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A new approach to infection prevention: A pilot study to evaluate a hand hygiene ambassador program in hospitals and clinics
ARTICLE IN PRESS American Journal of Infection Control 000 (2019) 1−3
Contents lists available at ScienceDirect
American Journal of Infection Control journal homepage: www.ajicjournal.org
Major Article
A new approach to infection prevention: A pilot study to evaluate a hand hygiene ambassador program in hospitals and clinics David J. Birnbach MD, MPH a,b,*, Taylor C. Thiesen BS b, Lisa F. Rosen MA b, Maureen Fitzpatrick MSN, APRN-BC b, Kristopher L. Arheart EdD c a b c
University of Miami Miller School of Medicine, Miami, FL UM-JMH Center for Patient Safety, University of Miami Miller School of Medicine, Miami, FL Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL
Key Words: Hand hygiene Infection prevention and control Alcohol-based handrub Patient safety Hand hygiene ambassadors
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. © 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Direct observation has long been established as the gold standard to verify adherence to hand hygiene compliance (HHC) guidelines.1-5 Moreover, direct observation may identify barriers to compliance and lead to institution-specific, targeted approaches.6-8 Other interventions to improve HHC have been tested, such as education9,10; reminder signs and cues11-14; performance feedback and automated systems15-18; facility design19,20; surveillance and video monitoring15; portable, mounted, and wearable alcohol-based handrub (ABHR)21,22; and multimodal strategies.3,23 Nonetheless, a sustained impact on hand hygiene rates varies considerably, and the problem of suboptimal HHC continues.24,25 In addition to the challenge of HHC for health care providers, patients and visitors may also bring pathogens into the hospital environment.11,26,27 Given the low rates of reported HHC throughout hospitals and clinics, one possible intervention to reduce pathogens that may be
*Address correspondence to David J. Birnbach, MD, MPH, University of Miami Miller School of Medicine, 1611 NW 12th Ave, C-300, Miami, FL 33131. E-mail address: [email protected] (D.J. Birnbach). Conflicts of interest: None to report.
brought into the health care environment from the community is to mandate hand hygiene on entry. This step assures that staff, patients, and visitors clean their hands at least once before entering patient areas.28 It has been shown in health care settings that directly observed hand hygiene ensures compliance.4 As in other industries, directly observed hand hygiene could be achieved with a dedicated attendant or “hand hygiene ambassador” (HHA) who dispenses ABHR directly onto the hands of all entrants either at the entrance to the hospital or entry to a particular unit. For example, as a result of the high risk of the norovirus on cruise ships, passengers often receive ABHR provided by HHAs.29 Although it is possible that this service would be welcomed by hospital entrants, there are currently no data to evaluate whether it would be perceived as an intrusion. A proposal to implement an HHA program at our hospital was challenged by those who believed that the presence of an HHA may be perceived negatively, potentially suggesting to patients that there is a problem with poor HHC or potentially insulting providers. Therefore, this pilot study to evaluate an HHA program was conducted to assess the perceptions of entrants (visitors, patients, and staff).
