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Feasibility and effectiveness of an electronic hand hygiene feedback device targeted to improve rates of hand hygiene
Journal of Hospital Infection 82 (2012) 271e273 Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Short report
Feasibility and effectiveness of an electronic hand hygiene feedback device targeted to improve rates of hand hygiene A.G. Sahud a, *, N. Bhanot a, S. Narasimhan a, E.S. Malka b a b
Division of Infectious Diseases, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA Institute for Health, Health Care Policy and Aging Research at Rutgers, The State University of New Jersey, New Jersey, USA
A R T I C L E
I N F O
Article history: Received 21 May 2012 Accepted 8 September 2012 Available online 24 October 2012 Keywords: Electronic device Hand hygiene compliance
S U M M A R Y
Various electronic tools have been developed to monitor hand hygiene compliance (HHC). A prospective, investigator-blinded, pilot study was conducted to evaluate the feasibility and effectiveness of an electronic hand hygiene feedback device to improve rates of hand hygiene. The first month of participation provided baseline rates of HHC (37%). During months 2e5, mean HHC rates were 43%, 44%, 45%, and 49% respectively (P < 0.001). Implementing this electronic device was feasible and showed a modest improvement in rates of HHC. Subsequent studies are warranted to validate the impact of such electronic devices on a larger scale. ª 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction When routinely performed, hand hygiene can substantially reduce hospital infections.1,2 Unfortunately, rates of hand hygiene compliance (HHC) are disappointing and rarely exceed 50%.1,3 Performing direct observations of hand hygiene is timeconsuming and cumbersome.4 Moreover, this methodology cannot provide for comprehensive individual rates of HHC because it would be logistically untenable. In response to the shortcomings of direct observations, various electronic tools have been developed to monitor and track HHC.5 However, challenges exist to overcome healthcare worker concerns such as accuracy of electronic devices and infringement of personal privacy.6 Our earlier study had demonstrated the accuracy and reliability of this device.7 The purpose of the current pilot study was to evaluate the feasibility and acceptance of * Corresponding author. Address: Division of Infectious Diseases, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA. Tel.: þ1 412 359 3683; fax: þ1 412 359 6899. E-mail address: [email protected] (A.G. Sahud).
implementing the hand hygiene feedback device (HHFD) over an extended period and to assess further its impact on HHC.
Methods Setting and design We conducted a prospective, investigator-blinded study from May 2011 through October 2011 at a nine-bed urgent care centre upon approval by the hospital Institutional Review Board. All of the 13 healthcare workers at the urgent care centre agreed to participate in the study and provided written informed consent.
Equipment design and functionality There were two types of electronic triggers installed within the patient rooms: room triggers and dispensing triggers. These devices issued radio frequency signals which were sent to the HHFD. The room triggers served to identify room entries made by the participants. The dispenser triggers were activated when the soap dispenser or the automatic hand sanitizer units
0195-6701/$ e see front matter ª 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jhin.2012.09.006
272
A.G. Sahud et al. / Journal of Hospital Infection 82 (2012) 271e273
were used. Installation of room and dispensing triggers required <10 min per room. The electronic triggers operated within the 2.4 GHz range, similar to the hospital Wi-Fi network. The cost of installation was less than $500.00 per room and $150.00 for each individual HHFD. Each HHFD measures 8 cm 3 cm 1.5 cm, weighs 70 g, and fits into one’s pocket. The device has a liquid crystal display (LCD) readout showing room entries, dispensing events, and compliance rate. Each room entry could receive credit for up to a maximum of two dispensing events. So, if a room entry were to be associated with more than two dispensing events, the number was recorded as two. A compliance score was calculated by the HHFD where each room entry was ideally associated with two dispensing events, one before contact with the patient or the environment and one afterwards. Therefore, HHC percentage compliance was calculated as follows: % compliance ¼
Total no: of recorded hand hygiene events ð2 total no: of recorded room entriesÞ
Upon entry into a patient room, the HHFD typically captured the room trigger signal within 30 s. Brief room entry encounters lasting <30 s were likely to have been unrecognized by the HHFD. Data were stored in the HHFD and uploaded to a server by attaching the device to a computer through a USB cable. The data were then displayed on a designated website. The uploading process required w15 s and each participant was required to upload the data at least every month. This device does not use a real-time location system and therefore cannot track an individual’s geographic location.
