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Impact of teaching interventions on nurse compliance with hand disinfection
Journal of Hospital Infection (2002) 51: 69±72 doi:10.1053/jhin.2002.1198, available online at http://www.idealibrary.com on
Impact of teaching interventions on nurse compliance with hand disinfection C. Colombo*, H. Giger*, J. Grote*, C. Deplazesz, W. Pletscherz, R. LuÈthiy and C. Ruef * *Division of Infectious Diseases and Hospital Epidemiology , yNursing Department of the University Hospital of Zurich and zCantonal Pharmacy of the Canton of Zurich, Switzerland Summary: The impact of teaching interventions and the availability of additional dispensers for alcoholic hand disinfection was measured during three study periods. A nursing care system of relevant nursing interventions was found to be a useful tool for the assessment of compliance with hand hygiene requirements if combined with an analysis of hand disinfectant use. This study shows that compliance with hand disinfection can be improved through targeted teaching and supportive structural improvements, and that this positive impact may persist even after targeted teaching activities have ended. & 2002 The Hospital Infection Society
Keywords: Alcoholic hand disinfectant; teaching intervention; compliance; hand hygiene.
Introduction Problems with hand hygiene compliance in hospitals are well known.1,2 Many factors may affect compliance including understaffing, perceived lack of time, negligence and material deficits such as the lack of easy access to alcohol dispensers. Furthermore, the role of hand colonization as a risk factor for the transmission of nosocomial pathogens may be underestimated by some healthcare workers (HCW). Introduction of accessible alcoholic-based hand antiseptics has been shown substantially to increase hand disinfection rates.3,4 In 1996, the usage level of the hand disinfectant glycerol±ethanol 1%/80% V/V (GA) in our hospital had decreased. The objective of the current study was to measure the impact of teaching interventions and the availability of additional hand-carried alcohol Received 26 June 2001; revised manuscript accepted 29 January 2002. Author for correspondence: C. Colombo RN, University Hospital of Zurich, Division of Infectious Diseases and Hospital Epidemiology, Raemistrasse 100, 8091 Zurich, Switzerland. Fax: 01/2554558; E-mail: [email protected]
0195-6701/02/010069 1 04 $35.00/0
dispensers on the usage of GA, using a novel method of indirect assessment of compliance. Our hypothesis was that targeted short-term teaching interventions, combined with improved availability of hand-carried alcohol dispensers, would result in increased use of alcoholic hand disinfectants, and thus improve compliance with guidelines for hand decontamination. Methods Study design The study was conducted in 1998 during three periods: a pre-intervention period (A); a period of intervention (B) and a follow-up period (C). Three surgical and two medical wards were selected as teaching and intervention areas (98 beds). In control areas, three surgical and two medical wards without teaching were selected (116 beds). Our six intensive care units (ICU, 53 beds) were all included in the teaching programme. Additional GA hand dispensers were only distributed on wards receiving teaching interventions. & 2002 The Hospital Infection Society
70
C. Colombo et al.
Teaching and structural intervention Teaching on the topic of alcoholic hand disinfection was carried out by three infection control nurses. The teaching method and content was standardized. Participants were invited to demonstrate their own hand disinfection technique, and the efficacy of alcoholic hand disinfection was evaluated using an ultraviolet light control system. In total, 480 HCWs (registered nurses and nursing assistants) were taught. To determine the usage level of GA, the amount of GA ordered (in litres) was determined. The remaining unused volumes of GA per study period on each ward, including those from the portable dispensers, were also assessed.
