Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare

Drastic hourly changes in hand hygiene workload and performance rates: a multicenter time series analysis

BACKGROUND

High hand hygiene (HH) workload is a commonly cited barrier to optimal HH performance. The objective of this study was to assess trends of HH workload as defined by HH opportunities (HHO) and performance rates over different time scales using automated HH monitoring system data.

METHODS

This multi-year retrospective observational study was conducted in 58 inpatient units located in 10 North American hospitals. HHO and HH rates were analyzed by time series mixed effects general additive model.

RESULTS

Median HH rates peaked at 50.0 between 6-7 am with a trough of 38.2 at 5 pm. HHO over hours in a day were highest at 184 per hospital unit per hour at 10 am with a trough of 49.0 between 2-3 am. Median rates for day and night shifts were 40.8 and 45.5 respectively (p=0.078). Weekend day shift had the lowest median rate (39.4) compared to any other 12-hour shift (p<0.1018). The median rates and HHO varied little across days in a week and months.

CONCLUSIONS

HH workload and performance rates were negatively correlated and changed drastically over hours in a day. Hospitals should consider HH workload in the development and timely delivery of improvement interventions.

Video Documentation in Thyroidectomy and an Evaluation of Operative Notes

Introduction Accurate and detailed documentation of surgical operation notes is crucial for post-operative care, research and academic purposes, and medico-legal clarity. Several studies have shown their defiency and inaccuracy sometimes, and some methods have been proposed to make them more objective. This study aimed to evaluate the completeness of thyroidectomy operative notes in a tertiary center and to assess the adequacy of video documentation by comparing it to the corresponding operative notes. Methods A retrospective review of thyroidectomy operative notes from 2010 to 2020 at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, was performed to ensure completeness. Subsequently, 15 thyroidectomies were video recorded, and their notes were compared to the corresponding written operative notes. The completeness score was calculated based on an item list that included items that had to be included in an operative note. An independent samples t-test was used to compare the completeness score means between the two groups. One-way analysis of variance was used to compare the completeness score means between two or more groups. Result A total of 385 thyroidectomy-operative notes were retrospectively reviewed. The completeness scores ranged between 6% and 89% for the various items that had to be documented, with a mean of 54.47%. The mean score of the video-documented operative record was 83.86%±12.84%, which was significantly higher than the corresponding written operative notes (47.53%±18.06%) (p <0.001). Conclusion Video documentation showed significant improvement compared to the corresponding written and retrospective operative notes. Video recording can also be a valuable tool when teaching anatomy and surgical skills and conducting research.

Current issues in hand hygiene

BACKGROUND

Multiple aspects of hand hygiene have changed in recent years.

METHODS

A PubMed search was conducted to identify recent articles about hand hygiene.

RESULTS

The COVID-19 pandemic caused temporary changes in hand hygiene compliance rates and shortages of alcohol-based hand sanitizers (ABHSs), and in marketing of some products that were ineffective or unsafe. Fortunately, ABHSs are effective against SARS-CoV-2 and other emerging pathogens including Candida auris and mpox. Proper placement, maintenance, and design of ABHS dispensers have gained additional attention. Current evidence suggests that if an adequate volume of ABHS has been applied to hands, personnel must rub their hands together for at least 15 seconds before hands feel dry (dry time), which is the primary driver of antimicrobial efficacy. Accordingly, practical methods of monitoring hand hygiene technique are needed. Direct observation of hand hygiene compliance remains a challenge in many healthcare facilities, generating increased interest in automated hand hygiene monitoring systems (AHHMSs). However, several barriers have hindered widespread adoption of AHHMSs. AHHMSs must be implemented as part of a multimodal improvement program to successfully improve hand hygiene performance rates.

CONCLUSIONS

Remaining gaps in our understanding of hand hygiene warrant continued research into factors impacting hand hygiene practices.

Effect of video camera monitoring feedback on hand hygiene compliance in neonatal intensive care unit, an interventional study

BACKGROUND

The purpose of this study was to determine whether use of a video camera surveillance system for hand hygiene (HH) monitoring, video-based education, and feedback could improve the HH compliance in a neonatal intensive care unit (NICU).

METHODS AND MATERIALS

This was an interventional before-after trial conducted in a level-III NICU between July 2019 and June 2020. HH compliance was measured using randomly selected video-camera footage in the baseline, intervention, and maintenance periods. After the baseline, an intervention consisting of feedback and education with video scenarios was implemented. The primary outcome was change in HH compliance. The compliance rates were analyzed as an interrupted time series (ITS) with a segmented regression model adjusted for autocorrelation for each study period.

RESULTS

We identified a total of 8335 HH indications. There were non significant increases in the total compliance rate (9.0%, 95% CI -2% to 20%) at the time of intervention and in the compliance rate after intervention (0.26%, 95% CI -0.31% to 0.84%) per day. The hand hygiene compliance before patient contact significantly increased (19.8%, 95% CI, 4.8%-34.8%). Incorrect glove use improved non-significantly with the intervention (-3.4%, 95% CI -13.4% to 6.7%).

CONCLUSION

In this study of HH monitoring using video-camera footage combined with an intervention including feedback and education, there were inconsistent improvements in HH compliance. However, these improvements were not sustained in the long term. Frequent feedback and education may be required to sustain high compliance.

Healthcare Personnel Hand Hygiene Compliance: Are We There Yet?

Purpose of Review

Poor hand hygiene is well documented as a factor in healthcare-associated infections and excellent rates of hand hygiene remains elusive.

Recent Findings

There is increased use of universal or increased gloving to minimize hand contamination, but its use does not replace hand hygiene opportunities. There is significant interest in electronic hand hygiene monitoring systems, but they are not without their unique issues. Behavioral psychology remains a significant factor in motivating hand hygiene behaviors; even in COVID-19, hand hygiene rates initially improved but trended down back to baseline while still dealing with the pandemic.

Summary

More emphasis should be placed on the how to properly perform hand hygiene and why it is so important, as well as the role of gloves, is needed. Continued investment and awareness of their status as role models from both system leadership and senior healthcare providers are needed.

Implementation Strategies for Preventing Healthcare-Associated Infections across the Surgical Pathway: An Italian Multisociety Document

Healthcare-associated infections (HAIs) result in significant patient morbidity and can prolong the duration of the hospital stay, causing high supplementary costs in addition to those already sustained due to the patient’s underlying disease. Moreover, bacteria are becoming increasingly resistant to antibiotics, making HAI prevention even more important nowadays. The public health consequences of antimicrobial resistance should be constrained by prevention and control actions, which must be a priority for all health systems of the world at all levels of care. As many HAIs are preventable, they may be considered an important indicator of the quality of patient care and represent an important patient safety issue in healthcare. To share implementation strategies for preventing HAIs in the surgical setting and in all healthcare facilities, an Italian multi-society document was published online in November 2022. This article represents an evidence-based summary of the document.

Evolution of the digital operating room: the place of video technology in surgery

PURPOSE

The aim of this review was to collate current evidence wherein digitalisation, through the incorporation of video technology and artificial intelligence (AI), is being applied to the practice of surgery. Applications are vast, and the literature investigating the utility of surgical video and its synergy with AI has steadily increased over the last 2 decades. This type of technology is widespread in other industries, such as autonomy in transportation and manufacturing.

METHODS

Articles were identified primarily using the PubMed and MEDLINE databases. The MeSH terms used were "surgical education", "surgical video", "video labelling", "surgery", "surgical workflow", "telementoring", "telemedicine", "machine learning", "deep learning" and "operating room". Given the breadth of the subject and the scarcity of high-level data in certain areas, a narrative synthesis was selected over a meta-analysis or systematic review to allow for a focussed discussion of the topic.

