American Journal of Infection Control 43 (2015) 821-5

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American Journal of Infection Control

American Journal of Infection Control

journal homepage: www.ajicjournal.org

Major article

An automated hand hygiene training system improves hand hygiene technique but not compliance Yen Lee Angela Kwok MBBS, MPH, MHM, PhD a, Michelle Callard GDip, CSIC, RN b, Mary-Louise McLaws DipTropPubHlth, MPHlth, PhDMed a, * a b

School of Public Health and Community Medicine, UNSW Medicine, UNSW Australia, Sydney, New South Wales, Australia Infection Prevention and Control Unit, Campbelltown and Camden Hospital, Sydney, New South Wales, Australia

Key Words: Compliance Cleansing technique Seven poses

Introduction: The hand hygiene technique that the World Health Organization recommends for cleansing hands with soap and water or alcohol-based handrub consists of 7 poses. We used an automated training system to improve clinicians’ hand hygiene technique and test whether this affected hospitalwide hand hygiene compliance. Methods: Seven hundred eighty-nine medical and nursing staff volunteered to participate in a selfdirected training session using the automated training system. The proportion of successful first attempts was reported for each of the 7 poses. Hand hygiene compliance was collected according to the national requirement and rates for 2011-2014 were used to determine the effect of the training system on compliance. Results: The highest pass rate was for pose 1 (palm to palm) at 77% (606 out of 789), whereas pose 6 (clean thumbs) had the lowest pass rate at 27% (216 out of 789). One hundred volunteers provided feedback to 8 items related to satisfaction with the automated training system and most (86%) expressed a high degree of satisfaction and all reported that this method was time-efficient. There was no significant change in compliance rates after the introduction of the automated training system. Observed compliance during the posttraining period declined but increased to 82% in response to other strategies. Conclusions: Technology for training clinicians in the 7 poses played an important education role but did not affect compliance rates. Crown Copyright Ó 2015 Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved.

Effective hand hygiene, undertaken at the right time and with the correct technique, either with soap and water or alcohol-based handrub (ABHR), can save lives.1-3 The World Health Organization guidelines provide instructions for the technique of hand hygiene.1,2 Incorrect or ineffective hand hygiene technique may result in the transmission of multiple-drug-resistant organisms within the health care setting.4 The effectiveness of hand hygiene with ABHR to remove pathogens from the palms, backs of hands, and between the fingers of health care workers (HCWs) is reliant on the technique of rubbing and the durationdapproximately 20 seconds to complete

* Address correspondence to Mary-Louise McLaws, DipTropPubHlth, MPHlth, PhDMed, School of Public Health and Community Medicine, University of New South Wales, Samuels Building, Level 3, Sydney, NSW 2052 Australia. E-mail address: [email protected] (M.-L. McLaws). Conflicts of interest: Glanta Company, Ltd, provided the Surewash automated training system.

all 7 poses.1 Poor technique has been associated with contamination of HCW fingertips with methicillin-resistant Staphylococcus aureus even after cleansing.5 The Australian Commission on Safety and Quality in Health Care has nominated the reduction of health careassociated infections as a priority for Australian public hospitals.6 Hospitalwide hand hygiene compliance rates in public hospitals must reach a threshold of at least 70%6,7 and rates for the 3 annual audit periods are reported publically.8 The correct hand hygiene technique for both forms of cleansing HCWs’ hands is an important factor of the act of compliance.1,9,10 We introduced an automated system with the aim of teaching the 7 hand hygiene poses to our clinical staff and herein we describe their perception of this self-directed learning. Because the automated training system has been reported elsewhere to have improved hand hygiene compliance by 65 percentage points,11 we compared the hospitalwide compliance rates before and after the introduction of the training system.

