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The search for an evidence-based intervention to improve hand hygiene compliance in a residential aged care facility
CSIRO PUBLISHING
Healthcare Infection, 2013, 18, 156–161 http://dx.doi.org/10.1071/HI13021
The search for an evidence-based intervention to improve hand hygiene compliance in a residential aged care facility Gail Abernethy1,4 BHealth, PGDPHTM, GCHSt Wendy Smyth2,3 MAppSc, MBus, PhD 1
Queensland Health, Herberton Hospital, Herberton, Qld 4887, Australia. Tropical Health Research Unit for Nursing and Midwifery Practice, Townsville Hospital and Health Service, Townsville, Qld 4814, Australia. 3 School of Nursing, Midwifery and Nutrition, James Cook University, Townsville, Qld 4811, Australia. 4 Corresponding author. Email: [email protected] 2
Abstract. Introduction: Healthcare-acquired infections are a major source of morbidity and mortality in people living in residential aged care facilities. Compliance with hand hygiene by healthcare workers can reduce the risk of infection to residents, yet compliance rates are generally low. Infection-control advocates within the aged care sector are looking to conduct programs to improve rates among their staff. This review was conducted to identify a reproducible intervention to improve staff hand hygiene compliance within an Australian residential aged care facility. Method: Medline, Embase, and CINAHL databases were searched for combinations of ‘hand hygiene’, ‘hand washing’, ‘residential aged care facility’, ‘aged care’, ‘nursing home’ and ‘long-term care facility’ from 2000 to current. Articles were excluded if the information was not clearly stated as pertaining to a residential aged care facility or if the data investigated staff knowledge or perceptions of hand hygiene. Results: Most of the five articles included in the review reported an improvement in compliance rates. Studies were multimodal, had an education or training component, and included the promotion of alcohol-based hand rubs. Several used aspects of the World Health Organization’s hand hygiene initiatives. Compliance audit tools across the studies were not consistent; thus, results may not be comparable. Conclusion: There are few published studies which report interventions that improve hand hygiene compliance among healthcare workers within residential aged care facilities. Successful studies included the promotion of alcoholbased hand rubs. More research is needed to improve hand hygiene compliance in the aged care sector. Received 5 July 2013, accepted 20 August 2013, published online 17 September 2013
Introduction Healthcare-acquired infection is a major cause of morbidity and mortality for people living in residential aged care facilities (RACF). RACF, which can also be termed nursing homes or long-term care facilities, provide nursing and/or personal care, accommodation, and related services to older people unable to care for themselves in their own homes. To receive government funding or gain approval to operate, RACF must meet certain standards of care which include infection prevention and control.1–3 The elderly are at increased risk of infection due to ageassociated immune changes, multiple co-morbidities, and impaired functional status.4,5 Residents of aged care facilities may also have invasive devices such as enteral feeding tubes or tracheostomies for their care, further increasing their risk of infection.3 By providing a home-like environment with shared facilities and common sources of air, food and water, the RACF may itself contribute to the transmission of infection among residents.6,7
It has been reported that 25% of all acute hospital admissions from nursing homes can be attributed to infection.8 Studies report the prevalence of infection in RACF ranges from 2.2% to 6.0%.5,9,10 Overall incidence rates are stated as 2.20 to 4.16 episodes per 1000 resident-care bed days.11–13 The number of elderly requiring residential care may be impacted by the trend across health sectors towards rapid discharge from acute facilities to non-acute facilities.4,6 A shorter length of stay in hospital will reduce the cost to, and burden on, the acute hospital sector but the patient may subsequently require admission to a RACF for nursing care. Compliance with hand hygiene by staff in RACF can contribute to effective infection prevention and control.14 Hand hygiene by healthcare personnel is regarded as one pillar of any infection prevention and control program. Studies suggest that staff compliance with hand hygiene is generally poor across all healthcare settings15 and that compliance rates among healthcare workers (HCW) in the aged care sector range from 9.3% to 54.0%.6,16 In an attempt
Journal compilation Ó Australasian College for Infection Prevention and Control 2013
www.publish.csiro.au/journals/hi
Improving hand hygiene compliance in aged care
Implications *
*
*
There are limited data from the residential aged care sector relating to interventions to improve hand hygiene compliance Interventions should be multifaceted, address local needs and include use of alcohol-based hand rubs Hand hygiene compliance audit tools may need refinement to be applicable for the residential agedcare environment
