Journal of Hospital Infection 88 (2014) 84e88 Available online at www.sciencedirect.com

Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin

Effect of a contact monitoring system with immediate visual feedback on hand hygiene compliance S.J. Storey a, G. FitzGerald a, G. Moore a, E. Knights b, S. Atkinson c, S. Smith c, O. Freeman d, P. Cryer e, A.P.R. Wilson a, * a

Department of Microbiology and Virology, University College London Hospitals, London, UK Heart Hospital, University College London Hospitals, London, UK c Institute for Occupational Ergonomics, Faculty of Engineering, University of Nottingham, Nottingham, UK d HCAI Service Users Research Forum, Faculty of Health and Human Sciences, University of West London, Brentford, UK e Intromed Ltd, Leicester, UK b

A R T I C L E

I N F O

Article history: Received 13 August 2013 Accepted 28 June 2014 Available online 24 July 2014 Keywords: Hand hygiene Healthcare-acquired infection Contact monitoring

S U M M A R Y

Background: Hand hygiene compliance is traditionally monitored by visual methods that are open to bias and strictly limited in time and place. Automatic monitoring may be more effective for infection control as well as performance management. Aim: To establish accuracy and acceptability of an automatic contact monitoring system for hand hygiene. Methods: Monitoring equipment was installed across 55 beds in three wards, and included modified identity badges, bedside furniture, sinks and alcohol gel dispensers. Badges were in near-skin contact (through uniform) and could detect alcohol vapour. All devices were linked by wi-fi. A traffic light system on the badge provided immediate feedback to staff and patients on the hand hygiene status of a member of staff on approach to a patient. Compliance was logged automatically. Following a period of immediate feedback, no visual feedback was given for two weeks. Subsequently, feedback was given using red/green lights for 10 days, followed by retrospective feedback to the ward. Hand hygiene was verified independently by an observer. Findings: Hand hygiene compliance increased from 21% of 97 opportunities to 66% of 197 opportunities during active immediate feedback. Compliance decreased when feedback was provided to wards retrospectively. Six staff (26%) avoided wearing a badge, saying that it was too heavy or they were not on the ward all day. Only three of 30 patients stated that they would challenge staff who had not performed hand hygiene. Conclusions: Automatic contact monitoring with immediate feedback was effective in increasing hand hygiene compliance, but feedback given retrospectively did not prevent a decrease in compliance. ª 2014 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

* Corresponding author: Address: Department of Microbiology and Virology, University College London Hospitals, 60 Whitfield Street, London W1T 4EU, UK. Tel.: þ44 (0) 203 44 79516; fax: þ44 (0) 2034479211. E-mail address: [email protected] (A.P.R. Wilson).

Introduction The prevalence of healthcare-associated infection (HCAI) is 6% in England and represents a major preventable cost.1 Hand hygiene is central to the campaign to reduce HCAI, and

http://dx.doi.org/10.1016/j.jhin.2014.06.014 0195-6701/ª 2014 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

S.J. Storey et al. / Journal of Hospital Infection 88 (2014) 84e88 Table I World Health Organization (WHO) Moments of Hand Hygiene detected by the test system WHO Moment of Hand Hygiene 1. Before patient contact

Detection Sink trap or alcohol vapour sensors before contact with patient area sensed Aseptic task not detected specifically Body fluid exposure not detected specifically Sink trap or alcohol vapour sensors after contact with patient’s bed/chair sensed Sink trap or alcohol vapour sensors after contact with patient area sensed

2. Before aseptic task 3. After body fluid exposure risk 4. After patient contact

5. After contact with patient surroundings

available evidence suggests that there is a direct link between hand hygiene and the frequency of these infections.2 Encouraging compliance is the main focus of infection control within hospitals. However, poor compliance remains a common problem, especially in critical care where there are frequent contacts between staff and patients. In 2005, the World Health Organization (WHO) undertook a major campaign to promote hand hygiene in hospitals through the use of alcohol hand gel, audit and feedback.3 Visual audit and feedback of hand hygiene compliance rates are mandatory in UK hospitals. Targets for compliance are generally very high (>90%) and are achieved according to published rates, but

