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New technology markedly improves hand-hygiene performance among healthcare workers after restroom visits
Journal of Hospital Infection xxx (2015) 1e3 Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Short report
New technology markedly improves hand-hygiene performance among healthcare workers after restroom visits H. Møller-Sørensen a, *, A. Korshin a, T. Mogensen b, N. Høiby c a
Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Denmark Hvidovre Hospital, Copenhagen University Hospital, Denmark c Department of Clinical Microbiology, Rigshospitalet, Copenhagen University Hospital, Denmark b
A R T I C L E
I N F O
Article history: Received 5 May 2015 Accepted 22 September 2015 Available online xxx Keywords: Compliance Hand hygiene Infection control
S U M M A R Y
The risks to patients from pathogens present on healthcare workers’ (HCWs’) hands are high; however, compliance with hand hygiene among HCWs is low. We devised a prospective intervention trial of a new hand-hygiene dispensing technology to improve HCWs’ compliance with hand hygiene. Baseline hand-hygiene compliance was observed for three months before and after an intervention consisting of implementation of an electronic device that reminds people to comply with hand hygiene after restroom visits. Compliance in hand-hygiene performance after restroom visits increased among HCWs from 66% to 91% after the intervention. ª 2015 Published by Elsevier Ltd on behalf of the Healthcare Infection Society.
Introduction The antiseptic era was introduced by Labaraque and Semmelweis in the 1800s.1 In today’s modern medical facilities, where patients often have indwelling catheters and have other risk factors exposing them to healthcare-acquired infections, it is widely accepted that compliance with good hand hygiene may reduce mortality and morbidity.1 However, compliance with hand hygiene is low and is consistently reported around 50% for healthcare workers (HCWs) and 20% for the public.2,3
* Corresponding author. Address: Department of Cardiothoracic Anesthesiology, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen OE, Denmark. Tel.: þ45 35451416. E-mail address: [email protected] (H. Møller-Sørensen).
These low compliance rates might contribute considerably to in-hospital morbidity and mortality.2e5 Interventions used to improve compliance have traditionally revolved around educational activities, but compliance with hand-hygiene measures among HCWs continues to be inadequate.5 Experience from the automobile industry suggests that simple technological advances may change human behavioural patterns to comply with safety recommendations. Simple auditory reminders have thus been shown to make drivers comply with seat-belt regulations, thereby decreasing injury from road traffic accidents.6 A similar technology could be used to change the behaviour of HCWs’ hand-hygiene performance. Therefore we conducted a prospective intervention trial of a new hand-hygiene dispensing technology aiming to improve hand hygiene.
http://dx.doi.org/10.1016/j.jhin.2015.09.012 0195-6701/ª 2015 Published by Elsevier Ltd on behalf of the Healthcare Infection Society. Please cite this article in press as: Møller-Sørensen H, et al., New technology markedly improves hand-hygiene performance among healthcare workers after restroom visits, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.09.012
2
H. Møller-Sørensen et al. / Journal of Hospital Infection xxx (2015) 1e3
Methods The regional ethics commission of the Copenhagen Region waived the need for informed consent as the study was appreciated as a quality-improvement study. The hypothesis was that a simple audiovisual reminder could improve hand-hygiene performance among HCWs after restroom visits. We also included patients and visitors, who are generally reported to meet hand-hygiene standards less often than HCWs, to see whether an effect could also be elicited among this group. Two university hospitals with four restroom locations each were included in the study. The four locations in each centre were divided into two with patient/visitors access and two with restricted HCW access. In the patient/visitors access restrooms a soap dispenser was available for hand hygiene. In the HCWonly restrooms both a soap dispenser and a hand alcohol-rub dispenser were available. An observational period of three months before the intervention was chosen to establish the baseline hand-hygiene compliance. Compliance was monitored by a hidden sound recorder, which counted toilet-flushing sounds and combined this with electronic logging of soap or alcohol rub dispensing. Compliance with hand hygiene was assumed if flushing sounds were established and an electronic log of soap or alcohol dispensing occurred in conjunction with the flushing sounds. After three months of observation the intervention was introduced. The intervention consisted of installation of a new dispenser system at each location. A Sanalert V5 intelligent soap dispenser (Nobak, Lyngby, Denmark) was installed in every location. In addition a Sanalert V5 intelligent alcoholrub dispenser was installed in each HCW-restricted location. The Sanalert V5 dispenser system is equipped with a sound wave sensor, an electronic processor, and a speaker and illumination system capable of eliciting audible and visual signals in response to sound waves. The system was programmed to sense flushing and elicit an audiovisual signal that would last until soap dispensing was performed. If dispensing were not performed the high-pitched sound would continue for 60 s. In locations where an alcohol-rub dispensing system was also installed (HCW-restricted areas) a blue pulsed light signal would make the restroom user aware of alcohol dispensing by turning on 10 s after soap dispensing had been performed, allowing the user time to dry-wipe the user’s hands before performing hand-alcohol sanitation. Details on how the system works can be found at www.nobak.com. After the intervention the compliance was monitored in the same way as in the observation period during a three-month follow-up period.
