Light-guided nudging and data-driven performance feedback improve hand hygiene compliance among nurses and doctors

Should automated electronic hand-hygiene monitoring systems be implemented in routine patient care? Systematic review and appraisal with Medical Research Council Framework for Complex Interventions

Manual hand-hygiene audit is time-consuming, labour-intensive and inaccurate. Automated hand-hygiene monitoring systems (AHHMSs) offer advantages (generation of standardized data, avoidance of the Hawthorne effect). World Health Organization Guidelines for Hand Hygiene published in 2009 suggest that AHHMSs are a possible alternative. The objective of this review was to assess the current state of the literature for AHHMSs and offer recommendations for use in real-world settings. This was a systematic literature review, and publications included were from the time that PubMed commenced until 19th November 2023. Forty-three publications met the criteria. Using the Medical Research Council's Framework for Developing and Evaluating Complex Interventions, two were categorized as intervention development studies. Thirty-nine were evaluations. Two described implementation in real-world settings. Most were small scale and short duration. AHHMSs in conjunction with additional intervention (visual or auditory cue, performance feedback) could increase hand hygiene compliance in the short term. Impact on infection rates was difficult to determine. In the few publications where costs and resources were considered, time devoted to improving hand hygiene compliance increased when an AHHMS was in use. Health workers' opinions about AHHMSs were mixed. In conclusion, at present too little is known about the longer-term advantages of AHHMSs to recommend uptake in routine patient care. Until more longer-term accounts of implementation (over 12 months) become available, efforts should be made to improve direct observation of hand hygiene compliance to improve its accuracy and credibility. The Medical Research Council Framework could be used to categorize other complex interventions involving use of technology to prevent infection to help establish readiness for implementation.

Hand hygiene compliance in nursing home wards: the effect of increased accessibility of alcohol-based hand rub

BACKGROUND

Elderly nursing home residents are vulnerable to infection from micro-organisms. Hand hygiene is considered one of the most important measures to prevent transmission.

AIM

To determine the effect of increased accessibility to alcohol-based hand rub (ABHR) in nursing home wards by monitoring hand hygiene compliance (HHC) among healthcare workers (HCWs).

METHODS

An 11-month intervention study was conducted in a Danish six-ward nursing home. Data were collected using an automatic hand hygiene monitoring system (AHHMS). After a baseline period, one extra ABHR dispenser was placed in each of the 150 apartments. Baseline HHC was compared with the HHC during an immediate intervention period and a long-term intervention period.

FINDINGS

A total of 159 HCWs were included. The AHHMS registered 341,078 hand hygiene opportunities. Overall baseline HHC was 31% (95% confidence interval: 30-32). A significant +18% absolute immediate effect (first five months) (95% CI: 17-19; P < 0.0001) and +13 percentage points (95% CI: 11-14; P < 0.0001) long-term effect (another four months) were recorded. HCWs working day shifts and short-term employees had a higher baseline HHC than HCWs working evening/night shifts. However, HCWs working night shifts achieved the greatest long-term effect with a mean +27 percentage point difference (P < 0.0001).

CONCLUSION

Placing an additional ABHR dispenser strategically within staff workflow significantly increased HHC among HCWs, demonstrating a noteworthy effect. The study is the first to report the effect on nursing home dispenser accessibility as a single intervention and to show a significant unmet potential.

Validation of a hand hygiene visual feedback system to improve compliance with drying time of alcohol-based hand rub in a neonatal intensive care unit: the Incubator Traffic Light system

BACKGROUND

Compliance with the recommended 30 s drying time of alcohol-based hand rub (ABHR) is often suboptimal. To increase hand hygiene compliance at a neonatal intensive care unit (NICU), we installed an Incubator Traffic Light (ITL) system which shows 'green light' to open incubator doors after the recommended drying time.

AIM

To measure the impact of this visual feedback system on NICU healthcare professionals' compliance with the recommended ABHR drying time.