amount over the calculated need per ward involved. Such calculations were not possible for ICUs where no LEP data are collected. In these units, therefore, we compared the measured amounts of GA used during each period per 1000 patient days. Statistical analysis We analysed time trends in the ratios of measured/ observed amounts (medical/surgical wards) or of measured amounts only (ICUs). Due to the small number of individually measured units, hypothesis tests for statistical significance were not done. Results
Assessment of nursing activities requiring alcoholic hand disinfection (LEP)5
Medical and surgical wards
At the University Hospital of Zurich, each direct nursing care intervention is routinely recorded by a measuring system called LEP.5 This system assigns a defined amount of time to a given nursing activity and is a factor-based patient classification model. Tests for validity and reliability concerning the quantitative dimensions of nursing activities have been performed prior to our study in 1994. From the complete list of nursing activities, a shorter list of activities was extracted which, based on generally accepted infection control guidelines,6 require alcoholic hand disinfection (e.g. changing a dressing, giving intravenous or oral medications, taking blood etc.). To calculate the theoretical amount of GA required for the study periods on the basis of this information, it was assumed that each alcoholic hand disinfection required a minimum of 3 mL of GA.7 The total amount of GA calculated as part of this model was then compared with the measured amount of GA used by calculating the ratio of the measured
The ratio between measured use and calculated need for GA ranged from 0.4 to 0.64 amongst the study wards at baseline (Table I). It increased by 98% during period B compared with period A on wards receiving teaching intervention and additional portable dispensers, and by 29% on non-intervention wards. On surgical wards with interventions, the increase was 89% compared with 1.6% on control wards. Similar changes were observed on the medical wards with a 110% increase on intervention wards vs. a 70% increase on control wards. A positive effect on actual use of GA was still measured during the follow-up period on surgical wards, whereas compliance with alcoholic hand disinfection apparently decreased on the comparison medical wards during the same period (Table I). The ratio between measured and calculated need for GA on surgical wards without intervention decreased slightly, whereas an increase was noticed on the medical wards during the follow-up period.
Table I Measured usage level and calculated need for glycerol±ethanol (GA) during periods A, B and C: surgical and medical wards Period A Wards Surgical Medical Surgical Medical
with intervention with intervention without intervention without intervention
Period B
Period C
Measured amount (L)*
Calculated need (L)y
Ratioz
Measured amount (L)
Calculated need (L)
Ratioz
Measured amount (L)
Calculated need (L)
Ratioz
127.25 85.75 175 95
289.36 213.61 273.36 215.02
0.44 0.40 0.64 0.44
194.75 136.15 163.5 129.5
235.09 161.75 250.19 172.15
0.83 0.84 0.65 0.75
215 81.1 106.5 101.5
167.32 120.29 189.91 123.92
1.28 0.67 0.56 0.82
*Measured amount amount of GA which was ordered through the pharmacy and actually used after remaining stocks had been subtracted; calculated need based on the total number of documented relevant nursing interventions, multiplied by 3 mL GA per intervention; z ratio measured amount divided by calculated need. y
Nurse compliance with hand disinfection
71
Table II Comparison of the measured amount of glycerol±ethanol (GA) usage (in L/1000 patient days) in intensive care units (ICUs) medical and surgical wards in the three study periods
Period A Period B Period C
ICU I
ICU II
ICU III
ICU IV
ICU V
ICU VI
Surgical with intervention
Surgical without intervention
Medical with intervention
Medical without intervention
122.8 114.7 146.3
105.8 116.5 91.9
126.1 134.4 135.5
100.9 152.5 208.9
131.3 199.4 154.1
50.8 116.7 107.4
18.4 34.1 48.9
22.6 24.5 20.7
16.4 32.1 25.8
14.7 25.8 27.5
