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International Journal of Nursing Practice 2015; 21: 709–715
RESEARCH PAPER
Effects of hand hygiene education and individual feedback on hand hygiene behaviour, MRSA acquisition rate and MRSA colonization pressure among intensive care unit nurses Hee-Kyung Chun RN MSN ICAPN Infection Control Nurse, Department of Infection Control, Kyung Hee University Medical Center, Seoul, South Korea
Kyung-Mi Kim RN PhD ICAPN Assistant Professor, Department of Nursing, Semyung University, Jecheon, South Korea
Ho-Ran Park RN PhD Professor, College of Nursing, The Catholic University of Korea, Seoul, South Korea
Accepted for publication August 2013 Chun H-K, Kim K-M, Park H-R. International Journal of Nursing Practice 2015; 21: 709–715 Effects of hand hygiene education and individual feedback on hand hygiene behaviour, MRSA acquisition rate and MRSA colonization pressure among intensive care unit nurses This study was conducted to increase the frequency and level of thoroughness of hand hygiene practice by nurses, and to assess the influence of the methicillin-resistant Staphylococcus aureus (MRSA) acquired incidence rate and the MRSA colonization pressure in a medical intensive care unit (MICU). A total of 24 MICU nurses received hand hygiene education and individual feedback of hand hygiene frequency and method after a session of education, and two posteducation evaluations were followed. The frequency of hand hygiene (P = 0.001) and the methodology score of hand hygiene increased significantly (P = 0.001). The MRSA acquisition rate decreased significantly, from 11.1% before the education to 0% after (P = 0.014). The MRSA colonization pressure decreased significantly from 39.5% to 8.6% after the education sessions (P = 0.001). This indicates that providing individual feedback after hand hygiene education was very effective in increasing nurses’ hand hygiene frequency and improving hand hygiene method; furthermore, it was expected to decrease health care-associated infections. Key words: hand hygiene, intensive care unit, methicillin-resistant Staphylococcus aureus.
INTRODUCTION Correspondence: Ho-Ran Park, College of Nursing, The Catholic University of Korea, 505 Banpodong Seochogu, 137-701 Seoul, South Korea. Email: [email protected] doi:10.1111/ijn.12288
Healthcare workers’ (HCWs) hands are a major source of cross-infection among health care-associated infections as they can be responsible for directly spreading microorganisms. As the number of microorganisms tends to © 2014 Wiley Publishing Asia Pty Ltd
H-K Chun et al.
710
increase when hand hygiene is inappropriate, maintaining the proper level of hand hygiene is important for minimizing the risk of cross-infections.1,2 Among HCWs, nurses have the most frequent contact with patients. Maintaining proper hand hygiene during nursing care has been known to directly reduce the number of health care-associated infections3 However, actual handwashing rate in nursing care has been reported to be as low as 13–20% in Korea and 15–34% in other countries.2,4–8 Various programmes have been developed to promote hand hygiene. However, Dorsey et al.9 found that signs posted with the Centers for Disease Control and Prevention’s (CDC) handwashing recommendations and the distribution of a copy of a related publication on handwashing to HCWs were not effective in increasing the hand hygiene implementation rate. Numerous studies on the appropriateness of hand hygiene methods, as well as the frequency of hand hygiene implementation, have been conducted. However, only a few studies have included individual feedback. Some researchers reported that providing feedback on the hand hygiene implementation rate and the appropriateness of the individual’s hand hygiene method increased hand hygiene.5,6,10 Moongtui et al. suggested that adjunct methods should be sought to promote the retention of the effect.5 In addition, observational studies on the effectiveness of hand hygiene using individual feedback are rare. There has not been a study measuring the effectiveness of this individual feedback method 6 weeks after the initial education. Methicillin-resistant Staphylococcus aureus (MRSA) acquisition pressure is defined as the proportion of patients colonized with the MRSA organism in a defined geographic area within a hospital during a specified time period. Acquisition of MRSA in intensive care unit (ICU) patients is strongly and independently influenced by colonization pressure.11,12 The hospital in which this study was conducted has been performing MRSA active surveillance cultures in the ICU since June 2008. The MRSA acquisition rate (10.3%) and the MRSA colonization pressure (28%) of the medical intensive care unit (MICU) were higher than in two other types of ICUs. Also, the MRSA isolation rate in the MICU was the highest among all the ICUs from September to October 2008. As such, an infection control intervention was needed. Therefore, this study was conducted as part of an effort to reduce the MRSA acquisition rate and the MRSA colonization pressure of MICU patients by providing individual feedback to MICU nurses on the © 2014 Wiley Publishing Asia Pty Ltd
appropriateness and the frequency of hand hygiene after hand hygiene education session.
