Comparing panic alarm systems for high-risk domestic abuse victims: a randomised controlled trial on prevention and criminal justice system outcomes

Background

The use of panic alarm systems for victims of domestic abuse is becoming increasingly popular. However, tests of these devices are rare. Consequently, it is presently unknown whether domestic abuse offenders are deterred by warning stickers informing them that a panic alarm system is installed on the premises, or whether alarm systems reduce domestic abuse recidivism. There is also a lack of data regarding whether adding an audio-recording feature to the panic alarm results in more prosecutions of domestic abuse offenders compared to standard panic alarm systems. Measuring the efficacy of warning stickers and audio recordings will enhance understanding of the overall effectiveness of panic alarm systems for domestic abuse.

Methods

This study used a pre-test-post-test, control group design, in which 300 eligible high-risk domestic abuse victims in London, UK, were randomly allocated to either a standard panic alarm system or a panic alarm system with audio-recording capabilities and a red warning sticker on a durable, A6-size sign displayed at eye level at the entrance to the premises. Each sticker was well lit to ensure maximum visibility. The gain scores of multiple measures at 6 months prior and 6 months post-randomisation were used to assess the treatment effects (including the number of calls for service, recorded crimes, and harm score), and a negative binomial generalised linear model was utilised to estimate the likelihood of criminal charges for domestic abuse offenders in the two systems.

Outcomes

Pre-post comparisons of recidivism suggested an overall reduction in both treatment arms, but there were no statistically significant differences between the two types of alarm systems across these crime measures. Nevertheless, the estimation model indicated a significant 57% increase in charges using the audio-recording alarm relative to the standard panic alarm system.

Conclusions

Using deterrent stickers to warn domestic abuse offenders of panic alarm systems does not lead to a reduction in subsequent harm to victims. Compared to ordinary panic alarms for high-risk domestic abuse victims, audio-recording systems provide valuable evidence that increases subsequent charges, and thus, these systems should be explored further.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11292-022-09505-1.

Compliance to hand hygiene and its determinant factors among Community Health Care Providers in Community Clinics: an observational study in Bangladesh

Background

Healthcare-associated infections caused by poor hand hygiene (HH) practices can affect both the care seekers and the health care providers (HCPs) while providing primary health care. No study has been conducted on the compliance of HH practices among the primary level HCPs in Bangladesh.

Objective

The study aimed to assess the compliance rates of HH and its determinant factors among Community Health Care Providers (CHCPs) in Community Clinics (CC).

Methods

A cross-sectional study was conducted from September 2019 to February 2020 among 150 randomly selected CHCPs with functional HH facilities in Patuakhali district, Bangladesh. Structured interviews and observation tools were used to collect data.

Results

Good HH compliance among CHCPs was found to be 16.7% (95% CI: 11.3-21.3). Out of all 1218 possible HH opportunities, only 255 (20.9%) resulted in any HH action. Presence of 70% alcohol-based hand sanitiser at the point of care (aOR: 6.4, 95% CI: 1.1-38.3), HH training (aOR: 4.6, 95% CI: 1.1-18.9), displayed visual cues (aOR: 4.4, 95% CI: 1.1-17.7), knowledge about HH (aOR: 3.8, 95% CI: 1.1-13.6) and number of HH opportunities (aOR: 0.6, 95% CI: 0.4-0.8) were factors associated with HH compliance.

Discussion

Overall HH compliance among CHCPs was relatively low. It was recommended to implement multimodal HH improvement strategies, including a continuous training program, supply of alcohol-based hand rub, reminder, provision of five moments of HH in the training modules and feedback on HH performance.

Nudging hand hygiene compliance: a large-scale field experiment on hospital visitors

BACKGROUND

Hospital-care-associated infections (HCAIs) represent the most frequent adverse event during care delivery, affecting hundreds of millions of patients around the world. Implementing and ensuring conformity to standard precautions, particularly best hand hygiene practices, is regarded as one of the most important and cheapest strategies for preventing HCAIs. However, despite consistent efforts at increasing conformity to standard hand hygiene practices at hospitals, research has repeatedly documented low conformity levels amongst staff, patients and visitors alike.

AIM

The behavioural sciences have documented the potential of adjusting seemingly irrelevant contextual features in order to 'nudge' people to conform to desirable behaviours such as hand hygiene compliance (HHC). In this field experiment we investigate the effect on HHC amongst visitors upon entry of a hospital by varying such features.

METHODS

Over 50 days, we observed the HHC of a total of 46,435 hospital visitors upon their entry to the hospital in a field experimental design covering eight variations over the salience, placement and assertion of the hand sanitizer in the foyer, including the presence of the yearly national HHC campaign and a follow up during the COVID-19 pandemic.