https://doi.org/10.1016/j.ajic.2019.11.007 0196-6553/© 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
ARTICLE IN PRESS D.J. Birnbach et al. / American Journal of Infection Control 00 (2019) 1−3
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METHODS Two hundred and twenty-five entrants to 5 lobbies of various health care settings (public hospital, private hospital, surgical center, cancer hospital, specialty hospital) affiliated with an academic medical center were surveyed by 2 trained observers. Hospital and clinic lobbies were selected because hand hygiene behaviors are easily observable, and they are the central entry point to approach not only medical professionals but also patients, visitors, and other ancillary hospital staff. The observers approached entrants in each of the various lobbies between the hours of 9 AM and 12 PM on random days over a 6-month period. Specific dates and time of data collection were recorded on the questionnaires. The same observers collected data at all sites. Observers wore hospital identification badges and white lab coats and identified individuals who did not perform hand hygiene at the ABHR stations on entry to the lobby. The observer then approached the entrants and asked for permission to administer ABHR (Purell, GoJo Industries, Akron, OH) on their hands. If they agreed to the application of ABHR (approximately 1.5 mL or the equivalent of 2 pumps), the observer also asked several questions (Table 1) and recorded the answers. Participant information was also recorded for sex and whether they were a patient, visitor, or health care provider. Once the data were collected from each of the sites, the responses were transferred onto a spreadsheet and verified for subsequent analysis. This study was granted exempt status by the University of Miami Miller School of Medicine institutional review board. Statistical analysis We tested models with each question as the outcome and location, sex, and the interaction of location and sex as predictors. None of the models had a significant location main effect or interaction effect. Likewise, we tested the same models with location, role, and the interaction of location and role. Again, the location main effect and the interaction effect were not significant in any of the models. Therefore, the data were combined over location for the analyses reported in Tables 2 and 3. A generalized linear model was used to analyze the binary outcome data. Separate models were run for sex and visitor type. Planned comparisons were made between groups. Frequency and percentage are reported for each group. The 2-tailed 0.05 alpha level was used to determine statistical significance. SAS 9.4 (SAS Institute Inc, Cary, NC) was used for all analyses. RESULTS When asked whether they think it is a good idea to have an HHA place ABHR on an entrant’s hands, and the majority of staff, visitors, and patients agreed (86.1% total; 85.6% staff; 93.8% visitors; 80.4% patients) (Table 3). However, one of the participating hospitals (a subspecialty cancer center) had a higher positive rate regarding the HHA than the others. When asked whether it is important to wash hands when entering a hospital or clinic, >98% agreed. As seen in Table 1 Survey questions for hospital lobby entrants 1. Do you think it is important for visitors and patients to clean their hands when entering the hospital? 2. Do you think there is a connection between unclean hands and spread of germs/infections in hospitals? 3. Do you think it is a good idea to have a hand hygiene service place alcohol-based handrub on an entrant’s hands?
Table 2 Characteristics of hospital lobby entrants surveyed in 5 hospitals combined by sex Women (122)
Men (103)
Question
Yes
No
Yes
No
P
1 2 3
121 (99.2%) 120 (98.4%) 99 (81.1%)
1 2 23
102 (99%) 102 (99%) 94 (91.3%)
1 1 9
NS NS .031
NS, not statistically significant.
Table 2, there was a statistically significant difference between sexes: 91.3% of men versus 81% of women responded positively to the concept of an HHA (P = .031). No one refused ABHR when asked by the observer. DISCUSSION The potential role of visitors in the transmission of health care− associated infection remains unclear, and little attention has been paid to understanding their role as vectors for organism transmission.30 Moreover, the lack of enforcement of hand hygiene for health care workers, as well as visitors before entering a patient’s room, may be allowing a direct source of pathogens to potentially infect the patient.31 The use of HHAs who directly observe ABHR application has been shown to significantly increase compliance with patients.32 HHC using an HHA, however, has not been evaluated for visitors and staff. In addition to the direct benefit of placing ABHR on entry to the hospital, the implementation of an HHA may also increase awareness and motivate subsequent hand hygiene in other hospital locations.12 This study had several limitations. First, ABHR was only applied with consent of the entrant. There was no evaluation of those who refused ABHR, as no one did. It is possible that an entrant may refuse, and how to address this potentiality needs to be determined by health care facilities prior to implementation. Second, there may have been some reluctance on the part of participants to say “no” to ABHR being placed into their hands and a similar reluctance to express disapproval of an HHA. Third, there may be a presumption on the part of the staff that they do not need to clean hands in the lobby because they will do it before patient contact on the