ICUs The amount of GA used per 1000 patient days increased by 129.7% during period B in one ICU unit, while it decreased by 6.6% in another. The mean increase was 40.4%. In the follow-up period, GA use changed in both directions in the various ICUs, ranging from an increase of 33.9% to a decrease of 22.7%. In comparing the average ratio of used GA per 1000 patient days of all ICUs (with teaching intervention, but without portable dispensers), we observed an overall increase of 30.9% from period A to B, and a moderate increase of 1.2% from B to C. Overall, the level of improvement was maintained during the follow-up period in most units (Table II). Discussion Using a computerized database of nursing activities to calculate the required amount of alcoholic hand disinfectant, we were able to show that teaching and distribution of portable dispensers of alcohol for hand disinfection had a positive impact on compliance during routine nursing activities. The use of data on the daily assessment of nursing activities (LEP) as a basis to calculate the need for alcoholic hand disinfection offers an alternative approach to direct observation, which might influence behaviour of the observed.8 This novel approach allows a direct assessment of specific nursing activities requiring alcoholic hand disinfection. Analysis of GA use in our ICUs revealed a very diverse pattern. Although not comparable with the results of the wards, a positive effect on use of GA in the intervention period compared with the pre-intervention period was observed, except in ICU I. The reason for this is unclear. Our data suggest that teaching intervention may be effective through raising awareness, supported by the distribution of portable GA dispensers. Compliance with recommendations for hand disinfection by HCWs is generally inappropriate and difficult to improve, even if multifaceted approaches to change hand hygiene behaviour are
used as shown by Larson.9 Material changes alone do not improve hand hygiene compliance significantly;10 however, indirect approaches appear worthwhile.11 Bittner and Rich have demonstrated a significant relation between compliance with standard handwashing recommendations and counting used paper hand towels as an indicator for the strength of compliance.12 As with our study, which used LEP data as a basis to measure compliance, the usage of paper hand towels may serve as a surrogate marker. We acknowledge the limitations of this study. First, the activities of other HCWs such as doctors and therapists were not measured and therefore not integrated into our analysis. Hence, data on GA use probably overestimate effective compliance of the nursing staff. Secondly, not every single documented nursing action may be associated with an episode of alcoholic hand disinfection. It is common practice for several nursing care actions to be performed consecutively, followed by only one alcoholic hand disinfection. Since the design of this study did not permit us to consider this situation, we may have underestimated true compliance. It is concluded, therefore, that compliance with alcoholic hand disinfection on surgical and medical wards, as well as ICUs, can be improved through a multidimensional intervention, and we note the novel integration of LEP as an inexpensive, indirect correlation factor.
References 1. Roberts SA, Findlay R, Lang SD. Investigation of an outbreak of multi-drug resistant Acinetobacter baumannii in an intensive care burns unit. J Hosp Infect 2001; 48: 228±232. 2. Doebbeling BN, Gail LS, Sheetz CT et al. Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. N Engl J Med 1992; 327: 88±93. 3. Bischoff WE, Reynolds TM, Sessler CN, Edmond MB, Wenzel RP. Handwashing compliance by health care workers. Arch Intern Med 2000; 160: 1017±1021.
72 4. Maury E, Alzieu M, Baudel JL et al. Availability of an alcoholic solution can improve hand disinfection compliance in an intensive care unit. Am J Respir Crit Care Med 2000; 162: 324±327. 5. GuÈntert BJ, Maeder Ch. Ein System zur Erfassung des Pflegeaufwandes. Darstellung der Methode SEP des UniversitaÈtsspitals ZuÈrich. Schriftenreihe SGGP 1994; 37: 17. 6. Centers for Disease Control and Prevention. Guidelines on isolation precautions in hospitals. Infect Cont Hosp Epidem 1996; 17: 65±67. 7. Widmer A, Francioli P. HaÈndewaschen mit desinfizierender Seife oder HaÈndedesinfektion? Mythen und Fakten. Swiss-Noso 1995; 2: 30. 8. Pittet D, Mourpuga P, Perneger TV. Compliance with handwashing in a teaching hospital. Infection control program. Ann Intern Med 1999; 130:126±130.
C. Colombo et al. 9. Larson EL, Bryan JL, Adler LM, Blanc C. A multifaceted approach to changing handwashing behavior. Am J Infect Control 1997; 25: 3±10. 10. Wurtz R, Moye G, Jovanovic B. Handwashing machines, handwashing compliance, and potential for cross-contamination. Am J Infect Control 1994; 22: 228±230. 11. Nishimura S, Kagehira M, Kono F, Nishimura M, Taenaka N. Handwashing before entering the intensive care unit: what we learned from continuous video-camera surveillance. Am J Infect Control 1999; 27: 367±369. 12. Bittner MJ, Rich EC. Surveillance of handwashing episodes in adult intensive-care units by measuring an index of soap and paper towel consumption. Clinical Performance and Quality Health Care 1998; 4: 179±182.