to reduce healthcare-acquired infections, the World Health Organisation (WHO) initiated the global ‘Clean Care is Safer Care’ campaign in 2005 as a means to promote hand hygiene. The National Hand Hygiene Initiative (NHHI) was instigated by the Australian Commission on Safety and Quality in Health Care in 2009 to improve hand hygiene compliance among staff in Australian hospitals. This hand hygiene culturechange program includes the appropriate use of alcohol-based hand rubs (ABHR), and hand hygiene education, whilst monitoring hand hygiene compliance and patient infection rates.17 Australian acute healthcare facilities need to be able to demonstrate how they meet the national standards for safety and quality in healthcare when they undergo accreditation. Standard 3 requires the implementation of a governance structure and systems for preventing and controlling healthcare-associated infections. The subsequent monitoring of compliance with national hand hygiene guidelines, and taking corrective action to address identified deficiencies falls within this Standard.18 To satisfy the Aged Care Act 1997, RACF in Australia must comply with the accreditation standards, as assessed by the Aged Care Standards and Accreditation Agency Ltd, which include an effective infection-control program.11 The guidelines for aged care facilities in relation to hand hygiene, at least in Australia, are not as prescriptive as those for acute healthcare facilities. Rather, they have a set of broad principles, which include the need to balance the provision of a safe environment with the residents’ quality of life.19 The Australian Guidelines for the Prevention and Control of Infection in Healthcare were released in 2010 and provide information for healthcare providers, including RACF, to develop infection-control protocols appropriate to their service. Geary et al.20 found 97% of the participant Australian long-term care facilities had an infection-control program in place by 2000 which suggests the industry has prioritised this area for resource allocation. Much work has been undertaken within the acute care sector regarding hand hygiene compliance and education programs.15,21–25 A Cochrane Review found only four studies, all of which were undertaken in an acute care setting, assessing the success of programs to improve hand hygiene compliance.15 The interventions, including hand hygiene product substitution and multimodal campaigns, had varying success at increasing hand hygiene compliance rates. Social
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marketing or interventions with staff involvement appeared effective but the authors suggest there was not enough evidence to be conclusive. In another systematic review, Huis and colleagues26 examined the determinants of behaviour change in hand hygiene improvement strategies in the acute care sector. In the 41 studies matching their criteria, they found certain combinations of determinants within an intervention, such as social influence, attitude, self-efficacy and addressing existing local barriers were necessary to improve compliance. From these two systematic reviews, it appears that interventions to improve hand hygiene compliance must be evidence-based and sustainable. Hand hygiene compliance is as important to the health of staff and residents of the RACF as it is in the acute care setting. Hand hygiene compliance can reduce the risk of healthcare-acquired infection to both residents and staff. This review was conducted to search the literature for a reproducible intervention to improve HCW hand hygiene compliance within an Australian RACF. Method Studies, published from 1 January 2000 to 22 March 2013 were identified through searching the Medline, Embase, and CINAHL databases. The search strategy included all English-language articles with the headings (‘intervention$’ or ‘effect$’ or ‘randomised controlled trial’ or ‘experiment$’ or ‘compar$’ or ‘evaluat$’) and (‘handwashing’ or ‘hand washing’ or ‘hand hygiene’). These were then combined with the terms (‘aged care’ or ‘nursing home’ or ‘residential aged care facility’ or ‘long-term care facilit$’), to retrieve n = 307 titles, including duplicates. The abstracts were inspected, and the full article retrieved where found relevant. Additional articles were also identified using cited-reference searching. All studies that involved interventions to improve healthcare worker compliance with hand hygiene in RACF were included in the review. Studies that reported only knowledge and attitudes to hand hygiene or healthcare-acquired infection rates were excluded. Studies with both acute and non-acute care site data were included if the RACF data were clearly identified. Results Five relevant papers specific to RACF were identified and are summarised in Table 1.16,27–30 Within these five studies, a variety of interventions to improve healthcare worker hand hygiene compliance were reported. Studies that reported healthcare-acquired infection rates following an intervention but not hand hygiene compliance were excluded from this review.31,32 Some studies included RACF and acute care hospital sites including rehabilitation, but the data pertaining to the RACF were not clearly identified and thus were also excluded from this review.6,33–35 The use of an alcohol-based hand rub (ABHR), either as a new product to the facility, providing pocket-sized products to staff or increasing availability of an existing product, was a component of four studies,16,27,29,30, while the fifth study