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there are clear differences between hand hygiene rates when the observer is obvious and when the observation is covert (30e50%).4 Observational methods are open to bias, the Hawthorne effect and poor reproducibility. The level of activity and distance of the observer affect the recorded level of compliance,5 and audit requires a member of staff to take time out of normal duties for several hours each month on each unit. The reputation of the hospital is affected by low published rates, but consistently high rates can result in declining efforts by staff to comply.6 In order to improve compliance, feedback should be positive, local and rapid.2 Electronic monitoring has promise but has not been validated sufficiently to date. Electronic monitoring systems have attempted to reduce the labour involved in routine audit, and to produce reproducible results at times of the day and in areas where direct observation is not practicable (e.g. single rooms and behind curtains). Education campaigns are effective in raising levels of hand hygiene compliance, but their effects are transient and they have to be repeated. Electronic systems may be able to provide continued and immediate feedback, but usually involve short-range radio frequency or ultrasonic monitors.4 Such systems measure proximity rather than contact, so the results are influenced by clinical staff who approach but do not touch a patient. The Green Badge System (Veraz Ltd, Lancaster, UK) electronically detects contact between staff, patients (when in a bed or chair) and patient equipment, as well as when staff clean their hands using a handwash basin or alcohol gel. The sequence of these events demonstrates compliance with the WHO Moments of Hand Hygiene. Use of a handwash basin/ alcohol gel is detected before and after contact with the patient’s bed/chair and the immediate environment [Moments 1

90 80 70 N or (%)

60 50 40 30 20 10 0

AHP

Nurse

SHO

Other

Overall

Average no. of first contacts

11.5

11.62

13.5

17.43

13.77

Average no. of breaches

4.08

4.73

2.5

6.88

4.09

Compliance (%)

64.49

59.25

81.48

60.52

70.26

Figure 1. Monitored hand hygiene compliance by staff role. First contact, first approach by staff member in a treatment episode terminated by hand hygiene after light changed from green. Average breaches, average number of failures to observe hand hygiene before touching a patient after touching the environment or another patient. SHO, senior house officer (junior doctor); AHP, allied health professional (e.g. physiotherapist).

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Table II Monitoring of hand hygiene compliance by electronic and visual methods with/without feedback Intervention (days, N)

First contacts in tagged area

Compliance by visual audit (all WHO Moments) Hand hygiene episodes/ opportunities (%)

Prestudy 1. Monitoring/green light only with no feedback (7, 97) 2. Monitoring/green, amber, red lights (14, 197) 3. Monitoring/green light only with no feedback (7, 99) 4. Green light with feedback by retrospective ward reports (12, 82)

Daily staff Gels/day/ Handwashes/ Handwashes Handwashes participants participant day/ over participant 45 s

Average (range)

Average (range)

Average (range)

Total

e 1665

498/1159 (43.0) e e e 414/884 (46.8) 14.1 (13e15) 9.5 (1e20) 1.10 (0e4)

e 107

3672

286/481 (59.6) 14.0 (12e16) 13.4 (3e28) 1.05 (0e5)

1369

1322

N (%)

e

Monitored compliance (WHO Moments 1,4, and 5) Hand hygiene/ opportunities (%)

4 (3.9)

e 361/1665 (21.6)

207

49 (23.7)

2443/3672 (66.5)

178/276 (64.6) 14.4 (11e19) 12.3 (3e25) 1.13 (0e5)

112

21 (18.8)

879/1369 (64.2)

304/539 (56.3) 13.3 (8e18) 14.2 (0e50) 0.73 (0e3)

68

18 (26.5)

1334/2100 (63.5)

WHO, World Health Organization. Prestudy vs green light with no feedback: not significant. Green light vs green/red lights: visual, c2 ¼ 19.4; monitored, c2 ¼ 922 (P < 0.001). Green/red light vs green light with no feedback: not significant. Green light with no feedback vs green light with feedback by ward report: visual, c2 ¼ 4.6 (P < 0.05); monitored, not significant.

(before patient contact), 4 (after patient contact) and 5 (after contact with surroundings)] (Table I). Moments 2 and 3 cannot be differentiated specifically, although sites touched immediately around the time of hand hygiene are recorded. Moments 1, 4 and 5 are differentiated. Feedback of performance is immediate by means of a coloured light mounted on an identity badge. The aim of this study was to determine the acceptability and efficacy of immediate automated feedback in improving hand hygiene compliance.

Methods Setting The trial was conducted in a specialist acute cardiac hospital with 96 inpatient beds, four theatres, four cardiac catheter beds and 281 nurses. There was no pre-existing wi-fi system. The hospital treats 6400 inpatients and 3700 day-case patients per year.