RESULTS

Three main themes were identified and analysed throughout this review, (1) the multifaceted utility of surgical video recording, (2) teleconferencing/telemedicine and (3) artificial intelligence in the operating room.

CONCLUSIONS

Evidence suggests the routine collection of intraoperative data will be beneficial in the advancement of surgery, by driving standardised, evidence-based surgical care and personalised training of future surgeons. However, many barriers stand in the way of widespread implementation, necessitating close collaboration between surgeons, data scientists, medicolegal personnel and hospital policy makers.

Investigation of individual nurses' relative hand hygiene performance using an anonymous automated electronic hand hygiene monitoring system and a nursing assignment schedule

BACKGROUND

We investigated whether an anonymous automated electronic monitoring system (EMS) could be used to compare hand hygiene (HH) performance of individual nurses.

METHODS

Prospective observational cohort study. HH performance in 10 acute-care patient rooms was estimated through an EMS that anonymously measured HH events, and room entries and exits. The association between patient room's HH compliance and the nurse in charge of each room was investigated by comparing percentile rank distributions, and through a negative binomial model.

RESULTS

Over 99 days, there were 38,596 HH events and 135,546 room entries and exits (global HH performance, 28%). For 10 of 54 (19%) nurses, the median HH percentile rank of the rooms to which they were assigned was higher than the group average (P < .001; range of percentiles, 64th to 85th). A lower median percentile was seen in 9/54 (17%) participants (P < .001; range of percentiles, 22nd to 39th). The negative binomial model confirmed this association and identified 15 of 54 high performers (range of adjusted incidence rate ratios [aIRR], 1.17-1.83) and 16 of 54 low performers (range of aIRR, 0.37-0.77).

DISCUSSION AND CONCLUSIONS

An association exists between a room's HH rate and its assigned nurse. This association could hold potential value for an individualized feedback strategy.

Health care workers' experiences of video-based monitoring of hand hygiene behaviors: a qualitative study

BACKGROUND

Hand hygiene is key to preventing health care-associated infections. Human observation is the gold standard for measuring compliance, but its utility is increasingly being questioned with calls for the use of video monitoring approaches. The utility of video-based systems to measure compliance according to the WHO 5 moments is largely unexamined, as is its acceptability amongst health care workers (HCW) and patients. This study examined HCW acceptability of video monitoring for hand hygiene auditing.

METHODS

Following trial of a video monitoring system (reported elsewhere), 5 participating HCW attended 2 in-depth group interviews where they reviewed the footage and explored responses to the approach. Transcripts were analyzed using thematic analysis.

RESULTS

Four themes were identified: 1) Fears; 2) Concerns for patients; 3) Changes to feedback; and 4) Behavioral responses to the cameras. HCWs expressed fears of punitive consequences, data security, and confidentiality. For patients, HCWs raised issues regarding invasion of privacy, ethics, and consent. HCWs suggested that video systems may result in less immediate feedback but also identified potential to use the footage for feedback. They also suggested that the Hawthorne Effect was less potent with video systems than human observation.

CONCLUSIONS

The acceptability of video monitoring systems for hand hygiene compliance is complex and has the potential to complicate practical implementation. Additionally, exploration of the acceptability to patients is warranted.

CHECKLIST

COREQ.

Electronic monitoring of doffing using video surveillance to minimise error rate and increase safety at Howard Springs International Quarantine Facility

Background

Safe donning and doffing of personal protective equipment (PPE) are critical to prevent transmission of infectious diseases. Novel strategies to improve infection prevention and control (IPC) adherence can optimise safety. We describe and quantify video surveillance of doffing at an outdoor hotel quarantine facility led by the Australian Medical Assistance Team in the Northern Territory, Australia.

Methods

Motion-activated video cameras were installed in seven areas where personnel doffed PPE upon exit from an area dedicated to quarantined residents. Video footage was reviewed daily and compliance issues were identified using a standardised checklist and risk graded to initiate feedback. We collated audit data from 1 February to 18 April 2021 to describe trends by month, staff group, doffing component and risk.

Results

In 235 h of video footage, 364 compliance issues were identified, of which none were considered high-risk compromising to PPE integrity. Compliance issues were low risk (55/364, 15%) or moderate risk (309/364, 85%) and the most common issue was missed or inadequate hand hygiene (156/364, 43%). Compliance issues per minute of video footage reviewed decreased following introduction of the activity, from 24 per 1000 in February to 7 per 1000 in March and April.

Conclusion

Video surveillance with feedback supported rapid response to improve IPC adherence in a challenging ambient environment. The activity focused on perfection to identify compliance issues that would go unreported in most healthcare settings and contributed to a suit of activities that prevented any high-risk PPE breaches or compromises to safety.

Assessment of the Hawthorne effect during central venous catheter manipulation

OBJECTIVES

To describe the compliance to the practices of hand hygiene and hub disinfection before manipulation of the central venous catheter in two moments: before and after educational intervention. Adherence to hand hygiene was assessed with two methods: direct observation and video camera.

METHODS

Before and after study conducted with the nursing team in an adult intensive care unit, in São Paulo, Brazil, including 180 observations using video cameras and direct observation. Hand hygiene compliance before catheter manipulation and compliance with the correct technique and the hub disinfection for five seconds were observed.

RESULTS

When video cameras recording was observed, hand hygiene compliance increased from 46% to 66% and the use of the proper technique increased from 23% to 46% (p < 0.05). Regarding hub disinfection compliance, no difference was observed between the periods. Hand hygiene compliance in direct observation increased from 83% to 87% and in indirect observation, from 46% to 66% after the intervention.

CONCLUSION

After the educational intervention, hand hygiene compliance before CVC manipulation and the use of the correct technique improved. When observed indirectly, the adherence to these practices was lower, reinforcing the Hawthorne effect.

Using video-based surveillance for monitoring hand hygiene compliance according to the World Health Organization (WHO) Five Moments framework: A pragmatic trial

Objective:

To examine the utility of video-based monitoring systems (VMSs) for auditing hand hygiene compliance according to the World Health Organization (WHO) Five Moments.

Design:

Pragmatic quasi-experimental observation trial.

Setting:

The New South Wales Biocontainment Centre, Westmead, New South Wales, Australia.

Participants:

Volunteer healthcare workers (HCWs).

Method:

Six high-fidelity simulations were recorded and subsequently assessed for their ability to audit hand hygiene compliance according to the WHO Five Moments for hand hygiene criteria using tools provided by the National Hand Hygiene Initiative (NHHI).

Results:

In total, 206 minutes of recorded footage were reviewed in 120 minutes, yielding 111 moments. Overall HCW hand hygiene compliance was 88% according to the WHO Five Moments framework. The cost per moment was $0.91 AUD ($0.66 USD) and the time required per moment was 64 seconds.

Conclusions:

Auditing of hand hygiene compliance according to all 5 of the WHO Five Moments from recorded footage is not only possible but provides cost and time savings. In addition, the process may produce output that is less subject to the biases inherent in direct human observational auditing.

Video engagement to improve handwashing duration: A longitudinal study assessing creative and messaging fatigue

BACKGROUND

Poor hand hygiene can contribute to increased rates of health care and community-acquired infections. Effective hand hygiene involves both a washer's technique and the duration of their wash.

