- Email: [email protected]
Role of a multimodal educational strategy on health care workers' handwashing
American Journal of Infection Control 44 (2016) 400-4
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Major article
Role of a multimodal educational strategy on health care workers’ handwashing Jo Andrea Watson RN, DNP, MSN, CCRN, CPAN * Infection Prevention Department, St. Mary’s Medical Center, Huntington, WV
Key Words: Hand hygiene hand hygiene compliance health care workers’ hand hygiene compliance World Health Organizations’ My 5 Moments for Hand Hygiene methodology
Background: Good hand hygiene is the single most important strategy used to prevent health care– associated infections (HAIs); however, health care workers’ (HCWs’) hand hygiene compliance rates range between 25% and 51%. This study aims to determine if a multimodal strategy using the World Health Organization’s (WHO’s) My 5 Moments for Hand Hygiene methodology increases HCWs’ compliance with handwashing and awareness of the importance of good hand hygiene in the prevention of HAIs. Methods: A quasi-experimental, 1-group pre-post survey design was used to test awareness and knowledge. A simple interrupted time series methodology at baseline and 3 months was used to monitor hand hygiene compliance. Results: Overall, HCWs’ hand hygiene compliance increased from 51.3% to 98.6%, with an odds ratio of 71.10. The pre-post survey demonstrated HCWs were aware and knowledgeable of the importance of good hand hygiene. Eight postsurvey questions focusing on the strategies used to promote hand hygiene demonstrated statistical significance using a 1-sample t test, with P values ranging from .000-.024. Conclusion: A multimodal approach using the WHO’s My 5 Moments for Hand Hygiene does increase HCWs’ hand hygiene compliance and awareness and knowledge of the importance of hand hygiene in the prevention of HAIs. Using this approach can produce a positive social change by reducing preventable disease and decreasing HAIs not only within a facility but also in the community. © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Institutional review board approval no.: Walden University (1015-13-0044855) and Marshall University (501578-2).
INTRODUCTION Health care–associated infections (HAIs) have become a worldwide problem causing infection prevention departments to look for ways to prevent or decrease the occurrence at their facilities. HAIs result in 99,000 deaths each year, with an estimated 2 million people contracting HAIs in the United States.1 HAIs have remained the leading cause of morbidity and mortality. In 2002, nearly 100,000 deaths were associated with 1.7 million HAIs in the United States. A total of 15%-30% of HAIs have impacted up to 10% of hospitalized patients and are considered preventable through improved hand hygiene.2 Health care administrators are concerned with the increase in HAIs because the Centers for Medicare and Medicaid
* Address correspondence to Jo Andrea Watson, RN, DNP, MSN, CCRN, CPAN, 44 Hickory Dr, Barboursville, WV 25504. E-mail address: [email protected] (J.A. Watson). Conflicts of interest: None to report.
Services will no longer reimburse hospitals for certain HAIs.1 Sax et al3 state adherence to good hand hygiene practices is the single most important strategy to use to prevent HAIs. Despite facilities stressing the importance of performing good hand hygiene to prevent disease and infection, hand hygiene compliance rates among health care workers (HCWs) remain low.2 Alemangno et al4 state HCWs’ hand hygiene compliance rates are usually 30%-60%, but they seldom exceed 50%, despite facilities’ attempts to maintain good infection control practices. Many strategies have been used to help improve hand hygiene compliance among HCWs, with education and training being the main strategies. These strategies have not been successful in producing a maintainable improvement. Grol and Grimshaw (as cited in Erasmus et al, 2011) concluded hand hygiene requires a comprehensive plan, targeting different problems and barriers to change with strategies at different levels to achieve sustainable changes in hand hygiene routines.5 In 2005, the World Health Organization (WHO) initiated the First Global Patient Safety Challenge. The WHO aimed to improve patient safety by promoting hand hygiene in health care facilities using a multimodal strategy using alcohol-based handrubs at the points of care with this challenge.6 The WHO introduced the My 5 Moments for Hand Hygiene strategy, designating specific moments when hand
0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.10.030
J.A. Watson / American Journal of Infection Control 44 (2016) 400-4
hygiene is required to effectively interrupt microbial transmission during the normal care of patients.7 Along with the introduction of the hand hygiene strategy, the WHO introduced a standardized tool for monitoring hand hygiene compliance based on the My 5 Moments for Hand Hygiene that has been successful in monitoring hand hygiene compliance among HCWs worldwide.3 Low compliance of handwashing in HCWs leads to HAI from disease transmission and results in preventable illness and death in HCWs and patients. Single interventions have not demonstrated sustained improvement in hand hygiene compliance among HCWs. A multimodal approach using the WHO’s My 5 Moments for Hand Hygiene may be more effective in improving hand hygiene compliance among HCWs than single intervention approaches. Applying a multimodal approach involves use of multiple strategies simultaneously. Leaders in the field have suggested singular interventions are insufficient to sustain behavioral change. Adopting a multimodal approach to improve hand hygiene is vital to achieving a reduction in HAIs.8 Further scholarship is needed to determine if combining these 2 approaches (multimodal and WHO) for handwashing can significantly improve HCWs’ handwashing compliance. Literature review According to Pincock et al,8 adopting a multimodal approach to improve hand hygiene is vital to achieving a reduction in HAIs. Two key factors have limited the adoption of a multimodal approach for hand hygiene. First, most hand hygiene studies emphasize the efficacy of singular interventions. Second, many of the studies have emphasized the methods for monitoring and recording hand hygiene compliance, not sustainability. Many studies using a multimodal approach have demonstrated an overall improvement in hand hygiene compliance. Mathai et al7 used a multimodal interventional strategy in a mixed medical-surgical intensive care unit with significant overall improvement in hand hygiene compliance among HCWs (26% to 57.36% after the intervention). Lam et al9 used a multimodal approach in a neonatal intensive care unit to improve overall hand hygiene compliance and impact nosocomial infections. The overall hand hygiene compliance increased from 40% to 53% before patient contact and 39% to 59% after patient contact. The study also showed a marked improvement in hand hygiene compliance during highrisk procedures, from 35% to 60%. Carboneau et al1 identified education, culture, and environment as the 3 main areas needing to be addressed to improve hand