FINDINGS

Our experiment found that varying seemingly irrelevant features increased HHC from a baseline of 0.4%-19.7% (47.6% during COVID-19). The experiment also found that the national HHC-campaign had no direct statistically significant effect on HHC.

CONCLUSION

Varying seemingly irrelevant contextual features provides an effective, generic, cheap and easy to scale approach to increasing HHC relative to sanitizing one's hands at hospitals.

Impact of Visibility and Accessibility on Healthcare Workers' Hand-Hygiene Behavior: A Comparative Case Study of Two Nursing Units in an Academic Medical Center

OBJECTIVES

This study aims to explore the impacts of visibility and accessibility of alcohol gel-based hand sanitizer dispensers (HSDs) on healthcare workers' hand-hygiene (HH) behaviors.

BACKGROUND

Despite the importance of HH in reducing nosocomial infection, few empirical studies have quantitatively investigated the impacts of unit shape and size, and the resulted visibility and accessibility on HH, due to the lack of consistent methods to measure and evaluate visibility.

METHODS

The research was developed as a cross-sectional comparative study of two nursing units (Units A and B) with similar patient acuity and nursing care model but different shape and layout. The study applied quantitative research methods including visibility and accessibility analysis using space syntax, 1-week on-site observation, and secondary data analysis on HH compliance rates.

RESULTS

Results indicate that the unit with higher visibility and accessibility is associated with higher HH frequencies. Unit B has significantly higher visibility of HSDs, p < .001, t(60) = 4.615, and significantly higher frequency of HH activity occurrences, 5.17% versus 1.52%; p < .001, t(16.750) = 5.332, than Unit A, even though Unit B has lower HSD to bed ratio (0.708:1 vs. 1.375:1). The linear regression models also demonstrate that visibility and accessibility of HSDs are significant predictors of HH behavior.

CONCLUSIONS

Overall, this exploratory study identified the importance of visibility of HSDs to improve the chances of HH. It also points out the impacts of nursing unit typology on the visibility of HSDs and in turn affects HH behavior.

Association between hospital outbreaks and hand hygiene: Insights from electronic monitoring

BACKGROUND

Hand hygiene (HH) is an important patient safety measure linked to prevention of healthcare-associated infection yet how outbreaks affect HH performance has not been formally evaluated.

METHODS

A controlled interrupted time series was performed across five acute-care academic hospitals using group electronic monitoring. This system captures 100% of all hand sanitizer and soap dispenser activations via a wireless signal to a wireless hub divided by a previously validated estimate of the number of daily HH opportunities per patient bed multiplied by the hourly census of patients on the unit. Daily HH adherence 60 days prior and 90 days following outbreak on inpatient units was compared to control units not in outbreak over the same period, using a Poisson regression model adjusting for correlation within hospitals and units. Predictors of HH improvement were assessed in this multivariate model.

RESULTS

In the 60 days prior to outbreak, units destined for outbreak had significantly lower HH adherence compared to control units (IRR of 0.91 (95% CI 0.90-0.93; p <0.0001). Following outbreak, the HH adherence among outbreak units increased above controls (IRR 1.04, 95% CI = 1.02-1.06; p <0.0001). Greater improvements were noted for outbreaks on surgical units, involving antibiotic-resistant organisms and enteric outbreaks, as well as those where healthcare workers became ill.

CONCLUSIONS

Hospital outbreaks tend to occur on units with lower HH adherence and are associated with rapid improvements in HH performance. Group electronic monitoring of HH could be used to develop novel prospective feedback interventions designed to avert hospital outbreaks.

A new approach to infection prevention: A pilot study to evaluate a hand hygiene ambassador program in hospitals and clinics

BACKGROUND

A pilot study was conducted to assess the perceptions of visitors, patients, and staff to the presence of a hand hygiene ambassador (HHA).

METHODS

Two hundred and twenty-five entrants to various health care settings were surveyed. Only entrants who failed to clean their hands at the alcohol-based handrub (ABHR) station on entry to the lobby were offered application of ABHR by an HHA. Several questions were also asked to assess their attitudes about the presence of an HHA.

RESULTS

When asked whether they think it is a good idea to have an HHA place ABHR on an entrant's hands, the majority of staff, visitors, and patients agreed. No one refused administration of handrub by the HHA.

DISCUSSION

HHA programs have direct and indirect benefits. Although the cost of such an initiative should be considered prior to implementation, it should be weighed against the annual spending for health care-associated infections.

CONCLUSIONS

Considering that hand hygiene compliance and health care-associated infection are clearly linked, a new approach using an HHA may help reduce infection, acting as a source of hand hygiene on entry to the hospital and possibly as a reminder to perform hand hygiene elsewhere in the hospital and clinics.