wards. Conversely, with the implementation of an HHA program they might not feel it necessary to clean hands on the wards because they performed hand hygiene in the lobby. However, it has been reported that increasing hand hygiene in the lobby may minimize pathogens being brought into a hospital or clinic and has no clear drawback.33 Finally, this study was limited to the hospital lobby entrants. Health care providers on the wards are instructed to comply with the World Health Organization (WHO) Five Moments of Hand Hygiene; however, the strategic placement of HHAs throughout the hospital may be useful to creating awareness of HHC and reinforce the WHO Five Moments of Hand Hygiene. This study demonstrates that the vast majority of entrants we queried believe that hand hygiene is important to reduce the risk of health care−associated infection. When approached, the majority of visitors, patients, and employees who had not performed hand hygiene at the entrance did not object to an HHA offering ABHR, and Table 3 Characteristics of hospital lobby entrants surveyed in 5 hospitals combined by role Staff (125)
Visitors (49)
Patients (51)
Question
Yes
No
Yes
No
Yes
No
1 2 3
124 (91.2%) 125 (100%) 107 (85.6%)
1 0 18
48 (97.9%) 47 (95.9%) 45 (91.8%)
1 2 4
50 (98%) 49 (96%) 41 (80.4%)
1 2 10
ARTICLE IN PRESS D.J. Birnbach et al. / American Journal of Infection Control 00 (2019) 1−3
agreed that it should become a routine practice. Of note, men responded more positively when asked about the HHA. As previous studies have shown, women are more hand hygiene compliant than men,34 and this may explain the reason women stated that an HHA was not as important as their male counterparts. It is not surprising that the positive response rate to an HHA was highest in the cancer center because of the awareness of risks in immunocompromised patients. Of note, one of the hospitals that participated in this study now has an identifiable HHA in their lobby offering ABHR to all entrants. A future study will explore expansion to other facilities. As individual hospitals face unique HHC challenges, customized approaches may determine how best to use an HHA and where they might be most effective.7 It may also be premature to suggest that HHA programs are the only answer. Although the cost of such an initiative should be considered prior to implementation, it should be weighed against the annual spending of almost $10 billion in the United States for health care−associated infections.35 Based on the results of this study, a more targeted approach directed to health care providers in specific clinical areas may be appropriate, and educational programs using HHAs can be tailored to specific areas such as medical and surgical floors and the intensive care unit. CONCLUSIONS Moving the needle on HHC has proven to be quite difficult. Numerous interventions have been tried and few have been shown to be sustainable.36 The innovative aspect of this study is the assessment of attitudes toward an individual who would be tasked with providing ABHR for hospital and clinic entrants. Perhaps the use of a human reminder (such as an HHA) will create awareness in the way that signs and other environmental engineering strategies have failed to achieve.37,38 Ideally, the WHO Five Moments of Hand Hygiene would be standard practice. Until we achieve that goal, we must continue to try new approaches such as HHAs to educate and increase awareness of the importance of HHC. References 1. Larson EL, Aiello AE, Cimiotti JP. Assessing nurses’ hand hygiene practices by direct observation or self-report. J Nurs Meas 2004;12:77-85. 2. Magaldi MC, Molloy J. Using student nurses as hand-washing ambassadors: a model to promote advocacy and enhance infection control practice. Nurse Educ 2010;35:183-5. 3. Chen JK, Wu KS, Lee SS, Lin HS, Tsai HC, Li CH, et al. Impact of implementation of the World Health Organization multimodal hand hygiene improvement strategy in a teaching hospital in Taiwan. Am J Infect Control 2016;44:222-7. 4. Cheng VCC, Wong SC, Wong SCY, Yuen KY. Directly observed hand hygiene−from healthcare workers to patients. J Hosp Infect 2019;101:380-2. 5. McLaws ML, Kwok YLA. Hand hygiene compliance rates: act or fiction? Am J Infect Control 2018;46:876-80. 6. Pan SC, Tien KL, Hung IC, Lin YJ, Sheng WH, Wang MJ, et al. Compliance of health care workers with hand hygiene practices: independent advantages of overt and covert observers. PLoS One 2013;8:e53746. 7. Chassin MR, Mayer C, Nether K. Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance. Jt Comm J Qual Patient Saf 2015;41:4-12. 8. Al-Tawfiq JA, Treble M, Abdrabalnabi R, Okeahialam C, Khazindar S, Myers S. Using targeted solution tools as an initiative to improve hand hygiene: challenges and lessons learned. Epidemiol Infect 2018;146:276-82. 9. Higgins A, Hannan MM. Improved hand hygiene technique and compliance in healthcare workers using gaming technology. J Hosp Infect 2013;84:32-7. 10. Fitzpatrick M, Everett-Thomas R, Nevo I, Shekhter I, Rosen LF, Scheinman SR, et al. A novel educational programme to improve knowledge regarding health careassociated infection and hand hygiene. Int J Nurs Pract 2011;17:269-74. 11. Birnbach DJ, Rosen LF, Fitzpatrick M, Arheart KL, Munoz-Price LS. An evaluation of hand hygiene in an intensive care unit: are visitors a potential vector for pathogens? J Infect Public Health 2015;8:570-4. 12. King D, Vlaev I, Everett-Thomas R, Fitzpatrick M, Darzi A, Birnbach DJ. “Priming” hand hygiene compliance in clinical environments. Health Psychol 2016;35:96-101.
