American Journal of Infection Control xxx (2014) 1-3
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Assessing the thoroughness of hand hygiene: “Seeing is believing” Sung-Ching Pan MD a, b, *, Evelyn Chen c, *, Kuei-Lien Tien RN d, I-Chen Hung RN d, Wang-Huei Sheng MD, PhD a, d, Yee-Chun Chen MD, PhD a, d, e, *, Shan-Chwen Chang MD, PhD a, d, e a
Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan c Taipei American School, Taipei, Taiwan d Center for Infection Control, National Taiwan University Hospital, Taipei, Taiwan e Department of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan b
Key Words: Patient safety Infection control Simulation
The thoroughness of hand hygiene (HH) was evaluated using a simulation method in which health care workers (HCWs) rubbed their hands with a fluorescent substance, washed with water, and placed their hands under an ultraviolet detector to identify areas missed. Most residue points were located in the tips of the nails (38.6%), followed by fingertips (17.4%). This stress-free “seeing is believing” program can encourage HCWs’ active participation in sustaining the HH culture of health care institutions. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Hospital-associated infection (HAI) is a major threat to patient safety. In high-income countries, HAI affects roughly 5%-15% of hospitalized patients and 9%-37% of patients in intensive care settings.1 In low-income countries, several single-hospital studies have suggested even higher prevalence rates, of 14.8%-19.1% of admitted patients.2-4 Thus, in 2005, the World Health Organization (WHO) launched the first global Patient Safety Challenge, “Clean Care is Safer Care.” Despite these efforts, however, ensuring that health care workers (HCWs) perform thorough HH and evaluating HH effectiveness remain ongoing challenges. The WHO has suggested that the appropriate duration of handwashing with soap and water of 40-60 seconds5; however, observational studies have found that HCWs had a significantly shorter duration of HH (6.6-30 seconds)6,7 and often failed to wash all hand surfaces.7,8 Thus, even if we can improve HCWs’ HH compliance, improper HH technique can
* Address correspondence to Yee-Chun Chen, MD, PhD, Department of Internal Medicine, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei 100, Taiwan. E-mail address: [email protected] (Y.-C. Chen). The Center for Excellence for Hand Hygiene is supported by the Center for Disease Control, Department of Health, Taiwan (EU098040). Y. C. Chen also received a grant from the Department of Health, Taiwan (DOH100-TD-B-111-001). These funding organizations were not involved in study design or conduct; data collection, management, analysis, or interpretation; or manuscript preparation and approval. Conflict of interest: None to report. * S.-C.P. and E.C. contributed equally to this work.
interfere with effective HH promotion. The concept of HH thoroughness is vague and difficult to express and has rarely been discussed in WHO HH guidelines, making it difficult to provide education, evaluation, and feedback regarding proper HH technique. National Taiwan University Hospital, a tertiary care hospital, adopted a WHO-based multimodal HH strategy in 2009. Since 2012, we have targeted the promoting proper HH procedures in conjunction with increasing HH compliance.9 The present study aimed to evaluate the thoroughness of HH in HCWs and to measure the effectiveness of incorporating a “seeing is believing” simulation education method for HH promotion. METHODS This study was approved by the Ethics Committee of National Taiwan University Hospital. Under the anonymity basis, oral informed consent was obtained from each participant. The HH technique campaign for HCWs was conducted between May 1 and May 30, 2012. The HCWs volunteered to participate in this event. We educated the HCWs on proper HH technique using a 7-step procedure with a Chinese Kong-Fuebased slogan: interior, exterior, interlacing, bow, thumbs, fingertips, and wrists (Fig 1). During the campaign, the HCWs were instructed to rub their hands with a fluorescent substance as they would normally do with soap and water or an alcohol-based cleaner, rinse their hands with water, and then place their hands under an ultraviolet detector (Brevis, Salt Lake City, UT) to identify any areas that they might have missed.
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.03.003
2
S.-C. Pan et al. / American Journal of Infection Control xxx (2014) 1-3
Fig 1. Seven-step hand hygiene technique and Chinese Kong-Fuebased slogan, 內外夾弓大立腕, indicating interior, exterior, interlacing, bow, thumbs, fingertips, and wrists, respectively.