User-centred participatory design of visual cues for isolation precautions

Background

Isolation precautions are intended to prevent transmission of infectious agents, yet healthcare provider (HCP) adherence remains suboptimal. This may be due to ambiguity regarding the required precautions or to cognitive overload of HCPs. In response to the challenge of changing HCP behaviour, increasing attention should be paid to the role of engineering controls and facility design that incorporate human factors elements. In the current study, we aimed to develop an isolation precaution signage system that provides visual cues, serves as a cognitive aid at the point of care, and removes ambiguity regarding which precautions are necessary (e.g. masks, gowns, gloves, single rooms) when caring for isolated patients.

Methods

We employed a user-centred, participatory design approach in which HCPs were actively involved in generating an isolation precaution signage system based on human factors design principles. HCPs were purposefully sampled for each design phase to include a representative sample of potential system users. We conducted front-end analysis through interviews and observations to identify challenges related to the existing signage and to establish design requirements for new signage. This was followed by the creation of user personas, design thinking workshops, and prototyping, which then underwent iterative cycles of evaluation. Graphical symbols were developed and tested for comprehensibility.

Results

Front-end analysis revealed several barriers to use of the current signage system such as unclear target audience, low signal-to-noise ratio, and ambiguity regarding the applicable precautions. A comprehensive list of design requirements was generated. The project ultimately resulted in a collection of validated, comprehensible symbols and signs for contact, droplet, and airborne isolation, as well as the identification of several systems-level solutions for work re-organisation to improve compliance with isolation precautions.

Conclusions

The introduction of visual cues in the form of signage offers a promising opportunity to make guidelines available directly at the frontline. Anecdotal evidence based on observations and interviews with HCP have shown that the current solution is superior to previous isolation signage. User-centred participatory design was a useful approach that holds potential for further improving design in healthcare settings.

Effect of Frequency of Changing Point-of-Use Reminder Signs on Health Care Worker Hand Hygiene Adherence: A Cluster Randomized Clinical Trial

IMPORTANCE

Although hand hygiene (HH) is considered the most effective strategy for preventing hospital-acquired infections, HH adherence rates remain poor.

OBJECTIVE

To examine whether the frequency of changing reminder signs affects HH adherence among health care workers.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized clinical trial in 9 US Department of Veterans Affairs acute care hospitals randomly assigned 58 inpatient units to 1 of 3 schedules for changing signs designed to promote HH adherence among health care workers: (1) no change; (2) weekly; and (3) monthly. Hand hygiene rates among health care workers were documented at entry and exit to patient rooms during the baseline period from October 1, 2014, to March 31, 2015, of normal signage and throughout the intervention period of June 8, 2015, to December 28, 2015. Data analyses were conducted in April 2018.

INTERVENTIONS

Hospital units were randomly assigned into 3 groups: (1) no sign changes throughout the intervention period, (2) signs changed weekly, and (3) signs changed monthly.

MAIN OUTCOMES AND MEASURES

Hand hygiene adherence as measured by covert observation. Interrupted time series analysis was used to examine changes in HH adherence from baseline through the intervention period by group.

RESULTS

Among 58 inpatient units, 19 units were assigned to the no change group, 19 units were assigned to the weekly change group, and 20 units were assigned to the monthly change group. During the baseline period, 9755 HH opportunities were observed at room entry and 10 095 HH opportunities were observed at room exit. During the intervention period, a total of 15 855 HH opportunities were observed at room entry, and 16 360 HH opportunities were observed at room exit. Overall HH adherence did not change from baseline compared with the intervention period at either room entry (4770 HH events [48.9%] vs 3057 HH events [50.1%]; P = .14) or exit (6439 HH events [63.8%] vs 4087 HH events [65.2%]; P = .06). In units that changed signs weekly, HH adherence declined from baseline at room entry (-1.9% [95% CI, -2.7% to -0.8%] per week; P < .001) and exit (-0.8% [95% CI, -1.5% to 0.1%] per week; P = .02). No significant changes in HH adherence were observed in other groups.

CONCLUSIONS AND RELEVANCE

The frequency of changing reminder signs had no effect on HH rates overall. Units assigned to change signs most frequently demonstrated worsening adherence. Considering the abundance of signs in the acute care environment, the frequency of changing signs did not appear to provide a strong enough cue by itself to promote behavioral change.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02223455.

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.

Safer health care environments by design

Health care environments can and are being designed to prevent injury, minimize human error, and actually promote improved health and safety. This article shows risk managers how evidence-based design is reducing medication error, staff injury, infection rates, patient falls, and more. Research knowledge can contribute to effective design solutions by simply clarifying a safety problem so solutions can be sought; it can inform the design process with potential solutions; or it can be part of a structured process where new research knowledge is created. This article shares specific examples of the types of research that can inform designing for a safer physical environment. A case study shows how one project in two phases benefited from engaging initially in a general way and later, in a highly structured process, to integrate the evidence to improve design for safety.