hygiene compliance. The study used a 6-sigma improvement methodology to address the issues. Hand hygiene compliance rates increased 20%, with a 51% decrease in methicillin-resistant Staphylococcus aureus cases noted over a 12month period after interventions addressing the 3 areas were implemented. Allegranzi et al10 also found the use of a multimodal interventional approach significantly improved hand hygiene compliance from 8% at baseline to 21.8% at follow-up (P < .001). An important conclusion to this study was the importance of having handrub easily available for staff to perform hand hygiene. Studies have shown a multimodal approach can have a positive long-term outcome. Four consecutive, multimodal 1-month campaigns were conducted to promote hand hygiene in Belgian hospitals between 2005 and 2011. Posters, educational sessions, promotion of alcohol-based handrub use, increasing patient awareness, and audits with performance feedback were the interventions used. Compliance with hand hygiene significantly increased from 49.6% to 68.6% during the first campaign, from 53.2% to 69.5% for the second campaign, from 58.0% to 69.1% for the third campaign, and from 62.3% to 72.9% for the fourth campaign. This study also noted physician compliance was markedly lower than nurses, and compliance rates were higher after patient contact and body fluid exposure risk than before patient contact and before performing aseptic procedures.11
401
The literature reports poor hand hygiene compliance may be the result of several barriers. The most common reasons HCWs report for lack of adherence to hand hygiene recommendations are skin irritation, inaccessible supplies, interference with worker-patient relations, patient needs perceived as priority, wearing gloves, forgetfulness, ignorance of guidelines, insufficient time, high workload, understaffing, and lack of scientific information demonstrating improved compliance decreases HAIs.12 In a qualitative study based on 17 focus groups, 4 themes emerged from the analyses. The themes were adherence to guidelines is compromised by HCW knowledge and beliefs, hand hygiene is practiced for personal protection, the external environment influences hand hygiene behavior, and professional responsibility. The study identified many reasons why hand hygiene practice was suboptimal despite the adoption of the WHO’s new accreditation guidelines and provincial strategy for hand hygiene. Many HCWs stated current guidelines for hand hygiene were unrealistic. Physicians stated the evidence was not sufficient to support the hand hygiene guidelines. Other HCWs stated current workload and patient needs often came before hand hygiene. Participants cited personal safety as the primary reason for hand hygiene practices, especially after patient contact rather than before patient contact. Participant’s also stated cited adherence by other HCWs, especially physicians, influenced their own attitudes and practices.13 A very important finding from the study by Jang et al13 was other HCWs considered their role models to be physicians. This was a significant finding when studies have shown physicians to have the lowest hand hygiene compliance rates compared with other HCWs.14-17 Conceptual models and theoretical frameworks Bandura’s social cognitive theory served as the foundation to address the problem of hand hygiene compliance among HCWs. The purpose of the theory is to understand and predict individual and group behaviors, identify methods where behavior can be modified or changed, and test interventions aimed at personality development, behavior pathology, and health promotion. The theory states individuals learn by direct experiences, human dialogue and interaction, and observation.18 The theory stresses the importance of an individual being actively involved with the environment and how people actively select their own role models and regulate their own attitudes and actions regarding learning. An important concept of Bandura’s theory is self-efficacy. Self-efficacy promotes learning and productive human function.19 Behavioral determinants, such as attitude, social influence, and self-efficacy, play a large role in hand hygiene compliance among HCWs.20 Bandura’s social cognitive theory was ideal for this hand hygiene study and target population because the theory deals with behavioral modification and how individuals decide to act and learn. The HCWs’ behavioral issues and beliefs associated with hand hygiene can affect hand hygiene compliance and how the individual accepts behavioral modification strategies. Awareness of the effects of poor hand hygiene in contributing to HAIs may help to produce effective and sustained behavior changes (self-efficacy), leading to good hand hygiene compliance.7 Purpose statement and project objectives The purpose of this study was to determine the extent to which a multimodal strategy for teaching and promoting hand hygiene increases HCWs’ compliance with handwashing. If a multimodal intervention strategy for hand hygiene improved hand hygiene compliance among HCWs, it may offer a sustainable program for maintaining compliance. Research has shown good hand hygiene prevents infection, but there is limited research available
402
J.A. Watson / American Journal of Infection Control 44 (2016) 400-4
demonstrating the use of a multimodal approach to sustain hand hygiene compliance among HCWs. The study’s goal was to use a multimodal approach using the WHO My 5 Moments for Hand Hygiene methodology to increase HCWs’ hand hygiene compliance. The WHO’s standardized tool to measure hand hygiene compliance was used to measure hand hygiene compliance. The objective of this study was to increase HCWs’ knowledge and awareness and perception of the importance of good hand hygiene and HCWs’ compliance with hand hygiene practices using a multimodal approach using the WHO’s My 5 Moments for Hand Hygiene. It was hoped making sure all staff members were aware of the impact hand hygiene plays in preventing or spreading infection to patients and others would help increase the hand hygiene compliance rate among all staff members. Research questions The first research question is as follows: Is there a significant difference in hand hygiene compliance rates among the pre–multimodal strategy intervention program to post–multimodal strategy intervention program, which includes the WHO’s My 5 Moments for Hand Hygiene? The second question is as follows: Is there a significant difference in knowledge and awareness of the importance of good hand hygiene from the pre–multimodal strategy intervention program to the post–multimodal strategy intervention program, which includes the WHO My 5 Moments for Hand Hygiene among HCWs? Location of study The study was conducted in a 393-bed, nonprofit, medical center located in West Virginia. The medical center is a teaching facility associated with a school of nursing, medical imaging, and respiratory and a university, which has a medical school, school of pharmacy, and school of physical therapy. The medical center is a level II trauma center and is a regional neuroscience, cancer, and heart center, and it serves a tristate area, including Ohio and Kentucky.