Study aims The aim of this study was to increase the frequency and level of thoroughness of hand hygiene as practised by nurses who were given individual feedback after a hand hygiene education session, and to assess the influence of the MRSA-acquired incidence rate and MRSA colonization pressure.
METHODS Design and sample This quasi-experimental study was performed in a tertiary care university teaching hospital with 850 beds from October 2008 to January 2009. Twenty-four nurses working in an MICU with 15 beds were enrolled. Observations were conducted before the education, and 1 week and 6 weeks after the hand hygiene education session (Fig. 1). This study was approved by the Institutional Review Board of the Catholic University of Korea College of Medicine.
Procedure Evaluation and individual feedback
Before the hand hygiene group education, hand hygiene frequency and methods were observed and the results were reported to each individual. Hand hygiene performance was documented based on a localized Korean tool adopted from the Association for Professionals in Infection Control guidelines.13 The frequency of hand hygiene was measured to determine whether hand hygiene was carried out, before and after six categorized nursing activities. The six nursing activities categorized to require hand hygiene were activities related to intravenous or intramuscular injection, respiratory ventilator care, care regarding excretion such as urine or stool, wound care, and nasogastric tube feeding. In total, 69 nursing activities required hand hygiene. The frequency of hand hygiene was calculated as ‘Number of hand hygiene activities conducted/Number of hand hygiene required × 100’ (%). The methods of hand hygiene were observed and scored based on the following: hand hygiene agent (0 for water, 1 for alcohol based gel or antiseptic soap), rubbing time (0 for less than 15 s, 1 for 15 s or more), area (0 for
Individual feedback on hand hygiene
711
Observation survey for hand washing frequency and method (n = 1194) Pre-education
Check-up of hand culture (n = 24) Survey of MRSA acquired incidence rate and MRSA colonization pressure
Education
Hand washing education programmes including individual feedback Group education for hand washing recommendation and effects Outcome of hand washing frequency and method Outcome of hand culture (n = 24)
1 week posteducation
Evaluation for hand washing frequency and method (n = 1152) Survey of MRSA acquired incidence rate and MRSA colonization pressure
Evaluation for hand washing freque ncy and method (n = 1176) 6 weeks posteducation
Survey of MRSA acquired i ncidence rate and MRSA colonization pressure
Figure 1. Study design.
less than three areas among palms, back of hands, wrists, fingers and finger tips, 1 for three or four areas, 2 for five areas) and drying method (0 for inadequate, 1 for paper towel usage after water and soap or waiting to dry after alcohol gel). The sum of the scores was used for evaluation. The investigator observed the hand hygiene performance of the nurses from approximately 1 m away from the patient’s bed twice a day during the time the nurse had the most frequent contact with patients (9:00 to 11:00 in the morning and 4:00 to 6:00 in the afternoon). Observations were completed at least 30 times on each nurse to ensure that every nurse was evaluated equally. The first observation was done 1 week after the group education to evaluate the immediate effect of individual feedback education on hand hygiene practices. The second observations were done 6 weeks after the education to evaluate the continuous effect of the group education as prior studies have shown that the performance of hand hygiene declined 3–4 weeks after the education (Fig. 1). Before education and after washing their hands, the right hand of every participant was cultured using a hand plate (Samlip general food, Gyeonggi-do, Korea) at a temperature of 30–35°C for 24–48 h in the incubator. A yellow zone around a colony indicates S. aureus. Individual reports of observed hand hygiene frequency, appropriateness of hand hygiene methods and hand culture results before education were handed out during
the group education. Hand plate photos of the hand culture results were also provided.