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Table 1. Summary of articles included in literature review Sample of healthcare workers (n)
Length of study
Location
Intervention
Control alternative
Compliance measure
Compliance improvement
Comments
Mody et al.42
Prospective intervention
32
1 year
USA
Inservice; poster displays; personal AHBR provided; facility AHBR provided
Inservice; poster displays
Self-report (Handwashing Practices Inventory)
Yes
Huang and Wu43
Prospective intervention
40
3 months
Taiwan
No comparison group
Direct observation (each participant observed for 30 min during one 8 h shift, pre- and postintervention)
Yes
Yeung et al.44
Cluster randomised control
188
7 months
Hong Kong
Basic life support education
Direct observation; 3300 hand hygiene opportunities observed
Yes
Compliance tool based on WHO guidelines
Kacelnik et al.45
Prospective intervention
Not stated
Not stated
Norway
Hand hygiene education; hands on training; increased AHBR availability; reminders (posters and verbal); feedback Personal AHBR provided; poster displays; free pens; hand hygiene education National campaign; advertising agency; internet resources; focus groups; hand hygiene education
No increase after education alone but did increase after introduction of ABHR; small sample; randomised groups by coin toss Small sample; locally developed compliance audit tool
No comparison group
Sales of ABHR product
Not measured directly
Ho et al.46
Cluster randomised control
810
4 months
Hong Kong
WHO multimodal strategy; personal ABHR provided; facility ABHR provided; education (including hand hygiene indications and techniques); measure skin moisture; hand inspection light cabinet; posters; feedback
Education (not including hand hygiene indications and techniques)
Direct observation (WHO 5 Moments); 11 669 hand hygiene opportunities observed
Yes
Compliance indicated by increased volume of ABHR stock purchased by study sites; 27% participation rate of nursing homes nationally; poor response rate of participants at follow up; staff numbers not reported Potential study site selection bias
G. Abernethy and W. Smyth
Design
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Reference
Improving hand hygiene compliance in aged care
made no changes to existing use or availability of ABHR in the study sites.28 In the United States of America, Mody29 found no change in self-reported compliance following education and reminder material (posters) but the introduction of an ABHR did improve compliance when compared with the control. A Hong Kong study reported that the introduction of a personal ABHR with education and reminder material (posters and pens) improved compliance when compared with the control group.30 The authors of this study found compliance also improved in the control group which received hand hygiene education whilst using soap and water to wash hands. Differences in the baseline characteristics of the intervention and control facilities and a high staff turnover during this study may have affected the results. Of the intervention arm, 43% of the staff left employment, and new employees were given feedback sessions rather than the full intervention. Increased availability of ABHR together with education, hands-on training, and reminder material (posters and feedback) significantly improved hand hygiene compliance in a small sample of nursing assistants over a 3-month period in a Taiwanese nursing home.16 In a study conducted in care and attention homes in Hong Kong that were already using ABHR, Ho et al.27 provided additional personal ABHR and instigated a WHO multimodal promotion strategy. This strategy included education, reminder material (posters, feedback), skin moisture level monitoring and hand inspection using fluorescent dye compared with generic health promotion education. The two intervention groups were also provided with slightly powdered or powderless gloves. Particular homes were invited to participate in this study due to the perceived positive attitudes of their management to government initiatives which may have influenced the outcome of the study. Hand hygiene compliance was measured at baseline, 1 and 4 months, showing an improvement in compliance within the intervention groups (from 27% to 60.6% and 22.2% to 48.6%).22 All five studies included in this review incorporated some form of staff education or training. Nursing assistants with more than 12 years of schooling were more likely to improve their knowledge regarding hand hygiene than those with less schooling in one study with a multicultural workforce.16 This may reflect that the educational portion of the intervention was not specifically designed for the audience level of understanding. Education alone made no difference to hand hygiene compliance in another study.29 A national campaign across Norway (Ren Omsorg: ‘Pure Care’), that reported nursing home (RACF) data separately from acute care data, used internet and hand hygiene education resources for local use as intervention strategies. Of the 240 Norwegian nursing homes that participated in the baseline data collection, only 45 returned evaluation data. The study demonstrated an increase in the usage of existing facility-wide ABHR28, thus suggesting increased compliance, however the poor response rate may limit the reliability of the results.