included the same questions as the initial survey, with additional questions to obtain HCWs’ opinion of the strategies and tools (multimodal intervention) used to promote hand hygiene in the organization. A baseline hand hygiene compliance observation was performed prior to the implementation of the multimodal strategies. A postintervention hand hygiene compliance observation was performed during the 12th week of the study. Hand hygiene observations used the WHO’s hand hygiene measurement tool. Therefore, a quantitative design was used to address the research question. The researcher and the infection prevention coordinator were trained and validated as hand hygiene observers using the WHO My 5 Moments for Hand Hygiene methodology. Hand hygiene observations count the number of observed moments requiring hand hygiene, which are referred to as opportunities. During an observation period, each opportunity is counted as met or missed. Hand hygiene compliance is determined by using the number of opportunities met compared with the total number of opportunities observed.3 A simple interrupted time series methodology at baseline and 3 months was used to monitor hand hygiene compliance. To determine whether hand hygiene compliance among the trial units were statistically significant, an odds ratio was performed using MedCalc 12.3 software system (MedCalc Software, Ostend, Belgium). SPSS software (SPSS, Chicago, IL) was used to perform Wilcoxon signed-rank tests along with mean, SD, and paired-samples t test for the Perception Survey and the same questions on the FollowUp Perception Survey. The hand hygiene study was based on the WHO’s My 5 Moments for Hand Hygiene methodology using the standardized measurement tool for hand hygiene observation and spreadsheet to collect data on hand hygiene compliance. The recommended indications for hand hygiene using the methodology identify specific points or moments during patient care when hand hygiene should be performed. Measures
Population and sampling The target population was HCWs with direct contact with patients. One intensive care unit, 1 specialty unit (pulmonary), and 1 medical-surgical unit were selected as the trial units. All staff members of the trial units were invited to participate in the study. Float and respiratory therapy staff were also invited to participate. The hospitalist group was invited to participate in the study because they were medical center employees and care for patients throughout the medical center. Participants had to be able to give informed consent, participate in the program by viewing the educational materials and video, complete surveys and demographic questionnaires, be willing to be observed, and have handwashing behaviors assessed. Staff members were excluded if they had characteristics or conditions that could provide difficulties or biases to the study, such as being on leave of absence during a portion of the study or transferring to a different department not included in the study during the time frame of the study. Study design and methods The study was conducted using a quasi-experimental, 1-group pre–awareness and perception survey and follow-up awareness and perception survey design to test awareness and knowledge. The awareness and perception survey contained questions to obtain HCWs’ opinion on HAIs and hand hygiene and HCWs’ awareness and knowledge of the importance of hand hygiene in the prevention of HAIs. The follow-up awareness and perception survey
Variables affecting hand hygiene compliance were measured to determine whether a multimodal approach using the WHO’s methodology increased HCWs’ hand hygiene compliance. The WHO’s educational tools for training, posters, and hand hygiene observation compliance forms were used. All of the WHO’s tools used for this study, which were downloaded from the WHO’s Web site, have been tested and validated by experts in the field, with many being used in previous studies.21 Procedure After consent was obtained, a baseline hand hygiene observation was performed prior to the educational module being placed in the participant’s computer classroom. Once the participants completed the educational module, and posters and brochures were placed in strategic locations on the trial units, the researcher made frequent rounds to answer questions related to the My 5 Moments for Hand Hygiene and to discuss hand hygiene compliance. Throughout the study, random hand hygiene compliance observations were conducted by the infection prevention coordinator and researcher to provide immediate feedback about the participant’s performance and show the participant the cleanliness of their hands under an ultraviolet light using Glo Germ (Glo Germ Co, Moab, UT). During week 10, the participants completed the Follow-Up Perception Survey. During week 12, the infection prevention coordinator and researcher performed the final hand hygiene observations, which were used to calculate the HCWs’ hand hygiene compliance for the
J.A. Watson / American Journal of Infection Control 44 (2016) 400-4
403
individual units and the overall hand hygiene compliance for the trial. Data analysis The WHO’s My 5 Moments for Hand Hygiene standardized measurement tool was used. All tests were assessed with a significance level of .05. Preliminary analysis started with characterization of the study sample at baseline. Descriptive statistics was calculated. Sums and percentages were used for nominal and ordinal level data. Mean, sums, and range were used for interval- and ratio-level data. Data obtained during the hand hygiene observations was entered into the spreadsheet, and hand hygiene compliance was calculated by the number of opportunities met compared with the total number of opportunities observed. Differences between pre- to postobservation compliance rates were analyzed using a 2-sample paired t test. Pre- and posttests of knowledge were analyzed using paired t tests or Wilcoxon signed-rank tests depending on the level of data and sample size. RESULTS The overall hand hygiene compliance rate for the study increased from 51.3% to 98.6%. Table 1 demonstrates the results of the odds ratio for overall hand hygiene observation. The mean and SD tests demonstrated HCWs understand the importance of hand hygiene, especially in the prevention of HAIs. The paired-sample t test demonstrated statistical significance for the following questions: (1) what is the average percentage of hospitalized patients who will develop an HAI (P = .003)?; and (2) on average, what percentage of situations requiring hand hygiene does HCWs in your hospital perform hand hygiene (P = .012)? A 1-sample t test was calculated for the 8 additional questions on the Follow-Up Perception Survey for HCWs. The results demonstrated HCWs felt the multimodal interventions helped to increase their awareness and knowledge of the importance hand hygiene compliance plays in the prevention of HAIs. The researcher was interested in knowing how individual professional categories performed pre– and post–hand hygiene intervention. The professional categories included registered nurses (RNs), medical doctors (MDs), and all other professions (others). Pre– hand hygiene intervention observation demonstrated the others group had the highest hand hygiene percentage of the overall opportunities observed (64%), followed by RNs (49%) and MDs (38%). Post–hand hygiene intervention observation demonstrated the others group performed hand hygiene in 100% of the opportunities observed, followed by RNs (99%) and MDs (97%). Figure 1 demonstrates these findings. An odds ratio was calculated to determine if the results for the professional categories were statistically significant by the statis-
Table 1 Odds ratio: overall hand hygiene observations Observed cases Cases with positive outcome First group, n Second group, n Cases with negative outcome First group, n Second group, n Results Odds ratio 95% confidence interval z Statistic Significance level, P
Value 150 77 2 73 71.1039 16.9919-297.5402 5.839 <.0001
Fig 1. Pre– and post–hand hygiene observation percentage by profession. Abbreviations: PostHHObs, post–hand hygiene observation; PreHHObs, pre–hand hygiene observation.
tical test used. The RN and MD categories were statistically significant (P < .0001 and P = .0008, respectively). The others category was not statistically significant (P = .08). The others category had a small number of participants, which may be the reason for the results. The odds ratio does demonstrate the multimodal approach using the WHO’s My 5 Moments for Hand Hygiene did significantly increase HCWs’ hand hygiene compliance rates. Discussion of findings in the context of the literature According to the literature, HCWs’ hand hygiene compliance rates range between 25% to 51%, even when HCWs state they perform hand hygiene when they should.22 The baseline (preintervention) hand hygiene compliance rate for the study was 51.3%. This was consistent with the literature. Multiple studies have demonstrated an increase in hand hygiene compliance rates after a multimodal approach was used, as occurred in this study, with the hand hygiene compliance rate increasing from 51.3% to 98.6%. A study by Carboneau et al1 saw a hand hygiene compliance rate increase of 20% over a 12month period when interventions were used addressing education, culture, and environment. A multimodal approach to improve hand hygiene compliance rates in an intensive care unit using a selfreport questionnaire and interventions, including education, posters, verbal reminders, and easy availability of products for hand hygiene, demonstrated a hand hygiene increase from 26% to 57.36%.7 This study did not focus on hand hygiene performance by professions; however, the researcher was able to demonstrate a difference pre– and post–hand hygiene observations between professions. The highest performing group both pre- and postintervention was the others category (from 64% to 100%). RNs were second (from 49% to 99%), whereas physicians were the lowest performers (from 38% to 97%). This is consistent with the literature. A study conducted in 2004 by the Tuscany Regional Health Authority stated hand hygiene compliance rates among physicians improved from 21% to 27% and for nurses improved from 32%
404
J.A. Watson / American Journal of Infection Control 44 (2016) 400-4
to 64%.15 Fakhry et al17 conducted a study using an electronic motion sensor–triggered device, with an audible reminder installed at unit entrances to measure staff and visitor hand hygiene compliance, and found nonclinical staff hand hygiene increased from 5.3% to 34.8% (P < .001), physician adherence increased from 4.5% to 38.3%, and nurse adherence increased from 5.4% to 43.4%. Alemangno et al4 conducted a study using an online educational program to increase participants’ knowledge and awareness of the importance of hand hygiene in the reduction of HAIs. The participants completed a pre- and postsurvey, which demonstrated increase awareness of the importance of hand hygiene and the effect of hand hygiene on HAIs. The results of this study indicated the HCWs believed the program was effective in providing an increase in knowledge and awareness of the importance of hand hygiene.