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13. Nevo I, Fitzpatrick M, Thomas RE, Gluck PA, Lenchus JD, Arheart KL, et al. The efficacy of visual cues to improve hand hygiene compliance. Simul Healthc 2010;5: 325-31. 14. Diegel-Vacek L, Ryan C. Promoting hand hygiene with a lighting prompt. HERD 2016;10:65-75. 15. Armellino D, Hussain E, Schilling ME, Senicola W, Eichorn A, Dlugacz Y, et al. Using high-technology to enforce low-technology safety measures: the use of thirdparty remote video auditing and real-time feedback in healthcare. Clin Infect Dis 2012;54:1-7. 16. Stewardson AJ, Sax H, Gayet-Ageron A, Touveneau S, Longtin Y, Zingg W, et al. Enhanced performance feedback and patient participation to improve hand hygiene compliance of health-care workers in the setting of established multimodal promotion: a single-centre, cluster randomized controlled trial. Lancet Infect Dis 2016;16:1345-55. 17. McCalla S, Reilly M, Thomas R, McSpedon-Rai D. An automated hand hygiene compliance system is associated with improved monitoring of hand hygiene. Am J Infect Control 2017;45:492-7. 18. McCalla S, Reilly M, Thomas R, McSpedon-Rai D, McMahon LA, Palumbo M. An automated hand hygiene compliance system is associated with decreased rates of health care-associated infections. Am J Infect Control 2018;46:1381-6. 19. Munoz-Price LS, Patel Z, Banks S, Arheart K, Eber S, Lubarsky DA, et al. Randomized crossover study evaluating the effect of a hand sanitizer dispenser on the frequency of hand hygiene among anesthesiology staff in the operating room. Infect Control Hosp Epidemiol 2014;35:717-20. 20. Birnbach DJ, Nevo I, Scheinman SR, Fitzpatrick M, Shekhter I, Lombard JL. Patient safety begins with proper planning: a quantitative method to improve hospital design. Qual Saf Health Care 2010;19:462-5. 21. Thomas BW, Berg-Copas GM, Vasquez DG, Jackson BL, Wetta-Hall R. Conspicuous vs customary location of hand hygiene agent dispensers on alcohol-based hand hygiene product usage in an intensive care unit. J Am Osteopath Assoc 2009;109: 263-7. 22. Keller J, Wolfensberger A, Clack L, Kuster SP, Dunic M, Eis D, et al. Do wearable alcohol-based hand rub dispensers increase hand hygiene compliance? A mixedmethods study. Antimicrob Resist Infect Control 2018;7:143. 23. Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection. J Hosp Infect 2009;73:305-15. 24. Gould DJ, Drey NS, Moralejo D, Grimshaw J, Chudleigh J. Interventions to improve hand hygiene compliance in patient care. J Hosp Infect 2008;68: 193-202. 25. Gould DJ, Moralejo D, Drey N, Chudleigh JH, Taljaard M. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev 2017;9: CD005186. 26. Cohen B, Hyman S, Rosenberg L, Larson E. Frequency of patient contact with health care personnel and visitors: implications for infection prevention. Jt Comm J Qual Patient Saf 2012;12:560-5. 27. Mody L, Washer LL, Kaye KS, Gibson K, Saint S, Reyes K, et al. Multidrug-resistant organisms in hospitals: what is on patient hands and in their rooms? Clin Infect Dis 2019;69:1837-44. 28. Birnbach DJ, Nevo I, Barnes S, Fitzpatrick M, Rosen LF, Everett-Thomas R, et al. Do hospital visitors wash their hands? Assessing the use of alcohol-based hand sanitizer in a hospital lobby. Am J Infect Control 2012;40:340-3. 29. Centers for Disease Control and Prevention. Facts about noroviruses on cruise ships. Available from: https://www.cdc.gov/nceh/vsp/pub/norovirus/norovirus. htm. Accessed May 13, 2019. 30. Banach DB, Bearman GM, Morgan DJ, Munoz-Price LS. Infection control precautions for visitors to healthcare facilities. Expert Rev Anti Infect Ther 2015;13:104750. 