METHODS

The purpose of this longitudinal study was 2-fold: to improve the ability of hand-washers to meet the recommended handwashing duration of ≥20 seconds and to assess the effect of washer fatigue with the intervention. An innovative system of smart connected soap and towel dispensers synchronized to engaging video content was implemented to meet this objective.

RESULTS

The intervention increased mean handwashing duration by 7.5 seconds (95% CI: 6.6, 8.4) and improved handwashing duration ≥20 seconds by 39.3% (P < .001). Using a similar cohort of hand-washers over 26 months, the video content had peak effect in month 1, and declined to a new steady state at month 11.

DISCUSSION

Handwashing for the recommended time can be difficult to achieve. Most hand hygiene studies examine the rate of completion without measuring duration.

CONCLUSIONS

Video engagement can improve and sustain handwashing duration. To mitigate creative and messaging fatigue, video content refresh for this intervention should be considered at 3 months for optimal effect or at 11 months prior to full decline to new steady state.

Hand Hygiene Behaviours Monitored by an Electronic System in the Intensive Care Unit-A Prospective Observational Study

BACKGROUND

Hand hygiene (HH) compliance is hard to improve and underlying behaviours are not clearly understood among healthcare workers.

AIM

To study healthcare workers' HH behaviours.

METHODS

Prospective observational study. Sanibit electronic hand hygiene system was installed in a 10-bed surgical intensive care unit that automatically detected HH opportunities when healthcare workers entered or exited a patient room, and tracked healthcare worker's HH compliance. HH compliance rate and patient contact time were calculated and analyzed at both the ICU and individual levels over time.

FINDINGS

A total of 27,692 HH opportunities were recorded during this 6-month trial period. The HH compliance rate was significantly higher when healthcare workers exited patient rooms than when they entered rooms (37.3% vs. 26.1%, P < 0.001). The full, partial, and total HH compliance rates of quick in-out of room (in room less than 3 seconds) events were significantly lower than those of long in-out room (in room more than 30 seconds) events (23.45% vs 32.77%, 21.44% vs 35.03%, and 44.88% vs 67.81% respectively) (P-value <0.001). There was also significantly differences in HH compliance among individual healthcare workers (P < 0.001). No statistically significant difference was found in overall HH compliance rate and patient contact time over hours of the day or days of the week except partial HH compliance rates.

CONCLUSION

Patterns of healthcare workers' HH behaviors are complex and variable, which could facilitate targeted and personalized interventions to improve HH compliance.

Guiding spatial attention by multimodal reward cues

Our attention is constantly captured and guided by visual and/or auditory inputs. One key contributor to selecting relevant information from the environment is reward prospect. Intriguingly, while both multimodal signal processing and reward effects on attention have been widely studied, research on multimodal reward signals is lacking. Here, we investigated this using a Posner task featuring peripheral cues of different modalities (audiovisual/visual/auditory), reward prospect (reward/no-reward), and cue-target stimulus-onset asynchronies (SOAs 100-1,300 ms). We found that audiovisual and visual reward cues (but not auditory ones) enhanced cue-validity effects, albeit with different time courses (Experiment 1). While the reward-modulated validity effect of visual cues was pronounced at short SOAs, the effect of audiovisual reward cues emerged at longer SOAs. Follow-up experiments exploring the effects of visual (Experiment 2) and auditory (Experiment 3) reward cues in isolation showed that reward modulated performance only in the visual condition. This suggests that the differential effect of visual and auditory reward cues in Experiment 1 is not merely a result of the mixed cue context, but confirms that visual reward cues have a stronger impact on attentional guidance in this paradigm. Taken together, it seems that adding an auditory reward cue to the inherently dominant visual one led to a shift/extension of the validity effect in time - instead of increasing its amplitude. While generally being in line with a multimodal cuing benefit, this specific pattern highlights that different reward signals are not simply combined in a linear fashion but lead to a qualitatively different process.

Implementing an electronic hand hygiene system improved compliance in the intensive care unit

BACKGROUND

Hand hygiene (HH) compliance is low and difficult to improve among health care workers. We aim to validate an electronic HH system and assess the impact of this system on HH compliance and quality changes over time at both group and individual levels.

METHODS

An automated electronic HH system was installed in a 10-bed surgical intensive care unit.

RESULTS

The full HH compliance rate increased significantly from 8.4% in week 1 to 20.5% in week 16 with week 10 being the highest (27.4%). The partial compliance rate maintained relative consistency between 13.2% and 20.0%. The combined compliance rate (full compliance rate + partial compliance rate) increased from 23.5% in week 1 to 34.6% in week 16 with week 10 being the highest (41.4%).

DISCUSSION

We found significant variations among providers in terms of HH opportunities per shift, full compliance, partial compliance and combined compliance rates. The average duration of hand rubbing over time in partial compliance occurrences did not change significantly over time.

CONCLUSIONS

A sensor-based platform with automated HH compliance and quality monitoring, real time feedback and comprehensive individual level analysis, improved providers' HH compliance in an intensive care unit. There were significant variations among individual providers.

Electronic Monitoring Systems for Hand Hygiene: Systematic Review of Technology

BACKGROUND

Hand hygiene is one of the most effective ways of preventing health care-associated infections and reducing their transmission. Owing to recent advances in sensing technologies, electronic hand hygiene monitoring systems have been integrated into the daily routines of health care workers to measure their hand hygiene compliance and quality.

OBJECTIVE

This review aims to summarize the latest technologies adopted in electronic hand hygiene monitoring systems and discuss the capabilities and limitations of these systems.

METHODS

A systematic search of PubMed, ACM Digital Library, and IEEE Xplore Digital Library was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were initially screened and assessed independently by the 2 authors, and disagreements between them were further summarized and resolved by discussion with the senior author.

RESULTS

In total, 1035 publications were retrieved by the search queries; of the 1035 papers, 89 (8.60%) fulfilled the eligibility criteria and were retained for review. In summary, 73 studies used electronic monitoring systems to monitor hand hygiene compliance, including application-assisted direct observation (5/73, 7%), camera-assisted observation (10/73, 14%), sensor-assisted observation (29/73, 40%), and real-time locating system (32/73, 44%). A total of 21 studies evaluated hand hygiene quality, consisting of compliance with the World Health Organization 6-step hand hygiene techniques (14/21, 67%) and surface coverage or illumination reduction of fluorescent substances (7/21, 33%).

CONCLUSIONS

Electronic hand hygiene monitoring systems face issues of accuracy, data integration, privacy and confidentiality, usability, associated costs, and infrastructure improvements. Moreover, this review found that standardized measurement tools to evaluate system performance are lacking; thus, future research is needed to establish standardized metrics to measure system performance differences among electronic hand hygiene monitoring systems. Furthermore, with sensing technologies and algorithms continually advancing, more research is needed on their implementation to improve system performance and address other hand hygiene-related issues.

Methodological and technical considerations for video-based auditing of hand hygiene compliance in clinical practice: an exploratory study

BACKGROUND

Direct observation is the gold standard method for measuring hand hygiene compliance but its utility is increasingly being questioned. Various alternative electronic methods have been proposed, yet there is a paucity of research examining the use of these according to the World Health Organization's (WHO) '5 Moments for Hand Hygiene'. As a part of the process of developing a video-based monitoring system (VMS) capable of measuring hand hygiene compliance against the 5 moments criteria this paper reports methodological and technical issues that might arise from the use of a VMS for auditing in clinical practice.

METHODS

In-depth semi-structured interviews were conducted with 27 Australian content experts in hand hygiene auditing and infection prevention to explore their responses to proposed VMS auditing approaches. Transcripts were analyzed using thematic and content analysis.