Implications This research study was conducted as a trial to see if the WHO’s My 5 Moments for Hand Hygiene methodology would improve hand hygiene compliance on the trial units. Because this study demonstrated a significant increase in hand hygiene compliance on the trial units, the methodology may produce similar results house-wide. This may help reduce the number of HAIs and improve patient outcomes.
Project strengths and limitations The main strength of the study was the educational material, which had been developed and validated by the WHO for use with the My 5 Moments for Hand Hygiene. Other strengths included obtaining the support of senior administration, the infection prevention department, and clinical managers of the trial units. The infection prevention department allocated time and a staff member to assist with data collection, which provided consistency during hand hygiene observations. Limitations of the study included 66 participants enrolling in the study; however, only 46 participants completed the follow-up survey. The reasons for participants not completing the survey included sudden medical leave, change in job positions, and termination. The surveys provided limitations when trying to compile the data. The time of year the study was held may have been a limitation. The study began in early December and concluded at the end of February. The post–hand hygiene observations occurred during high influenza season. It is possible that the result of increased compliance was because of staff being more vigilant about hand hygiene because of the increase in influenza cases. For future studies, the researcher recommends providing the educational module in a classroom setting or on the computer. The classroom setting would allow staff without easy access to computers or with reading comprehension challenges to be able to participant in the study. Developing a Likert scale for each question on the surveys would also assist with data analysis. Other
limitations seen in this study were things the researcher or other researchers would not be able to avoid. References 1. Carboneau C, Benge E, Jaco MT, Robinson M. A lean six sigma team increases hand hygiene compliance and reduces hospital-acquired MRSA infections by 51%. J Healthc Qual 2010;32:61-70. doi:10.1111/j.1945-1474.2009.00074.x. 2. Wilson S, Jacob CJ, Powell D. Behavior-change interventions to improve handhygiene practice: a review of alternatives to education. Crit Public Health 2011;21:119-27. doi:10.1080/09581591009786122. 3. Sax H, Allegrani B, Chraiti M, Boyce J, Larson E, Pittet D. The World Health Organization hand hygiene observation method. Am J Infect Control 2009;37:827-34. doi:10.1016/j.ajic.2009.07.003. 4. Alemangno SA, Guten SM, Warthman S, Youn E, Mackay DS. Online learning to improve hand hygiene knowledge and compliance among health care workers. J Contin Educ Nurs 2010;41:463-71. doi:10.3928/00220124-20100610-06. 5. Erasmus V, Huis A, Oenema A, Van Empelen P, Boog MC, Van Beeck EH, et al. The ACCOMPLISH study. A cluster randomized trial on the cost-effectiveness of a multicomponent intervention to improve hand hygiene compliance and reduce healthcare associated infections. BMC Public Health 2011;11:721. 6. Cheng VC, Tai JW, Ho SK, Chan JF, Hung KN, Ho PL, et al. Introduction of an electronic monitoring system for monitoring compliance with moments 1 and 4 of the WHO “My 5 moments for hand hygiene” methodology. BMC Infect Dis 2011;11:151. 7. Mathai AS, George SE, Abraham J. Efficacy of a multimodal intervention strategy in improving hand hygiene compliance in a tertiary level intensive care unit. Indian J Crit Care Med 2011;15:6-15. doi:10.4103/0972-5229.78215. 8. Pincock T, Bernstein P, Warthman S, Holst E. Applied epidemiology in health care settings and the community. Am J Infect Control 2012;40(Suppl):S18-27. doi:10.1016/j.ajic.2012.02.008. 9. Lam BC, Lee J, Lau YL. Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection. Pediatrics 2004;114:e565-71. doi:10.1542/peds.2004-1107. 10. Allegranzi B, Sax H, Bengaly L, Richet H, Minta DK, Chraiti M, et al. Successful implementation of the World Health Organization hand hygiene improvement strategy in a referral hospital in Mali, Africa. Infect Control Hosp Epidemiol 2010;31:133-41. doi:10.1086/649796. 11. Costers M, Viseur N, Catry B, Simon A. Four multifaceted countrywide campaigns to promote hand hygiene in Belgian hospitals between 2005 and 2011: impact on compliance to hand hygiene. Euro Surveill 2012;17. 12. Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Infect Dis 2001;7:234-40. 13. Jang JH, Wu S, Kizner D, Moor C, Tong A, McCreight L, et al. Physicians and hand hygiene practice: a focus group study. J Hosp Infect 2010;76:87-9. doi:10.1016/ j.jhin.2010.04.007. 14. Cantrell D, Shamriz O, Cohen MJ, Stern Z, Block C, Brezis M. Hand hygiene compliance by physicians: marked heterogeneity due to local culture? Am J Infect Control 2009;37:301-5. doi:10.1016/j.ajic.2008.05.001. 15. Saint S, Bartoloni A, Virgili G, Mannelli F, Fumagalli S, Di Martino P, et al. Marked variability in adherence to hand hygiene: a 5-unit observational study in Tuscany. Am J Infect Control 2009;37:306-10. doi:10.1016/j.ajic.2008.08.004. 16. Stevens MP, Hunter JD, Ober JF, Bearman G, Edmond MB. Watching them wash: description of a hand hygiene observation program. Infect Control Hosp Epidemiol 2010;31:198-9. doi:10.1086/650378. 17. Fakhry M, Hanna GB, Anderson O, Holmes A, Nathwani D. Effectiveness of an audible reminder on hand hygiene adherence. Am J Infect Control 2012;40:320-3. doi:10.1016/j.ajic.2011.05.023. 18. White KM, Dudley-Brown S. Translation of evidence into nursing and health care practice. New York (NY): Springer; 2012. 19. McEwen M, Wills EM. Theoretical basis for nursing. 3rd ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2011. 20. Wandel DD, Maes L, Labeau S, Vereecken C, Blot S. Behavioral determinants of hand hygiene compliance in intensive care units. Am J Crit Care 2010;19:230-9. doi:10.4037/ajcc2010892. 21. World Health Organization. WHO highlights importance of good hand hygiene for patient safety. 2012. Available from: www.who.int/entity/mediacentre/ news/notes/2012/hygiene_20120504/en/. Accessed December 9, 2015. 22. Fry DA, Burger TL. Hand hygiene compliance: Step up, reach out. Nurs Manage 2005;40-3.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Major article
Role of a multimodal educational strategy on health care workers’ handwashing Jo Andrea Watson RN, DNP, MSN, CCRN, CPAN * Infection Prevention Department, St. Mary’s Medical Center, Huntington, WV
Key Words: Hand hygiene hand hygiene compliance health care workers’ hand hygiene compliance World Health Organizations’ My 5 Moments for Hand Hygiene methodology
Background: Good hand hygiene is the single most important strategy used to prevent health care– associated infections (HAIs); however, health care workers’ (HCWs’) hand hygiene compliance rates range between 25% and 51%. This study aims to determine if a multimodal strategy using the World Health Organization’s (WHO’s) My 5 Moments for Hand Hygiene methodology increases HCWs’ compliance with handwashing and awareness of the importance of good hand hygiene in the prevention of HAIs. Methods: A quasi-experimental, 1-group pre-post survey design was used to test awareness and knowledge. A simple interrupted time series methodology at baseline and 3 months was used to monitor hand hygiene compliance. Results: Overall, HCWs’ hand hygiene compliance increased from 51.3% to 98.6%, with an odds ratio of 71.10. The pre-post survey demonstrated HCWs were aware and knowledgeable of the importance of good hand hygiene. Eight postsurvey questions focusing on the strategies used to promote hand hygiene demonstrated statistical significance using a 1-sample t test, with P values ranging from .000-.024. Conclusion: A multimodal approach using the WHO’s My 5 Moments for Hand Hygiene does increase HCWs’ hand hygiene compliance and awareness and knowledge of the importance of hand hygiene in the prevention of HAIs. Using this approach can produce a positive social change by reducing preventable disease and decreasing HAIs not only within a facility but also in the community. © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Institutional review board approval no.: Walden University (1015-13-0044855) and Marshall University (501578-2).