Evaluation of a two-sample process for prevention of ABO mistransfusions in a high volume academic hospital

Background

Acute haemolytic transfusion reactions due to ABO incompatible blood transfusion remain a leading cause of transfusion-associated morbidity and mortality in the USA. Erroneous patient identification and specimen labelling account for many errors that lead to ABO mistransfusions; these errors are largely preventable.

Methods

Our hospital requires a two-sample process of ABO/Rh typing prior to transfusion. Both samples must be drawn independently. To prevent simultaneous sample draw, our second sample tube has a unique pink top that is only available from the blood bank and can only be sent to the patient’s floor once the first sample arrives in the lab. We performed an audit of this process from 19 March to 30 July 2014 and 19 March to 30 July 2015.

Results

We reviewed type and crossmatch orders for 2702 new patients during the audit period and 824 patients (30.5%) required transfusion. All patients evaluated received compatible blood, and no mistransfusions were recorded using this method. Three per cent of testing was performed incorrectly, which safely defaulted to giving type O blood.

Conclusions

The two-sample protocol used by our institution can decrease the risk of mistransfusion. Our protocol was relatively inexpensive, safe, efficient and practical for adaptation by other hospitals.

Factors that influence hand hygiene practice amongst occupational therapy students

Purpose

Hand hygiene is the single most important intervention to reduce the risk of acquiring infection. All healthcare workers and healthcare students have a responsibility to prevent transmission of infection. The purpose of this study is to investigate students’ attitudes to hand hygiene following university-based education and practice placement. Students attended a lecture, completed an e-learning module, participated in a practical session using a ultra-violet light hand inspection cabinet and engaged in clinical placement.

Design/methodology/approach

In all, 64 students participated in a multimodal hand hygiene education programme before clinical placement, with each student completing an in-class questionnaire after placement. Data were analysed using descriptive and comparative statistics. Students rated educational methods that had most influence on them. Their preference was for a practical hand hygiene education session. Students were also influenced by the therapist they were on placement with. They were least influenced by the didactic college presentation.

Findings

This study highlights that students may be influenced by different methods of education at different stages in their course and that placement may be an important influencing factor in the earlier years of occupational therapy education.

Research limitations/implications

This study highlights the importance of the availability of a multimodal educational approach and clinical placement to promote increased compliance with hand hygiene amongst students.

Practical implications

University healthcare course curricula should include multimodal approaches to the education of hand hygiene. While hand hygiene e-learning modules are beneficial, they should be used in conjunction with a multimodal educational strategy that incorporates practical elements. The influence of the therapist on a students’ behaviour should be utilised to improve both student and professionals hand hygiene adherence.

Originality/value

Original piece of work that is not widely discussed in Occupational Therapy literature.

A ubiquitous but ineffective intervention: Signs do not increase hand hygiene compliance

Proper hand hygiene is critical for preventing healthcare-associated infection, but provider compliance remains suboptimal. While signs are commonly used to remind physicians and nurses to perform hand hygiene, the content of these signs is rarely based on specific, validated health behavior theories. This observational study assessed the efficacy of a hand hygiene sign disseminated by the Centers for Disease Control and Prevention in an intensive care unit compared to an optimized evidence-based sign designed by a team of patient safety experts. The optimized sign was developed by four patient safety experts to include known evidence-based components and was subsequently validated by surveying ten physicians and ten nurses using a 10 point Likert scale. Eighty-two physicians and 98 nurses (102 females; 78 males) were observed for hand hygiene (HH) compliance, and the total HH compliance rate was 16%. HH compliance was not significantly different among the signs (Baseline 10% vs. CDC 18% vs. OIS 20%; p=0.280). The findings of this study suggest that even when the content and design of a hand hygiene reminder sign incorporates evidence-based constructs, healthcare providers comply only a fraction of the time.

Assessment of Fidelity in Interventions to Improve Hand Hygiene of Healthcare Workers: A Systematic Review

OBJECTIVE

Compliance with hand hygiene in healthcare workers is fundamental to infection prevention yet remains a challenge to sustain. We examined fidelity reporting in interventions to improve hand hygiene compliance, and we assessed 5 measures of intervention fidelity: (1) adherence, (2) exposure or dose, (3) quality of intervention delivery, (4) participant responsiveness, and (5) program differentiation.

DESIGN

Systematic review

METHODS

A librarian performed searches of the literature in PubMed, Cumulative Index to Nursing and Allied Health (CINAHL), Cochrane Library, and Web of Science of material published prior to June 19, 2015. The review protocol was registered in PROSPERO International Prospective Register of Systematic Reviews, and assessment of study quality was conducted for each study reviewed.