Impact of teaching interventions on nurse compliance with hand disinfection C. Colombo*, H. Giger*, J. Grote*, C. Deplazesz, W. Pletscherz, R. LuÈthiy and C. Ruef * *Division of Infectious Diseases and Hospital Epidemiology , yNursing Department of the University Hospital of Zurich and zCantonal Pharmacy of the Canton of Zurich, Switzerland Summary: The impact of teaching interventions and the availability of additional dispensers for alcoholic hand disinfection was measured during three study periods. A nursing care system of relevant nursing interventions was found to be a useful tool for the assessment of compliance with hand hygiene requirements if combined with an analysis of hand disinfectant use. This study shows that compliance with hand disinfection can be improved through targeted teaching and supportive structural improvements, and that this positive impact may persist even after targeted teaching activities have ended. & 2002 The Hospital Infection Society
Keywords: Alcoholic hand disinfectant; teaching intervention; compliance; hand hygiene.
Introduction Problems with hand hygiene compliance in hospitals are well known.1,2 Many factors may affect compliance including understaffing, perceived lack of time, negligence and material deficits such as the lack of easy access to alcohol dispensers. Furthermore, the role of hand colonization as a risk factor for the transmission of nosocomial pathogens may be underestimated by some healthcare workers (HCW). Introduction of accessible alcoholic-based hand antiseptics has been shown substantially to increase hand disinfection rates.3,4 In 1996, the usage level of the hand disinfectant glycerol±ethanol 1%/80% V/V (GA) in our hospital had decreased. The objective of the current study was to measure the impact of teaching interventions and the availability of additional hand-carried alcohol Received 26 June 2001; revised manuscript accepted 29 January 2002. Author for correspondence: C. Colombo RN, University Hospital of Zurich, Division of Infectious Diseases and Hospital Epidemiology, Raemistrasse 100, 8091 Zurich, Switzerland. Fax: 01/2554558; E-mail: [email protected]
0195-6701/02/010069 1 04 $35.00/0
dispensers on the usage of GA, using a novel method of indirect assessment of compliance. Our hypothesis was that targeted short-term teaching interventions, combined with improved availability of hand-carried alcohol dispensers, would result in increased use of alcoholic hand disinfectants, and thus improve compliance with guidelines for hand decontamination. Methods Study design The study was conducted in 1998 during three periods: a pre-intervention period (A); a period of intervention (B) and a follow-up period (C). Three surgical and two medical wards were selected as teaching and intervention areas (98 beds). In control areas, three surgical and two medical wards without teaching were selected (116 beds). Our six intensive care units (ICU, 53 beds) were all included in the teaching programme. Additional GA hand dispensers were only distributed on wards receiving teaching interventions. & 2002 The Hospital Infection Society
70
C. Colombo et al.
Teaching and structural intervention Teaching on the topic of alcoholic hand disinfection was carried out by three infection control nurses. The teaching method and content was standardized. Participants were invited to demonstrate their own hand disinfection technique, and the efficacy of alcoholic hand disinfection was evaluated using an ultraviolet light control system. In total, 480 HCWs (registered nurses and nursing assistants) were taught. To determine the usage level of GA, the amount of GA ordered (in litres) was determined. The remaining unused volumes of GA per study period on each ward, including those from the portable dispensers, were also assessed.