Hand hygiene education
Hand hygiene education was performed for the group, and personal feedback on the appropriateness and frequency of hand hygiene was provided individually. Group education included the proper methods of hand hygiene based on the guidelines released by the CDC1 and the World Health Organization,14 as well as the importance of hand hygiene, with study results regarding the effect of hand hygiene. Group education was performed with a PowerPoint presentation. The group education lasting about 30 min was conducted by the investigator at the end of the work day. It was repeated for 5 days to ensure all participants received the education. Individual feedback on the appropriateness and frequency of hand hygiene was provided for 10 min after the group education. Individual feedback was confidential.
MRSA screening
The MICU patients were screened for MRSA acquisition by nasal swab culture within 24 h of admission at the start of the study and then once a week thereafter. When the follow-up culture was positive in a patient with an initial negative culture, the patient was defined to have acquired MRSA.13 MRSA acquisition rate was calculated monthly © 2014 Wiley Publishing Asia Pty Ltd
H-K Chun et al.
712
Figure 2. MRSA acquired incidence rates in pre-education vs. post-education periods. ( ) No. patients acquired MRSA, ( ) MRSA acquisition rates (%), ( ) MRSA acquisition rates (per 1000 patient-days). Pre, pre-education; Post I, 1 week after education; Post II, 6 weeks after education.
as ‘Number of patients who acquired MRSA/Number of patient admitted to MICU and Number of patient days’, before and after the education. The MRSA colonization pressure was calculated as ‘Number of patients with positive culture for MRSA/ Current number of patients in MICU × 100’ (%). The MRSA colonization pressure indicates that more patients with positive MRSA culture surfaces, could translate into a higher chance of MRSA transmission. When the MRSA colonization pressure is 30% or higher, the risk of transmitting MRSA to an MRSA negative patient is very high.11,12 This was calculated before and 6 weeks after the education.
Statistical analysis Windows SPSS version 12.0 (Chicago, IL, USA) was used for statistical analysis. The chi-square test was used for frequency measurement of hand washing before and after group education. One-way ANOVA and Dunnett’s multiple comparisons were used for methods of hand washing. The chi-square and Fisher’s exact tests were used to examine the MRSA acquisition rate and the colonization pressure. A P-value < 0.05 was considered statistically significant.
RESULTS Twenty-four nurses participated in the study. The group consisted of 23 female participants (95.8%) and their mean age was 32.9 ± 7.9 years. Their mean working period was 7.6 ± 8.1 years, with a mean of 2.9 ± 1.9 years of ICU working experience. © 2014 Wiley Publishing Asia Pty Ltd
A total of 1194 hand hygiene observations were made before the group education, 1152 hand hygiene observations were made 1 week after the education (first time post-education) and 1176 observations were made 6 weeks after the group education (second time posteducation).
Frequency of hand hygiene The overall frequency of hand hygiene increased from 46.8% before the educational sessions to 71.4% after the first education and to 64.9% at the second group education observations (P = 0001) (Fig. 2). Table 1 shows changes in the hand hygiene frequency by nursing activities before and after the group education, and was seen to have increased. When nurses came in contact with known MRSA isolated patients, vancomycin-resistant enterococci and imipenem-resistant Acinetobacter baumannii, the frequency of hand hygiene increased from 53.1% at pre-education to 74.1% and 71.7% at the first and second time of observations, respectively (P = 0.001).
Methods of hand hygiene The mean score for hand hygiene methods was 2.84 before the group education, and increased to 3.65 and 3.89 at the first and second posteducation observations, respectively (P = 0.001). The score for the hand hygiene agent increased from 0.99 to 1.00 at the first and second posteducation observation periods (P = 0.013 and 0.053). The score for hand hygiene time, hand hygiene area and drying methods were also increased (Table 2).