The odds ratio (OR) for the increase in compliance between the two periods for the different locations was calculated with 95% confidence interval (CI). P 0.05 was considered statistically significant.
Results We recorded 3290 visits in the observation period and 3996 after the intervention. 63% were collected from patients/ visitors restrooms. In one location, no measurements were available from the observation period due to technical difficulties causing fewer observations. Overall, the compliance rate increased from 46% in the observation period to 76% in the intervention period (OR: 1.66; 95% CI: 1.54‒1.79; P < 0.0001). The baseline compliance rates increased from 66% to 91% for HCWs (OR: 1.38; 95% CI: 1.23‒1.55; P < 0.0001) and from 28% to 70% for patients/visitors (OR: 2.46; 95% CI: 2.19‒2.76; P < 0.0001) (Table I). In one specific location the readings decreased from 1346 in the observation period to 536 in the intervention period, and non-compliant staff may thus have chosen alternative restrooms in the intervention period.
Discussion Trials that evaluate electronic counting technology for determining compliance rate are scarce, probably due to the complexity encountered in electronically identifying an event, where performance of hand hygiene is appropriate, and then linking it with electronic counting.7 We tried to overcome some of the challenges by using an approach where the secluded setting of restroom visits, which otherwise prohibits physical observation, is used as an advantage, allowing sound surveillance and a time-framed counting device to link a restroom visit with performance of hand hygiene. The compliance rate we found by this method was similar to the compliance rates reported by covert physical observation of HCWs’ restroom visits.2,8 We used the same approach to evaluate an intervention in which an alarm system, not unlike the systems used with success in the automobile seat-belt safety industry, enhanced the performance of hand hygiene. Our study’s compliance rate of 91% could be explained by the suitability of using an electronic reminder system. However, there are limitations to the preliminary study reported here. First, it does not have a patient outcome measure. Second, the method used assumes compliance when dispensing is performed; however, the quality of hand hygiene has been shown to differ considerably when determined by physical observation and quantified by electronic means.7,9 There are also some limitations to the technology. Some restroom visitors
Table I Compliance with hand-hygiene performance Location
All restrooms HCWs’ restroom Patient/visitors’ restrooms
No. of times hand hygiene performed/total no. of restroom visits (%) Pre intervention
Post intervention
1512/3290 (46.0%) 1010/1541 (65.5%) 502/1749 (28.7%)
3050/3996 (76.3%) 1037/1143 (90.7%) 2013/2853 (70.6%)
P-values for odds ratios
<0.0001 <0.0001 <0.0001
HCWs, healthcare workers. Please cite this article in press as: Møller-Sørensen H, et al., New technology markedly improves hand-hygiene performance among healthcare workers after restroom visits, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.09.012
H. Møller-Sørensen et al. / Journal of Hospital Infection xxx (2015) 1e3 will not flush and thus the technology will not count or intervene; others will flush after hand hygiene, although the latter can be overcome by expanding the time-period in the system during which hand hygiene has to be performed. Furthermore, we cannot exclude that some of the effect seen was due to HCWs deliberately choosing either not to flush or not to visit the surveyed restrooms. Certainly, we did observe a decrease in observed restroom visits at some locations after the intervention. Nor did we evaluate the long-term effect that ‘alarm fatigue’ might have on the improvement seen. Finally the method we describe cannot readily be applied to the five handhygiene moments identified by the World Health Organization in relation to direct patient care; other ways have to be devised.10 However, our study’s improvement to around 90% compliance among HCWs by applying a simple technology, with minor cost increases compared to current dispensing systems, deserves serious consideration when hospital management and administration are supplying hospital restrooms with new hand-hygiene dispensing equipment. It is well accepted that improvement in hand hygiene is necessary and is linked to better outcomes, and straightforward inexpensive solutions need to be taken into consideration to achieve this goal. Conflict of interest statement None declared. Funding sources The SanAlert V5 dispensers were sponsored by Nobak A/S.