RESULTS

Technical and methodological considerations for the use of VMS were interrelated and included concerns surrounding privacy, footage security, fears of surveillance and the potential for medico-legal consequences. Additionally, possible detrimental impacts on healthcare worker (HCW) -patient relationships, issues of cost versus benefits, HCW and patient safety and changes to feedback were also identified.

CONCLUSIONS

The primary methodological and technical issues to overcome in order to implement VMS for hand hygiene auditing in clinical practice, centered upon issues of acceptability to patients and health professionals, privacy, consent and liability.

CHECKLIST

COREQ.

Hand Hygiene, an Update

Hand hygiene by health care personnel is an important measure for preventing health care-associated infections, but adherence rates and technique remain suboptimal. Alcohol-based hand rubs are the preferred method of hand hygiene in most clinical scenarios, are more effective and better tolerated than handwashing, and their use has facilitated improved adherence rates. Obtaining accurate estimates of hand hygiene adherence rates using direct observations of personnel is challenging. Combining automated hand hygiene monitoring systems with direct observations is a promising strategy, and is likely to yield the best estimates of adherence. Greater attention to hand hygiene technique is needed.

MRSA Transmission in Intensive Care Units: Genomic Analysis of Patients, Their Environments, and Healthcare Workers

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA)-and now USA300 MRSA-is a significant intensive care unit (ICU) pathogen; healthcare worker (HCW) contamination may lead to patient cross-transmission.

METHODS

From September 2015 to February 2016, to study the spread of MRSA, we enrolled HCWs in 4 adult ICUs caring for patients on MRSA contact precautions. Samples were collected from patient body sites and high-touch surfaces in patient rooms. HCW hands, gloves, and personal protective equipment were sampled pre/post-patient encounter. Whole genome sequencing (WGS) was used to compare isolates from patients, HCWs, and environment.

RESULTS

There were 413 MRSA isolates sequenced (38% USA300, 52% USA100) from 66 patient encounters. Six of 66 HCWs were contaminated with MRSA prior to room entry. Isolates from a single patient encounter were typically either USA100 or USA300; in 8 (12%) encounters both USA300 and USA100 were isolated. WGS demonstrated that isolates from patients, HCWs, and environment often were genetically similar, although there was substantial between-encounter diversity. Strikingly, there were 5 USA100 and 1 USA300 clusters that contained similar strains (<22 single-nucleotide variants [SNVs], with most <10 SNVs) within the cluster despite coming from different encounters, suggesting intra- and inter-ICU spread of strains, that is, 4 of these genomic clusters were from encounters in the same ICU; 5 of 6 clusters occurred within 1 week.

CONCLUSIONS

We demonstrated frequent spread of MRSA USA300 and USA100 strains among patients, environment, and HCWs. WGS identified possible spread within and even between ICUs. Future analysis with detailed contact tracing in conjunction with genomic data may further elucidate pathways of MRSA spread and points for intervention.

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

Background

Evidence-based practices to increase hand hygiene compliance (HHC) among health care workers are warranted. We aimed to investigate the effect of a multimodal strategy on HHC.

Methods

During this 14-month prospective, observational study, an automated monitoring system was implemented in a 29-bed surgical ward. Hand hygiene opportunities and alcohol-based hand rubbing events were measured in patient and working rooms (medication, utility, storerooms, toilets). We compared baseline HHC of health care workers across periods with light-guided nudging from sensors on dispensers and data-driven performance feedback (multimodal strategy) using the Student's t test.

Results

The doctors (n = 10) significantly increased their HHC in patient rooms (16% vs 42%, P< .0001) and working rooms (24% vs 78%, P= .0006) when using the multimodal strategy. The nurses (n = 26) also increased their HHC significantly from baseline in both patient rooms (27% vs 43%, P = .0005) and working rooms (39% vs 64%, P< .0001). The nurses (n = 9), who subsequently received individual performance feedback, further increased HHC, compared with the period when they received group performance feedback (patient rooms: 43% vs 55%, P< .0001 and working rooms: 64% vs 80%, P< .0001).

Conclusions

HHC of doctors and nurses can be significantly improved with light-guided nudging and data-driven performance feedback using an automated hand hygiene system.

Introduction of Group Electronic Monitoring of Hand Hygiene on Inpatient Units: A Multicenter Cluster Randomized Quality Improvement Study

BACKGROUND

The current approach to measuring hand hygiene (HH) relies on human auditors who capture <1% of HH opportunities and rapidly become recognized by staff, resulting in inflation in performance. Group electronic monitoring is a validated method of measuring HH adherence, but data demonstrating the clinical impact of this technology are lacking.

METHODS

A stepped-wedge cluster randomized quality improvement study was performed on 26 inpatient medical and surgical units across 5 acute care hospitals in Ontario, Canada. The intervention involved daily HH reporting as measured by group electronic monitoring to guide unit-led improvement strategies. The primary outcome was monthly HH adherence (percentage) between baseline and intervention. Secondary outcomes included transmission of antibiotic-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and other healthcare-associated infections.

RESULTS

After adjusting for the correlation within inpatient units and hospitals, there was a significant overall improvement in HH adherence associated with the intervention (incidence rate ratio [IRR], 1.73 [95% confidence interval {CI}, 1.47-1.99]; P < .0001). Monthly HH adherence relative to the intervention increased from 29% (1 395 450/4 544 144) to 37% (598 035/1 536 643) within 1 month, followed by consecutive incremental increases up to 53% (804 108/1 515 537) by 10 months (P < .0001). There was a trend toward reduced healthcare-associated transmission of MRSA (IRR, 0.74 [95% CI, .53-1.04]; P = .08).

CONCLUSIONS

The introduction of a system for group electronic monitoring led to rapid, significant improvements in HH performance within a 2-year period. This method offers significant advantages over direct observation for measurement and improvement of HH.

Automatic detection of hand hygiene using computer vision technology

OBJECTIVE

Hand hygiene is essential for preventing hospital-acquired infections but is difficult to accurately track. The gold-standard (human auditors) is insufficient for assessing true overall compliance. Computer vision technology has the ability to perform more accurate appraisals. Our primary objective was to evaluate if a computer vision algorithm could accurately observe hand hygiene dispenser use in images captured by depth sensors.

MATERIALS AND METHODS

Sixteen depth sensors were installed on one hospital unit. Images were collected continuously from March to August 2017. Utilizing a convolutional neural network, a machine learning algorithm was trained to detect hand hygiene dispenser use in the images. The algorithm's accuracy was then compared with simultaneous in-person observations of hand hygiene dispenser usage. Concordance rate between human observation and algorithm's assessment was calculated. Ground truth was established by blinded annotation of the entire image set. Sensitivity and specificity were calculated for both human and machine-level observation.

RESULTS

A concordance rate of 96.8% was observed between human and algorithm (kappa = 0.85). Concordance among the 3 independent auditors to establish ground truth was 95.4% (Fleiss's kappa = 0.87). Sensitivity and specificity of the machine learning algorithm were 92.1% and 98.3%, respectively. Human observations showed sensitivity and specificity of 85.2% and 99.4%, respectively.

CONCLUSIONS

A computer vision algorithm was equivalent to human observation in detecting hand hygiene dispenser use. Computer vision monitoring has the potential to provide a more complete appraisal of hand hygiene activity in hospitals than the current gold-standard given its ability for continuous coverage of a unit in space and time.