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Since the studies used different techniques (self-report, direct observation and product usage) to assess hand hygiene compliance, the results of the individual studies are not directly comparable. In the study using participants’ selfreports, HCW were asked to nominate the number of times within the previous hour they had washed their hands at baseline, following the 3-week education intervention and 12 weeks after the introduction of the ABHR.29 The WHO audit tool was used in one study27; another used the WHO audit to guide their audit, but the actual tool utilised was not clearly articulated in the report.30 Hand hygiene compliance was observed by a trained research assistant using a locallydeveloped tool in the Taiwanese study.16 As already mentioned, the Norwegian study used product usage data from the supplier to monitor hand hygiene compliance.28 Discussion Our search yielded very few published articles describing interventions that improved hand hygiene compliance among HCW employed in RACF. The retrieved studies are drawn from the international literature due to the paucity of published Australian work on the topic. As the studies originate from Asia, Australia, Europe and North America, there will be differences in the type of facility and the level of care across the differing health systems described in the studies. There may also be variety in the skill level and training of HCW not clearly described in the retrieved literature between nations. However, we believe that compliance with hand hygiene is imperative for all those who provide care. Given that hand hygiene is recognised as a pivotal component of infection prevention and control worldwide, we feel that some reference to the international literature is appropriate. All studies used multimodal interventions, with one guided by the WHO strategy: ‘Clean Care is Safer Care’.27 Studies utilised combinations of ABHR use, education, hands-on training, social marketing, reminder materials (such as posters and pens) and performance feedback (Table 1). Multimodal strategies appear to have more effect on improving compliance than single interventions.15 One study looked at compliance following education only and found no change in self-reported compliance.29 The multimodal National Hand Hygiene Initiative (NHHI), based on the WHO ‘5 Moments for Hand Hygiene’ strategy, was shown to increase hand hygiene compliance in Australian acute care hospitals.17 The extension of this program, adapted to the RACF setting, may be valuable across the aged care sector. The results from the international studies found in this search suggest that the use of an ABHR was a factor in the success of their interventions. The introduction of ABHR, with or without accompanying education, was associated with an increase in hand hygiene compliance in the retrieved studies and supported in a recent review.36 Three studies in our search named which ABHR was used; of these, two used the WHO formulation.27,30 However, none of the studies gave explanation as to why the particular product had been selected.
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The appropriate selection and availability of ABHR was an essential component of the WHO ‘Clean Care is Safer Care’ initiative and an important consideration to achieve hand hygiene compliance.37 The WHO campaigns, which promote the availability and use of ABHR, are not yet documented as sustaining a high hand hygiene compliance rate.38 Interventions are more likely to be successful if specific to the setting,39 address local barriers and consider local healthcare worker needs.40 The studies incorporated a variety of education components and reminder materials, which included one-to-one training, fluorescent light boxes, posters, and promotional pens. None of the five RACF studies undertook pre-intervention needs assessments. However, this was undertaken in two studies whose RACF component of the data was not clearly identified. In those studies, the authors adapted the educational strategies to the needs of the healthcare worker and subsequently achieved an increase in compliance.6,35 Future studies about hand hygiene in RACF could consider including such an assessment. Each of the five RACF studies used a different method of compliance audit, which makes comparison of results problematic. These were: the WHO direct observation method,27 a locally- devised direct observation tool,16,30 selfreported compliance29 and the purchase of ABHR.28 Methodological issues, similar to other studies conducted in non-RACF settings,14,15 such as the selection of compliance audit tools and study site selection, limited the rigour of the retrieved studies. Audit tools may not take into consideration the shared community character of a RACF where staff may frequently make physical contact with residents during daily care, such as spontaneous hand holding or adjusting clothing.41 RACF are required to meet a certain standard of care to protect both staff and residents. Hand hygiene is an important part of the infection control and prevention program and those working in the aged care sector must aim for high compliance rates. There have been several reports on hand hygiene compliance interventions in the acute care sector yet few from those in the aged care sector. Limitations This review had some limitations as the literature search was restricted to the terms ‘hand washing’ or ‘hand hygiene’ and the timeframe of the search was a 13-year period to maintain currency. We acknowledge other infection prevention and control strategies in place, particularly in acute healthcare settings, including surveillance, staff health, asepsis; however, this review was restricted to hand hygiene initiatives in RACF.
G. Abernethy and W. Smyth
facilities for some time and the challenge is to further improve hand hygiene compliance. Interventions to improve compliance rates must be: multimodal, adapted to the setting, customised to local needs, and must use a valid audit tool to facilitate potential benchmarking. Infection-control advocates in the aged care sector would do well to undertake innovative projects to improve hand hygiene compliance and maintain a high compliance rate, to better protect residents and staff from healthcare-acquired infections, whilst not disregarding the residents’ need for caring human contact. Funding No funding was received in relation to the research presented or preparation of the manuscript. Conflict of Interest No conflict of interest exists. References 1.
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Conclusion There are limited published studies which report interventions that improve hand hygiene compliance among HCW within RACF. These studies have used various interventions but generally involve the introduction of, or increased access to, ABHR. In Australia, ABHR have been used in healthcare
12.