METHODS

Ten traffic light systems were installed on incubators at a NICU, five of which provided visual feedback, and five, serving as a control group, did not provide visual feedback. During a two-month period, the systems measured drying time between the moment of dispensing ABHR and opening the incubator's doors. The drying times of the incubators were compared with and without feedback.

FINDINGS

Of the 6422 recorded hand hygiene events, 658 were valid for data analysis. Compliance with correct drying time reached 75% (N = 397/526) for incubators equipped with visual feedback versus 36% (N = 48/132; P < 0.0001) for incubators lacking this feature.

CONCLUSION

The ITL improves compliance with the recommended 30 s ABHR drying time in a NICU setting.

Prevention and control of hospital-acquired infections with multidrug-resistant organism: A review

Multidrug-resistant is defined as nonsusceptibility to at least 1 agent in 3 or more antimicrobial categories. Controlling the spread of drug-resistant organisms is a key step in the management of hospital-acquired infections (HAIs). To review the progress of research on the prevention and control of HAIs with multidrug-resistant organism (MDRO) in the past 5 years, and to provide reference for the development of comprehensive measures for the prevention and control of HAIs with MDRO. We conducted a search in the PUBMED database for studies related to MDRO and HAIs from 2018 to 2023, then integrated this data with information sourced from the U.S.A. The Centers for Disease Control and Prevention. Utilizing information technology to monitor and provide feedback on hand hygiene practices can enhance compliance. Environmental disinfection techniques such as ultraviolet or hydrogen peroxide demonstrate potential in reducing MDRO transmission. While some studies support that contact isolation measures for MDRO-infected or colonized patients can reduce HAIs, others do not confirm this outcome. Approaches for MDRO colonization among patients or physicians may mitigate MDRO transmission risk. Implementing clusterization interventions proves to enhance efficiency and cost-effectiveness in preventing and controlling MDRO. Early screening for pathogen species emerges as a valuable strategy aiding in antimicrobial use control. Combined with evidence from the literature, implementing clusterization interventions that include measures such as monitoring and feedback on hand hygiene and improved environmental disinfection techniques can help prevent and control HAIs with MDRO. However, further clinical studies are needed to validate the optimal clusterization intervention.

Empowering health care workers with personalized data-driven feedback to boost hand hygiene compliance

BACKGROUND

Achieving high hand hygiene compliance among health care workers is a challenge, requiring effective interventions. This study investigated the impact of individualized feedback on hand hygiene compliance using an electronic monitoring system.

METHODS

A quasi-experimental intervention design with pretest-post-test was conducted in an orthopedic surgical ward. Participants served as their own controls. A 3-month baseline was followed by a 3-month intervention period. Hand hygiene events were recorded through sensors on dispensers, name tags, and near patient beds. Health care workers received weekly email feedback reports comparing their compliance with colleagues.

RESULTS

Nineteen health care workers (17 nurses, 2 doctors) were included. Hand hygiene compliance significantly improved by approximately 15% (P < .0001) across all rooms during the intervention. The most substantial improvement occurred in patient rooms (17%, P < .0001). Compliance in clean and contaminated rooms increased by 10% (P = .0068) and 5% (P = .0232). The average weekly email open rate for feedback reports was 46%.

CONCLUSIONS

Individualized feedback via email led to significant improvements in hand hygiene compliance among health care workers. The self-directed approach proved effective, and continuous exposure to the intervention showed promising results.

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.

Factors associated with better alcohol hand rub in 2020. Results from the French national audit "Pulpe'friction"

Background

The application of alcohol-based hand rub on hands (ABHR) can prevent the transmission of microorganisms. But, in some situations the practices remain perfectible.

Aim

The aim of this study was to assess the self-reported ABHR practices of healthcare workers (HCWs) and to identify the factors associated with better ABHR compliance.

Methods

A cross-sectional study was conducted using the French national "Pulpe'friction" audit, from 1st January 2020 to 31st December 2020, in healthcare facilities and social welfare facilities in France. Data were analyzed using descriptive statistics and multivariate logistic regression models.