3
References 1. McLaws M-L. The relationship between hand hygiene and health care-associated infection: it’s complicated. Infect Drug Resist 2015;8:7e18. 2. van der Vegt DSJM, Voss A. Are hospitals too clean to trigger good hand hygiene? J Hosp Infect 2009;72:218e220. 3. Marra AR, Edmond MB. New technologies to monitor healthcare worker hand hygiene. Clin Microbiol Infect 2014;20:29e33. 4. Smiddy MP, O’Connell R, Creedon SA. Systematic qualitative literature review of health care workers’ compliance with hand hygiene guidelines. Am J Infect Control 2015;43:269e274. 5. Ofek Shlomai N, Rao S, Patole S. Efficacy of interventions to improve hand hygiene compliance in neonatal units: a systematic review and meta-analysis. Eur J Clin Microbiol Infect Dis 2015;34:887e897. 6. Farmer CM, Wells JK. Effect of enhanced seat belt reminders on driver fatality risk. J Safety Res 2010;41:53e57. 7. Srigley JA, Gardam M, Fernie G, Lightfoot D, Lebovic G, Muller MP. Hand hygiene monitoring technology: a systematic review of efficacy. J Hosp Infect 2015;89:51e60. 8. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307e1312. 9. Magnus TP, Marra AR, Camargo TZS, et al. Measuring hand hygiene compliance rates in different special care settings: a comparative study of methodologies. Int J Infect Dis 2015;33:205e208. 10. 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.
Please cite this article in press as: Møller-Sørensen H, et al., New technology markedly improves hand-hygiene performance among healthcare workers after restroom visits, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.09.012
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Short report
New technology markedly improves hand-hygiene performance among healthcare workers after restroom visits H. Møller-Sørensen a, *, A. Korshin a, T. Mogensen b, N. Høiby c a
Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Denmark Hvidovre Hospital, Copenhagen University Hospital, Denmark c Department of Clinical Microbiology, Rigshospitalet, Copenhagen University Hospital, Denmark b
A R T I C L E
I N F O
Article history: Received 5 May 2015 Accepted 22 September 2015 Available online xxx Keywords: Compliance Hand hygiene Infection control
S U M M A R Y
The risks to patients from pathogens present on healthcare workers’ (HCWs’) hands are high; however, compliance with hand hygiene among HCWs is low. We devised a prospective intervention trial of a new hand-hygiene dispensing technology to improve HCWs’ compliance with hand hygiene. Baseline hand-hygiene compliance was observed for three months before and after an intervention consisting of implementation of an electronic device that reminds people to comply with hand hygiene after restroom visits. Compliance in hand-hygiene performance after restroom visits increased among HCWs from 66% to 91% after the intervention. ª 2015 Published by Elsevier Ltd on behalf of the Healthcare Infection Society.
Introduction The antiseptic era was introduced by Labaraque and Semmelweis in the 1800s.1 In today’s modern medical facilities, where patients often have indwelling catheters and have other risk factors exposing them to healthcare-acquired infections, it is widely accepted that compliance with good hand hygiene may reduce mortality and morbidity.1 However, compliance with hand hygiene is low and is consistently reported around 50% for healthcare workers (HCWs) and 20% for the public.2,3
* Corresponding author. Address: Department of Cardiothoracic Anesthesiology, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen OE, Denmark. Tel.: þ45 35451416. E-mail address: [email protected] (H. Møller-Sørensen).