Two infection control nurses assessed each participant’s performance and graphically recorded residue points and locations for 37 parts of the hand (Fig 2A), as well as the duration of HH. Results of the activity were recorded anonymously. Participants received feedback on how they performed, and each ward received group feedback. Information on participants’ sex, age, and professional category was collected before the intervention. RESULTS A total of 388 HCWs from 30 of the hospital’s 85 wards volunteered to participate in this study, including 64 doctors, 253 nurses, and 60 other HCWs. The average age of participants was 32.1 8.1 years (range, 18-60 years). The majority of participants were female (80.2%; 311 of 388). For all participants, the duration of HH exceeded the recommended 10-15 seconds, ranging from 11 to 260 seconds (mean, 57.4 38.9 seconds). Most participants could wash off the fluorescent agent, with 135 of 386 HCWs (34.8%) having zero residue points. Overall, a total of 880 residual spots were identified. The average number of residue points was 2.2 2.8 per participant (Table 1). The highest percentage of residue points was under the tips of the nails (38.6%; 340 of 880), followed by the fingertips (17.4%; 153 of 880) (Fig 2B). The number of residue points was not correlated with sex, professional category, or age. There was no statistically significant association between duration of HH and number of residue points (P ¼.15).
is its versatility, being suitable for use in different areas of medical practice (eg, diagnostic procedures, surgical procedures, central venous catheterization).10 A fluorescent-based simulation method was developed by infection preventionists at Amager Hospital, Copenhagen, Denmark, to assess HH techniques in a timely and cost-effective manner.11 This method had been used in a series of small studies examining medical students (n ¼ 75),12 nursing students (n ¼ 194),13 and HCWs in an orthopedic department (n ¼ 55).8 As reported here, advantages of using simulated education for HH include the opportunity to provide education throughout the hospital and immediate visual feedback on HH technique. Even though our HCWs tried to increase the duration of HH to prevent residual spots, a total of 880 missed spots on the hands were identified. We suggest that to ensure thorough HH, correct technique is as important as adequate duration. A Chinese Kong-Fuebased slogan was used to teach HCWs the importance of washing all parts of the hand, especially 立, which means standing the fingertips on the palm of the other hand to clean the fingers and nails. The slogan is fun, short, and easy to remember. Other countries can create their own culturally relevant slogans to reinforce HH techniques and provide some enjoyment during infection control education. In conclusion, the simulation technique can be successfully adapted for HH education. With no time constraints, most participants were willing to perform HH for longer than the recommended 10-15 seconds. This stress-free, seeing-is-believing program can encourage HCWs’ active participation in HH and promote HH culture in health care settings.
DISCUSSION Acknowledgment In this study, we have demonstrated that a stress-free, “seeing is believing” simulation program can be successfully adapted for HH education. We provided feedback to HCWs identifying the nails and fingertips as the most frequently missed spots. The integration of knowledge, practice, and visual feedback can strengthen the learning process and improve the compliance with and thoroughness of HH. Simulation techniques have been adopted in the health care system to protect patient safety. A benefit of simulation education
We thank David Devore for his critical review of the manuscript. We are grateful to members of the NTUH Center for Infection Control for their sustained support of the hand hygiene program, as well as the hospital staff for their commitment to improving patient safety and reducing health careeassociated infections. Author contributions: Y.-C.C., K.-L.T., and S.-C.P. conceived and designed the experiments; K.-L.T. and I.-C.H. performed the experiments; K.-L.T. and E.C. analyzed the data; E.C., Y.-C.C., and
S.-C. Pan et al. / American Journal of Infection Control xxx (2014) 1-3
3
Fig 2. Distributions (A) and percentages (B) of fluorescent agent residue in the 388 participants. The left side of the figure represents the ventral side of the hand; the right, the dorsal side.
Table 1 Duration of HH and distribution of residue points participants Parameter Hand rubbing time, s* Average By category
Residue points Average By category
Range
n/N
%
57.4 38.9 60
319 0/319 24/319 65/319 136/319 94/319
0 7.5 20.4 42.6 29.5
2.2 2.8 0-3 4-6 7-10 11-20
388 291/388 68/388 21/388 8/388
75.0 17.5 5.4 2.1
*For hand rubbing time, only 319 participants were assessed.
S.-C. P. wrote the manuscript; and W.-H.S. and Y.-C.C. coordinated the project. References 1. Vincent JL. Nosocomial infections in adult intensive-care units. Lancet 2003; 361:2068-77.