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www.publish.csiro.au/journals/hi
Healthcare Infection, 2013, 18, 156–161 http://dx.doi.org/10.1071/HI13021
The search for an evidence-based intervention to improve hand hygiene compliance in a residential aged care facility Gail Abernethy1,4 BHealth, PGDPHTM, GCHSt Wendy Smyth2,3 MAppSc, MBus, PhD 1
Queensland Health, Herberton Hospital, Herberton, Qld 4887, Australia. Tropical Health Research Unit for Nursing and Midwifery Practice, Townsville Hospital and Health Service, Townsville, Qld 4814, Australia. 3 School of Nursing, Midwifery and Nutrition, James Cook University, Townsville, Qld 4811, Australia. 4 Corresponding author. Email: [email protected] 2
Abstract. Introduction: Healthcare-acquired infections are a major source of morbidity and mortality in people living in residential aged care facilities. Compliance with hand hygiene by healthcare workers can reduce the risk of infection to residents, yet compliance rates are generally low. Infection-control advocates within the aged care sector are looking to conduct programs to improve rates among their staff. This review was conducted to identify a reproducible intervention to improve staff hand hygiene compliance within an Australian residential aged care facility. Method: Medline, Embase, and CINAHL databases were searched for combinations of ‘hand hygiene’, ‘hand washing’, ‘residential aged care facility’, ‘aged care’, ‘nursing home’ and ‘long-term care facility’ from 2000 to current. Articles were excluded if the information was not clearly stated as pertaining to a residential aged care facility or if the data investigated staff knowledge or perceptions of hand hygiene. Results: Most of the five articles included in the review reported an improvement in compliance rates. Studies were multimodal, had an education or training component, and included the promotion of alcohol-based hand rubs. Several used aspects of the World Health Organization’s hand hygiene initiatives. Compliance audit tools across the studies were not consistent; thus, results may not be comparable. Conclusion: There are few published studies which report interventions that improve hand hygiene compliance among healthcare workers within residential aged care facilities. Successful studies included the promotion of alcoholbased hand rubs. More research is needed to improve hand hygiene compliance in the aged care sector. Received 5 July 2013, accepted 20 August 2013, published online 17 September 2013
Introduction Healthcare-acquired infection is a major cause of morbidity and mortality for people living in residential aged care facilities (RACF). RACF, which can also be termed nursing homes or long-term care facilities, provide nursing and/or personal care, accommodation, and related services to older people unable to care for themselves in their own homes. To receive government funding or gain approval to operate, RACF must meet certain standards of care which include infection prevention and control.1–3 The elderly are at increased risk of infection due to ageassociated immune changes, multiple co-morbidities, and impaired functional status.4,5 Residents of aged care facilities may also have invasive devices such as enteral feeding tubes or tracheostomies for their care, further increasing their risk of infection.3 By providing a home-like environment with shared facilities and common sources of air, food and water, the RACF may itself contribute to the transmission of infection among residents.6,7
It has been reported that 25% of all acute hospital admissions from nursing homes can be attributed to infection.8 Studies report the prevalence of infection in RACF ranges from 2.2% to 6.0%.5,9,10 Overall incidence rates are stated as 2.20 to 4.16 episodes per 1000 resident-care bed days.11–13 The number of elderly requiring residential care may be impacted by the trend across health sectors towards rapid discharge from acute facilities to non-acute facilities.4,6 A shorter length of stay in hospital will reduce the cost to, and burden on, the acute hospital sector but the patient may subsequently require admission to a RACF for nursing care. Compliance with hand hygiene by staff in RACF can contribute to effective infection prevention and control.14 Hand hygiene by healthcare personnel is regarded as one pillar of any infection prevention and control program. Studies suggest that staff compliance with hand hygiene is generally poor across all healthcare settings15 and that compliance rates among healthcare workers (HCW) in the aged care sector range from 9.3% to 54.0%.6,16 In an attempt
Journal compilation Ó Australasian College for Infection Prevention and Control 2013
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Improving hand hygiene compliance in aged care
Implications *
*
*
There are limited data from the residential aged care sector relating to interventions to improve hand hygiene compliance Interventions should be multifaceted, address local needs and include use of alcohol-based hand rubs Hand hygiene compliance audit tools may need refinement to be applicable for the residential agedcare environment
