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A multifaceted pilot program to promote hand hygiene at a suburban fire department
American Journal of Infection Control 40 (2012) 324-7
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
A multifaceted pilot program to promote hand hygiene at a suburban fire department Christine McGuire-Wolfe MPH, CPH, EMT-P a, b, *, Donna Haiduven PhD, CIC, RN a, c, C. Duncan Hitchcock RN, EMT-P b a b c
Department of Global Health College of Public Health, University of South Florida, Tampa, FL Pasco County Fire Rescue, Pasco County, FL VA Research Center of Excellence, Tampa, FL
Key Words: Hand hygiene Handwashing Emergency medical services Firefighters Hand hygiene compliance Hand hygiene intervention
Background: Firefighters (FFs) and Emergency Medical Services (EMS) personnel provide care in uncontrolled settings, where the risk of hand contamination is great and opportunities for handwashing are few. Knowledge, attitudes, and beliefs about hand hygiene in this group have not been well reported. Methods: Written surveys were administered to FFs and EMS personnel to assess their practices, attitudes, and beliefs before and after installation of alcohol hand gel dispensers, hanging of reminder posters, and completion of PowerPoint training. Results: A majority of the participants (n ¼ 131; 58.5%) indicated they had not received any training on hand hygiene from the fire department before the intervention. Responses to Likert scale questions about attitudes, practices, and beliefs regarding handwashing did not reveal any statistically significant differences between preintervention and postintervention surveys; however, responses to direct questions about the impact of the intervention were more promising. Conclusions: Implementation and evaluation of an intervention to target groups of EMS personnel and FFs can guide future efforts to improve hand hygiene practices in this distinctive group. Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Hand hygiene is widely considered the most effective means of controlling the spread of infection.1-6 Although knowledge, attitudes, and beliefs about hand hygiene have been studied in a wide variety of health care personnel,5-12 emergency medical service (EMS) personnel and firefighters (FFs) have been neglected in this effort. These personnel operate in atypical health care settings that are often chaotic and poorly lit, in areas without access to running water. Often, after intense patient contacts in the field and in the back of an ambulance, EMS personnel and FFs return to their stations, where they eat and sleep. This unique dormitory-style setting provides a troublesome scenario for potential crosscontamination due to poor hand hygiene. In a meta-analysis of interventions designed to improve hand hygiene compliance, Pettit13 found that no one intervention was consistently successful in improving rates of compliance and concluded that “because of the complexity of the process of change,
* Address correspondence to Christine McGuire-Wolfe, MPH, CPH, EMT-P, 4111 Land O’Lakes Blvd, Suite 208, Land O’ Lakes, FL 34639. E-mail address: [email protected] (C. McGuire-Wolfe). Conflict of interest: None to report.
single interventions often fail, and a multi-modal, multi-disciplinary strategy is necessary.” The importance of easy access to alcohol hand rubs, cues to action (such as posters), and teaching and promoting hand hygiene have been emphasized in previous promotional campaigns.2-4,7,9,14 The objectives of the present study were to describe existing training, practices, beliefs, and attitudes in a sample of EMS personnel and FFs at a suburban fire department, and to assess the effectiveness of a 3-pronged intervention aimed at improving compliance with hand hygiene recommendations. METHODS Setting A multifaceted program was implemented to improve rates of hand hygiene in FFs and EMS personnel at Pasco County Fire Rescue (PCFR) in Florida. PCFR operates 23 fire stations in a 745 squaremile response zone with a combination of suburban and rural characteristics. The county’s current layout of fire stations did not provide easy access to soap and water before entering the stations’
0196-6553/$36.00 - Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.ajic.2011.06.003
C. McGuire-Wolfe et al. / American Journal of Infection Control 40 (2012) 324-7
325
Table 1 Reasons for not washing hands or using alcohol-based hand rub as often as recommended Barrier Forgetfulness Difficulty in finding water or hand rub Fatigue Belief that wearing gloves is a substitute for hand hygiene Belief that hand hygiene is not important Belief that hand hygiene is too time- consuming
Preintervention,* n (%) 65 26 6 18 0 2
(28.9) (11.6) (2.7) (8) (0) (0.9)
Postintervention,y n (%) 68 25 10 24 4 4
(31.1) (11.4) (4.6) (11.0) (1.8) (1.8)
c2
P
0.25 0.00 1.15 1.13 4.07z 0.69
.619 .963 .283 .786 .06 .40
* n¼225. y z
n¼219. Fisher’s exact test.