RESULTS

A total of 100 studies met the inclusion criteria. Only 8 of these 100 studies reported all 5 measures of intervention fidelity. In addition, 39 of 100 (39%) failed to include at least 3 fidelity measures; 20 of 100 (20%) failed to include 4 measures; 17 of 100 (17%) failed to include 2 measures, while 16 of 100 (16%) of the studies failed to include at least 1 measure of fidelity. Participant responsiveness and adherence to the intervention were the most frequently unreported fidelity measures, while quality of the delivery was the most frequently reported measure.

CONCLUSIONS

Almost all hand hygiene intervention studies failed to report at least 1 fidelity measurement. To facilitate replication and effective implementation, reporting fidelity should be standard practice when describing results of complex behavioral interventions such as hand hygiene.

Hand hygiene-related clinical trials reported since 2010: a systematic review

Considerable emphasis is currently placed on reducing healthcare-associated infection through improving hand hygiene compliance among healthcare professionals. There is also increasing discussion in the lay media of perceived poor hand hygiene compliance among healthcare staff. Our aim was to report the outcomes of a systematic search for peer-reviewed, published studies - especially clinical trials - that focused on hand hygiene compliance among healthcare professionals. Literature published between December 2009, after publication of the World Health Organization (WHO) hand hygiene guidelines, and February 2014, which was indexed in PubMed and CINAHL on the topic of hand hygiene compliance, was searched. Following examination of relevance and methodology of the 57 publications initially retrieved, 16 clinical trials were finally included in the review. The majority of studies were conducted in the USA and Europe. The intensive care unit emerged as the predominant focus of studies followed by facilities for care of the elderly. The category of healthcare worker most often the focus of the research was the nurse, followed by the healthcare assistant and the doctor. The unit of analysis reported for hand hygiene compliance was 'hand hygiene opportunity'; four studies adopted the 'my five moments for hand hygiene' framework, as set out in the WHO guidelines, whereas other papers focused on unique multimodal strategies of varying design. We concluded that adopting a multimodal approach to hand hygiene improvement intervention strategies, whether guided by the WHO framework or by another tested multimodal framework, results in moderate improvements in hand hygiene compliance.

Integrative review of implementation strategies for translation of research-based evidence by nurses

OBJECTIVES

The purpose of this review was to synthesize and critique experimental and/or quasi-experimental research that has evaluated implementation strategies for translation of research-based evidence into nursing practice.

BACKGROUND

Successfully implementing evidence-based research can improve patient outcomes. Identifying successful implementation strategies is imperative to move research-based evidence into practice.

RATIONALE

As implementation science gains popularity, it is imperative to understand the strategies that most effectively translate research-based evidence into practice.

DESCRIPTION

The review used the CINAHL and MEDLINE (Ovid) databases. Articles were included if they were experimental and/or quasi-experimental research designs, were written in English, and measured nursing compliance to translation of research-based evidence. An independent review was performed to select and critique the included articles.

OUTCOME

A wide array of interventions were completed, including visual cues, audit and feedback, educational meetings and materials, reminders, outreach, and leadership involvement. Because of the complex multimodal nature of the interventions and the variety of research topics, comparison across interventions was difficult.

CONCLUSION

Many difficulties exist in determining what implementation strategies are most effective for translation of research-based evidence into practice by nurses.

IMPLICATIONS

With these limited findings, further research is warranted to determine which implementation strategies most successfully translate research-based evidence into practice.

Systematic qualitative literature review of health care workers' compliance with hand hygiene guidelines

BACKGROUND

Acquisition of a health care-associated infection is a substantial risk to patient safety. When health care workers comply with hand hygiene guidelines, it reduces this risk. Despite a growing body of qualitative research in this area, a review of the qualitative literature has not been published.

METHODS

A systematic review of the qualitative literature.

RESULTS

The results were themed by the factors that health care workers identified as contributing to their compliance with hand hygiene guidelines. Contributing factors were conceptualized using a theoretical background. This review of the qualitative literature enabled the researchers to take an inductive approach allowing for all factors affecting the phenomenon of interest to be explored. Two core concepts seem to influence health care workers' compliance with hand hygiene guidelines. These are motivational factors and perceptions of the work environment. Motivational factors are grounded in behaviorism, and the way in which employees perceive their work environment relates to structural empowerment.

CONCLUSION

Noncompliance with hand hygiene guidelines remains a collective challenge that requires researchers to adopt a consistent and standardized approach. Theoretical models should be used intentionally to better explain the complexities of hand hygiene.