Study implementation Participants were asked to randomly choose an HHFD. The HHFDs were preprogrammed with a unique random number to anonymously identify the subject. The study investigators were blinded to the code assignment. Registration required the participants to provide their e-mail addresses that remained confidential and stored on a remote computer server to which the principal investigator (PI) had no access. After registration, the principal investigator reviewed hospital hand hygiene policy with the participants. The study was conducted over a five-month period. During month 1, the participants only received ‘real-time’ feedback on their HHC as depicted on their HHFD. This HHC data served as the baseline rate of HHC. During months 2e5, the study participants received individualized remarks on their HHC rates compared to their own baseline and with that of the other participants. The PI issued these monthly remarks (unique to each participant), using each participant’s specific rate of HHC and their personal behavioural trends. The PI was capable of assessing both group and individual rates of compliance while at the same time remaining blinded to the identity of each participant. The individualized feedback remarks were generated by the PI using the website message feature. Messages were issued to the participants at least once a month. Additionally, control recordings were performed regularly by the study investigators.
Statistical analysis All statistical analyses were performed using SAS 9.1 (SAS Institute, Cary, NC, USA). Standard descriptive statistics of
mean, standard deviation and range are reported for all summary count data by individual and then summarized across all individuals. ManteleHaenszel chi-square statistics were used to evaluate trends in percentage compliance over time. The homogeneity of association across all subjects was evaluated using the likelihood ratio chi-square for the three-way interaction of subject * compliance * month using the Proc CATMOD procedure in SAS. A logelinear model was assumed and zero count cells replaced with a value of 1E-20 to avoid Proc CATMOD from treating zero cells as structural zeros and deleting them from the analysis. Two-sided P 0.05 was used to determine statistical significance.
Results There were 13 participants including six nurses, four physicians, one physician assistant (PA), and two PA students who agreed to participate in the study. The two PA students only participated in the initial six weeks because their clinical rotation at the centre had ended. One physician who participated during month 1 left the study due to changes in work assignment. One participant did not complete month 5 due to vacation absence. Nine participants completed the entire study. Over the five-month study period, 12,541 room entries and 11,056 dispensing events were recorded. Mean compliance rates showed a modest increase over the course of the study from 37.2% in month 1 to 49.1% in month 5 (Table I). The percentage increase from baseline was 15.5, 18.2, 20.7, and 32.1 for months 2, 3, 4, and 5, respectively (Table II). Chisquare analysis showed a statistically significant increase in compliance over the course of the study (P < 0.001). After controlling for each participant, the increase in compliance remained statistically significant (P < 0.001) over the fivemonth period of the study. The association between compliance and months enrolled in the study remained homogeneous across the participants enrolled, as determined by a nonstatistically significant (P ¼ 1.000) three-way interaction term of (subject, compliance and month) in a logelinear model.
Discussion Our goal was to evaluate the feasibility of using an HHFD over a prolonged period of time and to assess the impact of this novel strategy on influencing rates of HHC. We propose that electronic systems such as the HHFD can be easily adaptable to the healthcare environment and provide an objective measure of individual rates of HHC. Additionally, providing targeted
Table I Descriptive statistics of compliance by month (proportion) Month 1 2 3 4 5
No. of participants
Mean compliance
SD
95% CI
13 12 10 10 9
0.372 0.429 0.439 0.448 0.491
0.097 0.160 0.163 0.210 0.172
0.313e0.430 0.328e0.531 0.322e0.556 0.298e0.599 0.358e0.623
SD, standard deviation; CI, confidence interval. Chi-square test for trend: P < 0.001.
A.G. Sahud et al. / Journal of Hospital Infection 82 (2012) 271e273 Table II Increase in hand hygiene compliance (HHC) serially during the intervention phase Month 1 2 3 4 5
Difference in HHC compared with baseline HHC
Percentage increase from baseline HHC
e 0.057 0.068 0.077 0.119
e 15.5 18.2 20.7 32.1
273
Conflict of interest statement A. Sahud, MD, is the inventor of this device. The device is patented and owned by the Allegheny Singer Research Institute. All other authors have no conflicts of interest to declare. Funding sources This study was funded by grants from The Suburban Health Foundation and the Verizon Foundation.