0196-6553/$36.00 - Crown Copyright Ó 2015 Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.04.201

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METHODS An automated training system was established in a 380-bed metropolitan teaching hospital in New South Wales for 8 months (January 1-August 31, 2013). In June 2013 the ABHR suppliers independently installed new dispensers around the hospital that incorporated an illustration of the 7 poses for hand hygiene on the wall mount. The hospital director, the Hospital Research Committee, and the University of New South Wales Ethics Committee approved the project. Staff from 18 inpatient medical, surgical, and maternity departments, including the emergency room, volunteered to partake in self-directed training. The participation rate was estimated using the total number of staff provided by the human resources department. An in-service was conducted by the research team in each department to explain to staff how to use the system and obtain immediate feedback on the correct technique for the 7 hand hygiene poses. Participants were told that the system employs gaming technology that uses automated feedback and the human desire for gains.10-13 Participants were instructed to place hands under the video camera housed within the machine and that the video would track the motion of dry hands as they mimicked each of the 7 hand hygiene poses. The participants were instructed to repeat a pose until the automated training system indicated their technique was correct. Participants were told that the system would collate rates of correct technique and provide them with their own lowest and highest rates by date for each attempt. Where the technique required correction staff received immediate feedback and provided with the opportunity to repeat the pose.11 There was no limit to the number of attempts each staff member could make. When staff reached 100% correct technique for the 7 poses, regardless of the number of attempts, they received a certificate of achievement. Participants were guaranteed all data were deidentified and their profession was not included in the data. The system provided each participant with a reference number to retain confidentiality. We reported the number of times a staff member attempted to pass all 7 poses for the first, second, and subsequent attempts, and the time (in seconds) taken to successfully complete each pose. To evaluate staff perception of the automated training system as a self-learning tool the software distributed an 8-item questionnaire to the volunteers at the completion of each participant’s training session. The 8 items for evaluation used a 5-point Likerttype response scale (1 ¼ strongly disagree, 2 ¼ disagree, 3 ¼ neutral, 4 ¼ agree, and 5 ¼ strongly agree). A comment box was also provided for volunteers to express any other perception they had about the automated training system. Completing the questionnaire was not compulsory. We reported the highest score, lower quartile (LQ) and upper quartile (UQ) scores of satisfaction with the training system. The 8 items were related to: Function of automated system 1. The user interface was clear and easy to use. 2. The instructions throughout the system training were easy to understand. Education training 3. The training slides contained useful information. 4. I learned something new about hand hygiene or using the system provided a good refresher about hand hygiene. 5. I learned a lot about better hand hygiene technique. 6. The assessment mode of was easy to follow.

7. I improved my hand hygiene technique as a result of using the automated training system. 8. The system is an innovative application of technology for hand hygiene. Hand hygiene compliance A beforeeafter design was used to evaluate the influence of the automated training system on the hospitalwide hand hygiene rate. Hand hygiene audits are undertaken in all public hospitals in accordance with the World Health Organization guidelines1 and the Australian National Hand Hygiene Initiative (NHHI)14 methodology for sample sizes and frequency of audits. Hand hygiene rates are reported for 3 audit periods each year. We compared hospitalwide compliance rates for the before, during, and after training periods for the following reasons: at our teaching hospital medical and nursing staff rotate through the departments, the number of hand hygiene opportunities in each ward would not have been sufficient to provide reliable rates, and Australian hand hygiene rates are reported as a hospitalwide rate.14 Trained hospital auditors collected hand hygiene data for the purpose of mandatory reporting to the NHHI. Rates are reported as hospitalwide on the MyHospitals website (www. myhospitals.gov.au) for public scrutiny with the interim benchmark of 70% compliance set by NHHI as the acceptable compliance level. The NHHI reports hand hygiene compliance for 3 audit periods every year: first reporting period November 1March 31, second reporting period April 1-June 30, and third reporting period July 1-October 31. The hospital rates for 2011 and 2012 were used for the preintervention baseline rates. Our intervention was completed at the end of August 2013 but we used the rates for the first to third reporting periods of 2013, which included observations of compliance in September, after our intervention, to measure compliance during the intervention. During the third reporting period of 2013, the medical staff hand hygiene compliance failed the accreditation review and a repeat audit was scheduled for the end of the first reporting period of 2014. Therefore, the rates for all 3 reporting periods of 2014 are provided to detect late changes in the postintervention periods due to a lag in response to improve or in response to an accreditation-related intervention. The hospital underwent accreditation during February in the first reporting period of 2014 and failed to gain accreditation. Therefore, several hand hygiene-related intervention strategies were implemented in the first reporting period of 2014 that included intensive education for doctors and training of medical heads of department as hand hygiene auditors to undertake auditing of their peers. Proportions based on the sample sizes used for the mandatory audits did not warrant precision to 1 decimal place and proportions were rounded up at 0.6 and rounded down at 0.5. Exact 95% confidence intervals were calculated for compliance and c2 test for trend in proportion for changes in hand hygiene rates over 3 reporting periods in each year, and over the entire period, were calculated using Open Source Epidemiologic Statistics for Public Health (OpenEpi version 3.01, Emory University, Atlanta, Ga). RESULTS Training in the 7 poses There were 1,411 staff members of whom 992 were clinical staff based at the hospital. Of these, 789 clinicians (79%) undertook the training. The average time staff took to complete each pose ranged from 9-11 seconds (Table 1). The highest pass rate for a first attempt was 77% for pose 1 (palm to palm) and 73% for pose 3 (palm to palm