Results

Of the 6769 HCWs, the average ABHR compliance was 75% "before patient contact," 95% "before an invasive technique," 86% "after patient contact," and 79% "after contact with patient surroundings." The main reported barriers were the availability, the discomfort and the harmfulness of the product. The factors significantly associated with a better compliance were the individual importance given to hand hygiene (HH); working in a healthcare facility, except in the situation "before an invasive technique"; medical profession "after patient contact"; paramedical profession "after contact with patient surroundings."

Discussion

These results call for national actions to fight the most reported barriers and raise awareness on the importance of HH, especially before touching the patient.

Best practices for implementing biosafety inspections in a clinical laboratory: Evidence from a multi-site experimental study

OBJECTIVES

To explore the key components when designing best practice inspection interventions, so as to induce high compliance with safety guidelines for laboratory workers.

METHODS

Five key components of an inspection intervention, identified from a focus group discussion, were used as the attributes of a discrete choice experiment (DCE). In the DCE, participants were presented with two hypothetical scenarios and asked to choose the scenario in which they were more willing to comply with the laboratory safety guidelines. Data were collected from 35 clinical laboratories in seven healthcare institutes located in Chengdu, China. In total, 188 laboratory workers completed the DCE. The collected data were analyzed using conditional logit regression and latent class analysis.

RESULTS

Five key attributes were identified as the most important ones to best ensure laboratory safety: the inspector, the inspection frequency, the inspection timing, the communication of the inspection outcome, and a follow-up with either a reward or a punishment. By investigating the laboratory workers' responses to the attributes, properly implementing the five attributes could improve the workers' compliance from 25.86% (at the baseline case) to 74.54%. Compliance could be further improved with the consideration of the laboratory workers' heterogeneous reactions. In this study, two classes of workers, A and B, were identified. Compliance percentages for Classes A and B would be improved to 85.48% and 81.84%, respectively, when the key attributes were properly implemented for each class. The employment type and the size of the laboratory could be used to predict class membership.

CONCLUSION

The findings indicate the importance of an employee-centered approach in encouraging a worker's compliance. This approach also supports the design of tailored interventions by considering the laboratory workers' heterogeneous responses to the interventions.

An interactive feedback system for increasing hand antisepsis adherence in stationary intensive care

BACKGROUND

Pathogens causing infections are in many cases transmitted via the hands of personnel. Thus, hand antisepsis has strong epidemiological evidence of infection prevention. Depending on various factors, hand antisepsis adherence ranges between 9.1% and 85.2%.

AIM

To evaluate a new transponder system that reminded medical staff to use an alcohol-based hand rub based on indication by giving real-time feedback, to detect hand antisepsis adherence.

METHODS

The monitoring system consisted of three components: a portable transponder detecting alcohol-based hand rub and able to give feedback; a beacon recognizing entries to and exits from the patient's surroundings; and a sensor placed at the hand-rub dispensers to count the number of hand rubs. With these components, the system provided feedback when hand antisepsis was not conducted although it was necessary according to moments 1, 4, and 5 of hand antisepsis. Adherence was measured in two use-cases with five phases, starting with the baseline measurement followed by intervention periods and phases without intervention to test the sustainability of the feedback.

FINDINGS

Using the monitoring system, hand antisepsis adherence was increased by up to 104.5% in comparison to the baseline measurement. When the intervention ceased, however, hand antisepsis adherence decreased to less than or equal to the baseline measurement.

CONCLUSION

A short-term intervention alone is not sufficient to lead to a long-term change in hand antisepsis adherence. Rather, permanent feedback and/or the integration in a multi-modal intervention strategy are necessary.

Implementation of an electronic hand hygiene monitoring system: Learnings on how to maximize the investment

BACKGROUND

Electronic monitoring systems (EMS) for measuring hand hygiene performance have many advantages. Previous studies have shared results of EMS in individual units or single institutions, without many details of implementation. The implementation steps for house wide use of an EMS in 12 hospitals are described.