31. Compton D, Davenport TE. Compliance with hand-washing guidelines among visitors from the community to acute care settings: a scoping review. J Acute Care Phys Ther 2018;9:19-34. 32. Cheng VC, Tai JW, Li WS, Chau PH, So SY, Wong LM, et al. Implementation of directly observed patient hand hygiene for hospitalized patients by hand hygiene ambassadors in Hong Kong. Am J Infect Control 2016;44:621-4. 33. Hobbs MA, Robinson S, Neyens DM, Steed C. Visitor characteristics and alcoholbased hand sanitizer dispenser locations at the hospital entrance: effect on visitor use rates. Am J Infect Control 2016;44:258-62. 34. Shim JY, Park S, Kim GE, Jeong YS, Kim JH, Lee E, et al. Does physician leadership influence followers’ hand hygiene compliance? Open Forum Infect Dis 2019;6:1-5. 35. Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, et al. Health careassociated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med 2013;173:2039-46. 36. Ibrahim MAB, Chow C, Poh BF, Ang B, Chow A. Differences in psychosocial determinants of hand hygiene between health care professional groups: insights from a mixed-methods analysis. Am J Infect Control 2018;46:253-60. 37. Birnbach DJ, Rosen LF, Fitzpatrick M, Everett-Thomas R, Arheart KL. A ubiquitous but ineffective intervention: signs do not increase hand hygiene compliance. J Infect Public Health 2017;10:295-8. 38. Schmidtke KA, Aujla N, Marshall T, Hussain A, Hodgkinson GP, Arheart K, et al. Using environmental engineering to increase hand hygiene compliance: a crossover study protocol. BMJ Open 2017;7:e017108.
Contents lists available at ScienceDirect
American Journal of Infection Control journal homepage: www.ajicjournal.org
Major Article
A new approach to infection prevention: A pilot study to evaluate a hand hygiene ambassador program in hospitals and clinics David J. Birnbach MD, MPH a,b,*, Taylor C. Thiesen BS b, Lisa F. Rosen MA b, Maureen Fitzpatrick MSN, APRN-BC b, Kristopher L. Arheart EdD c a b c
University of Miami Miller School of Medicine, Miami, FL UM-JMH Center for Patient Safety, University of Miami Miller School of Medicine, Miami, FL Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL
Key Words: Hand hygiene Infection prevention and control Alcohol-based handrub Patient safety Hand hygiene ambassadors
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. © 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Direct observation has long been established as the gold standard to verify adherence to hand hygiene compliance (HHC) guidelines.1-5 Moreover, direct observation may identify barriers to compliance and lead to institution-specific, targeted approaches.6-8 Other interventions to improve HHC have been tested, such as education9,10; reminder signs and cues11-14; performance feedback and automated systems15-18; facility design19,20; surveillance and video monitoring15; portable, mounted, and wearable alcohol-based handrub (ABHR)21,22; and multimodal strategies.3,23 Nonetheless, a sustained impact on hand hygiene rates varies considerably, and the problem of suboptimal HHC continues.24,25 In addition to the challenge of HHC for health care providers, patients and visitors may also bring pathogens into the hospital environment.11,26,27 Given the low rates of reported HHC throughout hospitals and clinics, one possible intervention to reduce pathogens that may be
*Address correspondence to David J. Birnbach, MD, MPH, University of Miami Miller School of Medicine, 1611 NW 12th Ave, C-300, Miami, FL 33131. E-mail address: [email protected] (D.J. Birnbach). Conflicts of interest: None to report.