These low compliance rates might contribute considerably to in-hospital morbidity and mortality.2e5 Interventions used to improve compliance have traditionally revolved around educational activities, but compliance with hand-hygiene measures among HCWs continues to be inadequate.5 Experience from the automobile industry suggests that simple technological advances may change human behavioural patterns to comply with safety recommendations. Simple auditory reminders have thus been shown to make drivers comply with seat-belt regulations, thereby decreasing injury from road traffic accidents.6 A similar technology could be used to change the behaviour of HCWs’ hand-hygiene performance. Therefore we conducted a prospective intervention trial of a new hand-hygiene dispensing technology aiming to improve hand hygiene.
http://dx.doi.org/10.1016/j.jhin.2015.09.012 0195-6701/ª 2015 Published by Elsevier Ltd on behalf of the Healthcare Infection Society. Please cite this article in press as: Møller-Sørensen H, et al., New technology markedly improves hand-hygiene performance among healthcare workers after restroom visits, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.09.012
2
H. Møller-Sørensen et al. / Journal of Hospital Infection xxx (2015) 1e3
Methods The regional ethics commission of the Copenhagen Region waived the need for informed consent as the study was appreciated as a quality-improvement study. The hypothesis was that a simple audiovisual reminder could improve hand-hygiene performance among HCWs after restroom visits. We also included patients and visitors, who are generally reported to meet hand-hygiene standards less often than HCWs, to see whether an effect could also be elicited among this group. Two university hospitals with four restroom locations each were included in the study. The four locations in each centre were divided into two with patient/visitors access and two with restricted HCW access. In the patient/visitors access restrooms a soap dispenser was available for hand hygiene. In the HCWonly restrooms both a soap dispenser and a hand alcohol-rub dispenser were available. An observational period of three months before the intervention was chosen to establish the baseline hand-hygiene compliance. Compliance was monitored by a hidden sound recorder, which counted toilet-flushing sounds and combined this with electronic logging of soap or alcohol rub dispensing. Compliance with hand hygiene was assumed if flushing sounds were established and an electronic log of soap or alcohol dispensing occurred in conjunction with the flushing sounds. After three months of observation the intervention was introduced. The intervention consisted of installation of a new dispenser system at each location. A Sanalert V5 intelligent soap dispenser (Nobak, Lyngby, Denmark) was installed in every location. In addition a Sanalert V5 intelligent alcoholrub dispenser was installed in each HCW-restricted location. The Sanalert V5 dispenser system is equipped with a sound wave sensor, an electronic processor, and a speaker and illumination system capable of eliciting audible and visual signals in response to sound waves. The system was programmed to sense flushing and elicit an audiovisual signal that would last until soap dispensing was performed. If dispensing were not performed the high-pitched sound would continue for 60 s. In locations where an alcohol-rub dispensing system was also installed (HCW-restricted areas) a blue pulsed light signal would make the restroom user aware of alcohol dispensing by turning on 10 s after soap dispensing had been performed, allowing the user time to dry-wipe the user’s hands before performing hand-alcohol sanitation. Details on how the system works can be found at www.nobak.com. After the intervention the compliance was monitored in the same way as in the observation period during a three-month follow-up period.
The odds ratio (OR) for the increase in compliance between the two periods for the different locations was calculated with 95% confidence interval (CI). P 0.05 was considered statistically significant.
Results We recorded 3290 visits in the observation period and 3996 after the intervention. 63% were collected from patients/ visitors restrooms. In one location, no measurements were available from the observation period due to technical difficulties causing fewer observations. Overall, the compliance rate increased from 46% in the observation period to 76% in the intervention period (OR: 1.66; 95% CI: 1.54‒1.79; P < 0.0001). The baseline compliance rates increased from 66% to 91% for HCWs (OR: 1.38; 95% CI: 1.23‒1.55; P < 0.0001) and from 28% to 70% for patients/visitors (OR: 2.46; 95% CI: 2.19‒2.76; P < 0.0001) (Table I). In one specific location the readings decreased from 1346 in the observation period to 536 in the intervention period, and non-compliant staff may thus have chosen alternative restrooms in the intervention period.
