Controlled Trial Measuring the Effect of a Feedback Intervention on Hand Hygiene Compliance in a Step-Down Unit
Objective. To evaluate hand hygiene compliance in 2 adult step-down units (SDUs).
Design. A 6-month (from March to September 2007), controlled trial comparing 2 SDUs, one with a feedback intervention program (ie, the intervention unit) and one without (ie, the control unit).
Setting. Two 20-bed SDUs at a tertiary care private hospital.
Methods. Hand hygiene episodes were measured by electronic recording devices and periodic observational surveys. In the intervention unit, feedback was provided by the SDU nurse manager, who explained twice a week to the healthcare workers the goals and targets for the process measures.
Results. A total of 117,579 hand hygiene episodes were recorded in the intervention unit, and a total of 110,718 were recorded in the control unit (P = .63). There was no significant difference in the amount of chlorhexidine used in the intervention and control units (34.0 vs 26.7 L per 1,000 patient-days; P = .36) or the amount of alcohol gel used (72.5 vs 70.7 L per 1,000 patient-days; P = .93). However, in both units, healthcare workers used alcohol gel more frequently than chlorhexidine (143.2 vs 60.7 L per 1,000 patient-days; P < .001). Nosocomial infection rates in the intervention and control units, respectively, were as follows: for bloodstream infection, 3.5 and 0.79 infections per 1,000 catheter-days (P = .18); for urinary tract infection, 15.8 and 15.7 infections per 1,000 catheter-days (P = .99); and for tracheostomy-associated pneumonia, 10.7 and 5.1 infections per 1,000 device-days (P = .13). There were no cases of infection with vancomycin-resistant enterococci and only a single case of infection with methicillin-resistant Staphylococcus aureus (in the control unit).
Conclusions. The feedback intervention regarding hand hygiene had no significant effect on the rate of compliance. Other measures must be used to increase and sustain the rate of hand hygiene compliance.
Received March 12, 2008; accepted May 13, 2008; electronically published July 16, 2008.
Hand hygiene is the most important measure for nosocomial infection prevention in healthcare settings.1 Different methodologies for hand hygiene compliance have been used.2,3 Frequently, infection control studies have attempted to make causal inferences regarding the effect of an intervention, by using quasi-experimental before-after study designs.4 There is little robust evidence to inform the choice of intervention to use to improve hand hygiene compliance.5 However, strategies have been developed for improving the hand hygiene practices of healthcare workers (HCWs), including feedback on compliance.6
HCWs typically comply poorly with hand hygiene practices,7 despite reports of their excellent compliance with infection control practices that include hand hygiene.6 The primary reasons reported by HCWs for poor compliance are as follows: side effects related to chemical products, lack of time due to excess workload, and unawareness of the benefits of such practices.2 Compliance rates of less than 50% have been reported worldwide, and the lowest rates are usually reported in intensive care units (ICUs).1,2
It is challenging to monitor hand hygiene compliance in a hospital setting other than an ICU; for example, it is more difficult to perform observations in a ward setting, because there is little visibility of patient rooms. Only a few studies have evaluated the rate of compliance with hand hygiene in step-down units (SDUs).8 The purpose of the present study was to evaluate compliance with hand hygiene in 2 similar adult SDUs by use of electronic recording devices attached to alcohol gel dispensers and by the application of a feedback strategy.
Methods
From March 20 to September 20, 2007, a controlled trial was conducted in two 20-bed SDUs in our hospital (Hospital Israelita Albert Einstein, São Paulo, Brazil), one with a feedback intervention program (ie, the intervention unit) and one without (ie, the control unit), to ascertain any differences in rates of hand hygiene compliance. Both units had the same physical layout (eg, all the rooms were single-bed rooms). The study was approved by the facility's institutional review board.
Hand hygiene episodes were recorded by electronic counting device (Signol 2109-01 model with no pager mode; Gojo Industries) for wall-mounted alcohol gel dispensers (Gojo NXT 1-L dispenser and Purell Hand Sanitizer; Gojo Industries).9 The counting device recorded every 2-second-long depression of the dispensing button as 1 episode, even if more than 1 aliquot of alcohol gel was dispensed. Chlorhexidine dispensers (2% chlorhexidine) were also available for use, but these dispensers did not have electronic counters. Both dispensers dispensed the same volume of product per use (approximately 1.3 mL) and were located in each patient's room.
From the total volume of product used and the volume released per hand hygiene episode, we calculated an estimated number of hand hygiene episodes for chlorhexidine per patient-day. The amount of alcohol gel (Purell Hand Instant Sanitizer; Gojo Industries) and chlorhexidine used per patient-day was also calculated.