Individual feedback on hand hygiene
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Table 1 Hand hygiene frequency by nursing activity Activity
Pre-education No (%)
Posteducation I No (%)
P†
Posteducation II No (%)
P‡
Related to intravenous/injection therapy Related to respiratory therapy Related to excretory management Related to wound dressing and drainage Related to nutritional support and oral medication Casual contact with patient Overall nursing activities
95/280 (33.9) 145/252 (57.5) 38/88 (43.2) 12/40 (30) 9/22 (40.9) 260/512 (50.8) 559/1194 (46.8)
171/260 (65.8) 255/334 (76.3) 69/92 (75.0) 27/52 (51.9) 5/10 (50.0) 296/404 (73.3) 823/1152 (71.4)
0.001 0.001 0.001 0.035 0.631 0.001 0.001
186/318 (58.5) 196/262 (74.8) 69/108 (63.9) 21/48 (43.8) 17/22 (77.3) 274/418 (65.6) 763/1176 (64.9)
0.001 0.001 0.004 0.185 0.014 0.001 0.001
†
Chi-square test: pre-education/posteducation I (1 week after education). ‡ Chi-square test: pre-education/posteducation II (6 weeks after education). No (%), No. hand hygiene/No. activity for which hand hygiene is recommended (hand hygiene frequency rate). Table 2 Comparison of content scores for each hand hygiene method Content (total score)
Hand hygiene agent (1) Hand hygiene time (1) Hand hygiene area (2) Drying method (1) Total score of hand hygiene method (1)
Pre-education
Posteducation I
N
Mean ± SD
N
Mean ± SD
559 559 559 559 559
0.99 ± 0.08 0.26 ± 0.44 0.78 ± 0.62 0.78 ± 0.42 2.84 ± 1.12
823 823 823 823 823
1.00 ± 0.00 0.63 ± 0.48 1.14 ± 0.55 0.87 ± 0.34 3.65 ± 1.11
P†§
0.013 0.001 0.001 0.001 0.001
Posteducation II N
Mean ± SD
763 763 763 763 763
1.00 ± 0.36 0.74 ± 0.44 1.20 ± 0.57 0.95 ± 0.22 3.89 ± 0.99
P‡§
0.053 0.001 0.001 0.001 0.001
†
Comparison between pre-education and posteducation (1 week after education). ‡ Comparison between pre-education and posteducation II (6 weeks after education). § One-way ANOVA with Dunnett’s t-test (two sided) as a control and comparison of all other groups. Each was regarded as independent. N, number of hand hygiene.
The score for hand hygiene methods after nursing care for patients with multiple drug resistance (MDR) microorganisms was increased from 1.52 ± 1.68 at pre-education, to 2.76 ± 1.91 and 2.79 ± 1.97 at first and second time posteducations periods (P = 0.001).
MRSA colonization pressure The MRSA colonization pressure was initially 39.5%, but was reduced to 28.8% at the first posteducation observation (P = 0.038) and to 8.6% at second postsession (P = 0.001) (Fig. 3).
MRSA acquisition rate
DISCUSSION
The MRSA acquisition rate decreased from 11.1% (5 patients) before the education to 2.7% (1 patient) (P = 0.215) at first group education and to 0% (0 patients) after the second round of observations (P = 0.014) (Fig. 2). The MRSA acquisition rate was 13.3 per 1000 patientdays before education and decreased to 2.6 and 0 per 1000 patient-days after the first and second observations, respectively (P = 0.118 and P = 0.071) (Fig. 2).
Hand hygiene is the easiest and most fundamental method to prevent health care-associated infections. It removes microorganisms acquired during nursing care for patients with an infection or a colonization of microorganisms. Hand hygiene also helps to prevent cross-infection between patients and HCWs.15 Nurses have a higher chance of direct contact with patients as compared with other HCWs, and therefore, proper hand hygiene for nurses is very effective in © 2014 Wiley Publishing Asia Pty Ltd
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H-K Chun et al.