living quarters. Alcohol-based hand rub was not readily available before the intervention. Implementation of a hand hygiene promotion program was complicated by a severe budget crisis, resulting in an overall budget decrease of $12 million (14%) in the 2-year period ending in 2010.15 This decrease reduced or eliminated existing programs within the department and did not allow for the development of new initiatives. Assessment All assessments and interventions used in this study were approved by the University of South Florida’s Institutional Review Board. Before the intervention, a 2-page, 16-item written survey was collected over a 12-day period in September 2009 through interoffice mail. This survey included Likert scale questions regarding attitudes, practices, and beliefs, as well as questions about barriers to and previous training on handwashing. A similar postintervention survey, revised to include 6 questions about the effectiveness of the interventions, was circulated over a 12-day period in May 2010. The Rescue Chief sent an interoffice memorandum requesting participation and stressing the importance of the project with each set of surveys. To protect the anonymity of responses, identifying information was not collected; thus, the preintervention and postintervention surveys could not be matched. Intervention A 10-minute PowerPoint presentation on the importance of hand hygiene was posted on each fire station’s shared computer’s hard drive. The presentation was prepared by the Hand Hygiene Resource Center based at the Saint Raphael Healthcare System in Connecticut.16 In November and December 2009, employees were instructed to view the presentation and provide written documentation of this task to the Training Division. There was no cost associated with this activity. Between October 2009 and December 2009, 2 alcohol-based hand rub dispensers and laminated 8- 10-inch posters carrying messages about the importance of hand hygiene were mounted in each station, within visual range when entering the station from the exterior vehicle bays. The content of the posters was obtained from the Centers for Disease Control and Prevention17 and the US Veterans Administration.18 An alcohol-based hand rub dispenser also was mounted in the interior of the ambulances, and additional hand hygiene posters were placed in the bathrooms. The posters were printed using existing supplies, and laminating supplies cost approximately $100. Alcohol-based hand rub dispensers were provided free of charge by the manufacturer (State Chemical, Cleveland, OH); PCFR was responsible for purchasing refills for the dispensers ($6.34 per 1,000 mL). Data analysis Data were entered and analyzed using EpiInfo version 3.5.1. For one specific 5-point Likert scale question (“There are many risks
associated with this jobdcatching an illness does not worry me”), “strongly disagree” and “somewhat disagree” responses were coded as “disagree to some extent” responses, and “no opinion,” “somewhat agree,” and “strongly agree” responses were coded as “agree to some extent.” For all other Likert scale questions, “strongly agree” and “somewhat agree” answers were coded as “agree to some extent” responses, and “no opinion,” “somewhat disagree,” and “strongly disagree” response were coded as “disagree to some extent.”5,7 Univariate analysis was performed, and barriers were compared as proportions using either the c2 or Fisher’s exact test. RESULTS Preintervention A total of 228 surveys were returned from 397 employees, for a response rate of 58.9%. A majority of participants (n ¼ 131; 58.5%) indicated they had not received any training on hand hygiene from the fire department during the term of their employment. Respondents identified barriers such as forgetfulness (28.9%), difficulty finding water or hand rub (11.6%), belief that wearing gloves was a substitute for hand hygiene (8%), and fatigue (2.7%) (Table 1). Responses to Likert scale questions regarding practices, attitudes, and beliefs are summarized in Table 2. In terms of reporting their own compliance with hand hygiene, 94% of respondents agreed to some extent that they consistently practiced hand hygiene when returning to the station after a call and after transporting a patient, However, participants seemed less confident regarding compliance of their coworkers. Only 71.9% and 68.9% agreed to some extent that their coworkers were regularly practicing hand hygiene after patient contact and when returning to the station from a call, respectively. Postintervention In the postintervention phase, 219 surveys were returned, for a 60% response rate. The total number of employees had decreased to 364 due to attrition since the preintervention surveys. More than 92% of employees indicated that they had received training on hand hygiene while employed at PCFR (P ¼ .000). Several barriers to hand hygiene compliance were reported frequently, including forgetfulness (31.1%), the belief that wearing gloves is a substitute for poor hygiene (11%), and fatigue (4.6%). Two barriers that were not identified in the preintervention survey but were reported by 1.8% of postintervention participants were the beliefs that hand hygiene is not important and is too time-consuming (Table 1). However, there were no statistically significant differences in identified barriers to practicing hand hygiene between the preintervention and postintervention surveys. Responses to Likert scale questions regarding attitudes, practices, and beliefs about handwashing were not statistically significantly different between the preintervention and postintervention surveys (Table 2). Responses to direct questions about the impact of the intervention were more positive (Table 3).