METHODS

Hospital resources used in this 3-year implementation included those for installation activities, initial education about the components and function of the EMS, evaluation of healthcare professionals' processes related to hand hygiene, routine data feedback in a variety of methods, continuous coaching and training on the EMS, incentive programs and strong leadership support.

RESULTS

Continual process improvement activities resulted in a 23% increase in hand hygiene performance, from 53% at baseline, to 76%.

DISCUSSION/CONCLUSION

Implementation of an EMS required many resources beyond those for the technology, but resulted in measurable improvement in hand hygiene performance.

Using nudges to promote clinical decision making of healthcare professionals: A scoping review

Nudging has been discussed in the context of policy and public health, but not so much within healthcare. This scoping review aimed to assess the empirical evidence on how nudging techniques can be used to affect the behavior of healthcare professionals (HCPs) in clinical settings. A systematic database search was conducted for the period January 2010-December 2020 using the PRISMA extension for Scoping Review checklist. Two reviewers independently screened each article for inclusion. Included articles were reviewed to extract key information about each intervention, including purpose, target behavior, measured outcomes, key findings, nudging strategies, intervention objectives and their theoretical underpinnings. Two independent dimensions, building on Kahneman's System 1 and System 2, were used to describe nudging strategies according to user action and timing of their implementation. Of the included 51 articles, 40 reported statistically significant results, six were not significant and two reported mixed results. Thirteen different nudging strategies were identified aimed at modifying four types of HPCs' behavior: prescriptions and orders, procedure, hand hygiene, and vaccination. The most common nudging strategy employed were defaults or pre-orders, followed by alerts or reminders, and active choice. Many interventions did not require any deliberate action from users, here termed passive interventions, such as automatically changing prescriptions to their generic equivalent unless indicated by the user. Passive nudges may be successful in changing the target outcome but may go unnoticed by the user. Future work should consider the broader ethical implications of passive nudges.

Clinical Evaluation of an Electronic Hand Hygiene Monitoring System

BACKGROUND

We aimed to test the accuracy of an electronic hand hygiene monitoring system (EHHMS) during daily clinical activities in different wards and with varying healthcare professions.

METHOD

The accuracy of an EHHMS ([blinded for reviewers]) was assessed during real clinical conditions by comparing events registered by two observers in parallel with events registered by the EHHMS. The events were categorized as true-positive, false-positive, and false-negative registrations. Sensitivity and positive predictive value (PPV) were calculated.

RESULTS

A total of 103 events performed by 25 healthcare workers (9 doctors, 11 nurses, and 5 cleaning assistants) were included in the analyses. The EHHMS had a sensitivity of 100% and a positive predictive value of 100% when measuring alcohol-based hand rub. When looking at the hand hygiene opportunities of all healthcare workers combined taking place in the patient rooms and working rooms, the sensitivity was 75% and the PPV 95%. For doctors' and nurses' taking care of patients in their beds the EHHMS had a sensitivity of 100% and a PPV of 94%.

CONCLUSION

The objective accuracy measures demonstrate that this EHHMS can capture hand hygiene behavior under clinical conditions in different settings with clinical healthcare workers but show less accuracy with cleaning assistants.

Internet of things in healthcare for patient safety: an empirical study

Introduction

This study evaluates the impact of an Internet of Things (IoT) intervention in a hospital unit and provides empirical evidence on the effects of smart technologies on patient safety (patient falls and hand hygiene compliance rate) and staff experiences.

Method

We have conducted a post-intervention analysis of hand hygiene (HH) compliance rate, and a pre-and post-intervention interrupted time-series (ITS) analysis of the patient falls rates. Lastly, we investigated staff experiences by conducting semi-structured open-ended interviews based on Roger’s Diffusion of Innovation Theory.

Results

The results showed that (i) there was no statistically significant change in the mean patient fall rates. ITS analysis revealed non-significant incremental changes in mean patient falls (− 0.14 falls/quarter/1000 patient-days). (ii) HH compliance rates were observed to increase in the first year then decrease in the second year for all staff types and room types. (iii) qualitative interviews with the nurses reported improvement in direct patient care time, and a reduced number of patient falls.