2. Kallel H, Bahoul M, Ksibi H, Dammak H, Chelly H, Hamida CB, et al. Prevalence of hospital-acquired infection in a Tunisian hospital. J Hosp Infect 2005;59:343-7. 3. Jroundi I, Khoudri I, Azzouzi A, Zeggwagh AA, Benbrahim NF, Hassouni F, et al. Prevalence of hospital-acquired infection in a Moroccan university hospital. Am J Infect Control 2007;35:412-6. 4. Faria S, Sodano L, Gjata A, Dauri M, Sabato AF, Bilaj A, et al. The first prevalence survey of nosocomial infections in the University Hospital Centre “Mother Teresa” of Tirana, Albania. J Hosp Infect 2007;65:244-50. 5. World Health Organization. WHO guidelines on hand hygiene in health care. Geneva, Switzerland: World Health Organization; 2009. 6. Larson E, Hughes C, Pyrek J, Sparks S, Cagatay E, Bartkus J. Changes in bacterial flora associated with skin damage on hands of health care personnel. Am J Infect Control 1998;26:513-21. 7. Taylor LJ. An evaluation of handwashing techniques: 2. Nurs Times 1978;74: 108-10. 8. Macdonald DJ, McKillop EC, Trotter S, Gray A. Improving hand-washing performance: a crossover study of hand-washing in the orthopaedic department. Ann R Coll Surg Engl 2006;88:289-91. 9. Pan SC, Tien KL, Hung IC, Lin YJ, Sheng WH, Wang MJ, et al. Compliance of health care workers with hand hygiene practices: independent advantages of overt and covert observers. PloS ONE 2013;8:e53746. 10. Schmidt E, Goldhaber-Fiebert SN, Ho LA, McDonald KM. Simulation exercises as a patient safety strategy: a systematic review. Ann Intern Med 2013;158: 426-32. 11. The Joint Commission. Measuring hand hygiene adherence: overcoming the challenges. Oakbrook Terrace [IL]: The Joint Commission; 2009. 12. Mittal MK, Morris JB, Kelz RR. Germ simulation: a novel approach for raising medical students awareness toward asepsis. Simul Healthc 2011;6:65-70. 13. Gantt LT, Webb-Corbett R. Using simulation to teach patient safety behaviors in undergraduate nursing education. J Nurs Educ 2010;49:48-51.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Assessing the thoroughness of hand hygiene: “Seeing is believing” Sung-Ching Pan MD a, b, *, Evelyn Chen c, *, Kuei-Lien Tien RN d, I-Chen Hung RN d, Wang-Huei Sheng MD, PhD a, d, Yee-Chun Chen MD, PhD a, d, e, *, Shan-Chwen Chang MD, PhD a, d, e a
Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan c Taipei American School, Taipei, Taiwan d Center for Infection Control, National Taiwan University Hospital, Taipei, Taiwan e Department of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan b
Key Words: Patient safety Infection control Simulation
The thoroughness of hand hygiene (HH) was evaluated using a simulation method in which health care workers (HCWs) rubbed their hands with a fluorescent substance, washed with water, and placed their hands under an ultraviolet detector to identify areas missed. Most residue points were located in the tips of the nails (38.6%), followed by fingertips (17.4%). This stress-free “seeing is believing” program can encourage HCWs’ active participation in sustaining the HH culture of health care institutions. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Hospital-associated infection (HAI) is a major threat to patient safety. In high-income countries, HAI affects roughly 5%-15% of hospitalized patients and 9%-37% of patients in intensive care settings.1 In low-income countries, several single-hospital studies have suggested even higher prevalence rates, of 14.8%-19.1% of admitted patients.2-4 Thus, in 2005, the World Health Organization (WHO) launched the first global Patient Safety Challenge, “Clean Care is Safer Care.” Despite these efforts, however, ensuring that health care workers (HCWs) perform thorough HH and evaluating HH effectiveness remain ongoing challenges. The WHO has suggested that the appropriate duration of handwashing with soap and water of 40-60 seconds5; however, observational studies have found that HCWs had a significantly shorter duration of HH (6.6-30 seconds)6,7 and often failed to wash all hand surfaces.7,8 Thus, even if we can improve HCWs’ HH compliance, improper HH technique can
* Address correspondence to Yee-Chun Chen, MD, PhD, Department of Internal Medicine, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei 100, Taiwan. E-mail address: [email protected] (Y.-C. Chen). The Center for Excellence for Hand Hygiene is supported by the Center for Disease Control, Department of Health, Taiwan (EU098040). Y. C. Chen also received a grant from the Department of Health, Taiwan (DOH100-TD-B-111-001). These funding organizations were not involved in study design or conduct; data collection, management, analysis, or interpretation; or manuscript preparation and approval. Conflict of interest: None to report. * S.-C.P. and E.C. contributed equally to this work.