326
C. McGuire-Wolfe et al. / American Journal of Infection Control 40 (2012) 324-7
Table 2 Selected Likert scale questions regarding practices, attitudes, and beliefs Agree to some extent
c2
P
0.52
.471
0.01
.924
0.06
.814
1.81
.178
0.43
.513
Disagree to some extent
I consistently wash my hands after returning to the station from a call. Preintervention 214 (95.5%) 10 (4.5%) Postintervention 204 (94.0%) 13 (6.0%) I consistently wash my hands or use alcohol-based hand gel after transporting a patient. Preintervention 211 (94.2%) 13 (5.8%) Postintervention 203 (94.0%) 13 (6.0%) My coworkers regularly wash their hands or use alcohol-based hand gel after patient contact. Preintervention 164 (73.9%) 61 (26.2%) Postintervention 156 (71.9%) 61 (28.9%) My coworkers regularly wash their hand or use alcohol-based hand gel when they return to the station from a call. Preintervention 155 (68.9%) 70 (31.1%) Postintervention 162 (74.7%) 55 (25.3%) I worry about what type of germs my coworkers might be spreading due to poor hand washing habits. Preintervention 142 (63.7%) 81 (36.3%) Postintervention 131 (60.7%) 85 (39.3%) Denominators differ due to differences in response rates.
Table 3 Attitudes regarding the impact of the intervention Strongly agree 1. Since installation of the alcohol hand gel dispensers and signs a. I notice that my coworkers are cleaning their hands more often. 52 (24.0%) b. I find myself cleaning my hands more often. 79 (36.4%) 2. The hand gel dispensers in the rescue increase the likelihood that I will clean my hands a. During and after patient care. 127 (58.8%) b. When returning from a call. 118 (54.4%) 3. The hand hygiene signs in the station help me to remember to clean my hands 61 (28.1%) 4. The PowerPoint training on hand hygiene reminded me about the importance 55 (25.5%) of handwashing or using alcohol hand gel
DISCUSSION Several barriers to hand hygiene were identified in this study. Fatigue, a barrier inherent to EMS and firefighting, is particularly difficult to counteract. Girou et al19 concluded that a hand hygiene campaign would not be successful at their institution unless a profound change in gloving practices occurred. Future hand hygiene campaigns at PCFR should include messages targeting fatigue as a barrier and misconceptions about the relationship between glove use and hand hygiene. The EMS workers and FFs in our sample demonstrated an understanding of the importance of hand hygiene and reported high levels of compliance for themselves, but identified concerns regarding their coworkers’ compliance. This discrepancy is consistent with the phenomenon of “social desirability,” wherein participants are more likely to report socially acceptable behaviors when self-reporting.20,21 The apparent discrepancy between the perceived benefits of intervention and the lack of corresponding changes in practices, attitudes, and beliefs, also may indicate a propensity of respondents to give a socially acceptable response (ie, that the interventions were helpful), or the inability of the Likert scale questions to represent actual practices, attitudes, and beliefs.20,21 Because of the nature of the fire department staffing design, this study had no control group. Moreover, it is important to mention that there was no observational method for reporting compliance with hand hygiene.9-11,20,22 PCFR’s hand hygiene promotion project did not provide messages endorsing hand hygiene from senior staff within the rank structure of the fire department. The importance of developing a culture of safety, including participation of senior staff in hand hygiene efforts, has been suggested previously.2,4,7,23,24 Helms et al8 stressed the importance of staff involvement in
