Effectiveness of an audible reminder on hand hygiene adherence

Behavioural determinants shaping infection prevention and control behaviour among healthcare workers in Dutch general practices: a qualitative study reflecting on pre-, during and post-COVID-19 pandemic

BACKGROUND

Since the Coronavirus Disease 2019 (COVID-19) pandemic, awareness of infection prevention and control (IPC) has increased in primary care settings. This study aimed to examine behavioural determinants shaping IPC behaviour pre-, during, and post-pandemic among healthcare workers (HCWs) in general practices, to inform optimised IPC in primary care.

METHODS

For this qualitative study, semi-structured in-depth interviews were conducted during two study periods: (1) pre-COVID-19 pandemic: July 2019-February 2020, with 14 general practitioners (GPs) and medical assistants, and (2) during the COVID-19 pandemic: July 2022-February 2023, with 22 GPs and medical assistants. The design was informed by behaviour change theories. Data were analysed using thematic analysis.

RESULTS

Main themes were: (1) risk perception and IPC awareness, (2) attitudes towards IPC and professional responsibility, (3) decision-making process and risk considerations for IPC adherence, (4) social norm and social influence in GP practice team, and (5) environmental context and resource availability in GP practice. During the pandemic, risk perception and awareness of the importance of IPC increased compared to the pre-pandemic period. A consistent belief emerged that IPC is part of professional responsibility, while needing to be balanced with other aspects of patient care. Decision-making is dependent on the individual GP and mainly influenced by risk assessments and sustainability considerations. The social context in the practice team can reinforce IPC behaviours. GP practice building and layout, and limited IPC resource and material availability were reported as main barriers.

CONCLUSIONS

The theory-informed insights of this study can be used for targeted interventions to optimise IPC behaviour in general practices. Adopting multifaceted strategies to target the various determinants is recommended to sustain IPC, by implementing continuous education using tailored communication, integrating IPC in work routines and organisational workflows, refining existing IPC protocols by incorporating decision-making tools for HCWs, fostering a culture of IPC through knowledge-sharing and teamwork, and addressing GP practice physical environment and IPC resource barriers.

Unpacking nudge sensu lato: insights from a scoping review

Nudges may play an important role in improving infection prevention and control (IPC) in hospitals. However, despite the novelty of the framework, their objectives, strategies and implementation approaches are not new. This review aims to provide an overview of the methods typically used by nudge interventions in IPC in hospitals targeting healthcare workers (HCWs). The initial search in PubMed yielded nine hits. Consequently, the search criteria were broadened and a second search was conducted, introducing 'nudge sensu lato' which incorporates insights from sources beyond the traditional nudge framework while maintaining the same objectives, strategies and approaches. During the second search, PubMed, Epistemonikos, Web of Science and PsycInfo were searched in accordance with the PRISMA guidelines. Abstracts were screened, and reviewers from an interdisciplinary team read the full text of selected papers. In total, 5706 unique primary studies were identified. Of these, 67 were included in the review, and only four were listed as nudge sensu stricto, focusing on changing HCWs' hand hygiene. All articles reported positive intervention outcomes. Of the 56 articles focused on improving hand hygiene compliance, 71.4% had positive outcomes. For healthcare equipment disinfection, 50% of studies showed significant results. Guideline adherence interventions had a 66.7% significant outcome rate. The concept of nudge sensu lato was introduced, encompassing interventions that employ strategies, methods and implementation approaches found in the nudge framework. The findings demonstrate that this concept can enhance the scientific development of more impactful nudges. This may help clinicians, researchers and policy makers to develop and implement effective nudging interventions.

Novel hand hygiene promotion method in a pediatric and maternity hospital: A quality improvement pilot project using auditory feedback

A pilot quality improvement project was conducted to examine the effect of playing an applause sound effect at a busy hospital concourse for three consecutive days whenever hand hygiene behavior was observed. The immediate effect was documented. The project demonstrated observable interest among people passing by, and hand hygiene events triggered by the sound effect represented 10.1% of all hand hygiene events documented. This supports the possible utility of this intervention in generating public awareness and increasing hand hygiene behavior and demonstrates the feasibility of a longer trial utilizing audio devices.