Computer Vision in the Operating Room: Opportunities and Caveats

Effectiveness of computer vision techniques has been demonstrated through a number of applications, both within and outside healthcare. The operating room environment specifically is a setting with rich data sources compatible with computational approaches and high potential for direct patient benefit. The aim of this review is to summarize major topics in computer vision for surgical domains. The major capabilities of computer vision are described as an aid to surgical teams to improve performance and contribute to enhanced patient safety. Literature was identified through leading experts in the fields of surgery, computational analysis and modeling in medicine, and computer vision in healthcare. The literature supports the application of computer vision principles to surgery. Potential applications within surgery include operating room vigilance, endoscopic vigilance, and individual and team-wide behavioral analysis. To advance the field, we recommend collecting and publishing carefully annotated datasets. Doing so will enable the surgery community to collectively define well-specified common objectives for automated systems, spur academic research, mobilize industry, and provide benchmarks with which we can track progress. Leveraging computer vision approaches through interdisciplinary collaboration and advanced approaches to data acquisition, modeling, interpretation, and integration promises a powerful impact on patient safety, public health, and financial costs.

Comparison of two electronic hand hygiene monitoring systems in promoting hand hygiene of healthcare workers in the intensive care unit

Background

Hand hygiene (HH) is the cornerstone of infection control, and the promotion of HH is the focus of the world. The study aims to compare the role of two different types of electronic hand hygiene monitoring systems (EHHMSs) in promoting HH of healthcare workers (HCWs) in the intensive care unit (ICU).

Methods

In a 16-bed ICU of a general tertiary hospital in Shenzhen, the research was divided into three stages with interrupted time series (ITS) design. In the first stage, the direct observation method was used to monitor and feed back the HH compliance rate of HCWs monthly. In the second stage, the type1 EHHMS was applied to monitor and feed back the individual number of HH events monthly. In the third stage, the type2 EHHMS with a function of instant reminder and feedback was employed, and the personal HH compliance rates were fed back monthly. Meanwhile, direct observation continued in the last two stages.

Results

In the second stage, The HH compliance rate increased. However, there was no significant difference in the trajectory of the rate compared with the first stage. In the first month of the third stage, the HH compliance rate increased by 12.324% immediately and then ascended by 1.242% over time. The number of HH events per bed day and HH products’ consumption per bed day were consistent with the change of HH compliance rate observed.

Conclusion

Monitoring and feedback can improve the HH of HCWs. The EHHMS, with the function of real-time reminders and feedback, has a more noticeable effect on promoting HH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05748-3.

Physicians' compliance for hand hygiene in medical outpatient clinics: automated hand-hygiene monitoring with touch sensor and wireless internet

BACKGROUND

Outpatient clinics are reservoirs for significant pathogens. Hand hygiene with alcohol-based hand rubs are measures currently in use to prevent horizontal transmission of infections. The extent of compliance with hand hygiene regulations is unclear and difficult to monitor.

METHODS

We built an automated monitoring system with a pressure sensor attached to the alcohol-based hand rubs containers. Wireless fidelity (WIFI)-assisted data collection took place over 9 weeks. Interventions included posters, email reminders and newsletters. Hand hygiene compliance before and after these interventions was evaluated.

RESULTS

Overall compliance with hand hygiene regulations was 6.48%; half of the physicians participating in our study performed hand hygiene at only 3.08% of patient visits. Twenty-four (17.9%) physicians performed hand hygiene with high compliance (≥10%), while 11.2% performed no hand hygiene at all. Physicians in academic positions and those with ≥20 years of experience performed hand hygiene less frequently than did other physicians. Compliance with hand hygiene regulations improved from 6.08% to 6.73% (P < .001) after intervention.

DISCUSSION

Compliance with hand hygiene among physicians in our outpatient clinics was very low and needs to improve.

CONCLUSIONS

Interventions improved the compliance somewhat, although additional interventions including education, training and feedback were suggested.

Reduction of Health Care-Associated Infections (HAIs) with Antimicrobial Inorganic Nanoparticles Incorporated in Medical Textiles: An Economic Assessment

Health care-associated infections (HAIs) affect millions of patients annually with up to 80,000 affected in Europe on any given day. This represents a significant societal and economic burden. Staff training, hand hygiene, patient identification and isolation and controlled antibiotic use are some of the standard ways to reduce HAI incidence but this is time consuming and subject and subject to rigorous implementation. In addition, the lack of antimicrobial activity of some disinfectants against healthcare-associated pathogens may also affect the efficacy of disinfection practices. Textiles are an attractive substrate for pathogens because of contact with the human body with the attendant warmth and moisture. Textiles and surfaces coated with engineered nanomaterials (ENMs) have shown considerable promise in reducing the microbial burden on those surfaces. Studies have also shown that this antimicrobial affect can reduce the incidence of HAIs. For all of the promising research, there has been an absence of study on the economic effectiveness of ENM coated materials in a healthcare setting. This article examines the relative economic efficacy of ENM coated materials against an antiseptic approach. The goal is to establish the economic efficacy of the widespread usage of ENM coated materials in a healthcare setting. In the absence of detailed and segregated costs, benefits and control variables over at least cross sectional data or time series, an aggregated approach is warranted. This approach, while relying on some supposition allows for a comparison with similar data regarding standard treatment to reduce HAIs and provides a reasonable economic comparison. We find that while, relative to antiseptics, ENM coated textiles represent a significant clinical advantage, they can also offer considerable cost savings.

Efficacy of covert closed-circuit television monitoring of the hand hygiene compliance of health care workers caring for patients infected with multidrug-resistant organisms in an intensive care unit

BACKGROUND

To compare covert closed-circuit television (CCTV) monitoring to standard overt observation in assessing the hand hygiene (HH) conduct of health care workers (HCWs) caring for patients infected with multidrug-resistant organisms (MDROs). This was a cross-sectional study in a general intensive care unit of a 1,000-bed university hospital.

METHODS

Forty-six general intensive care unit HCWs (staff physicians, registered nurses, and auxiliary workers) caring for contact isolation MDRO-infected patients. The study incorporated the following 3 phases: phase 1, establishment of interrater reliability between 2 simultaneous observers using the overt observation method; phase 2, establishment of interrater reliability between 2 simultaneous observers using the CCTV method; and phase 3, simultaneous monitoring of HH by both methods to evaluate the suitability of CCTV as an alternative to direct observation of the HH conduct of HCWs caring for MDRO-infected patients.

RESULTS

Overall, 1,104 opportunities to perform HH were documented during 49 observation sessions. The compliance rate observed by the overt method (37.3%) was significantly higher than that observed when only the covert method was used (26.5%). However, simultaneous overt-covert observations were found to have intraclass correlation coefficients of >0.85.

CONCLUSIONS

Covert CCTV observation of HCW HH compliance appears to provide a truer and more realistic picture than overt observation, probably because of its ability to neutralize the Hawthorne effect of overt observation. The high intraclass correlation coefficients between covert observation and overt observation supports this conclusion.

Audio and panoramic video recording in the operating room: legal and ethical perspectives

INTRODUCTION

The idea of video recording (VR) in the operating room (OR) with panoramic cameras and microphones is a new concept that is changing the approach to medical activities in the OR. However, VR in the OR has brought up many concerns regarding patient privacy and has highlighted legal and ethical issues that were never previously exposed.

AIM

To review the literature concerning these aspects and provide a better ethical and legal understanding of the new challenges concerning VR in the OR.