Somewhat agree
Neutral
Somewhat disagree
Strongly disagree
89 (41.0%) 74 (34.1%)
53 (24.4%) 28 (12.9%)
14 (6.5%) 23 (10.6%)
9 (4.1%) 13 (6.0%)
58 59 61 77
14 17 48 52
7 15 27 20
10 8 20 12
(26.9%) (27.2%) (28.1%) (35.6%)
(6.5%) (7.8%) (22.1%) (24.1%)
(3.2%) (6.9%) (12.4%) (9.3%)
(4.6%) (3.7%) (9.2%) (5.6%)
the entire intervention process, including the planning stages, principally in the form of a multidisciplinary hand hygiene team representing various groups within the organization. Inclusion of field personnel in the planning, implementation, and evaluation of future hand hygiene efforts is a realistic future goal for PCFR. Despite its limitations, this preliminary study has generated awareness about the importance of hand hygiene within this target population, provided initial training for personnel, and increased the availability of alcohol hand rub. The challenge lies in developing ongoing education about hand hygiene to improve the knowledge base and reinforce positive behavior change.4,10 Lessons from this pilot effort have important implications for future studies within this particular FF/EMS population, as well as in a wide variety of EMS and fire department settings. References 1. Boyce JM, Pittet D. Guideline for hand-hygiene in health care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Morb Mort Wkly Rep 2002;51:1-44. 2. Whitby M, Pessoa-Silav CL, McLaws ML, Allegranzi B, Sax H, Larson E, et al. Behavioral considerations for hand hygiene practices: the basic building blocks. J Hosp Infect 2007;65:1-8. 3. Trampuz A, Widmer AF. Hand hygiene: a frequently missed lifesaving opportunity during patient care. Mayo Clin Proc 2004;79:109-16. 4. Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 2009;73:303-15. 5. Sax H, Uckay I, Richet H, Allegranzi B, Pittet D. Determinants of good adherence to hand hygiene among healthcare workers who have extensive exposure to hand hygiene campaign. Infect Control Hosp Epidemiol 2007;28:1267-74. 6. Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol 2000;21:381-6. 7. Pittet D, Simon A, Hugonnet S, Pessoa-Silva C, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004;141:1-8.
C. McGuire-Wolfe et al. / American Journal of Infection Control 40 (2012) 324-7 8. Helms B, Dorval S, St Laurent P, Winter M. Improving hand hygiene compliance: a multidisciplinary approach. Am J Infect Control 2010;38:572-4. 9. Bischoff WE, Reynolds T, Sessler CN, Edmund MB, Wenzel RP. Handwashing compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med 2000;160:1017-21. 10. Larson EL, Bryan JL, Adler LM, Blane C. A multifaceted approach to changing handwashing behavior. Am J Infect Control 1997;25:3-10. 11. Korniewicz DM, El-Masri M. Exploring the factors associated with hand hygiene compliance of nurses during routine clinical practice. Appl Nurs Dis 2010;23:86-90. 12. De Wandel D, Maes L, Labeau S, Vereecken C, Blot S. Behavioral determinants of hand hygiene compliance in intensive care units. Am J Crit Care 2010;19:230-9. 13. Pettit D. Improving adherence to hand hygiene practice: a multi-disciplinary approach. Emerg Infect Dis 2001;7:234-40. 14. Kampf G. The six golden rules to improve compliance in hand hygiene. J Hosp Infect 2004;56:53-5. 15. Pasco County Office of Management and Budget. Annual budget reports. Available from: http://portal.pascocountyfl.net/portal/server.pt/community/ office_of_management_and_budget/218/home. Accessed November 4, 2010. 16. Saint Raphael Healthcare System. Hand hygiene resource center. Available from: http://www.handhygiene.org/slideshow/default.asp?var1¼screen01 .htm. Accessed October 18, 2010.
