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Educational programme to enhance stethoscope hygiene behaviour
Accepted Manuscript An Educational Program to Enhance Stethoscope Hygiene Behavior K. Jordan, J. Barrett, S. Murney, A. Whipp, J.O. Elliott PII:
S0195-6701(17)30164-0
DOI:
10.1016/j.jhin.2017.03.020
Reference:
YJHIN 5064
To appear in:
Journal of Hospital Infection
Received Date: 17 February 2017 Accepted Date: 17 March 2017
Please cite this article as: Jordan K, Barrett J, Murney S, Whipp A, Elliott JO, An Educational Program to Enhance Stethoscope Hygiene Behavior, Journal of Hospital Infection (2017), doi: 10.1016/ j.jhin.2017.03.020. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
An Educational Program to Enhance Stethoscope Hygiene Behavior Sirs: Several studies implicate stethoscopes as possible vectors of nosocomial infection. One
RI PT
systematic review reported that 87.3% of stethoscopes are colonized with micro-organisms, including MRSA, enterococci, and gram-negative bacteria, and many isolates are multi-drug resistant.1 Numbers of healthcare workers (HCWs) who report stethoscope cleaning with each
SC
patient encounter ranges from 2% to 24% 2 yet, we found only four studies that reported
strategies to improve stethoscope cleaning behaviors. Thus, a 14-week prospective observational
M AN U
cohort study aimed at improving stethoscope cleaning behavior in a community teaching hospital ICU was conducted.
In order to establish baseline behavior, we surveyed 253 HCW on stethoscope cleaning practices as well as other disinfection practices in order to mask our main outcome of interest.
TE D
Subsequently, three separate educational emails were sent to HCWs, (weeks zero, six and ten), reminder posters were placed throughout the ICU, and cleaning stations utilizing Webcol™ twoply, medium 70% isopropyl alcohol pads were strategically placed for easy access. Signs
EP
indicated that alcohol pads were for stethoscope cleaning only. A study coordinator counted and restocked the cleaning stations daily.
AC C
In an attempt to reduce the Hawthorne effect, and because of cost constraints, alcohol
pads were used as an objective measure of cleaning, rather than direct observation. We estimated that each patient would experience a maximum 11 separate HCW stethoscope encounters daily. The average daily census was also recorded in order to estimate numbers of pads needed if HCWs cleaned with each encounter. A post-intervention survey containing the same elements as our initial survey, plus additional questions on perceived barriers and
Page 1 of 4
ACCEPTED MANUSCRIPT
influences on cleaning, as well as preferences for reminder systems, was sent to participants at week seventeen. Pre and post surveys were linked for analysis via the McNemar test. Of 253 invited participants, 62 (24.5%) completed both surveys. An overall increase in
RI PT
frequency of stethoscope cleaning was reported, P = 0.023. Cleaning “before and/or after each patient encounter” increased from 16.4% to 22.0%, while cleaning “one time per day/more than 1 time per day” increased from 34.4% to 49.2%, Figure 1. Our average daily census (not
SC
including patients on isolation) was 25.8 (95%CI: 25.3-26.3). Average alcohol pad use dropped from 82/day to 37/day within 6 weeks, averaging 40/day for study remainder. Expected counts
M AN U
would be 77/day if all HCWs cleaned just once daily and approach 286/day (26 patients x 11 encounters) if cleaned with each encounter.
Our results support findings of two prior studies that used similar methods and demonstrated a positive impact on stethoscope hygiene.3,4 Our intervention was easy and
TE D
inexpensive to implement (approximately $650 US dollars) and required no significant time away from HCW duties. Though two other studies reported very high success rates of stethoscope cleaning with each encounter, those interventions required significant time
EP
commitments from HCWs to attend training workshops, discussion groups, and formal lectures over a one month period. 5,6
AC C
Several issues may have negatively impacted our results. Approximately 20% of
respondents reported that they did not receive or read the emails, and almost 40% reported reading only one email, suggesting that email messages/reminders may not be a reliable means to increase stethoscope cleaning. Instead, participants reported preferences for on-site poster reminders (48.4%) and strategically placed larger sized cleaning wipes (69%) as the best methods for improving stethoscope cleaning practices. Though initial alcohol pad counts
Page 2 of 4
ACCEPTED MANUSCRIPT
supported participant responses indicating a move to more frequent cleaning, these counts were not sustained. Participants, however, reported that alcohol pad size was a barrier to cleaning. If participants opted for alternate cleaning methods, the accuracy of the pad count as proxy for
RI PT
cleaning behavior could be impacted.
Our findings have limited generalizability (one institution) . Additionally, survey
response rates were low, and practices and preferences of non-responders could have been lower
SC
or higher than our findings. However, survey nonresponse bias is reported as less likely with physicians than the general public.7 Additionally, studies utilizing surveys are subject to
M AN U
response bias, as participants may overestimate positive behaviors in order to appear more vigilant. A study similar to ours used direct observation and noted a 25% increase in “cleaning at each encounter” compared to our 6% increase 4, however direct observation can inflate hygiene practice 3-fold.8 We used alcohol pad counts as an objective measure, but participants
TE D
may have used the pads for jobs other than cleaning stethoscopes, or used alternate cleaning methods. Signs were used to minimize this risk. Finally, the reported increase in stethoscope cleaning practices could be unrelated to our intervention, and could have occurred secondary to
EP
increased awareness following initial survey completion.