brought into the health care environment from the community is to mandate hand hygiene on entry. This step assures that staff, patients, and visitors clean their hands at least once before entering patient areas.28 It has been shown in health care settings that directly observed hand hygiene ensures compliance.4 As in other industries, directly observed hand hygiene could be achieved with a dedicated attendant or “hand hygiene ambassador” (HHA) who dispenses ABHR directly onto the hands of all entrants either at the entrance to the hospital or entry to a particular unit. For example, as a result of the high risk of the norovirus on cruise ships, passengers often receive ABHR provided by HHAs.29 Although it is possible that this service would be welcomed by hospital entrants, there are currently no data to evaluate whether it would be perceived as an intrusion. A proposal to implement an HHA program at our hospital was challenged by those who believed that the presence of an HHA may be perceived negatively, potentially suggesting to patients that there is a problem with poor HHC or potentially insulting providers. Therefore, this pilot study to evaluate an HHA program was conducted to assess the perceptions of entrants (visitors, patients, and staff).
https://doi.org/10.1016/j.ajic.2019.11.007 0196-6553/© 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
ARTICLE IN PRESS D.J. Birnbach et al. / American Journal of Infection Control 00 (2019) 1−3
2
METHODS Two hundred and twenty-five entrants to 5 lobbies of various health care settings (public hospital, private hospital, surgical center, cancer hospital, specialty hospital) affiliated with an academic medical center were surveyed by 2 trained observers. Hospital and clinic lobbies were selected because hand hygiene behaviors are easily observable, and they are the central entry point to approach not only medical professionals but also patients, visitors, and other ancillary hospital staff. The observers approached entrants in each of the various lobbies between the hours of 9 AM and 12 PM on random days over a 6-month period. Specific dates and time of data collection were recorded on the questionnaires. The same observers collected data at all sites. Observers wore hospital identification badges and white lab coats and identified individuals who did not perform hand hygiene at the ABHR stations on entry to the lobby. The observer then approached the entrants and asked for permission to administer ABHR (Purell, GoJo Industries, Akron, OH) on their hands. If they agreed to the application of ABHR (approximately 1.5 mL or the equivalent of 2 pumps), the observer also asked several questions (Table 1) and recorded the answers. Participant information was also recorded for sex and whether they were a patient, visitor, or health care provider. Once the data were collected from each of the sites, the responses were transferred onto a spreadsheet and verified for subsequent analysis. This study was granted exempt status by the University of Miami Miller School of Medicine institutional review board. Statistical analysis We tested models with each question as the outcome and location, sex, and the interaction of location and sex as predictors. None of the models had a significant location main effect or interaction effect. Likewise, we tested the same models with location, role, and the interaction of location and role. Again, the location main effect and the interaction effect were not significant in any of the models. Therefore, the data were combined over location for the analyses reported in Tables 2 and 3. A generalized linear model was used to analyze the binary outcome data. Separate models were run for sex and visitor type. Planned comparisons were made between groups. Frequency and percentage are reported for each group. The 2-tailed 0.05 alpha level was used to determine statistical significance. SAS 9.4 (SAS Institute Inc, Cary, NC) was used for all analyses. RESULTS When asked whether they think it is a good idea to have an HHA place ABHR on an entrant’s hands, and the majority of staff, visitors, and patients agreed (86.1% total; 85.6% staff; 93.8% visitors; 80.4% patients) (Table 3). However, one of the participating hospitals (a subspecialty cancer center) had a higher positive rate regarding the HHA than the others. When asked whether it is important to wash hands when entering a hospital or clinic, >98% agreed. As seen in Table 1 Survey questions for hospital lobby entrants 1. Do you think it is important for visitors and patients to clean their hands when entering the hospital? 2. Do you think there is a connection between unclean hands and spread of germs/infections in hospitals? 3. Do you think it is a good idea to have a hand hygiene service place alcohol-based handrub on an entrant’s hands?