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17. Centers for Disease Control and Prevention. Hand hygiene posters, August 2010. Available from: http://www.cdc.gov/handhygiene/index.html. Accessed October 18, 2010. 18. Department of Veteran’s Affairs. Hand hygiene posters. Available from: http://www.publichealth.va.gov/flu/materials/posters_hand_hygiene.asp#wa sh. Accessed October 18, 2010. 19. Girou E, Chai SH, Oppein F, Legrand P, Ducellier D, Cizeau F, et al. Misuse of gloves: the foundation for poor compliance with hand hygiene and potential for microbial transmission? J Hosp Infect 2004;57:162-9. 20. Adams SA, Matthews CE, Ebbeling CB, Moore CG, Cunningham JE, Fulton J, et al. The effect of social desirability and social approval on self-reports of physical activity. Am J Epidemiol 2005;161:389-98. 21. Holtgraves T. Social desirability and self-reports: testing models of socially desirable responding. Pers Soc Psychol Bull 2004;30:161-72. 22. Pittet D, Boyce JM. Hand hygiene and patient care: pursuing the Semmelweis legacy. Lancet Infect Dis 2001;1:9-20. 23. Sax H, Allegranzi B, Chraiti MN, Boyce J, Larson E, Pittet D. The World Health Organization hand hygiene observation method. Am J Infect Control 2009;37: 827-34. 24. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307-12.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
A multifaceted pilot program to promote hand hygiene at a suburban fire department Christine McGuire-Wolfe MPH, CPH, EMT-P a, b, *, Donna Haiduven PhD, CIC, RN a, c, C. Duncan Hitchcock RN, EMT-P b a b c
Department of Global Health College of Public Health, University of South Florida, Tampa, FL Pasco County Fire Rescue, Pasco County, FL VA Research Center of Excellence, Tampa, FL
Key Words: Hand hygiene Handwashing Emergency medical services Firefighters Hand hygiene compliance Hand hygiene intervention
Background: Firefighters (FFs) and Emergency Medical Services (EMS) personnel provide care in uncontrolled settings, where the risk of hand contamination is great and opportunities for handwashing are few. Knowledge, attitudes, and beliefs about hand hygiene in this group have not been well reported. Methods: Written surveys were administered to FFs and EMS personnel to assess their practices, attitudes, and beliefs before and after installation of alcohol hand gel dispensers, hanging of reminder posters, and completion of PowerPoint training. Results: A majority of the participants (n ¼ 131; 58.5%) indicated they had not received any training on hand hygiene from the fire department before the intervention. Responses to Likert scale questions about attitudes, practices, and beliefs regarding handwashing did not reveal any statistically significant differences between preintervention and postintervention surveys; however, responses to direct questions about the impact of the intervention were more promising. Conclusions: Implementation and evaluation of an intervention to target groups of EMS personnel and FFs can guide future efforts to improve hand hygiene practices in this distinctive group. Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Hand hygiene is widely considered the most effective means of controlling the spread of infection.1-6 Although knowledge, attitudes, and beliefs about hand hygiene have been studied in a wide variety of health care personnel,5-12 emergency medical service (EMS) personnel and firefighters (FFs) have been neglected in this effort. These personnel operate in atypical health care settings that are often chaotic and poorly lit, in areas without access to running water. Often, after intense patient contacts in the field and in the back of an ambulance, EMS personnel and FFs return to their stations, where they eat and sleep. This unique dormitory-style setting provides a troublesome scenario for potential crosscontamination due to poor hand hygiene. In a meta-analysis of interventions designed to improve hand hygiene compliance, Pettit13 found that no one intervention was consistently successful in improving rates of compliance and concluded that “because of the complexity of the process of change,
* Address correspondence to Christine McGuire-Wolfe, MPH, CPH, EMT-P, 4111 Land O’Lakes Blvd, Suite 208, Land O’ Lakes, FL 34639. E-mail address: [email protected] (C. McGuire-Wolfe). Conflict of interest: None to report.
single interventions often fail, and a multi-modal, multi-disciplinary strategy is necessary.” The importance of easy access to alcohol hand rubs, cues to action (such as posters), and teaching and promoting hand hygiene have been emphasized in previous promotional campaigns.2-4,7,9,14 The objectives of the present study were to describe existing training, practices, beliefs, and attitudes in a sample of EMS personnel and FFs at a suburban fire department, and to assess the effectiveness of a 3-pronged intervention aimed at improving compliance with hand hygiene recommendations. METHODS Setting A multifaceted program was implemented to improve rates of hand hygiene in FFs and EMS personnel at Pasco County Fire Rescue (PCFR) in Florida. PCFR operates 23 fire stations in a 745 squaremile response zone with a combination of suburban and rural characteristics. The county’s current layout of fire stations did not provide easy access to soap and water before entering the stations’
0196-6553/$36.00 - Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.ajic.2011.06.003
C. McGuire-Wolfe et al. / American Journal of Infection Control 40 (2012) 324-7
325
Table 1 Reasons for not washing hands or using alcohol-based hand rub as often as recommended Barrier Forgetfulness Difficulty in finding water or hand rub Fatigue Belief that wearing gloves is a substitute for hand hygiene Belief that hand hygiene is not important Belief that hand hygiene is too time- consuming
Preintervention,* n (%) 65 26 6 18 0 2
(28.9) (11.6) (2.7) (8) (0) (0.9)
Postintervention,y n (%) 68 25 10 24 4 4
(31.1) (11.4) (4.6) (11.0) (1.8) (1.8)
c2
P
0.25 0.00 1.15 1.13 4.07z 0.69
.619 .963 .283 .786 .06 .40
* n¼225. y z
n¼219. Fisher’s exact test.