amount over the calculated need per ward involved. Such calculations were not possible for ICUs where no LEP data are collected. In these units, therefore, we compared the measured amounts of GA used during each period per 1000 patient days. Statistical analysis We analysed time trends in the ratios of measured/ observed amounts (medical/surgical wards) or of measured amounts only (ICUs). Due to the small number of individually measured units, hypothesis tests for statistical significance were not done. Results
Assessment of nursing activities requiring alcoholic hand disinfection (LEP)5
Medical and surgical wards
At the University Hospital of Zurich, each direct nursing care intervention is routinely recorded by a measuring system called LEP.5 This system assigns a defined amount of time to a given nursing activity and is a factor-based patient classification model. Tests for validity and reliability concerning the quantitative dimensions of nursing activities have been performed prior to our study in 1994. From the complete list of nursing activities, a shorter list of activities was extracted which, based on generally accepted infection control guidelines,6 require alcoholic hand disinfection (e.g. changing a dressing, giving intravenous or oral medications, taking blood etc.). To calculate the theoretical amount of GA required for the study periods on the basis of this information, it was assumed that each alcoholic hand disinfection required a minimum of 3 mL of GA.7 The total amount of GA calculated as part of this model was then compared with the measured amount of GA used by calculating the ratio of the measured
The ratio between measured use and calculated need for GA ranged from 0.4 to 0.64 amongst the study wards at baseline (Table I). It increased by 98% during period B compared with period A on wards receiving teaching intervention and additional portable dispensers, and by 29% on non-intervention wards. On surgical wards with interventions, the increase was 89% compared with 1.6% on control wards. Similar changes were observed on the medical wards with a 110% increase on intervention wards vs. a 70% increase on control wards. A positive effect on actual use of GA was still measured during the follow-up period on surgical wards, whereas compliance with alcoholic hand disinfection apparently decreased on the comparison medical wards during the same period (Table I). The ratio between measured and calculated need for GA on surgical wards without intervention decreased slightly, whereas an increase was noticed on the medical wards during the follow-up period.
Table I Measured usage level and calculated need for glycerol±ethanol (GA) during periods A, B and C: surgical and medical wards Period A Wards Surgical Medical Surgical Medical
with intervention with intervention without intervention without intervention
Period B
Period C
Measured amount (L)*
Calculated need (L)y
Ratioz
Measured amount (L)
Calculated need (L)
Ratioz
Measured amount (L)
Calculated need (L)
Ratioz
127.25 85.75 175 95
289.36 213.61 273.36 215.02
0.44 0.40 0.64 0.44
194.75 136.15 163.5 129.5
235.09 161.75 250.19 172.15
0.83 0.84 0.65 0.75
215 81.1 106.5 101.5
167.32 120.29 189.91 123.92
1.28 0.67 0.56 0.82
*Measured amount amount of GA which was ordered through the pharmacy and actually used after remaining stocks had been subtracted; calculated need based on the total number of documented relevant nursing interventions, multiplied by 3 mL GA per intervention; z ratio measured amount divided by calculated need. y
Nurse compliance with hand disinfection
71
Table II Comparison of the measured amount of glycerol±ethanol (GA) usage (in L/1000 patient days) in intensive care units (ICUs) medical and surgical wards in the three study periods
Period A Period B Period C
ICU I
ICU II
ICU III
ICU IV
ICU V
ICU VI
Surgical with intervention
Surgical without intervention
Medical with intervention
Medical without intervention
122.8 114.7 146.3
105.8 116.5 91.9
126.1 134.4 135.5
100.9 152.5 208.9
131.3 199.4 154.1
50.8 116.7 107.4
18.4 34.1 48.9
22.6 24.5 20.7
16.4 32.1 25.8
14.7 25.8 27.5