A Crossover Randomized Controlled Trial of Priming Interventions to Increase Hand Hygiene at Ward Entrances

Background

Research conducted in the United States suggests that two primes (citrus smells and pictures of a person's eyes) can increase hand gel dispenser use on the day they are introduced in hospital. The current study, conducted at a hospital in the United Kingdom, evaluated the effectiveness of these primes, both in isolation and in combination, at the entry way to four separate wards, over a longer duration than the previous work.

Methods

A crossover randomized controlled trial was conducted. Four wards were allocated for 6 weeks of observation to each of four conditions, including “control,” “olfactory,” “visual,” or “both” (i.e., “olfactory” and “visual” combined). It was hypothesized that hand hygiene compliance would be greater in all priming conditions relative to the control condition. The primary outcome was whether people used the gel dispenser when they entered the wards. After the trial, a follow up survey of staff at the same hospital assessed the barriers to, and facilitators of, hand hygiene compliance. The trial data were analyzed using regression techniques and the survey data were analyzed using descriptive statistics.

Results

The total number of individuals observed in the trial was 9,811 (female = 61%), with similar numbers across conditions, including “control” N = 2,582, “olfactory” N = 2,700, “visual” N = 2,488, and “both” N = 2,141. None of the priming conditions consistently increased hand hygiene. The lowest percentage compliance was observed in the “both” condition (7.8%), and the highest was observed in the “visual” condition (12.7%). The survey was completed by 97 staff (female = 81%). “Environmental resources” and “social influences” were the greatest barriers to staff cleaning their hands.

Conclusions

Taken together, the current findings suggest that the olfactory and visual priming interventions investigated do not influence hand hygiene consistently. To increase the likelihood of such interventions succeeding, future research should focus on prospectively determined mechanisms of action.

Effect of voice reminder on compliance with recommended hand hygiene practise among health-care workers in Kano metropolis

Background

Poor compliance with recommended hand hygiene practise by health-care workers is an emerging public health threat associated with significant morbidity, mortality and spread of multidrug-resistant microorganisms.

Objective

This study assessed the effect of voice reminder on compliance with recommended hand hygiene practise among the baseline, and post-intervention compliance with recommended hand hygiene among health-care workers using the WHO checklist for observation of 5-moments of hand hygiene of health-care workers in Kano.

Methods

Quasi-experimental study design was used. A total of 408 (204 in each arm) baseline and post-intervention observations were conducted in two hospitals in Kano, selected using a multistage sampling technique. Voice reminders were installed in the intervention hospital, and post-intervention observation was conducted 3 months after introducing a voice reminder. SPSS version 22.0 was used for data analysis. Relationship between variables was tested using χ² and McNemar's test within the groups at 0.05 α-level of significance.

Results

Baseline compliance with hand hygiene in the intervention and control hospitals were 31.4% and 48.0%, respectively. Post-intervention compliance in the intervention and control hospitals were found to be 78.0% and 65.2%, respectively. Voice reminder improved compliance with hand hygiene practise when compared with baseline by +148% (P# = 0.3) in the intervention hospital compared with +36% (P# =0.1) in the control hospital. The differences were not statistically significant post-intervention when compared with the baseline.

Conclusions

Voice reminder intervention improved hand hygiene compliance among health-care workers in the intervention hospital compared with the control hospital. Voice reminders should be provided in the hospitals by stakeholders. This can help in improving compliance with hand hygiene among health-care workers and reducing the burden of hospital-acquired infections due to the hands of health-care workers.

Hand Hygiene during the Early Neonatal Period: A Mixed-Methods Observational Study in Healthcare Facilities and Households in Rural Cambodia

BACKGROUND

Globally, infections are the third leading cause of neonatal mortality. Predominant risk factors for facility-born newborns are poor hygiene practices that span both facilities and home environments. Current improvement interventions focus on only one environment and target limited caregivers, primarily birth attendants and mothers. To inform the design of a hand hygiene behavioural change intervention in rural Cambodia, a formative mixed-methods observational study was conducted to investigate the context-specific behaviours and determinants of handwashing among healthcare workers, and maternal and non-maternal caregivers along the early newborn care continuum.