CONCLUSIONS

There is a disparity between the two main legal models concerning VR in the OR, namely the European legal system (General Data Protection Regulation (GDPR)) and the American legal framework (Health Insurance Portability and Accountability Act (HIPAA)). This difference mainly deals with two distinct bioethical paradigms: GDPR places a strong emphasis on protecting patients' privacy to improve the public health system, whereas HIPAA indicates the need to generate protocols to safeguard the risks connected to medical activity and patient privacy. Following from this point, we may argue that, at the ethical and bioethical level, GDPR and HIPAA depend mainly on two different ethical models: a perspective based on moral acquaintances and weak proceduralism, respectively. It is worth noting the importance of developing additional guidelines concerning different world regions to avoid the ethical problems that may emerge when simply applying a foreign paradigm to a very different culture.

Accurate Measurement of Handwash Quality Using Sensor Armbands: Instrument Validation Study

BACKGROUND

Hand hygiene is a crucial and cost-effective method to prevent health care-associated infections, and in 2009, the World Health Organization (WHO) issued guidelines to encourage and standardize hand hygiene procedures. However, a common challenge in health care settings is low adherence, leading to low handwashing quality. Recent advances in machine learning and wearable sensing have made it possible to accurately measure handwashing quality for the purposes of training, feedback, or accreditation.

OBJECTIVE

We measured the accuracy of a sensor armband (Myo armband) in detecting the steps and duration of the WHO procedures for handwashing and handrubbing.

METHODS

We recruited 20 participants (10 females; mean age 26.5 years, SD 3.3). In a semistructured environment, we collected armband data (acceleration, gyroscope, orientation, and surface electromyography data) and video data from each participant during 15 handrub and 15 handwash sessions. We evaluated the detection accuracy for different armband placements, sensor configurations, user-dependent vs user-independent models, and the use of bootstrapping.

RESULTS

Using a single armband, the accuracy was 96% (SD 0.01) for the user-dependent model and 82% (SD 0.08) for the user-independent model. This increased when using two armbands to 97% (SD 0.01) and 91% (SD 0.04), respectively. Performance increased when the armband was placed on the forearm (user dependent: 97%, SD 0.01; and user independent: 91%, SD 0.04) and decreased when placed on the arm (user dependent: 96%, SD 0.01; and user independent: 80%, SD 0.06). In terms of bootstrapping, user-dependent models can achieve more than 80% accuracy after six training sessions and 90% with 16 sessions. Finally, we found that the combination of accelerometer and gyroscope minimizes power consumption and cost while maximizing performance.

CONCLUSIONS

A sensor armband can be used to measure hand hygiene quality relatively accurately, in terms of both handwashing and handrubbing. The performance is acceptable using a single armband worn in the upper arm but can substantially improve by placing the armband on the forearm or by using two armbands.

A new approach to infection prevention: A pilot study to evaluate a hand hygiene ambassador program in hospitals and clinics

BACKGROUND

A pilot study was conducted to assess the perceptions of visitors, patients, and staff to the presence of a hand hygiene ambassador (HHA).

METHODS

Two hundred and twenty-five entrants to various health care settings were surveyed. Only entrants who failed to clean their hands at the alcohol-based handrub (ABHR) station on entry to the lobby were offered application of ABHR by an HHA. Several questions were also asked to assess their attitudes about the presence of an HHA.

RESULTS

When asked whether they think it is a good idea to have an HHA place ABHR on an entrant's hands, the majority of staff, visitors, and patients agreed. No one refused administration of handrub by the HHA.

DISCUSSION

HHA programs have direct and indirect benefits. Although the cost of such an initiative should be considered prior to implementation, it should be weighed against the annual spending for health care-associated infections.

CONCLUSIONS

Considering that hand hygiene compliance and health care-associated infection are clearly linked, a new approach using an HHA may help reduce infection, acting as a source of hand hygiene on entry to the hospital and possibly as a reminder to perform hand hygiene elsewhere in the hospital and clinics.

Assessing the Hawthorne effect on hand hygiene compliance in an intensive care unit

Background

The influence of the Hawthorne effect on hand hygiene compliance in an intensive care unit was assessed using covert and overt direct observation.

Methods

The observational study was conducted from February to November 2018 in a 24-bed adult intensive care unit in a 243-bed tertiary care hospital, in four periods (P): P-1, February 5-March 3, 29 h (covert) and P-2, March 15-April 16, 33 h (overt), prior to an educational campaign on hand hygiene; and P-3, August 27-September 28, 33 h (covert) and P-4, October 3-November 6, 35 h (overt), after the campaign. Three 20-min observation sessions were performed daily, randomly distributed in the morning, afternoon and evening shifts, including holidays and weekends. Hand hygiene compliance rates observed in Periods 2 and 4 were displayed on an electronic panel installed in the unit. Hand hygiene compliance was assessed according to the World Health Organization “My Five Moments for Hand Hygiene” guidelines.

Results

Before the campaign, the overall hand hygiene compliance rate was 31.95% (340/1064, covert) versus 68.10% (790/1160, overt), and afterwards was 56.11% (615/1096, covert) versus 80.98% (1086/1341, overt). The infection rate was reduced by 22.62% (18.87% versus 14.60%).

Conclusions

The Hawthorne effect and educational campaign markedly influenced compliance with hand hygiene recommendations. The results suggest that combining overt and covert observation methods, including regular feedback on hand hygiene compliance displayed on an electronic panel, may be a valid alternative to increase real hand hygiene compliance rates in hospital practice.

Applying thematic synthesis to interpretation and commentary in epidemiological studies: identifying what contributes to successful interventions to promote hand hygiene in patient care

OBJECTIVES

Hand hygiene is considered the most important preventive measure for healthcare-associated infections, but adherence is suboptimal. We previously undertook a Cochrane Review that demonstrated that interventions to improve adherence are moderately effective. Impact varied between organisations and sites with the same intervention and implementation approaches. This study seeks to explore these differences.

METHODS

A thematic synthesis was applied to the original authors' interpretation and commentary that offered explanations of how hand hygiene interventions exerted their effects and suggested reasons why success varied. The synthesis used a published Cochrane Review followed by three-stage synthesis.

RESULTS

Twenty-one papers were reviewed: 11 randomised, 1 non-randomised and 9 interrupted time series studies. Thirteen descriptive themes were identified. They reflected a range of factors perceived to influence effectiveness. Descriptive themes were synthesised into three analytical themes: methodological explanations for failure or success (eg, Hawthorne effect) and two related themes that address issues with implementing hand hygiene interventions: successful implementation needs leadership and cooperation throughout the organisation (eg, visible managerial support) and understanding the context and aligning the intervention with it drives implementation (eg, embedding the intervention into wider patient safety initiatives).

CONCLUSIONS

The analytical themes help to explain the original authors' perceptions of the degree to which interventions were effective and suggested new directions for research: exploring ways to avoid the Hawthorne effect; exploring the impact of components of multimodal interventions; the use of theoretical frameworks for behaviour change; potential to embed interventions into wider patient safety initiatives; adaptations to demonstrate sustainability; and the development of systematic approaches to implementation. Our findings corroborate studies exploring the success or failure of other clinical interventions: context and leadership are important.

The impact of automatic video auditing with real-time feedback on the quality and quantity of handwash events in a hospital setting

BACKGROUND

Poor quality handwashing contributes to the spread of nosocomial infections. We investigate the impact of automatic video auditing (AVA) with feedback on the quality and quantity of handwashing in a hospital setting.