interfere with effective HH promotion. The concept of HH thoroughness is vague and difficult to express and has rarely been discussed in WHO HH guidelines, making it difficult to provide education, evaluation, and feedback regarding proper HH technique. National Taiwan University Hospital, a tertiary care hospital, adopted a WHO-based multimodal HH strategy in 2009. Since 2012, we have targeted the promoting proper HH procedures in conjunction with increasing HH compliance.9 The present study aimed to evaluate the thoroughness of HH in HCWs and to measure the effectiveness of incorporating a “seeing is believing” simulation education method for HH promotion. METHODS This study was approved by the Ethics Committee of National Taiwan University Hospital. Under the anonymity basis, oral informed consent was obtained from each participant. The HH technique campaign for HCWs was conducted between May 1 and May 30, 2012. The HCWs volunteered to participate in this event. We educated the HCWs on proper HH technique using a 7-step procedure with a Chinese Kong-Fuebased slogan: interior, exterior, interlacing, bow, thumbs, fingertips, and wrists (Fig 1). During the campaign, the HCWs were instructed to rub their hands with a fluorescent substance as they would normally do with soap and water or an alcohol-based cleaner, rinse their hands with water, and then place their hands under an ultraviolet detector (Brevis, Salt Lake City, UT) to identify any areas that they might have missed.
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.03.003
2
S.-C. Pan et al. / American Journal of Infection Control xxx (2014) 1-3
Fig 1. Seven-step hand hygiene technique and Chinese Kong-Fuebased slogan, 內外夾弓大立腕, indicating interior, exterior, interlacing, bow, thumbs, fingertips, and wrists, respectively.
Two infection control nurses assessed each participant’s performance and graphically recorded residue points and locations for 37 parts of the hand (Fig 2A), as well as the duration of HH. Results of the activity were recorded anonymously. Participants received feedback on how they performed, and each ward received group feedback. Information on participants’ sex, age, and professional category was collected before the intervention. RESULTS A total of 388 HCWs from 30 of the hospital’s 85 wards volunteered to participate in this study, including 64 doctors, 253 nurses, and 60 other HCWs. The average age of participants was 32.1 8.1 years (range, 18-60 years). The majority of participants were female (80.2%; 311 of 388). For all participants, the duration of HH exceeded the recommended 10-15 seconds, ranging from 11 to 260 seconds (mean, 57.4 38.9 seconds). Most participants could wash off the fluorescent agent, with 135 of 386 HCWs (34.8%) having zero residue points. Overall, a total of 880 residual spots were identified. The average number of residue points was 2.2 2.8 per participant (Table 1). The highest percentage of residue points was under the tips of the nails (38.6%; 340 of 880), followed by the fingertips (17.4%; 153 of 880) (Fig 2B). The number of residue points was not correlated with sex, professional category, or age. There was no statistically significant association between duration of HH and number of residue points (P ¼.15).
is its versatility, being suitable for use in different areas of medical practice (eg, diagnostic procedures, surgical procedures, central venous catheterization).10 A fluorescent-based simulation method was developed by infection preventionists at Amager Hospital, Copenhagen, Denmark, to assess HH techniques in a timely and cost-effective manner.11 This method had been used in a series of small studies examining medical students (n ¼ 75),12 nursing students (n ¼ 194),13 and HCWs in an orthopedic department (n ¼ 55).8 As reported here, advantages of using simulated education for HH include the opportunity to provide education throughout the hospital and immediate visual feedback on HH technique. Even though our HCWs tried to increase the duration of HH to prevent residual spots, a total of 880 missed spots on the hands were identified. We suggest that to ensure thorough HH, correct technique is as important as adequate duration. A Chinese Kong-Fuebased slogan was used to teach HCWs the importance of washing all parts of the hand, especially 立, which means standing the fingertips on the palm of the other hand to clean the fingers and nails. The slogan is fun, short, and easy to remember. Other countries can create their own culturally relevant slogans to reinforce HH techniques and provide some enjoyment during infection control education. In conclusion, the simulation technique can be successfully adapted for HH education. With no time constraints, most participants were willing to perform HH for longer than the recommended 10-15 seconds. This stress-free, seeing-is-believing program can encourage HCWs’ active participation in HH and promote HH culture in health care settings.