to reduce healthcare-acquired infections, the World Health Organisation (WHO) initiated the global ‘Clean Care is Safer Care’ campaign in 2005 as a means to promote hand hygiene. The National Hand Hygiene Initiative (NHHI) was instigated by the Australian Commission on Safety and Quality in Health Care in 2009 to improve hand hygiene compliance among staff in Australian hospitals. This hand hygiene culturechange program includes the appropriate use of alcohol-based hand rubs (ABHR), and hand hygiene education, whilst monitoring hand hygiene compliance and patient infection rates.17 Australian acute healthcare facilities need to be able to demonstrate how they meet the national standards for safety and quality in healthcare when they undergo accreditation. Standard 3 requires the implementation of a governance structure and systems for preventing and controlling healthcare-associated infections. The subsequent monitoring of compliance with national hand hygiene guidelines, and taking corrective action to address identified deficiencies falls within this Standard.18 To satisfy the Aged Care Act 1997, RACF in Australia must comply with the accreditation standards, as assessed by the Aged Care Standards and Accreditation Agency Ltd, which include an effective infection-control program.11 The guidelines for aged care facilities in relation to hand hygiene, at least in Australia, are not as prescriptive as those for acute healthcare facilities. Rather, they have a set of broad principles, which include the need to balance the provision of a safe environment with the residents’ quality of life.19 The Australian Guidelines for the Prevention and Control of Infection in Healthcare were released in 2010 and provide information for healthcare providers, including RACF, to develop infection-control protocols appropriate to their service. Geary et al.20 found 97% of the participant Australian long-term care facilities had an infection-control program in place by 2000 which suggests the industry has prioritised this area for resource allocation. Much work has been undertaken within the acute care sector regarding hand hygiene compliance and education programs.15,21–25 A Cochrane Review found only four studies, all of which were undertaken in an acute care setting, assessing the success of programs to improve hand hygiene compliance.15 The interventions, including hand hygiene product substitution and multimodal campaigns, had varying success at increasing hand hygiene compliance rates. Social
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marketing or interventions with staff involvement appeared effective but the authors suggest there was not enough evidence to be conclusive. In another systematic review, Huis and colleagues26 examined the determinants of behaviour change in hand hygiene improvement strategies in the acute care sector. In the 41 studies matching their criteria, they found certain combinations of determinants within an intervention, such as social influence, attitude, self-efficacy and addressing existing local barriers were necessary to improve compliance. From these two systematic reviews, it appears that interventions to improve hand hygiene compliance must be evidence-based and sustainable. Hand hygiene compliance is as important to the health of staff and residents of the RACF as it is in the acute care setting. Hand hygiene compliance can reduce the risk of healthcare-acquired infection to both residents and staff. This review was conducted to search the literature for a reproducible intervention to improve HCW hand hygiene compliance within an Australian RACF. Method Studies, published from 1 January 2000 to 22 March 2013 were identified through searching the Medline, Embase, and CINAHL databases. The search strategy included all English-language articles with the headings (‘intervention$’ or ‘effect$’ or ‘randomised controlled trial’ or ‘experiment$’ or ‘compar$’ or ‘evaluat$’) and (‘handwashing’ or ‘hand washing’ or ‘hand hygiene’). These were then combined with the terms (‘aged care’ or ‘nursing home’ or ‘residential aged care facility’ or ‘long-term care facilit$’), to retrieve n = 307 titles, including duplicates. The abstracts were inspected, and the full article retrieved where found relevant. Additional articles were also identified using cited-reference searching. All studies that involved interventions to improve healthcare worker compliance with hand hygiene in RACF were included in the review. Studies that reported only knowledge and attitudes to hand hygiene or healthcare-acquired infection rates were excluded. Studies with both acute and non-acute care site data were included if the RACF data were clearly identified. Results Five relevant papers specific to RACF were identified and are summarised in Table 1.16,27–30 Within these five studies, a variety of interventions to improve healthcare worker hand hygiene compliance were reported. Studies that reported healthcare-acquired infection rates following an intervention but not hand hygiene compliance were excluded from this review.31,32 Some studies included RACF and acute care hospital sites including rehabilitation, but the data pertaining to the RACF were not clearly identified and thus were also excluded from this review.6,33–35 The use of an alcohol-based hand rub (ABHR), either as a new product to the facility, providing pocket-sized products to staff or increasing availability of an existing product, was a component of four studies,16,27,29,30, while the fifth study