living quarters. Alcohol-based hand rub was not readily available before the intervention. Implementation of a hand hygiene promotion program was complicated by a severe budget crisis, resulting in an overall budget decrease of $12 million (14%) in the 2-year period ending in 2010.15 This decrease reduced or eliminated existing programs within the department and did not allow for the development of new initiatives. Assessment All assessments and interventions used in this study were approved by the University of South Florida’s Institutional Review Board. Before the intervention, a 2-page, 16-item written survey was collected over a 12-day period in September 2009 through interoffice mail. This survey included Likert scale questions regarding attitudes, practices, and beliefs, as well as questions about barriers to and previous training on handwashing. A similar postintervention survey, revised to include 6 questions about the effectiveness of the interventions, was circulated over a 12-day period in May 2010. The Rescue Chief sent an interoffice memorandum requesting participation and stressing the importance of the project with each set of surveys. To protect the anonymity of responses, identifying information was not collected; thus, the preintervention and postintervention surveys could not be matched. Intervention A 10-minute PowerPoint presentation on the importance of hand hygiene was posted on each fire station’s shared computer’s hard drive. The presentation was prepared by the Hand Hygiene Resource Center based at the Saint Raphael Healthcare System in Connecticut.16 In November and December 2009, employees were instructed to view the presentation and provide written documentation of this task to the Training Division. There was no cost associated with this activity. Between October 2009 and December 2009, 2 alcohol-based hand rub dispensers and laminated 8- 10-inch posters carrying messages about the importance of hand hygiene were mounted in each station, within visual range when entering the station from the exterior vehicle bays. The content of the posters was obtained from the Centers for Disease Control and Prevention17 and the US Veterans Administration.18 An alcohol-based hand rub dispenser also was mounted in the interior of the ambulances, and additional hand hygiene posters were placed in the bathrooms. The posters were printed using existing supplies, and laminating supplies cost approximately $100. Alcohol-based hand rub dispensers were provided free of charge by the manufacturer (State Chemical, Cleveland, OH); PCFR was responsible for purchasing refills for the dispensers ($6.34 per 1,000 mL). Data analysis Data were entered and analyzed using EpiInfo version 3.5.1. For one specific 5-point Likert scale question (“There are many risks
associated with this jobdcatching an illness does not worry me”), “strongly disagree” and “somewhat disagree” responses were coded as “disagree to some extent” responses, and “no opinion,” “somewhat agree,” and “strongly agree” responses were coded as “agree to some extent.” For all other Likert scale questions, “strongly agree” and “somewhat agree” answers were coded as “agree to some extent” responses, and “no opinion,” “somewhat disagree,” and “strongly disagree” response were coded as “disagree to some extent.”5,7 Univariate analysis was performed, and barriers were compared as proportions using either the c2 or Fisher’s exact test. RESULTS Preintervention A total of 228 surveys were returned from 397 employees, for a response rate of 58.9%. A majority of participants (n ¼ 131; 58.5%) indicated they had not received any training on hand hygiene from the fire department during the term of their employment. Respondents identified barriers such as forgetfulness (28.9%), difficulty finding water or hand rub (11.6%), belief that wearing gloves was a substitute for hand hygiene (8%), and fatigue (2.7%) (Table 1). Responses to Likert scale questions regarding practices, attitudes, and beliefs are summarized in Table 2. In terms of reporting their own compliance with hand hygiene, 94% of respondents agreed to some extent that they consistently practiced hand hygiene when returning to the station after a call and after transporting a patient, However, participants seemed less confident regarding compliance of their coworkers. Only 71.9% and 68.9% agreed to some extent that their coworkers were regularly practicing hand hygiene after patient contact and when returning to the station from a call, respectively. Postintervention In the postintervention phase, 219 surveys were returned, for a 60% response rate. The total number of employees had decreased to 364 due to attrition since the preintervention surveys. More than 92% of employees indicated that they had received training on hand hygiene while employed at PCFR (P ¼ .000). Several barriers to hand hygiene compliance were reported frequently, including forgetfulness (31.1%), the belief that wearing gloves is a substitute for poor hygiene (11%), and fatigue (4.6%). Two barriers that were not identified in the preintervention survey but were reported by 1.8% of postintervention participants were the beliefs that hand hygiene is not important and is too time-consuming (Table 1). However, there were no statistically significant differences in identified barriers to practicing hand hygiene between the preintervention and postintervention surveys. Responses to Likert scale questions regarding attitudes, practices, and beliefs about handwashing were not statistically significantly different between the preintervention and postintervention surveys (Table 2). Responses to direct questions about the impact of the intervention were more positive (Table 3).