Acknowledgements We acknowledge P. O’Keefe and A. Moore of O’Keefe Electronics for electronic design and assistance.
remarks to healthcare workers may positively influence their hand hygiene behaviour. Although the results demonstrated a modest increase in rates of HHC, these findings should be interpreted in light of the study limitations. Specific data on HHC prior to and after patient encounters could not be differentiated. Participants entering into a patient room with another healthcare provider potentially could have received credit for a dispensing event, and vice versa, if two people stood in proximity to the same dispensing unit. However, a post-study analysis of the entire data set revealed that this occurred in <1% of cases. A greater number of study participants from a variety of healthcare worker disciplines would have allowed for detection of different HHC trends for each category of healthcare provider. The HHFD cannot determine the quality of HHC, i.e. if the product was correct for the requisite amount of time; it can only determine whether HHC occurs. Thus, direct observation and continuing education at periodic intervals would still be needed in conjunction with the use of an electronic system to educate and assess hand hygiene technique. The study was also limited by its small number of participants but it was possible to obtain a substantial number of room entries and dispensing events during the study period which partially offset this deficiency. The cost of the HHFD system deserves consideration and yet the losses associated with even one hospital-acquired infection need to be built into a comprehensive costebenefit analysis. We intend to conduct subsequent studies to validate the impact of such electronic devices on a larger scale.
References 1. Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. 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 Recomm Rep 2002;51(RR-16):1e45. 2. Pittet D, Allegranzi B, Boyce J. The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations. Infect Control Hosp Epidemiol 2009;30:611e622. 3. Pittet D. Compliance with hand disinfection and its impact on hospital-acquired infections. J Hosp Infect 2001;48(Suppl. A): S40eS46. 4. Boyce JM. Measuring healthcare worker hand hygiene activity: current practices and emerging technologies. Infect Control Hosp Epidemiol 2011;32:1016e1028. 5. Marra AR, Moura Jr DF, Paes AT, dos Santos OF, Edmond MB. Measuring rates of hand hygiene adherence in the intensive care setting: a comparative study of direct observation, product usage, and electronic counting devices. Infect Control Hosp Epidemiol 2010;31:796e801. 6. Ellingson K, Polgreen PM, Schneider A, et al. Healthcare personnel perceptions of hand hygiene monitoring technology. Infect Control Hosp Epidemiol 2011;32:1091e1096. 7. Sahud AG, Bhanot N, Radhakrishnan A, Bajwa R, Manyam H, Post JC. An electronic hand hygiene surveillance device: a pilot study exploring surrogate markers for hand hygiene compliance. Infect Control Hosp Epidemiol 2010;31:634e639.
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Short report
Feasibility and effectiveness of an electronic hand hygiene feedback device targeted to improve rates of hand hygiene A.G. Sahud a, *, N. Bhanot a, S. Narasimhan a, E.S. Malka b a b
Division of Infectious Diseases, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA Institute for Health, Health Care Policy and Aging Research at Rutgers, The State University of New Jersey, New Jersey, USA
A R T I C L E
I N F O
Article history: Received 21 May 2012 Accepted 8 September 2012 Available online 24 October 2012 Keywords: Electronic device Hand hygiene compliance
S U M M A R Y
Various electronic tools have been developed to monitor hand hygiene compliance (HHC). A prospective, investigator-blinded, pilot study was conducted to evaluate the feasibility and effectiveness of an electronic hand hygiene feedback device to improve rates of hand hygiene. The first month of participation provided baseline rates of HHC (37%). During months 2e5, mean HHC rates were 43%, 44%, 45%, and 49% respectively (P < 0.001). Implementing this electronic device was feasible and showed a modest improvement in rates of HHC. Subsequent studies are warranted to validate the impact of such electronic devices on a larger scale. ª 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction When routinely performed, hand hygiene can substantially reduce hospital infections.1,2 Unfortunately, rates of hand hygiene compliance (HHC) are disappointing and rarely exceed 50%.1,3 Performing direct observations of hand hygiene is timeconsuming and cumbersome.4 Moreover, this methodology cannot provide for comprehensive individual rates of HHC because it would be logistically untenable. In response to the shortcomings of direct observations, various electronic tools have been developed to monitor and track HHC.5 However, challenges exist to overcome healthcare worker concerns such as accuracy of electronic devices and infringement of personal privacy.6 Our earlier study had demonstrated the accuracy and reliability of this device.7 The purpose of the current pilot study was to evaluate the feasibility and acceptance of * Corresponding author. Address: Division of Infectious Diseases, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, USA. Tel.: þ1 412 359 3683; fax: þ1 412 359 6899. E-mail address: [email protected] (A.G. Sahud).
implementing the hand hygiene feedback device (HHFD) over an extended period and to assess further its impact on HHC.