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Table 1. Summary of articles included in literature review Sample of healthcare workers (n)
Length of study
Location
Intervention
Control alternative
Compliance measure
Compliance improvement
Comments
Mody et al.42
Prospective intervention
32
1 year
USA
Inservice; poster displays; personal AHBR provided; facility AHBR provided
Inservice; poster displays
Self-report (Handwashing Practices Inventory)
Yes
Huang and Wu43
Prospective intervention
40
3 months
Taiwan
No comparison group
Direct observation (each participant observed for 30 min during one 8 h shift, pre- and postintervention)
Yes
Yeung et al.44
Cluster randomised control
188
7 months
Hong Kong
Basic life support education
Direct observation; 3300 hand hygiene opportunities observed
Yes
Compliance tool based on WHO guidelines
Kacelnik et al.45
Prospective intervention
Not stated
Not stated
Norway
Hand hygiene education; hands on training; increased AHBR availability; reminders (posters and verbal); feedback Personal AHBR provided; poster displays; free pens; hand hygiene education National campaign; advertising agency; internet resources; focus groups; hand hygiene education
No increase after education alone but did increase after introduction of ABHR; small sample; randomised groups by coin toss Small sample; locally developed compliance audit tool
No comparison group
Sales of ABHR product
Not measured directly
Ho et al.46
Cluster randomised control
810
4 months
Hong Kong
WHO multimodal strategy; personal ABHR provided; facility ABHR provided; education (including hand hygiene indications and techniques); measure skin moisture; hand inspection light cabinet; posters; feedback
Education (not including hand hygiene indications and techniques)
Direct observation (WHO 5 Moments); 11 669 hand hygiene opportunities observed
Yes
Compliance indicated by increased volume of ABHR stock purchased by study sites; 27% participation rate of nursing homes nationally; poor response rate of participants at follow up; staff numbers not reported Potential study site selection bias
G. Abernethy and W. Smyth
Design
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Improving hand hygiene compliance in aged care
made no changes to existing use or availability of ABHR in the study sites.28 In the United States of America, Mody29 found no change in self-reported compliance following education and reminder material (posters) but the introduction of an ABHR did improve compliance when compared with the control. A Hong Kong study reported that the introduction of a personal ABHR with education and reminder material (posters and pens) improved compliance when compared with the control group.30 The authors of this study found compliance also improved in the control group which received hand hygiene education whilst using soap and water to wash hands. Differences in the baseline characteristics of the intervention and control facilities and a high staff turnover during this study may have affected the results. Of the intervention arm, 43% of the staff left employment, and new employees were given feedback sessions rather than the full intervention. Increased availability of ABHR together with education, hands-on training, and reminder material (posters and feedback) significantly improved hand hygiene compliance in a small sample of nursing assistants over a 3-month period in a Taiwanese nursing home.16 In a study conducted in care and attention homes in Hong Kong that were already using ABHR, Ho et al.27 provided additional personal ABHR and instigated a WHO multimodal promotion strategy. This strategy included education, reminder material (posters, feedback), skin moisture level monitoring and hand inspection using fluorescent dye compared with generic health promotion education. The two intervention groups were also provided with slightly powdered or powderless gloves. Particular homes were invited to participate in this study due to the perceived positive attitudes of their management to government initiatives which may have influenced the outcome of the study. Hand hygiene compliance was measured at baseline, 1 and 4 months, showing an improvement in compliance within the intervention groups (from 27% to 60.6% and 22.2% to 48.6%).22 All five studies included in this review incorporated some form of staff education or training. Nursing assistants with more than 12 years of schooling were more likely to improve their knowledge regarding hand hygiene than those with less schooling in one study with a multicultural workforce.16 This may reflect that the educational portion of the intervention was not specifically designed for the audience level of understanding. Education alone made no difference to hand hygiene compliance in another study.29 A national campaign across Norway (Ren Omsorg: ‘Pure Care’), that reported nursing home (RACF) data separately from acute care data, used internet and hand hygiene education resources for local use as intervention strategies. Of the 240 Norwegian nursing homes that participated in the baseline data collection, only 45 returned evaluation data. The study demonstrated an increase in the usage of existing facility-wide ABHR28, thus suggesting increased compliance, however the poor response rate may limit the reliability of the results.