DISCUSSION Acknowledgment In this study, we have demonstrated that a stress-free, “seeing is believing” simulation program can be successfully adapted for HH education. We provided feedback to HCWs identifying the nails and fingertips as the most frequently missed spots. The integration of knowledge, practice, and visual feedback can strengthen the learning process and improve the compliance with and thoroughness of HH. Simulation techniques have been adopted in the health care system to protect patient safety. A benefit of simulation education
We thank David Devore for his critical review of the manuscript. We are grateful to members of the NTUH Center for Infection Control for their sustained support of the hand hygiene program, as well as the hospital staff for their commitment to improving patient safety and reducing health careeassociated infections. Author contributions: Y.-C.C., K.-L.T., and S.-C.P. conceived and designed the experiments; K.-L.T. and I.-C.H. performed the experiments; K.-L.T. and E.C. analyzed the data; E.C., Y.-C.C., and
S.-C. Pan et al. / American Journal of Infection Control xxx (2014) 1-3
3
Fig 2. Distributions (A) and percentages (B) of fluorescent agent residue in the 388 participants. The left side of the figure represents the ventral side of the hand; the right, the dorsal side.
Table 1 Duration of HH and distribution of residue points participants Parameter Hand rubbing time, s* Average By category
Residue points Average By category
Range
n/N
%
57.4 38.9 60
319 0/319 24/319 65/319 136/319 94/319
0 7.5 20.4 42.6 29.5
2.2 2.8 0-3 4-6 7-10 11-20
388 291/388 68/388 21/388 8/388
75.0 17.5 5.4 2.1
*For hand rubbing time, only 319 participants were assessed.
S.-C. P. wrote the manuscript; and W.-H.S. and Y.-C.C. coordinated the project. References 1. Vincent JL. Nosocomial infections in adult intensive-care units. Lancet 2003; 361:2068-77.
2. Kallel H, Bahoul M, Ksibi H, Dammak H, Chelly H, Hamida CB, et al. Prevalence of hospital-acquired infection in a Tunisian hospital. J Hosp Infect 2005;59:343-7. 3. Jroundi I, Khoudri I, Azzouzi A, Zeggwagh AA, Benbrahim NF, Hassouni F, et al. Prevalence of hospital-acquired infection in a Moroccan university hospital. Am J Infect Control 2007;35:412-6. 4. Faria S, Sodano L, Gjata A, Dauri M, Sabato AF, Bilaj A, et al. The first prevalence survey of nosocomial infections in the University Hospital Centre “Mother Teresa” of Tirana, Albania. J Hosp Infect 2007;65:244-50. 5. World Health Organization. WHO guidelines on hand hygiene in health care. Geneva, Switzerland: World Health Organization; 2009. 6. Larson E, Hughes C, Pyrek J, Sparks S, Cagatay E, Bartkus J. Changes in bacterial flora associated with skin damage on hands of health care personnel. Am J Infect Control 1998;26:513-21. 7. Taylor LJ. An evaluation of handwashing techniques: 2. Nurs Times 1978;74: 108-10. 8. Macdonald DJ, McKillop EC, Trotter S, Gray A. Improving hand-washing performance: a crossover study of hand-washing in the orthopaedic department. Ann R Coll Surg Engl 2006;88:289-91. 9. Pan SC, Tien KL, Hung IC, Lin YJ, Sheng WH, Wang MJ, et al. Compliance of health care workers with hand hygiene practices: independent advantages of overt and covert observers. PloS ONE 2013;8:e53746. 10. Schmidt E, Goldhaber-Fiebert SN, Ho LA, McDonald KM. Simulation exercises as a patient safety strategy: a systematic review. Ann Intern Med 2013;158: 426-32. 11. The Joint Commission. Measuring hand hygiene adherence: overcoming the challenges. Oakbrook Terrace [IL]: The Joint Commission; 2009. 12. Mittal MK, Morris JB, Kelz RR. Germ simulation: a novel approach for raising medical students awareness toward asepsis. Simul Healthc 2011;6:65-70. 13. Gantt LT, Webb-Corbett R. Using simulation to teach patient safety behaviors in undergraduate nursing education. J Nurs Educ 2010;49:48-51.