System Informed consent was obtained from staff wearing the badges. Although the patients were not tagged directly, contact with a patient was detected when he/she was in bed or sitting in a chair. The coronary unit has 10 beds in a single room plus one side room. The third floor ward has four four-bed bays, four twobed bays and seven single rooms. The fourth floor ward has four

two-bed bays and 12 single rooms. After excluding critical care and day-case units and other beds where patients were unable to consent, the system was installed in the 55 bed spaces available. Beds, overbed tables and chairs were tagged with a device that generated a unique electronic signature when the tagged object was touched. Another device was placed in the waste pipe from ward sinks (but not those in ensuite patient rooms) to detect use of soap and water. Staff wore a modified identity badge and lanyard during normal work, and this provided near-skin contact (through uniform) with the sensor in the badge. A sensor in the identity badge detected the use of alcohol gel by the vapour produced. All devices were connected by a wi-fi system. A light on the badge changed colour (green, amber, red) according to the detection of patient contact after touching the environment with (green) or without (red) hand hygiene. The default setting was amber, indicating that hand hygiene was required. The system supports monitoring of the WHO Moments of Hand Hygiene (Table I). Before entering the bed space, the healthcare worker performs hand hygiene and the badge light changes from amber to green. If contact is made in the patient zone, the green light flashes. If contact is registered in another patient zone without hand hygiene, the light turns red. Provided that the badge is worn externally, the red or amber light could be seen by the patient, the wearer and other staff, prompting hand hygiene. Hand hygiene opportunities and compliance were logged automatically throughout the shift. The study ran every day between 10:00 h and 16:00 h to allow system support, and deployment and collection of badges within

S.J. Storey et al. / Journal of Hospital Infection 88 (2014) 84e88 a single shift. Work was performed in four phases to separate the effects of feedback from participation in the study: electronic and visual monitoring with badges set with a green light with no feedback (two weeks, Phase 1), monitoring when badges were set to change from green and amber to red if hand hygiene was needed (10 days, Phase 2), badges set with a green light with no feedback (one week, Phase 3), and feedback given retrospectively using tables and graphs posted at the nurses’ stations (two weeks, Phase 4). There was a washout week between each phase. Patients were given an information sheet and informed consent was obtained. The system was demonstrated to each patient. To ascertain patient responses to the effectiveness of the green light, the research team included a service user who was involved in preparation of the patient information literature and questionnaires, and interviewing patients. Staff were assured anonymity. The study was approved by the National Research Ethics Service Committee London 11/LO/0731. Nurses, allied health professionals (e.g. physiotherapists) and junior doctors were approached. The latter were ward based.

Hand hygiene The outcome measure for electronic monitoring was hand hygiene compliance, defined as the percentage of opportunities where hands were cleaned at a handwash basin or with alcohol gel before moving to a different patient zone (i.e. WHO Moments 1, 4 and 5). The proportion of handwashes exceeding 45 s in duration, in accordance with the WHO criteria, was also recorded. The outcome measure for visual audit was compliance expressed as a percentage of opportunities where hand hygiene was observed (i.e. before/after touching a patient, before aseptic procedures, after body fluid exposure and after touching patient surroundings). Independent visual observation was conducted by research staff in 20-min sessions at random times during each day, covering at least 15 hand hygiene opportunities on each of the target wards. Staff were alerted to empty dispensers, dropped gloves and missed high-risk opportunities in all phases. The number of staff members who were not wearing a badge externally was recorded. The University College London Hospital Hand Hygiene Observation Tool 2005 was used.7,8

Staff acceptance Staff questionnaires were given to all participants. Questions included how easy it was to see the colour of the light when wearing a badge, ease of wear, likely effectiveness in improving hand hygiene compliance, challenges by patients, and avoidance of wearing a badge. Patient questionnaires were administered by the patient representative and/or the research nurse. Patients were asked about the meaning of the coloured lights, challenging staff on the basis of a red light, and whether the system gave them confidence in staff infection prevention practice.

Results Data were collected from 63 distinct tagged patientebed combinations as some patients were moved between beds. The number of hand hygiene events and the proportion of >45-s handwashes increased with immediate feedback (Table II, Figure 1). Electronically monitored compliance rose three-fold

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(from 21.6% to 66.5%), and the significant improvement in Phase 2 was maintained in the subsequent two weeks when no feedback was given (Phase 3) (Table II). There was a significant increase in compliance in the visually monitored audits, but it was less marked (from 46.8% to 59.6%). When overall electronic compliance was fed back retrospectively using email and graphs at the nurses’ stations (Phase 4), compliance decreased from 59.2e81.5% to 33.3e56.5% depending on staff group. In total, 67 staff participated in the study, but only 23 agreed to complete questionnaires (14 nurses, five healthcare assistants, three physiotherapists and one ward clerk). Staff indicated that they would not mind being challenged by patients. All but one of the staff found the coloured lights easy to see, although six were unaware of the colour whilst wearing the badge. Twenty (87%) staff found the badge easy to wear, and 19 (79%) thought it would improve hand hygiene. Although not raised in the questionnaire, one member of staff wanted to know how the information would be used and if it might result in disciplinary action. Feedback was therefore given by staff group rather than by individual staff member. Six (26%) staff chose not to participate in the trial and questionnaire because they found the badge too heavy or they were not on the ward all day. The response scores for each question were similar across professions, but nurses were more likely to think that the system would be effective. Doctors were identified by 19 (84%) respondents as the group least likely to wear badges, and no doctors agreed to complete the questionnaire. Forty-one patients participated in Phase 2 of the study. Thirty patients agreed to complete the questionnaire and 27 of them had seen staff wearing the badges. Five patients had seen an amber light and nine patients had seen a red light. All patients understood the meaning of a green light, 27 understood the meaning of a red light but 22 did not understand the meaning of an amber light. Of 30 patients, 27 thought that the system would improve hand hygiene. Only three patients reported that they would challenge a staff member wearing a red badge. Patients felt that they were not in the correct line of sight, the badge might not be working, they did not want to upset staff or they could not see the light clearly. One patient challenged a member of staff who subsequently took no action. Most patients (27, 90%) felt more confident about infection prevention on the ward if they could see that the staff badge was green.