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

Much of the effort devoted to promoting better hand hygiene is based on the belief that poor hand hygiene reflects poor motivation. We argue, however, that automatic unconscious behaviour driven by 'mental models' is an important contributor to what actually happens. Mental models are concepts of reality--imaginary, often blurred, and sometimes unstable. Human beings use them to reduce mental load and free up capacity in the conscious mind to focus on deliberate activities. They are pragmatic solutions to the complexity of life. Knowledge of such mental processes helps healthcare designers and clinicians overcome barriers to behavioural change. This article reviews the concept of mental models and considers how it can be used to improve hand hygiene and patient safety.

Community respiratory virus infection in hematopoietic stem cell transplantation recipients and household member characteristics

PURPOSE/OBJECTIVES

To determine if children or the number of contacts living in an immediate household increases the risk of community respiratory virus (CRV) acquisition in hematopoietic stem cell transplantation (HSCT) recipients.

DESIGN

Retrospective, exploratory study.

SETTING

National Cancer Institute-designated comprehensive cancer center located in the Southeast.

SAMPLE

720 adult outpatients post-autologous or allogeneic HSCT.

METHODS

Data were gathered using a retrospective medical record review from July 1, 2006, to December 31, 2009. Summary statistics were used to describe sample characteristics. Binary logistic regression was used to determine whether the number of household member contacts or number of children in each age group was a significant predictor of CRV infection. Multivariate linear regression was used to investigate predictors of the number of CRV infections.

MAIN RESEARCH VARIABLES

The dependent variable was acquisition of CRV infection. Independent variables included the number of children in the household and the number of household members.

FINDINGS

Across all HSCT recipients, children aged 0-4 years (p = 0.01) and 5-12 years (p = 0.001) predicted CRV infection. The allogeneic group had the greatest incidence of CRV infection and was most sensitive to the presence of young children. The total number of household members was not a predictor of CRV infection.

CONCLUSIONS

Households with children aged 12 years and younger more than doubled the risk of an HSCT recipient acquiring CRV infection. Additional studies are needed to test interventions designed to interrupt household transmission of CRV infection from children to vulnerable HSCT recipients.

IMPLICATIONS FOR NURSING

Household contacts, particularly children, should be included in HSCT teaching. As indicated by the potentially high number of days from transplantation to acquisition of CRV infection, re-education and continuing focus on prevention of CRV infection should be reinforced throughout the lengthy transplantation period.

Hospital hand hygiene compliance improves with increased monitoring and immediate feedback

BACKGROUND

Health care-associated infections are serious complications impacting 2 million patients and accounting for approximately 100,000 deaths per year. In the present study, we evaluated the effectiveness of a new hand hygiene monitoring program (HHMP) and measured the sustainability of this effectiveness over a 1-year period.

METHODS

The HHMP consisted of 4 key components: extensive education, conspicuous and visible monitors, immediate feedback concerning compliance to health care workers, and real-time data dissemination to leadership. The HHMP was implemented in 2 hospital care units. Two different, but similar, departments served as controls, and hand hygiene compliance was monitored via the "secret shopper" technique. All 4 departments were followed for 12 months.

RESULTS

Both experimental departments showed statistically significant increases in hand hygiene compliance. Experimental department 1 increased compliance from 49% to an average of 90%, and experimental department 2 increased compliance from 60% to an average of 96%. Both experimental departments were able to sustain these results for at least 6 months. Compliance rates were significantly higher in the experimental departments compared with the control departments. No significant changes were seen in the control departments.

CONCLUSIONS

These finding suggest that continuous monitoring by salient observers and immediate feedback are critical to the success of hand hygiene programs.

A study of the efficacy of flashing lights to increase the salience of alcohol-gel dispensers for improving hand hygiene compliance

BACKGROUND

Many interventions have been implemented to improve hand hygiene compliance, each with varying effects and monetary costs. Although some previous studies have addressed the issue of conspicuousness, we found only 1 study that considered improving hand hygiene by using flashing lights.

METHOD

Our attention theory-based hypothesis tested whether a simple red light flashing at 2-3 Hz affixed to the alcohol gel dispensers, within the main hospital entrance, would increase hand hygiene compliance over the baseline rate. Baseline and intervention observations were completed over five 60-minute periods (Monday-Friday) from 7:30 to 8:30 AM using a covert observation method.

RESULTS

Baseline hand hygiene compliance was 12.4%. Our intervention increased compliance to 23.5% during cold weather and 27.1% during warm weather. Overall, our pooled compliance rate increased to 25.3% (P < .0001).

CONCLUSIONS

A simple, inexpensive flashing red light affixed to alcohol gel dispensers was sufficiently salient to approximately double overall hand hygiene compliance within the main hospital entrance. We hypothesize that our intervention drew attention to the dispensers, which then reminded employees and visitors alike to wash their hands. Compliance was worse during cold days, presumably related to more individuals wearing gloves.