Y.L.A. Kwok et al. / American Journal of Infection Control 43 (2015) 821-5

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Table 1 Time to complete each pose and pass rate on first correct attempt for each pose Pose

Duration in seconds

Pass at first attempt

9 (5-33)

77 (606/789)

5 (9/183)

100 (9/9)

11 (8-57)

49 (383/789)

1 (5/406)

100 (5/5)

9 (8-55)

73 (575/789)

3 (7/214)

100 (7/7)

Tips backs of fingers to each palm

10 (8-49)

53 (415/789)

1 (5/374)

100 (5/5)

Circular motions

10 (8-50)

50 (391/789)

1 (4/398)

100 (4/4)

Clean thumbs

11 (9-105)

27 (216/789)

0.5 (3/573)

100 (3/3)

9 (9-65)

39 (311/789)

0.2 (1/478)

100 (1/1)

Hand movements for each pose Palm to palm

Palm over back, each hand left and right

Palm to palm interlaced fingers

Clean wrists

Participants who failed pose and reattempts to pass

Pass on reattempts

NOTE. Duration in seconds: mean (range); Pass at first attempt, Participants who failed, Pass on reattempts: %(n/N).

interlaced fingers). The poorest pass rate for a first attempt was associated with pose 6 (clean thumbs), 27%, followed by pose 2 (palm over back, each hand left and right), 49%, and pose 5 (circular

motions), 50%. Between 95% and 99.8% of participants did not undertake a repeated attempt at a failed pose. Of the repeated attempts for poses 1-7, all passed.

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Table 2 Hand hygiene compliance rates before, during, and after the introduction of the automated training system National hand hygiene compliance rate

Preintervention First 2011 Second 2011 Third 2011 First 2012 Second 2012 Third 2012 Intervention First 2013 Second 2013 Third 2013 Postintervention First 2014 Second 2014 Third 2014

Hospitalwide hand hygiene compliance rate

(95% Confidence interval) [n/N]

Reporting period 69 71 73 74 76 76

(67-69) [193,336/28,1231] (71-72) [214,685/301,175] (72-73) [235,518/324,423] (73.7-74) [287,220/389,077] (75.6-75.8) [261,298/345,195] (76.3-76.6) [319,147/417,490]

77 (76-77) [354,593/461,082] 78 (78.2-78.4) [329,565/420,922] 79 (78.8-79) [384,643/487,175] 80.3 (80.1-80.4) [430,833/536,855] 81 (81-81.1) [378,812/467,880] 81.9 (81.8-82) [439,856/537,154]

70 71 72 72 74 76

(69-72) (69-73) (70-74) (70-74) (72-75) (75-78)

[1,539/2,187] [2,012/2,837] [1,592/2,203] [1,679/2,323] [2,004/2,716] [2,571/3,370]

P value (c2 trend in change of annual rate) .17 (1.88)

An automated hand hygiene training system improves hand hygiene technique but not compliance.

The hand hygiene technique that the World Health Organization recommends for cleansing hands with soap and water or alcohol-based handrub consists of ...
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