INTRODUCTION Health care–associated infections (HAIs) have become a worldwide problem causing infection prevention departments to look for ways to prevent or decrease the occurrence at their facilities. HAIs result in 99,000 deaths each year, with an estimated 2 million people contracting HAIs in the United States.1 HAIs have remained the leading cause of morbidity and mortality. In 2002, nearly 100,000 deaths were associated with 1.7 million HAIs in the United States. A total of 15%-30% of HAIs have impacted up to 10% of hospitalized patients and are considered preventable through improved hand hygiene.2 Health care administrators are concerned with the increase in HAIs because the Centers for Medicare and Medicaid
* Address correspondence to Jo Andrea Watson, RN, DNP, MSN, CCRN, CPAN, 44 Hickory Dr, Barboursville, WV 25504. E-mail address: [email protected] (J.A. Watson). Conflicts of interest: None to report.
Services will no longer reimburse hospitals for certain HAIs.1 Sax et al3 state adherence to good hand hygiene practices is the single most important strategy to use to prevent HAIs. Despite facilities stressing the importance of performing good hand hygiene to prevent disease and infection, hand hygiene compliance rates among health care workers (HCWs) remain low.2 Alemangno et al4 state HCWs’ hand hygiene compliance rates are usually 30%-60%, but they seldom exceed 50%, despite facilities’ attempts to maintain good infection control practices. Many strategies have been used to help improve hand hygiene compliance among HCWs, with education and training being the main strategies. These strategies have not been successful in producing a maintainable improvement. Grol and Grimshaw (as cited in Erasmus et al, 2011) concluded hand hygiene requires a comprehensive plan, targeting different problems and barriers to change with strategies at different levels to achieve sustainable changes in hand hygiene routines.5 In 2005, the World Health Organization (WHO) initiated the First Global Patient Safety Challenge. The WHO aimed to improve patient safety by promoting hand hygiene in health care facilities using a multimodal strategy using alcohol-based handrubs at the points of care with this challenge.6 The WHO introduced the My 5 Moments for Hand Hygiene strategy, designating specific moments when hand
0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.10.030
J.A. Watson / American Journal of Infection Control 44 (2016) 400-4
hygiene is required to effectively interrupt microbial transmission during the normal care of patients.7 Along with the introduction of the hand hygiene strategy, the WHO introduced a standardized tool for monitoring hand hygiene compliance based on the My 5 Moments for Hand Hygiene that has been successful in monitoring hand hygiene compliance among HCWs worldwide.3 Low compliance of handwashing in HCWs leads to HAI from disease transmission and results in preventable illness and death in HCWs and patients. Single interventions have not demonstrated sustained improvement in hand hygiene compliance among HCWs. A multimodal approach using the WHO’s My 5 Moments for Hand Hygiene may be more effective in improving hand hygiene compliance among HCWs than single intervention approaches. Applying a multimodal approach involves use of multiple strategies simultaneously. Leaders in the field have suggested singular interventions are insufficient to sustain behavioral change. Adopting a multimodal approach to improve hand hygiene is vital to achieving a reduction in HAIs.8 Further scholarship is needed to determine if combining these 2 approaches (multimodal and WHO) for handwashing can significantly improve HCWs’ handwashing compliance. Literature review According to Pincock et al,8 adopting a multimodal approach to improve hand hygiene is vital to achieving a reduction in HAIs. Two key factors have limited the adoption of a multimodal approach for hand hygiene. First, most hand hygiene studies emphasize the efficacy of singular interventions. Second, many of the studies have emphasized the methods for monitoring and recording hand hygiene compliance, not sustainability. Many studies using a multimodal approach have demonstrated an overall improvement in hand hygiene compliance. Mathai et al7 used a multimodal interventional strategy in a mixed medical-surgical intensive care unit with significant overall improvement in hand hygiene compliance among HCWs (26% to 57.36% after the intervention). Lam et al9 used a multimodal approach in a neonatal intensive care unit to improve overall hand hygiene compliance and impact nosocomial infections. The overall hand hygiene compliance increased from 40% to 53% before patient contact and 39% to 59% after patient contact. The study also showed a marked improvement in hand hygiene compliance during highrisk procedures, from 35% to 60%. Carboneau et al1 identified education, culture, and environment as the 3 main areas needing to be addressed to improve hand hygiene compliance. The study used a 6-sigma improvement methodology to address the issues. Hand hygiene compliance rates increased 20%, with a 51% decrease in methicillin-resistant Staphylococcus aureus cases noted over a 12month period after interventions addressing the 3 areas were implemented. Allegranzi et al10 also found the use of a multimodal interventional approach significantly improved hand hygiene compliance from 8% at baseline to 21.8% at follow-up (P < .001). An important conclusion to this study was the importance of having handrub easily available for staff to perform hand hygiene. Studies have shown a multimodal approach can have a positive long-term outcome. Four consecutive, multimodal 1-month campaigns were conducted to promote hand hygiene in Belgian hospitals between 2005 and 2011. Posters, educational sessions, promotion of alcohol-based handrub use, increasing patient awareness, and audits with performance feedback were the interventions used. Compliance with hand hygiene significantly increased from 49.6% to 68.6% during the first campaign, from 53.2% to 69.5% for the second campaign, from 58.0% to 69.1% for the third campaign, and from 62.3% to 72.9% for the fourth campaign. This study also noted physician compliance was markedly lower than nurses, and compliance rates were higher after patient contact and body fluid exposure risk than before patient contact and before performing aseptic procedures.11