METHODS

Direct observations of hygiene practices of all individuals providing care to 46 newborns across eight facilities and the associated communities were completed and hand hygiene compliance was assessed. Semi-structured interactive interviews were subsequently conducted with 35 midwives and household members to explore the corresponding cognitive, emotional and environmental factors influencing the observed key hand hygiene behaviours.

RESULTS

Hand hygiene opportunities during newborn care were frequent in both settings (n = 1319) and predominantly performed by mothers, fathers and non-parental caregivers. Compliance with hand hygiene protocol across all caregivers, including midwives, was inadequate (0%). Practices were influenced by the lack of accessible physical infrastructure, time, increased workload, low infection risk perception, nurture-related motives, norms and inadequate knowledge.

CONCLUSIONS

Our findings indicate that an effective intervention in this context should be multi-modal to address the different key behaviour determinants and target a wide range of caregivers.

Hand(y) hygiene insights: Applying three theoretical models to investigate hospital patients' and visitors' hand hygiene behavior

BACKGROUND

Improving hand hygiene in hospitals is the most efficient method to prevent healthcare-associated infections. The hand hygiene behavior of hospital patients and visitors is not well-researched, although they pose a risk for the transmission of pathogens. Therefore, the present study had three aims: (1) Finding a suitable theoretical model to explain patients' and visitors' hand hygiene practice; (2) Identifying important predictors for their hand hygiene behavior; and (3) Comparing the essential determinants of hand hygiene behavior between healthcare professionals from the literature to our non-professional sample.

METHODS

In total N = 1,605 patients and visitors were surveyed on their hand hygiene practice in hospitals. The employed questionnaires were based on three theoretical models: a) the Theory of Planned Behavior (TPB); b) the Health Action Process Approach (HAPA); and c) the Theoretical Domains Framework (TDF). Structural equation modeling was used to analyze the data. To compare our results to the determinants of healthcare workers' hand hygiene behavior, we searched for studies that used one of the three theoretical models.

RESULTS

Among patients, 52% of the variance in the hand hygiene behavior was accounted for by the TDF domains, 44% by a modified HAPA model, and 40% by the TPB factors. Among visitors, these figures were 59%, 37%, and 55%, respectively. Two clusters of variables surfaced as being essential determinants of behavior: self-regulatory processes and social influence processes. The critical determinants for healthcare professionals' hand hygiene reported in the literature were similar to the findings from our non-professional sample.

CONCLUSIONS

The TDF was identified as the most suitable model to explain patients' and visitors' hand hygiene practices. Patients and visitors should be included in existing behavior change intervention strategies. Newly planned interventions should focus on targeting self-regulatory and social influence processes to improve effectiveness.

Qualitative interview study exploring frontline managers' contributions to hand hygiene standards and audit: Local knowledge can inform practice

BACKGROUND

Frontline managers promote hand hygiene standards and adherence to hand hygiene protocols. Little is known about this aspect of their role.

METHODS

Qualitative interview study with frontline managers on 2 acute admission wards in a large National Health Service Trust in the United Kingdom.

RESULTS

Managers reported that hand hygiene standards and audit were modeled on World Health Organization guidelines. Hand hygiene outside the immediate patient zone was not documented but managers could identify when additional indications for hand hygiene presented. They considered that audit was worthwhile to remind staff that hand hygiene is important but did not regard audit findings as a valid indicator of practice. Managers identified differences in the working patterns of nurses and doctors that affect the number and types of hand hygiene opportunities and barriers to hand hygiene. Ward managers were accepted as the custodians of hand-hygiene standards.

CONCLUSIONS

Frontline managers identified many of the issues currently emerging as important in contemporary infection prevention practice and research and could apply them locally. Their views should be represented when hand hygiene guidelines are reviewed and updated.