Figure 3. MRSA colonization pressure in pre-education vs. the posteducation period. Pre, pre-education; Post I, 1 week after education; Post II, 6 weeks after education.
preventing the propagation of health care-associated infections. The reason for conducting a single-group intervention in this study was that there were three shifts of nurses working in the MICU. As such, conducting two group interventions was not possible. The study period was fall and winter, with no new interns and residents in the hospital. Therefore, the reduction of the MRSA acquisition rate and the colonization pressure was considered an effect of the reduction of cross-infection due to an increase in the hand hygiene implementation rate. In one Korean study, the implementation rate of hand washing was 33.5% in a surgical ICU before improving hand washing programme.2 Pittet et al. reported that the frequency of hand hygiene increased from 48% to 66% after applying a multidimensional programme, including seven education sessions, promotion for hand sanitizers and feedback.16 Jeong and Choe has reported that hand hygiene promotion increased the implementation of hand hygiene from 33.5% to 58.4% in a surgical ICU.2 In the present study, the individual feedback given after a group education for hand hygiene improved the frequency of hand hygiene. This result indicated that individual feedback increased the awareness for hand hygiene, as well as improving the methods of hand hygiene. Some studies have reported that the effect of a hand hygiene improvement programme lasted less than 4 weeks.10,17 In the present study, the frequency of hand hygiene at the second posteducation observation period © 2014 Wiley Publishing Asia Pty Ltd
decreased compared with the first, but increased significantly when compared with its original state (P = 0.001). The score for hand hygiene was even higher for the second session, which showed more prolonged effect than previous studies. During the 4 month study, the MRSA acquisition rate decreased from 11.1% at the first posteducation observation period to 0% after the second posteducation. Although there was no significant difference in the statistics, the MRSA acquisition rate corrected during ICU admissions tended to decrease from 13.0/1000 patientdays prior to the education to 0/1000 patient-days after the second posteducation period. In Kim and Choi’s study, as hand hygiene frequency showed an increase from 15.6% to 46.9%, MRSA nasal colonization decreased from 42.8% to 18.6%.3 In Jeong and Choe’s study, for the 5 months of the hand hygiene period, there was no difference in the incidence of infection.2 To identify the effect of hand hygiene on the prevention of health careassociated infections, the improvement of hand hygiene should be maintained for a long period of time and thus, hand hygiene education for HCWs should be carried out persistently. If MRSA colonization pressure is greater than 30%, there is a high probability for MRSA cross-infection within the area.12,18 Before the education, the MRSA colonization pressure was 39.5%, but decreased to 28.8% and 8.6% at the first and second posteducation observations. As the
Individual feedback on hand hygiene
MRSA colonization pressure decreased, the probability of MRSA cross-infection also decreased. Before the education, the hand hygiene frequency and methods were observed without prior information. However, after the group education and individual feedback data, nurses became aware that their hand hygiene would be observed and they would need to wash their hands more frequently and properly. However, we found that the individual feedback provided improved both frequency and methods of hand hygiene, and the effect persisted longer than seen in previous studies. This indicates that health care-associated infections can be decreased by maintaining proper hand hygiene.
Conclusion Hand hygiene education and individual feedback of hand hygiene frequency and method were effective in increasing hand hygiene frequency and improving nurses’ methodology scores of hand hygiene. Also, it was proven to decrease MRSA acquisition rate and MRSA colonization pressure. This study was conducted only with targeted ICU nurses, so further study would be helpful on the effect of individual feedback for hand hygiene to HCWs including doctors, paramedics and technicians on the incidence of health care-associated infections.
REFERENCES 1 Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infection Control Hospital Epidemiology 2002; 23: S3–S40. 2 Jeong JS, Choe MA. The effect of hand washing improving programs on the adherence of hand washing and nosocomial infections in a surgical intensive care unit. Korean Journal of Nosocomial Infection Control 2004; 9: 117–129. 3 Kim NC, Choi KO. Effects on nurses’ hand washing behavior and reduction of respiratory isolation rate of MRSA of the hand washing education. Korean Journal of Adult Nursing 2002; 14: 26–33. 4 Lee MH, Kang HS. A comparative study on professionspecific handwashing practices of ICU health care providers. Journal of Korean Academy of Fundamentals of Nursing 2007; 14: 297–305. 5 Moongtui W, Gauthier DK, Turner JG. Using peer feedback to improve handwashing and glove usage among Thai health care workers. American Journal of Infection Control 2000; 28: 365–369.