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Since the studies used different techniques (self-report, direct observation and product usage) to assess hand hygiene compliance, the results of the individual studies are not directly comparable. In the study using participants’ selfreports, HCW were asked to nominate the number of times within the previous hour they had washed their hands at baseline, following the 3-week education intervention and 12 weeks after the introduction of the ABHR.29 The WHO audit tool was used in one study27; another used the WHO audit to guide their audit, but the actual tool utilised was not clearly articulated in the report.30 Hand hygiene compliance was observed by a trained research assistant using a locallydeveloped tool in the Taiwanese study.16 As already mentioned, the Norwegian study used product usage data from the supplier to monitor hand hygiene compliance.28 Discussion Our search yielded very few published articles describing interventions that improved hand hygiene compliance among HCW employed in RACF. The retrieved studies are drawn from the international literature due to the paucity of published Australian work on the topic. As the studies originate from Asia, Australia, Europe and North America, there will be differences in the type of facility and the level of care across the differing health systems described in the studies. There may also be variety in the skill level and training of HCW not clearly described in the retrieved literature between nations. However, we believe that compliance with hand hygiene is imperative for all those who provide care. Given that hand hygiene is recognised as a pivotal component of infection prevention and control worldwide, we feel that some reference to the international literature is appropriate. All studies used multimodal interventions, with one guided by the WHO strategy: ‘Clean Care is Safer Care’.27 Studies utilised combinations of ABHR use, education, hands-on training, social marketing, reminder materials (such as posters and pens) and performance feedback (Table 1). Multimodal strategies appear to have more effect on improving compliance than single interventions.15 One study looked at compliance following education only and found no change in self-reported compliance.29 The multimodal National Hand Hygiene Initiative (NHHI), based on the WHO ‘5 Moments for Hand Hygiene’ strategy, was shown to increase hand hygiene compliance in Australian acute care hospitals.17 The extension of this program, adapted to the RACF setting, may be valuable across the aged care sector. The results from the international studies found in this search suggest that the use of an ABHR was a factor in the success of their interventions. The introduction of ABHR, with or without accompanying education, was associated with an increase in hand hygiene compliance in the retrieved studies and supported in a recent review.36 Three studies in our search named which ABHR was used; of these, two used the WHO formulation.27,30 However, none of the studies gave explanation as to why the particular product had been selected.
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The appropriate selection and availability of ABHR was an essential component of the WHO ‘Clean Care is Safer Care’ initiative and an important consideration to achieve hand hygiene compliance.37 The WHO campaigns, which promote the availability and use of ABHR, are not yet documented as sustaining a high hand hygiene compliance rate.38 Interventions are more likely to be successful if specific to the setting,39 address local barriers and consider local healthcare worker needs.40 The studies incorporated a variety of education components and reminder materials, which included one-to-one training, fluorescent light boxes, posters, and promotional pens. None of the five RACF studies undertook pre-intervention needs assessments. However, this was undertaken in two studies whose RACF component of the data was not clearly identified. In those studies, the authors adapted the educational strategies to the needs of the healthcare worker and subsequently achieved an increase in compliance.6,35 Future studies about hand hygiene in RACF could consider including such an assessment. Each of the five RACF studies used a different method of compliance audit, which makes comparison of results problematic. These were: the WHO direct observation method,27 a locally- devised direct observation tool,16,30 selfreported compliance29 and the purchase of ABHR.28 Methodological issues, similar to other studies conducted in non-RACF settings,14,15 such as the selection of compliance audit tools and study site selection, limited the rigour of the retrieved studies. Audit tools may not take into consideration the shared community character of a RACF where staff may frequently make physical contact with residents during daily care, such as spontaneous hand holding or adjusting clothing.41 RACF are required to meet a certain standard of care to protect both staff and residents. Hand hygiene is an important part of the infection control and prevention program and those working in the aged care sector must aim for high compliance rates. There have been several reports on hand hygiene compliance interventions in the acute care sector yet few from those in the aged care sector. Limitations This review had some limitations as the literature search was restricted to the terms ‘hand washing’ or ‘hand hygiene’ and the timeframe of the search was a 13-year period to maintain currency. We acknowledge other infection prevention and control strategies in place, particularly in acute healthcare settings, including surveillance, staff health, asepsis; however, this review was restricted to hand hygiene initiatives in RACF.
G. Abernethy and W. Smyth
facilities for some time and the challenge is to further improve hand hygiene compliance. Interventions to improve compliance rates must be: multimodal, adapted to the setting, customised to local needs, and must use a valid audit tool to facilitate potential benchmarking. Infection-control advocates in the aged care sector would do well to undertake innovative projects to improve hand hygiene compliance and maintain a high compliance rate, to better protect residents and staff from healthcare-acquired infections, whilst not disregarding the residents’ need for caring human contact. Funding No funding was received in relation to the research presented or preparation of the manuscript. Conflict of Interest No conflict of interest exists. References 1.
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Conclusion There are limited published studies which report interventions that improve hand hygiene compliance among HCW within RACF. These studies have used various interventions but generally involve the introduction of, or increased access to, ABHR. In Australia, ABHR have been used in healthcare
12.
13.
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