Discussion Trials that evaluate electronic counting technology for determining compliance rate are scarce, probably due to the complexity encountered in electronically identifying an event, where performance of hand hygiene is appropriate, and then linking it with electronic counting.7 We tried to overcome some of the challenges by using an approach where the secluded setting of restroom visits, which otherwise prohibits physical observation, is used as an advantage, allowing sound surveillance and a time-framed counting device to link a restroom visit with performance of hand hygiene. The compliance rate we found by this method was similar to the compliance rates reported by covert physical observation of HCWs’ restroom visits.2,8 We used the same approach to evaluate an intervention in which an alarm system, not unlike the systems used with success in the automobile seat-belt safety industry, enhanced the performance of hand hygiene. Our study’s compliance rate of 91% could be explained by the suitability of using an electronic reminder system. However, there are limitations to the preliminary study reported here. First, it does not have a patient outcome measure. Second, the method used assumes compliance when dispensing is performed; however, the quality of hand hygiene has been shown to differ considerably when determined by physical observation and quantified by electronic means.7,9 There are also some limitations to the technology. Some restroom visitors
Table I Compliance with hand-hygiene performance Location
All restrooms HCWs’ restroom Patient/visitors’ restrooms
No. of times hand hygiene performed/total no. of restroom visits (%) Pre intervention
Post intervention
1512/3290 (46.0%) 1010/1541 (65.5%) 502/1749 (28.7%)
3050/3996 (76.3%) 1037/1143 (90.7%) 2013/2853 (70.6%)
P-values for odds ratios
<0.0001 <0.0001 <0.0001
HCWs, healthcare workers. Please cite this article in press as: Møller-Sørensen H, et al., New technology markedly improves hand-hygiene performance among healthcare workers after restroom visits, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.09.012
H. Møller-Sørensen et al. / Journal of Hospital Infection xxx (2015) 1e3 will not flush and thus the technology will not count or intervene; others will flush after hand hygiene, although the latter can be overcome by expanding the time-period in the system during which hand hygiene has to be performed. Furthermore, we cannot exclude that some of the effect seen was due to HCWs deliberately choosing either not to flush or not to visit the surveyed restrooms. Certainly, we did observe a decrease in observed restroom visits at some locations after the intervention. Nor did we evaluate the long-term effect that ‘alarm fatigue’ might have on the improvement seen. Finally the method we describe cannot readily be applied to the five handhygiene moments identified by the World Health Organization in relation to direct patient care; other ways have to be devised.10 However, our study’s improvement to around 90% compliance among HCWs by applying a simple technology, with minor cost increases compared to current dispensing systems, deserves serious consideration when hospital management and administration are supplying hospital restrooms with new hand-hygiene dispensing equipment. It is well accepted that improvement in hand hygiene is necessary and is linked to better outcomes, and straightforward inexpensive solutions need to be taken into consideration to achieve this goal. Conflict of interest statement None declared. Funding sources The SanAlert V5 dispensers were sponsored by Nobak A/S.
3
References 1. McLaws M-L. The relationship between hand hygiene and health care-associated infection: it’s complicated. Infect Drug Resist 2015;8:7e18. 2. van der Vegt DSJM, Voss A. Are hospitals too clean to trigger good hand hygiene? J Hosp Infect 2009;72:218e220. 3. Marra AR, Edmond MB. New technologies to monitor healthcare worker hand hygiene. Clin Microbiol Infect 2014;20:29e33. 4. Smiddy MP, O’Connell R, Creedon SA. Systematic qualitative literature review of health care workers’ compliance with hand hygiene guidelines. Am J Infect Control 2015;43:269e274. 5. Ofek Shlomai N, Rao S, Patole S. Efficacy of interventions to improve hand hygiene compliance in neonatal units: a systematic review and meta-analysis. Eur J Clin Microbiol Infect Dis 2015;34:887e897. 6. Farmer CM, Wells JK. Effect of enhanced seat belt reminders on driver fatality risk. J Safety Res 2010;41:53e57. 7. Srigley JA, Gardam M, Fernie G, Lightfoot D, Lebovic G, Muller MP. Hand hygiene monitoring technology: a systematic review of efficacy. J Hosp Infect 2015;89:51e60. 8. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307e1312. 9. Magnus TP, Marra AR, Camargo TZS, et al. Measuring hand hygiene compliance rates in different special care settings: a comparative study of methodologies. Int J Infect Dis 2015;33:205e208. 10. 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.
Please cite this article in press as: Møller-Sørensen H, et al., New technology markedly improves hand-hygiene performance among healthcare workers after restroom visits, Journal of Hospital Infection (2015), http://dx.doi.org/10.1016/j.jhin.2015.09.012