Methods Setting and design We conducted a prospective, investigator-blinded study from May 2011 through October 2011 at a nine-bed urgent care centre upon approval by the hospital Institutional Review Board. All of the 13 healthcare workers at the urgent care centre agreed to participate in the study and provided written informed consent.
Equipment design and functionality There were two types of electronic triggers installed within the patient rooms: room triggers and dispensing triggers. These devices issued radio frequency signals which were sent to the HHFD. The room triggers served to identify room entries made by the participants. The dispenser triggers were activated when the soap dispenser or the automatic hand sanitizer units
0195-6701/$ e see front matter ª 2012 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jhin.2012.09.006
272
A.G. Sahud et al. / Journal of Hospital Infection 82 (2012) 271e273
were used. Installation of room and dispensing triggers required <10 min per room. The electronic triggers operated within the 2.4 GHz range, similar to the hospital Wi-Fi network. The cost of installation was less than $500.00 per room and $150.00 for each individual HHFD. Each HHFD measures 8 cm 3 cm 1.5 cm, weighs 70 g, and fits into one’s pocket. The device has a liquid crystal display (LCD) readout showing room entries, dispensing events, and compliance rate. Each room entry could receive credit for up to a maximum of two dispensing events. So, if a room entry were to be associated with more than two dispensing events, the number was recorded as two. A compliance score was calculated by the HHFD where each room entry was ideally associated with two dispensing events, one before contact with the patient or the environment and one afterwards. Therefore, HHC percentage compliance was calculated as follows: % compliance ¼
Total no: of recorded hand hygiene events ð2 total no: of recorded room entriesÞ
Upon entry into a patient room, the HHFD typically captured the room trigger signal within 30 s. Brief room entry encounters lasting <30 s were likely to have been unrecognized by the HHFD. Data were stored in the HHFD and uploaded to a server by attaching the device to a computer through a USB cable. The data were then displayed on a designated website. The uploading process required w15 s and each participant was required to upload the data at least every month. This device does not use a real-time location system and therefore cannot track an individual’s geographic location.
Study implementation Participants were asked to randomly choose an HHFD. The HHFDs were preprogrammed with a unique random number to anonymously identify the subject. The study investigators were blinded to the code assignment. Registration required the participants to provide their e-mail addresses that remained confidential and stored on a remote computer server to which the principal investigator (PI) had no access. After registration, the principal investigator reviewed hospital hand hygiene policy with the participants. The study was conducted over a five-month period. During month 1, the participants only received ‘real-time’ feedback on their HHC as depicted on their HHFD. This HHC data served as the baseline rate of HHC. During months 2e5, the study participants received individualized remarks on their HHC rates compared to their own baseline and with that of the other participants. The PI issued these monthly remarks (unique to each participant), using each participant’s specific rate of HHC and their personal behavioural trends. The PI was capable of assessing both group and individual rates of compliance while at the same time remaining blinded to the identity of each participant. The individualized feedback remarks were generated by the PI using the website message feature. Messages were issued to the participants at least once a month. Additionally, control recordings were performed regularly by the study investigators.
Statistical analysis All statistical analyses were performed using SAS 9.1 (SAS Institute, Cary, NC, USA). Standard descriptive statistics of
mean, standard deviation and range are reported for all summary count data by individual and then summarized across all individuals. ManteleHaenszel chi-square statistics were used to evaluate trends in percentage compliance over time. The homogeneity of association across all subjects was evaluated using the likelihood ratio chi-square for the three-way interaction of subject * compliance * month using the Proc CATMOD procedure in SAS. A logelinear model was assumed and zero count cells replaced with a value of 1E-20 to avoid Proc CATMOD from treating zero cells as structural zeros and deleting them from the analysis. Two-sided P 0.05 was used to determine statistical significance.
Results There were 13 participants including six nurses, four physicians, one physician assistant (PA), and two PA students who agreed to participate in the study. The two PA students only participated in the initial six weeks because their clinical rotation at the centre had ended. One physician who participated during month 1 left the study due to changes in work assignment. One participant did not complete month 5 due to vacation absence. Nine participants completed the entire study. Over the five-month study period, 12,541 room entries and 11,056 dispensing events were recorded. Mean compliance rates showed a modest increase over the course of the study from 37.2% in month 1 to 49.1% in month 5 (Table I). The percentage increase from baseline was 15.5, 18.2, 20.7, and 32.1 for months 2, 3, 4, and 5, respectively (Table II). Chisquare analysis showed a statistically significant increase in compliance over the course of the study (P < 0.001). After controlling for each participant, the increase in compliance remained statistically significant (P < 0.001) over the fivemonth period of the study. The association between compliance and months enrolled in the study remained homogeneous across the participants enrolled, as determined by a nonstatistically significant (P ¼ 1.000) three-way interaction term of (subject, compliance and month) in a logelinear model.