A systematic approach for the location of hand sanitizer dispensers in hospitals

Compliance with hand hygiene practices is directly affected by the accessibility and availability of cleaning agents. Nevertheless, the decision of where to locate these dispensers is often not explicitly or fully addressed in the literature. In this paper, we study the problem of selecting the locations to install alcohol-based hand sanitizer dispensers throughout a hospital unit as an indirect approach to maximize compliance with hand hygiene practices. We investigate the relevant criteria in selecting dispenser locations that promote hand hygiene compliance, propose metrics for the evaluation of various location configurations, and formulate a dispenser location optimization model that systematically incorporates such criteria. A complete methodology to collect data and obtain the model parameters is described. We illustrate the proposed approach using data from a general care unit at a collaborating hospital. A cost analysis was performed to study the trade-offs between usability and cost. The proposed methodology can help in evaluating the current location configuration, determining the need for change, and establishing the best possible configuration. It can be adapted to incorporate alternative metrics, tailored to different institutions and updated as needed with new internal policies or safety regulation.

Assessing the optimal location for alcohol-based hand rub dispensers in a patient room in an intensive care unit

BACKGROUND

The introduction of alcohol-based hand rub dispensers has had a positive influence on compliance of healthcare workers with the recommended guidelines for hand hygiene. However, establishing the best location for alcohol-based hand rub dispensers remains a problem, and no method is currently available to optimize the location of these devices. In this paper we describe a method to determine the optimal location for alcohol-based hand rub dispensers in patient rooms.

METHODS

We composed a method that consists of a combination of qualitative and quantitative research methods. Firstly, different arrangements of dispensers were determined based on the results of two types of assessment: workflow observations and interviews with nurses and physicians. Each arrangement was then evaluated using two types of assessment: interviews with nurses and physicians and electronic measurements of the user frequency of the dispensers. This procedure was applied in a single-bed patient room on a thoracic surgery intensive care unit.

RESULTS

The workflow observations revealed that the activities of patient care were most often at the entrance and near the computer at the right side of the test room. Healthcare workers stated that the location of the dispenser should meet several requirements. Measurements of the frequency of use showed that the dispenser located near the computer, at the back of the room, was used less frequently than the dispenser located near the sink and the dispenser located at the entrance to the room.

CONCLUSION

The applied method has potential for determining the optimal location for alcohol-based hand rub dispensers in a patient room. Workflow observations and the expressed preferences of healthcare workers guide the choice for the location of alcohol-based hand rub dispensers. These choices may be optimized based on measurement of the frequency of use of the dispensers.

Food safety in home kitchens: a synthesis of the literature

Although foodborne illness is preventable, more than 56,000 people per year become ill in the U.S., creating high economic costs, loss of productivity and reduced quality of life for many. Experts agree that the home is the primary location where foodborne outbreaks occur; however, many consumers do not believe the home to be a risky place. Health care professionals need to be aware of consumers' food safety attitudes and behaviors in the home and deliver tailored food safety interventions that are theory-based. Thus, the purpose of this paper is to synthesize/summarize the food safety literature by examining the following: consumers' perceptions and attitudes towards food safety and their susceptibility to foodborne illness in the home, work, and school; common risky food safety practices and barriers to handling food safely; and the application of theory-based food safety interventions. Findings will help healthcare professionals become more aware of consumers' food safety attitudes and behaviors and serve to inform future food safety interventions.

Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation

Despite the potential dangers of clinical tasks being forgotten, few researchers have investigated prospective memory (PM) - the ability to remember to execute future tasks - in health-care contexts. Visual cues help people remember to execute intentions at the appropriate moment. Using an intensive care unit simulator, we investigated whether nurses' memory for future tasks improves when visual cues are present, and how nurses manage PM demands. Twenty-four nurses participated in a 40-minute scenario simulating the start of a morning shift. The scenario included eight PM tasks. The presence or absence of a visually conspicuous cue for each task was manipulated. The presence of a visual cue improved recall compared to no cue (64% vs. 50%, p = 0.03 one-tailed, η(p)(2) = 0.15). Nurses used deliberate reminders to manage their PM demands. PM in critical care might be supported by increasing the visibility of cues related to tasks.

PRACTITIONER SUMMARY

Nurses must remember to execute multiple future tasks to ensure patient safety. We investigated the effect of visual cues on nurses' ability to remember future tasks. Experimental manipulation of cues in a representative intensive care unit simulation indicated that visual cues increase the likelihood that future tasks are executed.

Sustained improvements in handwashing indicators more than 5 years after a cluster-randomised, community-based trial of handwashing promotion in Karachi, Pakistan

OBJECTIVE

To evaluate handwashing behaviour 5 years after a handwashing intervention in Karachi, Pakistan.