ICUs The amount of GA used per 1000 patient days increased by 129.7% during period B in one ICU unit, while it decreased by 6.6% in another. The mean increase was 40.4%. In the follow-up period, GA use changed in both directions in the various ICUs, ranging from an increase of 33.9% to a decrease of 22.7%. In comparing the average ratio of used GA per 1000 patient days of all ICUs (with teaching intervention, but without portable dispensers), we observed an overall increase of 30.9% from period A to B, and a moderate increase of 1.2% from B to C. Overall, the level of improvement was maintained during the follow-up period in most units (Table II). Discussion Using a computerized database of nursing activities to calculate the required amount of alcoholic hand disinfectant, we were able to show that teaching and distribution of portable dispensers of alcohol for hand disinfection had a positive impact on compliance during routine nursing activities. The use of data on the daily assessment of nursing activities (LEP) as a basis to calculate the need for alcoholic hand disinfection offers an alternative approach to direct observation, which might influence behaviour of the observed.8 This novel approach allows a direct assessment of specific nursing activities requiring alcoholic hand disinfection. Analysis of GA use in our ICUs revealed a very diverse pattern. Although not comparable with the results of the wards, a positive effect on use of GA in the intervention period compared with the pre-intervention period was observed, except in ICU I. The reason for this is unclear. Our data suggest that teaching intervention may be effective through raising awareness, supported by the distribution of portable GA dispensers. Compliance with recommendations for hand disinfection by HCWs is generally inappropriate and difficult to improve, even if multifaceted approaches to change hand hygiene behaviour are
used as shown by Larson.9 Material changes alone do not improve hand hygiene compliance significantly;10 however, indirect approaches appear worthwhile.11 Bittner and Rich have demonstrated a significant relation between compliance with standard handwashing recommendations and counting used paper hand towels as an indicator for the strength of compliance.12 As with our study, which used LEP data as a basis to measure compliance, the usage of paper hand towels may serve as a surrogate marker. We acknowledge the limitations of this study. First, the activities of other HCWs such as doctors and therapists were not measured and therefore not integrated into our analysis. Hence, data on GA use probably overestimate effective compliance of the nursing staff. Secondly, not every single documented nursing action may be associated with an episode of alcoholic hand disinfection. It is common practice for several nursing care actions to be performed consecutively, followed by only one alcoholic hand disinfection. Since the design of this study did not permit us to consider this situation, we may have underestimated true compliance. It is concluded, therefore, that compliance with alcoholic hand disinfection on surgical and medical wards, as well as ICUs, can be improved through a multidimensional intervention, and we note the novel integration of LEP as an inexpensive, indirect correlation factor.
References 1. Roberts SA, Findlay R, Lang SD. Investigation of an outbreak of multi-drug resistant Acinetobacter baumannii in an intensive care burns unit. J Hosp Infect 2001; 48: 228±232. 2. Doebbeling BN, Gail LS, Sheetz CT et al. Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. N Engl J Med 1992; 327: 88±93. 3. Bischoff WE, Reynolds TM, Sessler CN, Edmond MB, Wenzel RP. Handwashing compliance by health care workers. Arch Intern Med 2000; 160: 1017±1021.
72 4. Maury E, Alzieu M, Baudel JL et al. Availability of an alcoholic solution can improve hand disinfection compliance in an intensive care unit. Am J Respir Crit Care Med 2000; 162: 324±327. 5. GuÈntert BJ, Maeder Ch. Ein System zur Erfassung des Pflegeaufwandes. Darstellung der Methode SEP des UniversitaÈtsspitals ZuÈrich. Schriftenreihe SGGP 1994; 37: 17. 6. Centers for Disease Control and Prevention. Guidelines on isolation precautions in hospitals. Infect Cont Hosp Epidem 1996; 17: 65±67. 7. Widmer A, Francioli P. HaÈndewaschen mit desinfizierender Seife oder HaÈndedesinfektion? Mythen und Fakten. Swiss-Noso 1995; 2: 30. 8. Pittet D, Mourpuga P, Perneger TV. Compliance with handwashing in a teaching hospital. Infection control program. Ann Intern Med 1999; 130:126±130.
C. Colombo et al. 9. Larson EL, Bryan JL, Adler LM, Blanc C. A multifaceted approach to changing handwashing behavior. Am J Infect Control 1997; 25: 3±10. 10. Wurtz R, Moye G, Jovanovic B. Handwashing machines, handwashing compliance, and potential for cross-contamination. Am J Infect Control 1994; 22: 228±230. 11. Nishimura S, Kagehira M, Kono F, Nishimura M, Taenaka N. Handwashing before entering the intensive care unit: what we learned from continuous video-camera surveillance. Am J Infect Control 1999; 27: 367±369. 12. Bittner MJ, Rich EC. Surveillance of handwashing episodes in adult intensive-care units by measuring an index of soap and paper towel consumption. Clinical Performance and Quality Health Care 1998; 4: 179±182.