326
C. McGuire-Wolfe et al. / American Journal of Infection Control 40 (2012) 324-7
Table 2 Selected Likert scale questions regarding practices, attitudes, and beliefs Agree to some extent
c2
P
0.52
.471
0.01
.924
0.06
.814
1.81
.178
0.43
.513
Disagree to some extent
I consistently wash my hands after returning to the station from a call. Preintervention 214 (95.5%) 10 (4.5%) Postintervention 204 (94.0%) 13 (6.0%) I consistently wash my hands or use alcohol-based hand gel after transporting a patient. Preintervention 211 (94.2%) 13 (5.8%) Postintervention 203 (94.0%) 13 (6.0%) My coworkers regularly wash their hands or use alcohol-based hand gel after patient contact. Preintervention 164 (73.9%) 61 (26.2%) Postintervention 156 (71.9%) 61 (28.9%) My coworkers regularly wash their hand or use alcohol-based hand gel when they return to the station from a call. Preintervention 155 (68.9%) 70 (31.1%) Postintervention 162 (74.7%) 55 (25.3%) I worry about what type of germs my coworkers might be spreading due to poor hand washing habits. Preintervention 142 (63.7%) 81 (36.3%) Postintervention 131 (60.7%) 85 (39.3%) Denominators differ due to differences in response rates.
Table 3 Attitudes regarding the impact of the intervention Strongly agree 1. Since installation of the alcohol hand gel dispensers and signs a. I notice that my coworkers are cleaning their hands more often. 52 (24.0%) b. I find myself cleaning my hands more often. 79 (36.4%) 2. The hand gel dispensers in the rescue increase the likelihood that I will clean my hands a. During and after patient care. 127 (58.8%) b. When returning from a call. 118 (54.4%) 3. The hand hygiene signs in the station help me to remember to clean my hands 61 (28.1%) 4. The PowerPoint training on hand hygiene reminded me about the importance 55 (25.5%) of handwashing or using alcohol hand gel
DISCUSSION Several barriers to hand hygiene were identified in this study. Fatigue, a barrier inherent to EMS and firefighting, is particularly difficult to counteract. Girou et al19 concluded that a hand hygiene campaign would not be successful at their institution unless a profound change in gloving practices occurred. Future hand hygiene campaigns at PCFR should include messages targeting fatigue as a barrier and misconceptions about the relationship between glove use and hand hygiene. The EMS workers and FFs in our sample demonstrated an understanding of the importance of hand hygiene and reported high levels of compliance for themselves, but identified concerns regarding their coworkers’ compliance. This discrepancy is consistent with the phenomenon of “social desirability,” wherein participants are more likely to report socially acceptable behaviors when self-reporting.20,21 The apparent discrepancy between the perceived benefits of intervention and the lack of corresponding changes in practices, attitudes, and beliefs, also may indicate a propensity of respondents to give a socially acceptable response (ie, that the interventions were helpful), or the inability of the Likert scale questions to represent actual practices, attitudes, and beliefs.20,21 Because of the nature of the fire department staffing design, this study had no control group. Moreover, it is important to mention that there was no observational method for reporting compliance with hand hygiene.9-11,20,22 PCFR’s hand hygiene promotion project did not provide messages endorsing hand hygiene from senior staff within the rank structure of the fire department. The importance of developing a culture of safety, including participation of senior staff in hand hygiene efforts, has been suggested previously.2,4,7,23,24 Helms et al8 stressed the importance of staff involvement in
Somewhat agree
Neutral
Somewhat disagree
Strongly disagree
89 (41.0%) 74 (34.1%)
53 (24.4%) 28 (12.9%)
14 (6.5%) 23 (10.6%)
9 (4.1%) 13 (6.0%)
58 59 61 77
14 17 48 52
7 15 27 20
10 8 20 12
(26.9%) (27.2%) (28.1%) (35.6%)
(6.5%) (7.8%) (22.1%) (24.1%)
(3.2%) (6.9%) (12.4%) (9.3%)
(4.6%) (3.7%) (9.2%) (5.6%)