AC C
K. Jordana J. Barrettb S. Murneyc A. Whippa J.O. Elliotta,d a Department of Medical Education, OhioHealth Riverside Methodist Hospital, Columbus, OH b Department of Infectious Disease, The Ohio State University, Columbus OH c Central Ohio Primary Care Physicians, Inc., Columbus, OH d OhioHealth Research Institute, Columbus, OH E-mail address: [email protected]
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References 1. Burrie NA. Stethoscopes as vectors of infections. AMSJ, 2011;2:32-35.
RI PT
2. Shaw F, Cooper S. Stethoscope hygiene: A best practice review of the literature. Aust Nurs Midwifery J 2014;21(8):28-31. 3. Hill C, King T, Day R. A strategy to reduce MRSA colonization of stethoscopes. J Hosp Infect 2006;62(1):122-123. doi: S0195-6701(05)00168-4 [pii].
SC
4. Zaghi J, Zhou J, Graham DA, Potter-Bynoe G, Sandora TJ. Improving stethoscope disinfection at a children's hospital. Infect Control Hosp Epidemiol 2013;34(11):1189-1193. doi: 10.1086/673454 [doi].
M AN U
5. Uneke CJ, Ndukwe CD, Nwakpu KO, Nnabu RC, Ugwuoru CD, Prasopa-Plaizier N. Stethoscope disinfection campaign in a Nigerian teaching hospital: Results of a before-and-after study. J Infect Dev Ctries 2014;8(1):86-93. doi: 10.3855/jidc.2696 [doi]. 6. Grecia SC, Malanyaon O, Aguirre C. The effect of an educational intervention on the contamination rates of stethoscopes and on the knowledge, attitudes, and practices regarding the stethoscope use of healthcare providers in a tertiary care hospital. Philipp J Microbiol Infect Dis 2008;37:20-33.
TE D
7. Kellerman SE, Herold J. Physician response to surveys. A review of the literature. Am J Prev Med. 2001;20(1):61-67. doi: S0749-3797(00)00258-0 [pii].
AC C
EP
8. Srigley JA, Furness CD, Baker GR, Gardam M. Quantification of the hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: A retrospective cohort study. BMJ Qual Saf 2014;23(12):974-980. doi: 10.1136/bmjqs-2014-003080 [doi].
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ACCEPTED MANUSCRIPT
S0195-6701(17)30164-0
DOI:
10.1016/j.jhin.2017.03.020
Reference:
YJHIN 5064
To appear in:
Journal of Hospital Infection
Received Date: 17 February 2017 Accepted Date: 17 March 2017
Please cite this article as: Jordan K, Barrett J, Murney S, Whipp A, Elliott JO, An Educational Program to Enhance Stethoscope Hygiene Behavior, Journal of Hospital Infection (2017), doi: 10.1016/ j.jhin.2017.03.020. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
An Educational Program to Enhance Stethoscope Hygiene Behavior Sirs: Several studies implicate stethoscopes as possible vectors of nosocomial infection. One
RI PT
systematic review reported that 87.3% of stethoscopes are colonized with micro-organisms, including MRSA, enterococci, and gram-negative bacteria, and many isolates are multi-drug resistant.1 Numbers of healthcare workers (HCWs) who report stethoscope cleaning with each
SC
patient encounter ranges from 2% to 24% 2 yet, we found only four studies that reported
strategies to improve stethoscope cleaning behaviors. Thus, a 14-week prospective observational
M AN U
cohort study aimed at improving stethoscope cleaning behavior in a community teaching hospital ICU was conducted.
In order to establish baseline behavior, we surveyed 253 HCW on stethoscope cleaning practices as well as other disinfection practices in order to mask our main outcome of interest.
TE D
Subsequently, three separate educational emails were sent to HCWs, (weeks zero, six and ten), reminder posters were placed throughout the ICU, and cleaning stations utilizing Webcol™ twoply, medium 70% isopropyl alcohol pads were strategically placed for easy access. Signs
EP
indicated that alcohol pads were for stethoscope cleaning only. A study coordinator counted and restocked the cleaning stations daily.
AC C
In an attempt to reduce the Hawthorne effect, and because of cost constraints, alcohol
pads were used as an objective measure of cleaning, rather than direct observation. We estimated that each patient would experience a maximum 11 separate HCW stethoscope encounters daily. The average daily census was also recorded in order to estimate numbers of pads needed if HCWs cleaned with each encounter. A post-intervention survey containing the same elements as our initial survey, plus additional questions on perceived barriers and
Page 1 of 4
ACCEPTED MANUSCRIPT
influences on cleaning, as well as preferences for reminder systems, was sent to participants at week seventeen. Pre and post surveys were linked for analysis via the McNemar test. Of 253 invited participants, 62 (24.5%) completed both surveys. An overall increase in
RI PT
frequency of stethoscope cleaning was reported, P = 0.023. Cleaning “before and/or after each patient encounter” increased from 16.4% to 22.0%, while cleaning “one time per day/more than 1 time per day” increased from 34.4% to 49.2%, Figure 1. Our average daily census (not
SC
including patients on isolation) was 25.8 (95%CI: 25.3-26.3). Average alcohol pad use dropped from 82/day to 37/day within 6 weeks, averaging 40/day for study remainder. Expected counts
M AN U
would be 77/day if all HCWs cleaned just once daily and approach 286/day (26 patients x 11 encounters) if cleaned with each encounter.