Focusing on Families and Visitors Reduces Healthcare Associated Respiratory Viral Infections in a Neonatal Intensive Care Unit

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Healthcare-associated respiratory viral infections (HARVIs) result in significant harm to infants in the neonatal intensive care unit (NICU). Healthcare workers and visitors can serve as transmission vectors to patients. We hypothesized that improved family and visitor hand hygiene (FVHH) and visitor screening would reduce HARVIs by at least 25%.

Effects of Audio-Visual Stimulation on Hand Hygiene Compliance among Family and Non-Family Visitors of Pediatric Wards: A Quasi-Experimental Pre-post Intervention Study

PURPOSE

This study aimed to identify the differences in interventional effects on hand hygiene compliance (HHC) among families and visitors in pediatric wards.

DESIGN & METHODS

A total of 2787 family and non-family visitors entering through the glass sliding door of 6 pediatric wards at a university children's hospital were observed for 4 h, respectively, before and after interventions between April 27 and May 20, 2018. In the first intervention, a visual stimulus emphasized the location of the hand sanitizer. In the second intervention, an additional auditory stimulus transmitted a cue through a motion sensor speaker.

RESULTS

During the preliminary observation, the HHC rates of family and non-family visitors were 0.0% and 1.5%, respectively; after the visual stimulus, they were 0.6% and 5.4%, and after the audio-visual stimulus, 1.8% and 8.2%. There was a significant increase in the overall HHC with the visual (OR, 5.22; 95% CI, 1.76-20.90) and audio-visual (OR, 8.67; 95% CI, 3.08-33.70) stimuli (Fisher's exact test, p < .05).

CONCLUSIONS

The HHC of family and non-family visitors entering pediatric wards was very low and the audio-visual stimulus was found to be more effective than was the visual stimulus alone.

PRACTICE IMPLICATIONS

To reduce healthcare-associated infection, pediatric wards must actively implement effective interventions. Using audio-visual stimulation to increase HHC among visitors will provide advantages. Follow-up research should examine the current state of HHC among visitors in various locations and conditions.

Family Experiences and Perspectives on Infection Prevention in Pediatric Long-Term Care

PURPOSE

Residents of pediatric long-term care facilities (pLTCF) are particularly vulnerable to healthcare-associated infections. The aims of this qualitative study were to (a) explore perspectives on infection prevention among families visiting children in pLTCF and (b) identify facilitators of and barriers to optimal hand hygiene.

DESIGN AND METHODS

Semistructured, in-depth interviews with 10 family members visiting two New York City metropolitan area facilities were analyzed to identify themes.

FINDINGS

"Everyone follows the rules" and "infections are inevitable" were primary themes. Participants reported "common sense" as a facilitator and "distraction" as a major barrier to prevention practices.

CONCLUSION

Current education for visitors may be inadequate to improve infection prevention behaviors.

CLINICAL RELEVANCE

Nurse-led education strategies for infection prevention should be tested and modified for families visiting pLTCF.

Infection Control and the Need for Family-/Child-Centered Care

Patient- and family-centered care (FCC) has become central to the delivery of medical care over the last 20 years and has been shown to improve patient outcomes. Infection control practices have the potential to greatly influence family centeredness and care providers, and hospital personnel must consider the potential impacts of isolation and the use of personal protective equipment (PPE). Approaching infection control with the perspective of FCC requires balancing patient safety and overall patient well-being. In this chapter, authors consider infection control and the benefits of FCC, family and sibling visitation, the use of playrooms, animals in healthcare settings including animal-assisted interventions, the potential adverse effects of infection control practices, and strategies to mitigate these impacts.

Isolation Precautions for Visitors to Healthcare Settings

Visitors may be involved in infection transmission within healthcare settings; however, there is currently limited published data on this subject. This chapter describes situations in which visitor-associated infection transmission occurred and highlights the potential role of visitors in the transmission of pathogenic organisms that can lead to outbreaks in healthcare settings. Infection prevention measures, including isolation precautions and visitor restriction, may be utilized and potentially adapted in order to protect patients and their visitors as well as healthcare personnel. The practical and ethical challenges regarding the use of isolation precautions among visitors to healthcare facilities are discussed.

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Role of a multimodal educational strategy on health care workers' handwashing

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.