Discussion Accurate estimation of hand hygiene compliance is difficult, especially if the staff know the observer and are aware that their performance is being judged. Compliance behind curtains, at night or in a single room often goes unmonitored, and internally reported compliance rates are often overestimated. The Green Badge System of hand hygiene monitoring is unusual as it detects contact between staff, patients and their environment, rather than proximity; and it detects duration and frequency of use of alcohol hand rub and handwashing. Immediate and/or retrospective feedback to staff allowed compliance reports to be made at any time, supporting root cause analysis and governance. Immediate feedback was associated with improved hand hygiene compliance, and could be used at any time or location in the ward. Most systems based on wearing a device rely on proximity sensors. Cheng et al. used an electronic radioproximity sensor

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badge worn by staff to detect use of alcohol gel and soap, with a beacon on the wall at the bed head to detect presence in the patient zone.4 Hand hygiene before and after touching a patient was only 35%, compared with 89% when a visual audit was conducted concurrently. However, contact was inferred rather than measured, and pocket alcohol gel dispensers were not included in the system. Electronic devices worn by staff connected wirelessly to alcohol gel dispensers have also been used in a teaching environment to define patient environmental zones.9 Another system used an alcohol sensor badge and a red light to signal the need for hand hygiene on room entry or exit, but did not measure compliance within the room.10 Nevertheless, compliance improved significantly. A voice alert prompt or a monitor of dispenser use can increase compliance on entering and leaving an isolation room, provided that feedback is given.11e13 However, a significant increase in dispenser use may not be reflected in a significant increase in compliance, as determined by visual audit.14 Devices counting the use of gel do not measure the Five Moments of Hand Hygiene, and may differ widely from results of direct observation. The system tested in this study documented contact between staff and the patient’s chair or bed, but in future, a patient wrist band monitor could be used to detect contact with the patient regardless of where they are situated. The contact monitoring system does not include all five WHO Moments of Hand Hygiene, but complements visual audit, particularly out of hours or out of line of sight. As feedback is immediate and automatic, HCAI rates may benefit in view of the link between hand hygiene compliance and reduced HCAI. However, a larger trial is needed to test that expectation. The cost of equipment and installation was approximately £150 per bed, and the cost of maintenance was approximately £12 per bed per year. Although greater than the cost of a monthly visual audit, it could be continuous rather than a few hours per month. The costs would fall significantly with production volumes and miniaturization. Staff acceptance was generally good, and both staff and patients understood the meaning of a red light. However, no doctors agreed to complete the questionnaire. The amber light should be abandoned as patients did not understand its meaning. A patient information sheet and inclusion in the ward induction would be needed if the system was in routine use. Direct challenges of members of staff by patients were uncommon. Staff expectation of a red light being seen was sufficient to prompt hand hygiene, particularly as it was seen by colleagues. As this was a research study, disciplinary action could not be used, but staff did prompt other staff to wash their hands if a red light was visible. Feedback of realistic and accurate hand hygiene compliance rates is essential to minimize the risk of transmission of infection on staff hands. Current visual methods of audit are labour intensive and may be inaccurate. Proximity monitoring may flag non-compliance when this is not the case. Automatic contact hand hygiene systems should be further developed to provide point-of-care feedback to patients and staff, data for root cause analysis, and for training purposes.

Acknowledgements The authors wish to thank all the staff of the Heart Hospital and Joao Concalves for helping to undertake this study.

Conflict of interest statement P. Cryer has previously received benefits through the provision of advisory services to Veraz Ltd. The other authors report no conflicts of interest. Funding sources This study was funded by an educational grant from Veraz Ltd, with the support of the Small Business Research Initiative at the Department of Health and the National Institute for Health Research University College London Hospitals Biomedical Research Centre.

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Effect of a contact monitoring system with immediate visual feedback on hand hygiene compliance.

Hand hygiene compliance is traditionally monitored by visual methods that are open to bias and strictly limited in time and place. Automatic monitorin...
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