METHODS

AVA systems were mounted over all handwash sinks in a surgical unit. Phase 1 established baseline handwashing quality and quantity. Phase 2 examined the impact of real-time performance feedback, and phase 3 examined the incremental impact of weekly team performance reports. Phase 4 remeasured the baseline without feedback.

RESULTS

A total of 3,606 handwash events were audited. During phase 2 and 3, compliance with the World Health Organization technique improved from 15.7%-46% (P < .0001), and the average number of handwash events per patient per day increased from 0.91-2.25 (P < .0001). Performance returned to baseline in phase 4.

CONCLUSIONS

AVA with real-time feedback significantly improved the quality and quantity of handwashing. The combination of AVA with electronic monitoring will allow simultaneous auditing of hand hygiene quantity and quality. The impact of cognitive offloading onto the technology may have contributed to the return to baseline at the end of the study, and suggests further research is required in this area.

Hand hygiene compliance monitoring: Do video-based technologies offer opportunities for the future?

Hand hygiene is universally recognised as the primary measure to reduce healthcare-associated infections. Studies have convincingly demonstrated a link between increased hand hygiene compliance and reductions in rates of healthcare-associated infections. Direct observation is considered the gold standard method for monitoring hand hygiene compliance. Despite the acknowledged benefits of this approach, recent literature has highlighted a range of issues impacting on the reliability and validity of this data collection technique. The rise of technology in healthcare provides opportunity for alternative methods that promise advantages over direct human observation. There have been no published examples of systems that are able to capture data consistent with all the WHO '5 Moments for Hand Hygiene'. In this paper we explore current human-based auditing practises for monitoring hand hygiene compliance and raise for discussion and debate video-based technologies to monitor hand hygiene compliance. We raise questions regarding hybrid approaches that incorporate both direct human observation and indirect video-based surveillance, and the possible advantages and disadvantages therein for monitoring hand hygiene compliance. We suggest that such methods have the potential to ameliorate, or minimise, the inherent biases associated with direct observation, notably the Hawthorne Effect. Future research into the utility of a hybrid approach to auditing, including the technical specifications, efficacy, cost effectiveness and acceptability of such a model is warranted.

Audiovisual recording in the emergency department: Ethical and legal issues

Emergency physicians, organizations and healthcare institutions should recognize the value to clinicians and patients of HIPAA-compliant audiovisual recording in emergency departments (ED). They should promote consistent specialty-wide policies that emphasize protecting patient privacy, particularly in patient-care areas, where patients and staff have a reasonable expectation of privacy and should generally not be recorded without their prospective consent. While recordings can help patients understand and recall vital parts of their ED experience and discharge instructions, using always-on recording devices should be regulated and restricted to areas in which patient care is not occurring. Healthcare institutions should provide HIPAA-compliant methods to securely store and transmit healthcare-sensitive recordings and establish protocols. Protocols should include both consent procedures their staff can use to record and publish (print or electronic) audiovisual images and appropriate disciplinary measures for staff that violate them. EDs and institutions should publicly post their rules governing ED recordings, including a ban on all surreptitious or unconsented recordings. However, local institutions may lack the ability to enforce these rules without multi-party consent statutes in those states (the majority) where it doesn't exist. Clinicians imaging patients in international settings should be guided by the same ethical norms as they are at their home institution.

A Simple Method for Estimating Hand Hygiene Use Among Anesthesia Personnel: Development, Validation, and Use in a Quality Improvement Project

BACKGROUND

Frequent hand hygiene by anesthesia personnel may be an important factor in reducing contamination of IV lines and medication access ports and may reduce hospital-acquired infections. Measurement of hand hygiene frequency at the individual clinician level by direct observation or electronic devices is cumbersome and expensive. We developed and validated a simple method for estimating hand hygiene frequency by individual anesthesia providers and utilized it in a quality improvement initiative to increase hand hygiene use.

METHODS

Pump-style, alcohol-based hand hygiene container weight at the anesthesia work station was measured before and after each surgical operation and converted to estimated number of accesses (pumps) per hour. Video observation was used to validate the estimated hand hygiene use. A quality improvement initiative utilized periodic measurement of hand hygiene frequency via the validated method, and incorporated individual provider feedback, email reminders, monthly departmental performance reports, and reminders in the electronic anesthesia record. Segmented linear regression was used to evaluate the effect of the intervention on hand hygiene use.

RESULTS

Delivered product per pump was consistent for containers at least half-full and averaged (mean ± SD) 0.92 ± 0.13 g per pump. Video observation in 26 cases showed a strong correlation between observed hand hygiene episodes and estimated hand hygiene use frequency based on weight change of the container (linear regression, R = 0.97, P < .0001). Median hand hygiene frequency was near 0 at baseline but increased progressively throughout the intervention period (segmented linear regression, overall R = 0.76, P < .0001; change of intercept or mean hand hygiene after initiation of intervention [parameter estimate ± SE] [0.970 ± 0.29], P = .0008).

CONCLUSIONS

A low-cost, simple method for measuring individual anesthesia clinician use of hand hygiene intraoperatively based on container weight change is feasible and sufficiently accurate to support a quality improvement initiative to increase its use.

Effect of camera monitoring and feedback along with training on hospital infection rate in a neonatal intensive care unit

BACKGROUND

In terms of pediatric healthcare-associated infections (HAI), neonatal intensive care units (NICU) constitute the greatest risk. Contacting a health care personnel, either directly or indirectly, elevates NICU occurrence rate and risks other infants in the same unit. In this study, it is aimed to retrospectively analyze the effect of the training along with camera monitoring and feedback (CMAF) to control the infection following a small outbreak.

METHODS

ESBL producing Klebsiella pneumoniae was detected on three infants in May 2014 at the isolation room of Sakarya University Hospital NICU. Precautions were taken to prevent further spread of the infection. The infected infants were isolated and the decolonization process was initiated. For this aspect, health care workers (HCWs) in NICU were trained for infection control measures. An infection control committee has monitored the HCWs. Before monitoring, an approval was obtained from the hospital management and HCWs were informed about the CMAF, who were then periodically updated. On a weekly basis, NICU workers were provided with the feedbacks. Epidemic period and post-epidemic control period (June-July-August 2014) were evaluated and p value < 0.05 was considered statistically significant.

RESULTS

Healthcare-associated infection (HAI) density was 9.59% before the onset of the CMAF, whereas it was detected as 2.24% during the CMAF period (p < 0.05). Following the precautions, HAI and HAI density rates have reduced to 76.6% and 74.85%, respectively. Moreover, hand hygiene compliance of health care workers was found 49.0% before the outbreak, whereas this rate has elevated to 62.7% after CMAF.

CONCLUSIONS

Healthcare workers should be monitored in order to increase their compliance for infection control measures. Here, we emphasized that that CMAF of health workers may contribute reducing the HAI rate in the NICU.

The use of privacy-protected computer vision to measure the quality of healthcare worker hand hygiene

OBJECTIVES

(i) To demonstrate the feasibility of automated, direct observation and collection of hand hygiene data, (ii) to develop computer visual methods capable of reporting compliance with moment 1 (the performance of hand hygiene before touching a patient) and (iii) to report the diagnostic accuracy of automated, direct observation of moment 1.

DESIGN

Observation of simulated hand hygiene encounters between a healthcare worker and a patient.

SETTING

Computer laboratory in a university.

PARTICIPANTS

Healthy volunteers.

MAIN OUTCOME MEASURES

Sensitivity and specificity of automatic detection of the first moment of hand hygiene.