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6 Rosenthal VD, McCormick RD, Guzman S, Villamayor C, Orellano PW. Effect of education and performance feedback on handwashing: The benefit of administrative support in Argentinean hospitals. American Journal of Infection Control 2003; 31: 85–92. 7 Kim JM, Park ES, Jeong JS et al. 1996 national nosocomial infection surveillance in Korea. Korean Journal of Nosocomial Infection Control 1997; 2: 157–176. 8 Park ES, Park MR, Kim JE et al. Multicenter ICU surveillance study for nosocomial infection in Korea. Korean Journal of Nosocomial Infection Control 2003; 8: 23– 33. 9 Dorsey ST, Cydulka RK, Emerman CL. Is handwashing teachable?: Failure to improve handwashing behavior in an urban emergency department. Academic Emergency Medicine 1996; 3: 360–365. 10 Dubbert PM, Dolce J, Richter W, Miller M, Chapman SW. Increasing ICU staff handwashing: Effects of education and group feedback. Infection Control Hospital Epidemiology 1990; 11: 191–193. 11 Ajao AO, Harris AD, Roghmann MC et al. Systematic review of measurement and adjustment for colonization pressure in studies of sethicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococci, and Clostridium difficile acquisition. Infection Control and Hospital Epidemiology 2011; 32: 481–489. 12 Merrer J, Santoli F, Appéré de Vecchi C, Tran B, De Jonghe B, Outin H. ‘Colonization Pressure’ and risk of acquisition of methicillin-resistant Staphylococcus aureus in a medical intensive care unit. Infection Control and Hospital Epidemiology 2000; 32: 718–723. 13 APIC. Guide to the elimination of methicillin-resistant Staphylococcus aureus (MRSA) transmission in hospital settings. Washington, DC: APIC headqauters, 2007. 14 Pittet D, Allegranzi B, Boyce J. The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations. Infection Control Hospital Epidemiology 2009; 30: 611–622. 15 Larson EL. APIC guideline for handwashing and hand antisepsis in health care settings. American Journal of Infection Control 1995; 23: 251–269. 16 Pittet D, Hugonnet S, Harbarth S et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. The Lancet 2000; 356: 1307–1312. 17 Khatib M, Jamaleddine G, Abdallah A, Ibrahim Y. Hand washing and use of gloves while managing patients receiving mechanical ventilation in the ICU. Chest 1999; 116: 172– 175. 18 Eveillard M, Lancien E, Hidri N et al. Estimation of methicillin-resistant Staphylococcus aureus transmission by considering colonization pressure at the time of hospital admission. Journal of Hospital Infection 2005; 60: 27–31. © 2014 Wiley Publishing Asia Pty Ltd
International Journal of Nursing Practice 2015; 21: 709–715
RESEARCH PAPER
Effects of hand hygiene education and individual feedback on hand hygiene behaviour, MRSA acquisition rate and MRSA colonization pressure among intensive care unit nurses Hee-Kyung Chun RN MSN ICAPN Infection Control Nurse, Department of Infection Control, Kyung Hee University Medical Center, Seoul, South Korea
Kyung-Mi Kim RN PhD ICAPN Assistant Professor, Department of Nursing, Semyung University, Jecheon, South Korea
Ho-Ran Park RN PhD Professor, College of Nursing, The Catholic University of Korea, Seoul, South Korea
Accepted for publication August 2013 Chun H-K, Kim K-M, Park H-R. International Journal of Nursing Practice 2015; 21: 709–715 Effects of hand hygiene education and individual feedback on hand hygiene behaviour, MRSA acquisition rate and MRSA colonization pressure among intensive care unit nurses This study was conducted to increase the frequency and level of thoroughness of hand hygiene practice by nurses, and to assess the influence of the methicillin-resistant Staphylococcus aureus (MRSA) acquired incidence rate and the MRSA colonization pressure in a medical intensive care unit (MICU). A total of 24 MICU nurses received hand hygiene education and individual feedback of hand hygiene frequency and method after a session of education, and two posteducation evaluations were followed. The frequency of hand hygiene (P = 0.001) and the methodology score of hand hygiene increased significantly (P = 0.001). The MRSA acquisition rate decreased significantly, from 11.1% before the education to 0% after (P = 0.014). The MRSA colonization pressure decreased significantly from 39.5% to 8.6% after the education sessions (P = 0.001). This indicates that providing individual feedback after hand hygiene education was very effective in increasing nurses’ hand hygiene frequency and improving hand hygiene method; furthermore, it was expected to decrease health care-associated infections. Key words: hand hygiene, intensive care unit, methicillin-resistant Staphylococcus aureus.