METHODS

In 2003, we randomised neighbourhoods to control, handwashing promotion, or handwashing promotion and water treatment. Intervention households were given soap +/- water treatment product and weekly handwashing education for 9 months. In 2009, we re-enrolled 461 households from the three study groups: control (160), handwashing (141), and handwashing + water treatment (160) and assessed hygiene-related outcomes, accounting for clustering.

RESULTS

Intervention households were 3.4 times more likely than controls to have soap at their handwashing stations during the study visit [293/301 (97%) vs. 45/159 (28%), P < 0.0001]. While nearly all households reported handwashing after toileting, intervention households more commonly reported handwashing before cooking [relative risk (RR) 1.2 (95% confidence interval (CI) 1.0-1.4)] and before meals [RR 1.7 (95% CI, 1.3-2.1)]. Control households cited a mean of 3.87 occasions for washing hands; handwashing households, 4.74 occasions; and handwashing + water treatment households, 4.78 occasions (P < 0.0001). Households reported purchasing a mean of 0.65 (control), 0.91 (handwashing) and 1.1 (handwashing + water treatment) bars of soap/person/month (P < 0.0001).

CONCLUSIONS

Five years after receiving handwashing promotion, intervention households were more likely to have soap at the household handwashing station, know key times to wash hands and report purchasing more soap than controls, suggesting habituation of improved handwashing practices in this population. Intensive handwashing promotion may be an effective strategy for habituating hygiene behaviours and improving health.

Infection prevention and control during prolonged human space travel

Prolonged human spaceflight to another planet or an asteroid will introduce unique challenges of mitigating the risk of infection. During space travel, exposure to microgravity, radiation, and stress alter human immunoregulatory responses, which can in turn impact an astronaut's ability to prevent acquisition of infectious agents or reactivation of latent infection. In addition, microgravity affects virulence, growth kinetics, and biofilm formation of potential microbial pathogens. These interactions occur in a confined space in microgravity, providing ample opportunity for heavy microbial contamination of the environment. In addition, there is the persistence of aerosolized, microbe-containing particles. Any mission involving prolonged human spaceflight must be carefully planned to minimize vulnerabilities and maximize the likelihood of success.

Bundling hand hygiene interventions and measurement to decrease health care-associated infections

Proper performance of hand hygiene at key moments during patient care is the most important means of preventing health care-associated infections (HAIs). With increasing awareness of the cost and societal impact caused by HAIs has come the realization that hand hygiene improvement initiatives are crucial to reducing the burden of HAIs. Multimodal strategies have emerged as the best approach to improving hand hygiene compliance. These strategies use a variety of intervention components intended to address obstacles to complying with good hand hygiene practices, and to reinforce behavioral change. Although research has substantiated the effectiveness of the multimodal design, challenges remain in promoting widespread adoption and implementation of a coordinated approach. This article reviews elements of a multimodal approach to improve hand hygiene and advocates the use of a "bundled" strategy. Eight key components of this bundle are proposed as a cohesive program to enable the deployment of synergistic, coordinated efforts to promote good hand hygiene practice. A consistent, bundled methodology implemented at multiple study centers would standardize processes and allow comparison of outcomes, validation of the methodology, and benchmarking. Most important, a bundled approach can lead to sustained infection reduction.

Do hospital visitors wash their hands? Assessing the use of alcohol-based hand sanitizer in a hospital lobby

BACKGROUND

Reports regarding hand hygiene compliance (HHC) among hospital visitors are limited. Although there is an implicit assumption that the availability of alcohol-based hand sanitizer (AHS) promotes visitor HHC, the degree of AHS use by visitors remains unclear. To assess AHS use, we observed visitor HHC and how it is affected by visual cues in a private university hospital.

METHODS

Using an observational controlled study, we tested 3 interventions: a desk sign mandating all visitors to use AHS, a free-standing AHS dispenser directly in front of a security desk, and a combination of a freestanding AHS dispenser and a sign.

RESULTS

HHC was 0.52% at baseline and did not improve significantly when the desk sign was provided as a cue 0.67% (P = .753). However, HHC did improve significantly with use of the freestanding AHS dispenser (9.33%) and the sign and dispenser combination (11.67%) (P < .001 for all comparisons of dispenser alone and sign and dispenser with baseline and sign alone). The degree of improvement with the sign and dispenser combination over the dispenser was not statistically significant.

CONCLUSIONS

Hospital visitors represent an important factor in infection prevention. A coordinated effort is needed to increase visitor HHC, including an evaluation of the AHS placement, education of visitors on the importance of HHC, and evaluation of corresponding changes in hand hygiene behavior.