Table 2 Characteristics of hospital lobby entrants surveyed in 5 hospitals combined by sex Women (122)
Men (103)
Question
Yes
No
Yes
No
P
1 2 3
121 (99.2%) 120 (98.4%) 99 (81.1%)
1 2 23
102 (99%) 102 (99%) 94 (91.3%)
1 1 9
NS NS .031
NS, not statistically significant.
Table 2, there was a statistically significant difference between sexes: 91.3% of men versus 81% of women responded positively to the concept of an HHA (P = .031). No one refused ABHR when asked by the observer. DISCUSSION The potential role of visitors in the transmission of health care− associated infection remains unclear, and little attention has been paid to understanding their role as vectors for organism transmission.30 Moreover, the lack of enforcement of hand hygiene for health care workers, as well as visitors before entering a patient’s room, may be allowing a direct source of pathogens to potentially infect the patient.31 The use of HHAs who directly observe ABHR application has been shown to significantly increase compliance with patients.32 HHC using an HHA, however, has not been evaluated for visitors and staff. In addition to the direct benefit of placing ABHR on entry to the hospital, the implementation of an HHA may also increase awareness and motivate subsequent hand hygiene in other hospital locations.12 This study had several limitations. First, ABHR was only applied with consent of the entrant. There was no evaluation of those who refused ABHR, as no one did. It is possible that an entrant may refuse, and how to address this potentiality needs to be determined by health care facilities prior to implementation. Second, there may have been some reluctance on the part of participants to say “no” to ABHR being placed into their hands and a similar reluctance to express disapproval of an HHA. Third, there may be a presumption on the part of the staff that they do not need to clean hands in the lobby because they will do it before patient contact on the wards. Conversely, with the implementation of an HHA program they might not feel it necessary to clean hands on the wards because they performed hand hygiene in the lobby. However, it has been reported that increasing hand hygiene in the lobby may minimize pathogens being brought into a hospital or clinic and has no clear drawback.33 Finally, this study was limited to the hospital lobby entrants. Health care providers on the wards are instructed to comply with the World Health Organization (WHO) Five Moments of Hand Hygiene; however, the strategic placement of HHAs throughout the hospital may be useful to creating awareness of HHC and reinforce the WHO Five Moments of Hand Hygiene. This study demonstrates that the vast majority of entrants we queried believe that hand hygiene is important to reduce the risk of health care−associated infection. When approached, the majority of visitors, patients, and employees who had not performed hand hygiene at the entrance did not object to an HHA offering ABHR, and Table 3 Characteristics of hospital lobby entrants surveyed in 5 hospitals combined by role Staff (125)
Visitors (49)
Patients (51)
Question
Yes
No
Yes
No
Yes
No
1 2 3
124 (91.2%) 125 (100%) 107 (85.6%)
1 0 18
48 (97.9%) 47 (95.9%) 45 (91.8%)
1 2 4
50 (98%) 49 (96%) 41 (80.4%)
1 2 10
ARTICLE IN PRESS D.J. Birnbach et al. / American Journal of Infection Control 00 (2019) 1−3