Conclusion

This study provides empirical evidence of some positive changes in the outcome variables of interest and the interviews with the staff of that unit reported similar results as well. Notably, our observations identified behavioral and environmental issues as being particularly important for ensuring success during an IoT innovation implementation within a hospital setting.

Analysis of social interactions and risk factors relevant to the spread of infectious diseases at hospitals and nursing homes

Ensuring the safety of healthcare workers is vital to overcome the ongoing COVID-19 pandemic. We here present an analysis of the social interactions between the healthcare workers at hospitals and nursing homes. Using data from an automated hand hygiene system, we inferred social interactions between healthcare workers to identify transmission paths of infection in hospitals and nursing homes. A majority of social interactions occurred in medication rooms and kitchens emphasising that health-care workers should be especially aware of following the infection prevention guidelines in these places. Using epidemiology simulations of disease at the locations, we found no need to quarantine all healthcare workers at work with a contagious colleague. Only 14.1% and 24.2% of the health-care workers in the hospitals and nursing homes are potentially infected when we disregard hand sanitization and assume the disease is very infectious. Based on our simulations, we observe a 41% and 26% reduction in the number of infected healthcare workers at the hospital and nursing home, when we assume that hand sanitization reduces the spread by 20% from people to people and 99% from people to objects. The analysis and results presented here forms a basis for future research to explore the potential of a fully automated contact tracing systems.

Hand hygiene compliance of healthcare workers before and during the COVID-19 pandemic: A long-term follow-up study

Background

Information about the long-term effects of hand hygiene (HH) interventions is needed. We aimed to investigate the change in HH compliance (HHC) of healthcare workers (HCWs) once a data-driven feedback intervention was stopped, and to assess if the COVID-19 pandemic influenced the HH behavior.

Methods

We conducted an observational, extension trial in a surgical department between January 2019–December 2020. Doctors (n = 19) and nurses (n = 53) were included and their HHC was measured using an electronic HH monitoring system (EHHMS). We compared the changes in HHC during 3 phases: (1) Intervention (data presentation meetings), (2) Prepandemic follow-up and (3) Follow-up during COVID-19.

Results

The HHC during phase 1 (intervention), phase 2 (prepandemic follow-up) and phase 3 (follow-up during COVID-19) was 58%, 46%, and 34%, respectively. Comparison analyses revealed that the HHC was significantly lower in the prepandemic follow-up period (46% vs 58%, P < .0001) and in the follow-up period during COVID-19 (34% vs 58%, P < .0001) compared with the intervention period (phase 1).

Conclusions

Despite the COVID-19 pandemic, the HHC of the HCWs significantly decreased over time once the data presentation meetings from management stopped. This study demonstrates that HCWs fall back into old HH routines once improvement initiatives are stopped.

Assessing the clinical accuracy of a hand hygiene system: Learnings from a validation study

There is a need to establish validation standards that allow for comparison of automated hand hygiene systems. To assess the accuracy of an innovative monitoring tool (Sani nudge), 2 test nurses performed clinical standard tasks while being observed by 2 infection preventionists. Data from the direct observations were compared with data obtained from the hand hygiene system (Sani nudge) using an independent-event approach. We identified 54 true-positive events (100% system accuracy) and 4 true-negative events (100% system accuracy). No false-positive or false-negative events were identified. We found this approach to be feasible and clinically useful to validate hand hygiene systems in the future.

Effectiveness of an electronic hand hygiene monitoring system in increasing compliance and reducing healthcare-associated infections

During an interventional study in a nephrology department, we investigated the effect of an electronic hand hygiene monitoring system on the hand hygiene compliance of healthcare workers (N = 99) and hospital-acquired bloodstream infections. The hand hygiene compliance of the doctors and nurses improved significantly during the intervention phase when they received group and individual feedback based on actionable insights from the electronic hand hygiene monitoring system. The improvements in hand hygiene compliance were associated with a significant reduction in the number of hospital-acquired bloodstream infections.