Our results support findings of two prior studies that used similar methods and demonstrated a positive impact on stethoscope hygiene.3,4 Our intervention was easy and
TE D
inexpensive to implement (approximately $650 US dollars) and required no significant time away from HCW duties. Though two other studies reported very high success rates of stethoscope cleaning with each encounter, those interventions required significant time
EP
commitments from HCWs to attend training workshops, discussion groups, and formal lectures over a one month period. 5,6
AC C
Several issues may have negatively impacted our results. Approximately 20% of
respondents reported that they did not receive or read the emails, and almost 40% reported reading only one email, suggesting that email messages/reminders may not be a reliable means to increase stethoscope cleaning. Instead, participants reported preferences for on-site poster reminders (48.4%) and strategically placed larger sized cleaning wipes (69%) as the best methods for improving stethoscope cleaning practices. Though initial alcohol pad counts
Page 2 of 4
ACCEPTED MANUSCRIPT
supported participant responses indicating a move to more frequent cleaning, these counts were not sustained. Participants, however, reported that alcohol pad size was a barrier to cleaning. If participants opted for alternate cleaning methods, the accuracy of the pad count as proxy for
RI PT
cleaning behavior could be impacted.
Our findings have limited generalizability (one institution) . Additionally, survey
response rates were low, and practices and preferences of non-responders could have been lower
SC
or higher than our findings. However, survey nonresponse bias is reported as less likely with physicians than the general public.7 Additionally, studies utilizing surveys are subject to
M AN U
response bias, as participants may overestimate positive behaviors in order to appear more vigilant. A study similar to ours used direct observation and noted a 25% increase in “cleaning at each encounter” compared to our 6% increase 4, however direct observation can inflate hygiene practice 3-fold.8 We used alcohol pad counts as an objective measure, but participants
TE D
may have used the pads for jobs other than cleaning stethoscopes, or used alternate cleaning methods. Signs were used to minimize this risk. Finally, the reported increase in stethoscope cleaning practices could be unrelated to our intervention, and could have occurred secondary to
EP
increased awareness following initial survey completion.
AC C
K. Jordana J. Barrettb S. Murneyc A. Whippa J.O. Elliotta,d a Department of Medical Education, OhioHealth Riverside Methodist Hospital, Columbus, OH b Department of Infectious Disease, The Ohio State University, Columbus OH c Central Ohio Primary Care Physicians, Inc., Columbus, OH d OhioHealth Research Institute, Columbus, OH E-mail address: [email protected]
Page 3 of 4
ACCEPTED MANUSCRIPT
References 1. Burrie NA. Stethoscopes as vectors of infections. AMSJ, 2011;2:32-35.
RI PT
2. Shaw F, Cooper S. Stethoscope hygiene: A best practice review of the literature. Aust Nurs Midwifery J 2014;21(8):28-31. 3. Hill C, King T, Day R. A strategy to reduce MRSA colonization of stethoscopes. J Hosp Infect 2006;62(1):122-123. doi: S0195-6701(05)00168-4 [pii].
SC
4. Zaghi J, Zhou J, Graham DA, Potter-Bynoe G, Sandora TJ. Improving stethoscope disinfection at a children's hospital. Infect Control Hosp Epidemiol 2013;34(11):1189-1193. doi: 10.1086/673454 [doi].
M AN U
5. Uneke CJ, Ndukwe CD, Nwakpu KO, Nnabu RC, Ugwuoru CD, Prasopa-Plaizier N. Stethoscope disinfection campaign in a Nigerian teaching hospital: Results of a before-and-after study. J Infect Dev Ctries 2014;8(1):86-93. doi: 10.3855/jidc.2696 [doi]. 6. Grecia SC, Malanyaon O, Aguirre C. The effect of an educational intervention on the contamination rates of stethoscopes and on the knowledge, attitudes, and practices regarding the stethoscope use of healthcare providers in a tertiary care hospital. Philipp J Microbiol Infect Dis 2008;37:20-33.
TE D
7. Kellerman SE, Herold J. Physician response to surveys. A review of the literature. Am J Prev Med. 2001;20(1):61-67. doi: S0749-3797(00)00258-0 [pii].
AC C
EP
8. Srigley JA, Furness CD, Baker GR, Gardam M. Quantification of the hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: A retrospective cohort study. BMJ Qual Saf 2014;23(12):974-980. doi: 10.1136/bmjqs-2014-003080 [doi].
Page 4 of 4
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