401
The literature reports poor hand hygiene compliance may be the result of several barriers. The most common reasons HCWs report for lack of adherence to hand hygiene recommendations are skin irritation, inaccessible supplies, interference with worker-patient relations, patient needs perceived as priority, wearing gloves, forgetfulness, ignorance of guidelines, insufficient time, high workload, understaffing, and lack of scientific information demonstrating improved compliance decreases HAIs.12 In a qualitative study based on 17 focus groups, 4 themes emerged from the analyses. The themes were adherence to guidelines is compromised by HCW knowledge and beliefs, hand hygiene is practiced for personal protection, the external environment influences hand hygiene behavior, and professional responsibility. The study identified many reasons why hand hygiene practice was suboptimal despite the adoption of the WHO’s new accreditation guidelines and provincial strategy for hand hygiene. Many HCWs stated current guidelines for hand hygiene were unrealistic. Physicians stated the evidence was not sufficient to support the hand hygiene guidelines. Other HCWs stated current workload and patient needs often came before hand hygiene. Participants cited personal safety as the primary reason for hand hygiene practices, especially after patient contact rather than before patient contact. Participant’s also stated cited adherence by other HCWs, especially physicians, influenced their own attitudes and practices.13 A very important finding from the study by Jang et al13 was other HCWs considered their role models to be physicians. This was a significant finding when studies have shown physicians to have the lowest hand hygiene compliance rates compared with other HCWs.14-17 Conceptual models and theoretical frameworks Bandura’s social cognitive theory served as the foundation to address the problem of hand hygiene compliance among HCWs. The purpose of the theory is to understand and predict individual and group behaviors, identify methods where behavior can be modified or changed, and test interventions aimed at personality development, behavior pathology, and health promotion. The theory states individuals learn by direct experiences, human dialogue and interaction, and observation.18 The theory stresses the importance of an individual being actively involved with the environment and how people actively select their own role models and regulate their own attitudes and actions regarding learning. An important concept of Bandura’s theory is self-efficacy. Self-efficacy promotes learning and productive human function.19 Behavioral determinants, such as attitude, social influence, and self-efficacy, play a large role in hand hygiene compliance among HCWs.20 Bandura’s social cognitive theory was ideal for this hand hygiene study and target population because the theory deals with behavioral modification and how individuals decide to act and learn. The HCWs’ behavioral issues and beliefs associated with hand hygiene can affect hand hygiene compliance and how the individual accepts behavioral modification strategies. Awareness of the effects of poor hand hygiene in contributing to HAIs may help to produce effective and sustained behavior changes (self-efficacy), leading to good hand hygiene compliance.7 Purpose statement and project objectives The purpose of this study was to determine the extent to which a multimodal strategy for teaching and promoting hand hygiene increases HCWs’ compliance with handwashing. If a multimodal intervention strategy for hand hygiene improved hand hygiene compliance among HCWs, it may offer a sustainable program for maintaining compliance. Research has shown good hand hygiene prevents infection, but there is limited research available
402
J.A. Watson / American Journal of Infection Control 44 (2016) 400-4
demonstrating the use of a multimodal approach to sustain hand hygiene compliance among HCWs. The study’s goal was to use a multimodal approach using the WHO My 5 Moments for Hand Hygiene methodology to increase HCWs’ hand hygiene compliance. The WHO’s standardized tool to measure hand hygiene compliance was used to measure hand hygiene compliance. The objective of this study was to increase HCWs’ knowledge and awareness and perception of the importance of good hand hygiene and HCWs’ compliance with hand hygiene practices using a multimodal approach using the WHO’s My 5 Moments for Hand Hygiene. It was hoped making sure all staff members were aware of the impact hand hygiene plays in preventing or spreading infection to patients and others would help increase the hand hygiene compliance rate among all staff members. Research questions The first research question is as follows: Is there a significant difference in hand hygiene compliance rates among the pre–multimodal strategy intervention program to post–multimodal strategy intervention program, which includes the WHO’s My 5 Moments for Hand Hygiene? The second question is as follows: Is there a significant difference in knowledge and awareness of the importance of good hand hygiene from the pre–multimodal strategy intervention program to the post–multimodal strategy intervention program, which includes the WHO My 5 Moments for Hand Hygiene among HCWs? Location of study The study was conducted in a 393-bed, nonprofit, medical center located in West Virginia. The medical center is a teaching facility associated with a school of nursing, medical imaging, and respiratory and a university, which has a medical school, school of pharmacy, and school of physical therapy. The medical center is a level II trauma center and is a regional neuroscience, cancer, and heart center, and it serves a tristate area, including Ohio and Kentucky.