agreed that it should become a routine practice. Of note, men responded more positively when asked about the HHA. As previous studies have shown, women are more hand hygiene compliant than men,34 and this may explain the reason women stated that an HHA was not as important as their male counterparts. It is not surprising that the positive response rate to an HHA was highest in the cancer center because of the awareness of risks in immunocompromised patients. Of note, one of the hospitals that participated in this study now has an identifiable HHA in their lobby offering ABHR to all entrants. A future study will explore expansion to other facilities. As individual hospitals face unique HHC challenges, customized approaches may determine how best to use an HHA and where they might be most effective.7 It may also be premature to suggest that HHA programs are the only answer. Although the cost of such an initiative should be considered prior to implementation, it should be weighed against the annual spending of almost $10 billion in the United States for health care−associated infections.35 Based on the results of this study, a more targeted approach directed to health care providers in specific clinical areas may be appropriate, and educational programs using HHAs can be tailored to specific areas such as medical and surgical floors and the intensive care unit. CONCLUSIONS Moving the needle on HHC has proven to be quite difficult. Numerous interventions have been tried and few have been shown to be sustainable.36 The innovative aspect of this study is the assessment of attitudes toward an individual who would be tasked with providing ABHR for hospital and clinic entrants. Perhaps the use of a human reminder (such as an HHA) will create awareness in the way that signs and other environmental engineering strategies have failed to achieve.37,38 Ideally, the WHO Five Moments of Hand Hygiene would be standard practice. Until we achieve that goal, we must continue to try new approaches such as HHAs to educate and increase awareness of the importance of HHC. References 1. Larson EL, Aiello AE, Cimiotti JP. Assessing nurses’ hand hygiene practices by direct observation or self-report. J Nurs Meas 2004;12:77-85. 2. Magaldi MC, Molloy J. Using student nurses as hand-washing ambassadors: a model to promote advocacy and enhance infection control practice. Nurse Educ 2010;35:183-5. 3. Chen JK, Wu KS, Lee SS, Lin HS, Tsai HC, Li CH, et al. Impact of implementation of the World Health Organization multimodal hand hygiene improvement strategy in a teaching hospital in Taiwan. Am J Infect Control 2016;44:222-7. 4. Cheng VCC, Wong SC, Wong SCY, Yuen KY. Directly observed hand hygiene−from healthcare workers to patients. J Hosp Infect 2019;101:380-2. 5. McLaws ML, Kwok YLA. Hand hygiene compliance rates: act or fiction? Am J Infect Control 2018;46:876-80. 6. Pan SC, Tien KL, Hung IC, Lin YJ, Sheng WH, Wang MJ, et al. Compliance of health care workers with hand hygiene practices: independent advantages of overt and covert observers. PLoS One 2013;8:e53746. 7. Chassin MR, Mayer C, Nether K. Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance. Jt Comm J Qual Patient Saf 2015;41:4-12. 8. Al-Tawfiq JA, Treble M, Abdrabalnabi R, Okeahialam C, Khazindar S, Myers S. Using targeted solution tools as an initiative to improve hand hygiene: challenges and lessons learned. Epidemiol Infect 2018;146:276-82. 9. Higgins A, Hannan MM. Improved hand hygiene technique and compliance in healthcare workers using gaming technology. J Hosp Infect 2013;84:32-7. 10. Fitzpatrick M, Everett-Thomas R, Nevo I, Shekhter I, Rosen LF, Scheinman SR, et al. A novel educational programme to improve knowledge regarding health careassociated infection and hand hygiene. Int J Nurs Pract 2011;17:269-74. 11. Birnbach DJ, Rosen LF, Fitzpatrick M, Arheart KL, Munoz-Price LS. An evaluation of hand hygiene in an intensive care unit: are visitors a potential vector for pathogens? J Infect Public Health 2015;8:570-4. 12. King D, Vlaev I, Everett-Thomas R, Fitzpatrick M, Darzi A, Birnbach DJ. “Priming” hand hygiene compliance in clinical environments. Health Psychol 2016;35:96-101.
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