METHODS

We captured video and depth images using a Kinect camera and developed computer visual methods to automatically detect the use of alcohol-based hand rub (ABHR), rubbing together of hands and subsequent contact of the patient by the healthcare worker using depth imagery.

RESULTS

We acquired images from 18 different simulated hand hygiene encounters where the healthcare worker complied with the first moment of hand hygiene, and 8 encounters where they did not. The diagnostic accuracy of determining that ABHR was dispensed and that the patient was touched was excellent (sensitivity 100%, specificity 100%). The diagnostic accuracy of determining that the hands were rubbed together after dispensing ABHR was good (sensitivity 83%, specificity 88%).

CONCLUSIONS

We have demonstrated that it is possible to automate the direct observation of hand hygiene performance in a simulated clinical setting. We used cheap, widely available consumer technology and depth imagery which potentially increases clinical application and decreases privacy concerns.

Current issues in hand hygiene

Although substantial improvements in hand hygiene practices have occurred in recent years, many health care facilities continue to encounter challenges in achieving and maintaining high levels of hand hygiene compliance. Issues of current interest include the optimum dose of alcohol-based handrub (ABHR) that should be applied, the impact of hand size and alcohol-based handrub dry times have on efficacy, and ideal hand hygiene technique. There is a need to determine which additional promotional activities can augment improvements in hand hygiene that are achieved by implementing the multimodal improvement strategy recommended by the World Health Organization. Monitoring hand hygiene performance and providing personnel with feedback on their performance are essential elements of successful improvement programs. Further research is needed to establish the most effective methods of providing feedback. Additional studies are needed to optimize strategies for performing direct observation of hand hygiene compliance, and to determine the role of supplementing direct observations using automated monitoring systems.

Technology for the prevention of antimicrobial resistance and healthcare-associated infections; 2017 Geneva IPC-Think Tank (Part 2)

Background

The high burden of healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) is partially due to excessive antimicrobial use both in human and animal medicine worldwide. How can technology help to overcome challenges in infection prevention and control (IPC) and to prevent HAI and emerging AMR?

Methods

In June 2017, 42 international experts convened in Geneva, Switzerland to discuss four potential domains of technology in IPC and AMR: 1) role and potential contribution of microbiome research; 2) whole genome sequencing; 3) effectiveness and benefit of antimicrobial environmental surfaces; and 4) future research in hand hygiene.

Results

Research on the microbiome could expand understanding of antimicrobial use and also the role of probiotics or even faecal transplantation for therapeutic purposes. Whole genome sequencing will provide new insights in modes of transmission of infectious diseases. Although it is a powerful tool for public health epidemiology, some challenges with interpretation and costs still need to be addressed. The effectiveness and cost-effectiveness of antimicrobially coated or treated environmental high-touch surfaces requires further research before they can be recommended for routine use. Hand hygiene implementation can be advanced, where technological enhancement of surveillance, technique and compliance are coupled with reminders for healthcare professionals.

Conclusions

The four domains of technological innovation contribute to the prevention of HAI and AMR at different levels. Microbiome research may offer innovative concepts for future prevention, whole genome sequencing could detect new modes of transmission and become an additional tool for effective public health epidemiology, antimicrobial surfaces might help to decrease the environment as source of transmission but continue to raise more questions than answers, and technological innovation may have a role in improving surveillance approaches and supporting best practice in hand hygiene.

The effect of eye images and a social norms message on healthcare provider hand hygiene adherence

BACKGROUND

Depictions of eye images and messages encouraging compliance with social norms have successfully motivated behavioral change in a variety of experimental and applied settings. We studied the effect of these 2 visual cues on hand hygiene adherence in a cohort of hospital-based healthcare providers participating in an electronic monitoring and feedback program.

METHODS

Prospective, quasi-experimental study utilizing an interrupted time-series design. Intervention placards depicting an image of eyes, a social norms message, or a control placard were placed near soap and alcohol-based hand-rub dispensers on 2 hospital units. Placards were alternated every 10 days. Hand hygiene opportunities and adherence rates were assessed electronically via the CenTrak Hand Hygiene Compliance Solution.

RESULTS

A total of 166 nurses and certified nursing assistants (74 on a medical-surgical unit and 92 on a progressive care unit) were monitored electronically over the 4-month study period. In total, 184,172 electronic observations were collected (110,903 on a medical-surgical unit and 73,269 on a progressive care unit). The median daily number of electronic observations was 1,471 (interquartile range, 1,337-1,584). The preintervention baseline hand hygiene adherence rate was 70%. No statistically significant increase in hand hygiene adherence was observed as a result of either intervention.

CONCLUSION

Displaying eye images or a social norms message in the hospital environment did not result in measurable improvements in HH adherence in a cohort of healthcare providers participating in an electronic monitoring and feedback program.

Video Surveillance of Hand Hygiene: A Better Tool for Monitoring and Ensuring Hand Hygiene Adherence

Introduction

Hand hygiene practice, as correctly said, is the backbone of infection control and it has been proven to limit infections in hospital settings. Currently most healthcare facilities monitor hand hygiene compliance by direct observation technique.

We decided to use video surveillance as a tool to monitor hand hygiene compliance and its impact.

Materials and Methods

This study was conducted over a period of 6 months from March 2018 to August 2018 at Apex Hospital, Jaipur, India.

We compared direct observation of ICU, High Dependency Units, and Emergency with video surveillance in these areas.

Results and Observations

In this study, direct observation and video audit were compared from March 2018 to August 2018. During March to August, average compliance rates of direct observation and video surveillance were compared. In month of march, they were 67% and 20%, respectively and in the month of august, they were 81% and 47%, respectively.

Conclusion

In our study, We can conclude in our study that video monitoring combined with direct observation can produce a significant and sustained improvement in hand hygiene compliance and can improve quality of patient care.

How to cite this article

Sharma S, Khandelwal V, Mishra G. Video Surveillance of Hand Hygiene: A Better Tool for Monitoring and Ensuring Hand Hygiene Adherence. Indian J Crit Care Med 2019;23(5):224–226.

Audio-video recording during laparoscopic surgery reduces irrelevant conversation between surgeons: a cohort study

Background

The prevalence of perioperative surgical complications is a worldwide issue: In many cases, these events are preventable. Audio-video recording during laparoscopic surgery provides useful information for the purposes of education and event analyses, and may have an impact on the focus of the surgeons operating. The aim of the present study was to investigate how audio-video recording in the operating room during laparoscopic surgery affects the focus of the surgeon and his/her assistant.

Methods

A group of laparoscopic procedures where video recording only was performed was compared to a group where both audio and video recordings were made. All laparoscopic procedures were performed at Lindesberg Hospital, Sweden, during the period August to September 2017. The primary outcome was conversation not relevant to the ongoing procedure. Secondary outcomes were intra- and postoperative adverse events or complications, operation time and number of times the assistant was corrected by the surgeon.

Results

The study included 41 procedures, 20 in the video only group and 21 in the audio-video group. The material comprised laparoscopic cholecystectomies, totally extraperitoneal inguinal hernia repairs and bariatric surgical procedures. Irrelevant conversation time fell from 4.2% of surgical time to 1.4% when both audio and video recordings were made (p = 0.002). No differences in perioperative adverse event or complication rates were seen.

Conclusion

Audio-video recording during laparoscopic abdominal surgery reduces irrelevant conversation time and may improve intraoperative safety and surgical outcome.

Trial registration

Available at FOU Sweden (ID: 232771) and retrospectively at Clinical trials.gov (ID: NCT03425175; date of registration 7/2 2018).