included the same questions as the initial survey, with additional questions to obtain HCWs’ opinion of the strategies and tools (multimodal intervention) used to promote hand hygiene in the organization. A baseline hand hygiene compliance observation was performed prior to the implementation of the multimodal strategies. A postintervention hand hygiene compliance observation was performed during the 12th week of the study. Hand hygiene observations used the WHO’s hand hygiene measurement tool. Therefore, a quantitative design was used to address the research question. The researcher and the infection prevention coordinator were trained and validated as hand hygiene observers using the WHO My 5 Moments for Hand Hygiene methodology. Hand hygiene observations count the number of observed moments requiring hand hygiene, which are referred to as opportunities. During an observation period, each opportunity is counted as met or missed. Hand hygiene compliance is determined by using the number of opportunities met compared with the total number of opportunities observed.3 A simple interrupted time series methodology at baseline and 3 months was used to monitor hand hygiene compliance. To determine whether hand hygiene compliance among the trial units were statistically significant, an odds ratio was performed using MedCalc 12.3 software system (MedCalc Software, Ostend, Belgium). SPSS software (SPSS, Chicago, IL) was used to perform Wilcoxon signed-rank tests along with mean, SD, and paired-samples t test for the Perception Survey and the same questions on the FollowUp Perception Survey. The hand hygiene study was based on the WHO’s My 5 Moments for Hand Hygiene methodology using the standardized measurement tool for hand hygiene observation and spreadsheet to collect data on hand hygiene compliance. The recommended indications for hand hygiene using the methodology identify specific points or moments during patient care when hand hygiene should be performed. Measures
Population and sampling The target population was HCWs with direct contact with patients. One intensive care unit, 1 specialty unit (pulmonary), and 1 medical-surgical unit were selected as the trial units. All staff members of the trial units were invited to participate in the study. Float and respiratory therapy staff were also invited to participate. The hospitalist group was invited to participate in the study because they were medical center employees and care for patients throughout the medical center. Participants had to be able to give informed consent, participate in the program by viewing the educational materials and video, complete surveys and demographic questionnaires, be willing to be observed, and have handwashing behaviors assessed. Staff members were excluded if they had characteristics or conditions that could provide difficulties or biases to the study, such as being on leave of absence during a portion of the study or transferring to a different department not included in the study during the time frame of the study. Study design and methods The study was conducted using a quasi-experimental, 1-group pre–awareness and perception survey and follow-up awareness and perception survey design to test awareness and knowledge. The awareness and perception survey contained questions to obtain HCWs’ opinion on HAIs and hand hygiene and HCWs’ awareness and knowledge of the importance of hand hygiene in the prevention of HAIs. The follow-up awareness and perception survey
Variables affecting hand hygiene compliance were measured to determine whether a multimodal approach using the WHO’s methodology increased HCWs’ hand hygiene compliance. The WHO’s educational tools for training, posters, and hand hygiene observation compliance forms were used. All of the WHO’s tools used for this study, which were downloaded from the WHO’s Web site, have been tested and validated by experts in the field, with many being used in previous studies.21 Procedure After consent was obtained, a baseline hand hygiene observation was performed prior to the educational module being placed in the participant’s computer classroom. Once the participants completed the educational module, and posters and brochures were placed in strategic locations on the trial units, the researcher made frequent rounds to answer questions related to the My 5 Moments for Hand Hygiene and to discuss hand hygiene compliance. Throughout the study, random hand hygiene compliance observations were conducted by the infection prevention coordinator and researcher to provide immediate feedback about the participant’s performance and show the participant the cleanliness of their hands under an ultraviolet light using Glo Germ (Glo Germ Co, Moab, UT). During week 10, the participants completed the Follow-Up Perception Survey. During week 12, the infection prevention coordinator and researcher performed the final hand hygiene observations, which were used to calculate the HCWs’ hand hygiene compliance for the
J.A. Watson / American Journal of Infection Control 44 (2016) 400-4
403
individual units and the overall hand hygiene compliance for the trial. Data analysis The WHO’s My 5 Moments for Hand Hygiene standardized measurement tool was used. All tests were assessed with a significance level of .05. Preliminary analysis started with characterization of the study sample at baseline. Descriptive statistics was calculated. Sums and percentages were used for nominal and ordinal level data. Mean, sums, and range were used for interval- and ratio-level data. Data obtained during the hand hygiene observations was entered into the spreadsheet, and hand hygiene compliance was calculated by the number of opportunities met compared with the total number of opportunities observed. Differences between pre- to postobservation compliance rates were analyzed using a 2-sample paired t test. Pre- and posttests of knowledge were analyzed using paired t tests or Wilcoxon signed-rank tests depending on the level of data and sample size. RESULTS The overall hand hygiene compliance rate for the study increased from 51.3% to 98.6%. Table 1 demonstrates the results of the odds ratio for overall hand hygiene observation. The mean and SD tests demonstrated HCWs understand the importance of hand hygiene, especially in the prevention of HAIs. The paired-sample t test demonstrated statistical significance for the following questions: (1) what is the average percentage of hospitalized patients who will develop an HAI (P = .003)?; and (2) on average, what percentage of situations requiring hand hygiene does HCWs in your hospital perform hand hygiene (P = .012)? A 1-sample t test was calculated for the 8 additional questions on the Follow-Up Perception Survey for HCWs. The results demonstrated HCWs felt the multimodal interventions helped to increase their awareness and knowledge of the importance hand hygiene compliance plays in the prevention of HAIs. The researcher was interested in knowing how individual professional categories performed pre– and post–hand hygiene intervention. The professional categories included registered nurses (RNs), medical doctors (MDs), and all other professions (others). Pre– hand hygiene intervention observation demonstrated the others group had the highest hand hygiene percentage of the overall opportunities observed (64%), followed by RNs (49%) and MDs (38%). Post–hand hygiene intervention observation demonstrated the others group performed hand hygiene in 100% of the opportunities observed, followed by RNs (99%) and MDs (97%). Figure 1 demonstrates these findings. An odds ratio was calculated to determine if the results for the professional categories were statistically significant by the statis-
Table 1 Odds ratio: overall hand hygiene observations Observed cases Cases with positive outcome First group, n Second group, n Cases with negative outcome First group, n Second group, n Results Odds ratio 95% confidence interval z Statistic Significance level, P
Value 150 77 2 73 71.1039 16.9919-297.5402 5.839 <.0001
Fig 1. Pre– and post–hand hygiene observation percentage by profession. Abbreviations: PostHHObs, post–hand hygiene observation; PreHHObs, pre–hand hygiene observation.
tical test used. The RN and MD categories were statistically significant (P < .0001 and P = .0008, respectively). The others category was not statistically significant (P = .08). The others category had a small number of participants, which may be the reason for the results. The odds ratio does demonstrate the multimodal approach using the WHO’s My 5 Moments for Hand Hygiene did significantly increase HCWs’ hand hygiene compliance rates. Discussion of findings in the context of the literature According to the literature, HCWs’ hand hygiene compliance rates range between 25% to 51%, even when HCWs state they perform hand hygiene when they should.22 The baseline (preintervention) hand hygiene compliance rate for the study was 51.3%. This was consistent with the literature. Multiple studies have demonstrated an increase in hand hygiene compliance rates after a multimodal approach was used, as occurred in this study, with the hand hygiene compliance rate increasing from 51.3% to 98.6%. A study by Carboneau et al1 saw a hand hygiene compliance rate increase of 20% over a 12month period when interventions were used addressing education, culture, and environment. A multimodal approach to improve hand hygiene compliance rates in an intensive care unit using a selfreport questionnaire and interventions, including education, posters, verbal reminders, and easy availability of products for hand hygiene, demonstrated a hand hygiene increase from 26% to 57.36%.7 This study did not focus on hand hygiene performance by professions; however, the researcher was able to demonstrate a difference pre– and post–hand hygiene observations between professions. The highest performing group both pre- and postintervention was the others category (from 64% to 100%). RNs were second (from 49% to 99%), whereas physicians were the lowest performers (from 38% to 97%). This is consistent with the literature. A study conducted in 2004 by the Tuscany Regional Health Authority stated hand hygiene compliance rates among physicians improved from 21% to 27% and for nurses improved from 32%
404
J.A. Watson / American Journal of Infection Control 44 (2016) 400-4
to 64%.15 Fakhry et al17 conducted a study using an electronic motion sensor–triggered device, with an audible reminder installed at unit entrances to measure staff and visitor hand hygiene compliance, and found nonclinical staff hand hygiene increased from 5.3% to 34.8% (P < .001), physician adherence increased from 4.5% to 38.3%, and nurse adherence increased from 5.4% to 43.4%. Alemangno et al4 conducted a study using an online educational program to increase participants’ knowledge and awareness of the importance of hand hygiene in the reduction of HAIs. The participants completed a pre- and postsurvey, which demonstrated increase awareness of the importance of hand hygiene and the effect of hand hygiene on HAIs. The results of this study indicated the HCWs believed the program was effective in providing an increase in knowledge and awareness of the importance of hand hygiene.