Discussion Our goal was to evaluate the feasibility of using an HHFD over a prolonged period of time and to assess the impact of this novel strategy on influencing rates of HHC. We propose that electronic systems such as the HHFD can be easily adaptable to the healthcare environment and provide an objective measure of individual rates of HHC. Additionally, providing targeted
Table I Descriptive statistics of compliance by month (proportion) Month 1 2 3 4 5
No. of participants
Mean compliance
SD
95% CI
13 12 10 10 9
0.372 0.429 0.439 0.448 0.491
0.097 0.160 0.163 0.210 0.172
0.313e0.430 0.328e0.531 0.322e0.556 0.298e0.599 0.358e0.623
SD, standard deviation; CI, confidence interval. Chi-square test for trend: P < 0.001.
A.G. Sahud et al. / Journal of Hospital Infection 82 (2012) 271e273 Table II Increase in hand hygiene compliance (HHC) serially during the intervention phase Month 1 2 3 4 5
Difference in HHC compared with baseline HHC
Percentage increase from baseline HHC
e 0.057 0.068 0.077 0.119
e 15.5 18.2 20.7 32.1
273
Conflict of interest statement A. Sahud, MD, is the inventor of this device. The device is patented and owned by the Allegheny Singer Research Institute. All other authors have no conflicts of interest to declare. Funding sources This study was funded by grants from The Suburban Health Foundation and the Verizon Foundation.
Acknowledgements We acknowledge P. O’Keefe and A. Moore of O’Keefe Electronics for electronic design and assistance.
remarks to healthcare workers may positively influence their hand hygiene behaviour. Although the results demonstrated a modest increase in rates of HHC, these findings should be interpreted in light of the study limitations. Specific data on HHC prior to and after patient encounters could not be differentiated. Participants entering into a patient room with another healthcare provider potentially could have received credit for a dispensing event, and vice versa, if two people stood in proximity to the same dispensing unit. However, a post-study analysis of the entire data set revealed that this occurred in <1% of cases. A greater number of study participants from a variety of healthcare worker disciplines would have allowed for detection of different HHC trends for each category of healthcare provider. The HHFD cannot determine the quality of HHC, i.e. if the product was correct for the requisite amount of time; it can only determine whether HHC occurs. Thus, direct observation and continuing education at periodic intervals would still be needed in conjunction with the use of an electronic system to educate and assess hand hygiene technique. The study was also limited by its small number of participants but it was possible to obtain a substantial number of room entries and dispensing events during the study period which partially offset this deficiency. The cost of the HHFD system deserves consideration and yet the losses associated with even one hospital-acquired infection need to be built into a comprehensive costebenefit analysis. We intend to conduct subsequent studies to validate the impact of such electronic devices on a larger scale.
References 1. Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. 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 Recomm Rep 2002;51(RR-16):1e45. 2. Pittet D, Allegranzi B, Boyce J. The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations. Infect Control Hosp Epidemiol 2009;30:611e622. 3. Pittet D. Compliance with hand disinfection and its impact on hospital-acquired infections. J Hosp Infect 2001;48(Suppl. A): S40eS46. 4. Boyce JM. Measuring healthcare worker hand hygiene activity: current practices and emerging technologies. Infect Control Hosp Epidemiol 2011;32:1016e1028. 5. Marra AR, Moura Jr DF, Paes AT, dos Santos OF, Edmond MB. Measuring rates of hand hygiene adherence in the intensive care setting: a comparative study of direct observation, product usage, and electronic counting devices. Infect Control Hosp Epidemiol 2010;31:796e801. 6. Ellingson K, Polgreen PM, Schneider A, et al. Healthcare personnel perceptions of hand hygiene monitoring technology. Infect Control Hosp Epidemiol 2011;32:1091e1096. 7. Sahud AG, Bhanot N, Radhakrishnan A, Bajwa R, Manyam H, Post JC. An electronic hand hygiene surveillance device: a pilot study exploring surrogate markers for hand hygiene compliance. Infect Control Hosp Epidemiol 2010;31:634e639.