Strategies to prevent healthcare-associated infections through hand hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Moment-specific compliance with hand hygiene

BACKGROUND

Hand hygiene is an important component of patient-safety education. The World Health Organization recommends the use of hand hygiene measures at five clinical moments. While previous studies have treated hand hygiene as a single entity, we investigated whether and how the compliance of students may vary across the five clinical moments. We also studied their reasons for non-compliance with a view to inform teaching.

METHOD

A voluntary self-administered questionnaire survey was conducted on a convenient sample of 339 medical and nursing students. The five clinical moments studied were: before touching a patient (moment 1); before a clean/aseptic procedure (moment 2); after body fluid exposure risk (moment 3); after touching a patient (moment 4); and after touching the patient's surroundings (moment 5).

RESULTS

The overall reported compliance rate was 83.0 per cent. The compliance rates were significantly lower at moments 1 and 5. Nursing students reported better overall compliance (p = 0.01), and at moments 2 (p = 0.0001) and 3 (p = 0.0001), than medical students. Medical students fared better at moment 4 (p = 0.009). The most common reason reported for non-compliance was 'forgetfulness'.

DISCUSSION

We identified differences in compliance rates across the five clinical moments of hand hygiene. Education programmes should not treat the hand hygiene process as a single entity, but should adopt a moment-specific approach to promote recall, with particular emphases on moments 1 and 5. Nursing and medical students may require different education strategies. Future studies on hand hygiene may also adopt a moment-specific approach.

A study of the efficacy of flashing lights to increase the salience of alcohol-gel dispensers for improving hand hygiene compliance

BACKGROUND

Many interventions have been implemented to improve hand hygiene compliance, each with varying effects and monetary costs. Although some previous studies have addressed the issue of conspicuousness, we found only 1 study that considered improving hand hygiene by using flashing lights.

METHOD

Our attention theory-based hypothesis tested whether a simple red light flashing at 2-3 Hz affixed to the alcohol gel dispensers, within the main hospital entrance, would increase hand hygiene compliance over the baseline rate. Baseline and intervention observations were completed over five 60-minute periods (Monday-Friday) from 7:30 to 8:30 AM using a covert observation method.

RESULTS

Baseline hand hygiene compliance was 12.4%. Our intervention increased compliance to 23.5% during cold weather and 27.1% during warm weather. Overall, our pooled compliance rate increased to 25.3% (P < .0001).

CONCLUSIONS

A simple, inexpensive flashing red light affixed to alcohol gel dispensers was sufficiently salient to approximately double overall hand hygiene compliance within the main hospital entrance. We hypothesize that our intervention drew attention to the dispensers, which then reminded employees and visitors alike to wash their hands. Compliance was worse during cold days, presumably related to more individuals wearing gloves.

Automated and electronically assisted hand hygiene monitoring systems: a systematic review

BACKGROUND

Hand hygiene is one of the most effective ways to prevent transmission of health care-associated infections. Electronic systems and tools are being developed to enhance hand hygiene compliance monitoring. Our systematic review assesses the existing evidence surrounding the adoption and accuracy of automated systems or electronically enhanced direct observations and also reviews the effectiveness of such systems in health care settings.

METHODS

We systematically reviewed PubMed for articles published between January 1, 2000, and March 31, 2013, containing the terms hand AND hygiene or hand AND disinfection or handwashing. Resulting articles were reviewed to determine if an electronic system was used.

RESULTS

We identified 42 articles for inclusion. Four types of systems were identified: electronically assisted/enhanced direct observation, video-monitored direct observation systems, electronic dispenser counters, and automated hand hygiene monitoring networks. Fewer than 20% of articles identified included calculations for efficiency or accuracy.

CONCLUSIONS

Limited data are currently available to recommend adoption of specific automatic or electronically assisted hand hygiene surveillance systems. Future studies should be undertaken that assess the accuracy, effectiveness, and cost-effectiveness of such systems. Given the restricted clinical and infection prevention budgets of most facilities, cost-effectiveness analysis of specific systems will be required before these systems are widely adopted.