the entire intervention process, including the planning stages, principally in the form of a multidisciplinary hand hygiene team representing various groups within the organization. Inclusion of field personnel in the planning, implementation, and evaluation of future hand hygiene efforts is a realistic future goal for PCFR. Despite its limitations, this preliminary study has generated awareness about the importance of hand hygiene within this target population, provided initial training for personnel, and increased the availability of alcohol hand rub. The challenge lies in developing ongoing education about hand hygiene to improve the knowledge base and reinforce positive behavior change.4,10 Lessons from this pilot effort have important implications for future studies within this particular FF/EMS population, as well as in a wide variety of EMS and fire department settings. References 1. Boyce JM, Pittet D. Guideline for hand-hygiene in health care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Morb Mort Wkly Rep 2002;51:1-44. 2. Whitby M, Pessoa-Silav CL, McLaws ML, Allegranzi B, Sax H, Larson E, et al. Behavioral considerations for hand hygiene practices: the basic building blocks. J Hosp Infect 2007;65:1-8. 3. Trampuz A, Widmer AF. Hand hygiene: a frequently missed lifesaving opportunity during patient care. Mayo Clin Proc 2004;79:109-16. 4. Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 2009;73:303-15. 5. Sax H, Uckay I, Richet H, Allegranzi B, Pittet D. Determinants of good adherence to hand hygiene among healthcare workers who have extensive exposure to hand hygiene campaign. Infect Control Hosp Epidemiol 2007;28:1267-74. 6. Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol 2000;21:381-6. 7. Pittet D, Simon A, Hugonnet S, Pessoa-Silva C, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004;141:1-8.
C. McGuire-Wolfe et al. / American Journal of Infection Control 40 (2012) 324-7 8. Helms B, Dorval S, St Laurent P, Winter M. Improving hand hygiene compliance: a multidisciplinary approach. Am J Infect Control 2010;38:572-4. 9. Bischoff WE, Reynolds T, Sessler CN, Edmund MB, Wenzel RP. Handwashing compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med 2000;160:1017-21. 10. Larson EL, Bryan JL, Adler LM, Blane C. A multifaceted approach to changing handwashing behavior. Am J Infect Control 1997;25:3-10. 11. Korniewicz DM, El-Masri M. Exploring the factors associated with hand hygiene compliance of nurses during routine clinical practice. Appl Nurs Dis 2010;23:86-90. 12. De Wandel D, Maes L, Labeau S, Vereecken C, Blot S. Behavioral determinants of hand hygiene compliance in intensive care units. Am J Crit Care 2010;19:230-9. 13. Pettit D. Improving adherence to hand hygiene practice: a multi-disciplinary approach. Emerg Infect Dis 2001;7:234-40. 14. Kampf G. The six golden rules to improve compliance in hand hygiene. J Hosp Infect 2004;56:53-5. 15. Pasco County Office of Management and Budget. Annual budget reports. Available from: http://portal.pascocountyfl.net/portal/server.pt/community/ office_of_management_and_budget/218/home. Accessed November 4, 2010. 16. Saint Raphael Healthcare System. Hand hygiene resource center. Available from: http://www.handhygiene.org/slideshow/default.asp?var1¼screen01 .htm. Accessed October 18, 2010.
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17. Centers for Disease Control and Prevention. Hand hygiene posters, August 2010. Available from: http://www.cdc.gov/handhygiene/index.html. Accessed October 18, 2010. 18. Department of Veteran’s Affairs. Hand hygiene posters. Available from: http://www.publichealth.va.gov/flu/materials/posters_hand_hygiene.asp#wa sh. Accessed October 18, 2010. 19. Girou E, Chai SH, Oppein F, Legrand P, Ducellier D, Cizeau F, et al. Misuse of gloves: the foundation for poor compliance with hand hygiene and potential for microbial transmission? J Hosp Infect 2004;57:162-9. 20. Adams SA, Matthews CE, Ebbeling CB, Moore CG, Cunningham JE, Fulton J, et al. The effect of social desirability and social approval on self-reports of physical activity. Am J Epidemiol 2005;161:389-98. 21. Holtgraves T. Social desirability and self-reports: testing models of socially desirable responding. Pers Soc Psychol Bull 2004;30:161-72. 22. Pittet D, Boyce JM. Hand hygiene and patient care: pursuing the Semmelweis legacy. Lancet Infect Dis 2001;1:9-20. 23. Sax H, Allegranzi B, Chraiti MN, Boyce J, Larson E, Pittet D. The World Health Organization hand hygiene observation method. Am J Infect Control 2009;37: 827-34. 24. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307-12.