Feedback was provided by the SDU nurse manager, who explained the goals and targets for the process measures in the intervention unit twice per week. HCWs were encouraged to use alcohol gel before and after all the activities performed during the work shift. Nosocomial infection rates were shown monthly to the HCWs in the intervention unit. Feedback was presented to each HCW separately, showing the total number of times the dispensers were used in each patient room in which the HCW worked. These numbers were placed in the medical chart so that the HCWs could review them and improve their performance. They could also review the number of times that other HCWs used dispensers, thus promoting a comparison of hand hygiene compliance among them. Given that the majority of SDU HCWs were nurses, working every day with the same patients during different shifts, we provided feedback only to the nurses, even though other care providers also used the dispensers. We maintained the same HCW team during the entire period of the study in each unit, with the intention of avoiding crossover of nursing staff during the shifts.
We assessed all of the nursing activities described in the medical records during a 24-hour period, using a standardized tool to estimate the number of hand hygiene opportunities. This estimate included the need for hand hygiene before and after every individual HCW-related activity. On the same day of this assessment, an anonymous, 31-item questionnaire was administered to unit nurses on all shifts at the start of the study to assess self-reported compliance with infection control practices, emphasizing hand hygiene compliance.1 These items pertained to the activities carried out by the HCWs and were categorized as follows: 7 items on HCW contact with patient (eg, superficial contact with a patient's skin), 5 items on HCW contact with a patient's blood (eg, central venous catheter manipulation), 2 items on respiratory care (eg, tracheal aspiration secretions), 2 items on genitourinary tract care (eg, urinary catheter manipulation), 1 item on gastrointestinal care (patient feeding), and 14 items on other types of patient care (eg, ocular hygiene). The primary rationale for this questionnaire was to estimate the perception of the number of hand hygiene opportunities per hour in the SDUs.
Nosocomial infection surveillance was performed by trained infection control practitioners using Center for Disease Control and Prevention definitions in both units during the study.10
Nasal samples for methicillin-resistant Staphylococcus aureus (MRSA) screening cultures were obtained from patients on admission and every 4 days for both units, and the overall prevalence was defined as the proportion of patients colonized and infected with MRSA over the course of the study (if a patient was found to be MRSA positive from the surveillance culture, the patient was placed under contact precautions). Pulsed-field gel electrophoresis (PFGE) was performed on all MRSA isolates. The criteria utilized for interpreting PFGE patterns were previously described by Tenover et al.11 The following variables were calculated for the duration of the study: mean length of SDU stay, occupancy rate, nurse-to-patient ratio, the amount of antibiotics used (in defined daily doses), and the rate of use of invasive devices. In addition to this, we analyzed the nurses' workload using the mean Therapeutic Intervention Scoring System.12
Statistical analyses were performed using SPSS, version 13.0 (SPSS). Comparisons between study periods were performed using the Fisher exact test, the χ2 test, and the Student t test for equal variances. All tests of statistical significance were 2 sided, with the significance level set at .05.
Results
Study Sample, Compliance, and Demographic Characteristics
In the intervention unit, a total of 3,504 patient-days, 117,579 electronic counter alcohol gel dispensing episodes, and 219 patients screened for MRSA were recorded. In the control unit, a total of 3,665 patient-days, 110,718 electronic counter alcohol gel dispensing episodes, and 227 patients screened for MRSA were recorded (Table 1). There was no significant difference between the intervention and control units in the amount of chlorhexidine used (34.0 vs 26.7 L per 1,000 patient-days; P = .36) or the amount of alcohol gel used (72.5 vs 70.7 L per 1,000 patient-days; P = .93). However, in both units, HCWs used alcohol gel more frequently than chlorhexidine (143.2 vs 60.7 L per 1,000 patient-days; P < .001). Given the volume of chlorhexidine dispensed by the chlorhexidine dispenser (1.3 mL per use), the estimated number of episodes of hand hygiene with chlorhexidine per patient-day was 7.5 in the intervention unit and 5.6 in control unit (P = .59). There was no significant difference in the number of times that dispensers were used in the intervention and control units (41.1 vs 35.8 hand hygiene episodes per patient-day; P = .56) (Table 2). A total of 77% of HCWs from the intervention unit and 73% of HCWs from the control unit participated in the entire study. Reasons given by HCWs who did not participate in the entire study (23% of HCWs from the intervention unit and 27% of HCW from the control unit) were the desire to take vacations or the necessity to work in the ICU or other wards of the hospital.
No differences were found in length of SDU stay, mean occupancy rate, nurse-to-patient ratio, or rates of urinary catheter use, central venous catheter use, or ventilation assistance (ie, use of bilevel positive airway pressure device) between the 2 units studied (Table 1). There was a trend toward more consumption of antibiotics in the intervention unit (P = .07) (Table 1). There was no significant difference in the mean score derived from the Therapeutic Intervention Scoring System between the intervention and control units (16 vs 17; P = .85) (Table 1).