Implications This research study was conducted as a trial to see if the WHO’s My 5 Moments for Hand Hygiene methodology would improve hand hygiene compliance on the trial units. Because this study demonstrated a significant increase in hand hygiene compliance on the trial units, the methodology may produce similar results house-wide. This may help reduce the number of HAIs and improve patient outcomes.
Project strengths and limitations The main strength of the study was the educational material, which had been developed and validated by the WHO for use with the My 5 Moments for Hand Hygiene. Other strengths included obtaining the support of senior administration, the infection prevention department, and clinical managers of the trial units. The infection prevention department allocated time and a staff member to assist with data collection, which provided consistency during hand hygiene observations. Limitations of the study included 66 participants enrolling in the study; however, only 46 participants completed the follow-up survey. The reasons for participants not completing the survey included sudden medical leave, change in job positions, and termination. The surveys provided limitations when trying to compile the data. The time of year the study was held may have been a limitation. The study began in early December and concluded at the end of February. The post–hand hygiene observations occurred during high influenza season. It is possible that the result of increased compliance was because of staff being more vigilant about hand hygiene because of the increase in influenza cases. For future studies, the researcher recommends providing the educational module in a classroom setting or on the computer. The classroom setting would allow staff without easy access to computers or with reading comprehension challenges to be able to participant in the study. Developing a Likert scale for each question on the surveys would also assist with data analysis. Other
limitations seen in this study were things the researcher or other researchers would not be able to avoid. References 1. Carboneau C, Benge E, Jaco MT, Robinson M. A lean six sigma team increases hand hygiene compliance and reduces hospital-acquired MRSA infections by 51%. J Healthc Qual 2010;32:61-70. doi:10.1111/j.1945-1474.2009.00074.x. 2. Wilson S, Jacob CJ, Powell D. Behavior-change interventions to improve handhygiene practice: a review of alternatives to education. Crit Public Health 2011;21:119-27. doi:10.1080/09581591009786122. 3. Sax H, Allegrani B, Chraiti M, Boyce J, Larson E, Pittet D. The World Health Organization hand hygiene observation method. Am J Infect Control 2009;37:827-34. doi:10.1016/j.ajic.2009.07.003. 4. Alemangno SA, Guten SM, Warthman S, Youn E, Mackay DS. Online learning to improve hand hygiene knowledge and compliance among health care workers. J Contin Educ Nurs 2010;41:463-71. doi:10.3928/00220124-20100610-06. 5. Erasmus V, Huis A, Oenema A, Van Empelen P, Boog MC, Van Beeck EH, et al. The ACCOMPLISH study. A cluster randomized trial on the cost-effectiveness of a multicomponent intervention to improve hand hygiene compliance and reduce healthcare associated infections. BMC Public Health 2011;11:721. 6. Cheng VC, Tai JW, Ho SK, Chan JF, Hung KN, Ho PL, et al. Introduction of an electronic monitoring system for monitoring compliance with moments 1 and 4 of the WHO “My 5 moments for hand hygiene” methodology. BMC Infect Dis 2011;11:151. 7. Mathai AS, George SE, Abraham J. Efficacy of a multimodal intervention strategy in improving hand hygiene compliance in a tertiary level intensive care unit. Indian J Crit Care Med 2011;15:6-15. doi:10.4103/0972-5229.78215. 8. Pincock T, Bernstein P, Warthman S, Holst E. Applied epidemiology in health care settings and the community. Am J Infect Control 2012;40(Suppl):S18-27. doi:10.1016/j.ajic.2012.02.008. 9. Lam BC, Lee J, Lau YL. Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection. Pediatrics 2004;114:e565-71. doi:10.1542/peds.2004-1107. 10. Allegranzi B, Sax H, Bengaly L, Richet H, Minta DK, Chraiti M, et al. Successful implementation of the World Health Organization hand hygiene improvement strategy in a referral hospital in Mali, Africa. Infect Control Hosp Epidemiol 2010;31:133-41. doi:10.1086/649796. 11. Costers M, Viseur N, Catry B, Simon A. Four multifaceted countrywide campaigns to promote hand hygiene in Belgian hospitals between 2005 and 2011: impact on compliance to hand hygiene. Euro Surveill 2012;17. 12. Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Infect Dis 2001;7:234-40. 13. Jang JH, Wu S, Kizner D, Moor C, Tong A, McCreight L, et al. Physicians and hand hygiene practice: a focus group study. J Hosp Infect 2010;76:87-9. doi:10.1016/ j.jhin.2010.04.007. 14. Cantrell D, Shamriz O, Cohen MJ, Stern Z, Block C, Brezis M. Hand hygiene compliance by physicians: marked heterogeneity due to local culture? Am J Infect Control 2009;37:301-5. doi:10.1016/j.ajic.2008.05.001. 15. Saint S, Bartoloni A, Virgili G, Mannelli F, Fumagalli S, Di Martino P, et al. Marked variability in adherence to hand hygiene: a 5-unit observational study in Tuscany. Am J Infect Control 2009;37:306-10. doi:10.1016/j.ajic.2008.08.004. 16. Stevens MP, Hunter JD, Ober JF, Bearman G, Edmond MB. Watching them wash: description of a hand hygiene observation program. Infect Control Hosp Epidemiol 2010;31:198-9. doi:10.1086/650378. 17. Fakhry M, Hanna GB, Anderson O, Holmes A, Nathwani D. Effectiveness of an audible reminder on hand hygiene adherence. Am J Infect Control 2012;40:320-3. doi:10.1016/j.ajic.2011.05.023. 18. White KM, Dudley-Brown S. Translation of evidence into nursing and health care practice. New York (NY): Springer; 2012. 19. McEwen M, Wills EM. Theoretical basis for nursing. 3rd ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2011. 20. Wandel DD, Maes L, Labeau S, Vereecken C, Blot S. Behavioral determinants of hand hygiene compliance in intensive care units. Am J Crit Care 2010;19:230-9. doi:10.4037/ajcc2010892. 21. World Health Organization. WHO highlights importance of good hand hygiene for patient safety. 2012. Available from: www.who.int/entity/mediacentre/ news/notes/2012/hygiene_20120504/en/. Accessed December 9, 2015. 22. Fry DA, Burger TL. Hand hygiene compliance: Step up, reach out. Nurs Manage 2005;40-3.