Colonization and Infection Rates
One hundred seventy-three (79.1%) of 219 patients in the intervention unit and 188 (82.8%) of 227 patients in the control unit were screened for MRSA carriage at admission (P = .26). At admission, 7 (3.2%) of the 219 patients in the intervention unit and 5 (2.2%) of the 227 patients in the control unit were identified as carriers of MRSA (P = .52).
Six (2.8%) of the remaining 212 patients in the intervention unit and 5 (2.2%) of the remaining 222 patients in the control unit were identified as carriers of MRSA after admission (P = .71). There was no difference in median time to acquisition of MRSA between the intervention and control units (15 vs 12 days; P = .31).
Of the 13 MRSA isolates recovered from culture on or after admission to the intervention unit, 3 (23.1%) were clone A (A5, A9, and A10), and 3 (23.1%) were clone B (2 were clone B2 and 1 was clone B4). Of the 10 MRSA isolates recovered from culture on or after admission to the control unit, 3 (30%) were clone A (2 were clone A2 and 1 was clone A11), and 2 (20%) were clone B (B4 and B5).
Nosocomial infection rates in the intervention and control units, respectively, were as follows: for bloodstream infection, 3.5 and 0.79 infections per 1,000 catheter-days (P = .18); for urinary tract infection, 15.8 and 15.7 infections per 1,000 catheter-days (P = 1.0); and for pneumonia, 10.7 and 5.1 infections per 1,000 device-days (P = .13) (Table 2).
In the intervention unit, there were 4 cases of bloodstream infection (1 due to Staphylococcus haemolyticus, 2 due to S. hominis, and 1 due to Pseudomonas aeruginosa); 9 cases of urinary tract infection (2 due to P. aeruginosa, 2 due to Escherichia coli,1 due to Enterococcus faecium, 2 due to E. faecalis, and 2 due to Klebsiella pneumoniae); and 13 cases of pneumonia (7 due to P. aeruginosa and 6 due to unidentified organisms).
In the control unit, there was 1 case of bloodstream infection (due to E. faecalis); 10 cases of urinary tract infection (1 due to E. coli, 5 due to K. pneumoniae, 1 due to Acinetobacter baumannii,1 due to E. faecalis, 1 due to Serratia marcescens, and 1 due to Candida tropicalis); and 8 cases of pneumonia (2 due to P. aeruginosa, 1 due to S. aureus, and 5 due to unidentified organisms).
Of the 7 cases of pneumonia due to P. aeruginosa, 5 were determined to be polymicrobial: 3 in the intervention unit (2 with K. pneumoniae isolated and 1 with A. baumannii and E. coli isolated) and 2 in the control unit (1 with Achromobacter xylosoxidans isolated and 1 with methicillin-susceptible S. aureus isolated). There were no cases of infection with vancomycin-resistant enterococci and, in the control unit, only a single case of infection with MRSA (this case patient had had 7 screening cultures negative for MRSA).
Compliance Questionnaire
Seventy-seven HCWs answered the questionnaire (100% compliance rate for HCWs working in the units). The results of the questionnaire evaluating the number of hand hygiene opportunities were compared with the results from the medical records. For the intervention unit, the questionnaire responses indicated there were 55 hand hygiene opportunities per hour in the morning, 71 in the afternoon, and 107 in the evening, and the medical records indicated there were 57 hand hygiene opportunities per hour in the morning, 44 in the afternoon, and 29 in the evening. For the control unit, the questionnaire responses indicated there were 43 hand hygiene opportunities per hour in the morning, 40 in the afternoon, and 173 in the evening, and the medical records indicated there were 59 hand hygiene opportunities per hour in the morning, 46 in the afternoon, and 35 in the evening.
Discussion
There is a need for improving study designs in reports of hand hygiene intervention. The great majority of hand hygiene studies involve an uncontrolled before-after study design5 or a controlled before-after study design with a nonequivalent control group.13 These designs do not have a standard nomenclature and are hampered by confounding and by regression to the mean.4 These quasi-experimental study designs are frequently used whenever it is not logistically feasible to conduct a controlled trial.14 In our study, we had 2 similar adult SDUs (intervention and control) that permitted us to develop, in an ethical fashion, a controlled trial study that observed a simple feedback intervention with HCWs by use of electronic counting devices for improving hand hygiene compliance.
Although the majority of studies on hand hygiene compliance use some form of data collection, including direct observation,1,6,7 methods for monitoring hand hygiene are not yet standardized.15 Other techniques can be employed, such as using electronic counting devices for hand washing9 and/or measuring the consumption of soap or alcohol hand rubs.16 We decided to use electronic counting devices in all the rooms in the intervention unit to monitor hand hygiene compliance. In this way, the nurse manager could give personal feedback to each nurse, twice per week showing them the number of times that they used alcohol gel hand rubs and once a month showing them the total amount of soap and alcohol gel consumed in the intervention unit.
Surprisingly, in both units, the consumption of alcohol gel was nearly 2.5-fold higher than that of chlorhexidine (143.2 vs 60.7 L per 1,000 patient-days). Other studies have demonstrated that compliance with alcoholic preparations increases significantly over time.17 Bischoff et al.7 documented significant improvement after a 6-month observational period. Pittet et al.18 observed improvement during a 3-year observational period, and, although enhanced compliance with hand hygiene using an alcohol-based product was evident as early as the first 6 months of observation, compliance rates stabilized in the last 18 months of their study.
In both units, the majority of patients who acquired MRSA after admission were colonized with the same strains of MRSA (clones A and B), but the units did not differ in the rate of MRSA acquisition. Our data show a low rate of MRSA colonization on admission, as well as low rates of hospital-acquired colonization and infection with MRSA. Other studies have reported rates of MRSA colonization on and after admission that are higher than ours.19,20 In our study, there was only 1 patient with MRSA infection in the control unit; this patient had 7 screening cultures negative for MRSA. This differs from previous data showing that MRSA colonization of nares, either present at admission to the hospital or acquired during hospitalization, increases the risk for MRSA infection.21 However, it is difficult to compare our colonization or infection rates with those in other studies, because the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance System (formerly the National Healthcare Safety Network) emphasizes data from intensive care settings.22
Our study is the first, to our knowledge, to perform a controlled clinical trial and to assess hand hygiene compliance using electronic counting devices in an SDU. However, this mode of monitoring is not new in other hospital settings.12,23 Importantly, no differences in potential confounders were observed between the intervention and control units, including mean length of SDU stay, occupancy rate, ratio of nurse to patient, duration of antibiotic use in terms of defined daily doses, and duration of use of invasive device.
The Centers for Disease Control and Prevention's guideline on hand hygiene reports that the optimal volume of cleaning agent used per hand hygiene episode is unknown and that the manufacturer's recommendations should be followed, but it does state that 0.2–0.5 mL per hand hygiene episode is not sufficient.2 Another study recommends 1.5–3.0 mL per use.24 In our study, if the HCW quickly used the dispenser twice (during a 2-second period), the electronic counting device would record only 1 episode, even if more than 1 aliquot of alcohol gel was dispensed. This may explain the low calculated volume (approximately 0.6 mL) for each alcohol gel use.
There was a discrepancy between the expected number of hand hygiene observations obtained via chart review and the actual number of observations in both units, which we believe reflects suboptimal compliance. Moreover, because it is very likely that some opportunities for hand hygiene could not be gleaned from a review of the medical records, our estimates of the compliance rate are likely too high. We suspect that night shift HCWs overestimated their activities and their opportunities for hand hygiene because their work shift is twice as long (12 hours, compared with 6 hours for the other shifts). It is interesting that this finding was consistent across both units. Self-reports of practice have shown that nursing assistants significantly overestimated their hand hygiene compliance after nursing care, compared with direct observations.25 In observational studies conducted in hospitals, HCWs washed their hands an average of 5–30 times per shift.26,27
There are several limitations to this study. First, we did not visually assess hand hygiene compliance before and after patient contacts, nor did we evaluate handwashing technique. However, the Hawthorne effect would confound an observational study in which hand washing is being documented.16 Second, we monitored only the use of alcohol gel with electronic counting devices, but we had the data on the quantities of chlorhexidine and alcohol gel consumed in the units, which we used to corroborate the HCWs' preference for the alcohol gel product. Third, because this intervention was performed at a single medical center, these results may not be generalizable to other hospitals. The short follow-up period and the low incidence of MRSA colonization and infection in SDU patients limited our ability to detect a difference in MRSA acquisition rates between the 2 units. Finally, 23% of HCWs from the intervention unit and 27% of HCWs from the control unit did not participate in the entire study. Communication exchange between nurses from both units may have happened; however, the feedback certainly did not.
In conclusion, the rate of consumption of alcohol gel preparations was higher than that of chlorhexidine. Feedback of data on product use resulted in no significant improvement in rates of compliance with hand hygiene. Other measures, including positive deviance28 for developing accountability among HCWs, must be used to increase and sustain rates of hand hygiene compliance.
Acknowledgments
Financial support. This work was supported in part by Instituto Israelita de Ensino e Pesquisa Albert Einstein and Gojo Latin America.
Potential conflicts of interest. L.B. is an employee of Gojo Latin America. Gojo Latin America approved the study but did not have a role in study design, data acquisition, data analysis, or manuscript preparation.
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