INTRODUCTION Correspondence: Ho-Ran Park, College of Nursing, The Catholic University of Korea, 505 Banpodong Seochogu, 137-701 Seoul, South Korea. Email: [email protected] doi:10.1111/ijn.12288
Healthcare workers’ (HCWs) hands are a major source of cross-infection among health care-associated infections as they can be responsible for directly spreading microorganisms. As the number of microorganisms tends to © 2014 Wiley Publishing Asia Pty Ltd
H-K Chun et al.
710
increase when hand hygiene is inappropriate, maintaining the proper level of hand hygiene is important for minimizing the risk of cross-infections.1,2 Among HCWs, nurses have the most frequent contact with patients. Maintaining proper hand hygiene during nursing care has been known to directly reduce the number of health care-associated infections3 However, actual handwashing rate in nursing care has been reported to be as low as 13–20% in Korea and 15–34% in other countries.2,4–8 Various programmes have been developed to promote hand hygiene. However, Dorsey et al.9 found that signs posted with the Centers for Disease Control and Prevention’s (CDC) handwashing recommendations and the distribution of a copy of a related publication on handwashing to HCWs were not effective in increasing the hand hygiene implementation rate. Numerous studies on the appropriateness of hand hygiene methods, as well as the frequency of hand hygiene implementation, have been conducted. However, only a few studies have included individual feedback. Some researchers reported that providing feedback on the hand hygiene implementation rate and the appropriateness of the individual’s hand hygiene method increased hand hygiene.5,6,10 Moongtui et al. suggested that adjunct methods should be sought to promote the retention of the effect.5 In addition, observational studies on the effectiveness of hand hygiene using individual feedback are rare. There has not been a study measuring the effectiveness of this individual feedback method 6 weeks after the initial education. Methicillin-resistant Staphylococcus aureus (MRSA) acquisition pressure is defined as the proportion of patients colonized with the MRSA organism in a defined geographic area within a hospital during a specified time period. Acquisition of MRSA in intensive care unit (ICU) patients is strongly and independently influenced by colonization pressure.11,12 The hospital in which this study was conducted has been performing MRSA active surveillance cultures in the ICU since June 2008. The MRSA acquisition rate (10.3%) and the MRSA colonization pressure (28%) of the medical intensive care unit (MICU) were higher than in two other types of ICUs. Also, the MRSA isolation rate in the MICU was the highest among all the ICUs from September to October 2008. As such, an infection control intervention was needed. Therefore, this study was conducted as part of an effort to reduce the MRSA acquisition rate and the MRSA colonization pressure of MICU patients by providing individual feedback to MICU nurses on the © 2014 Wiley Publishing Asia Pty Ltd
appropriateness and the frequency of hand hygiene after hand hygiene education session.
Study aims The aim of this study was to increase the frequency and level of thoroughness of hand hygiene as practised by nurses who were given individual feedback after a hand hygiene education session, and to assess the influence of the MRSA-acquired incidence rate and MRSA colonization pressure.
METHODS Design and sample This quasi-experimental study was performed in a tertiary care university teaching hospital with 850 beds from October 2008 to January 2009. Twenty-four nurses working in an MICU with 15 beds were enrolled. Observations were conducted before the education, and 1 week and 6 weeks after the hand hygiene education session (Fig. 1). This study was approved by the Institutional Review Board of the Catholic University of Korea College of Medicine.
Procedure Evaluation and individual feedback
Before the hand hygiene group education, hand hygiene frequency and methods were observed and the results were reported to each individual. Hand hygiene performance was documented based on a localized Korean tool adopted from the Association for Professionals in Infection Control guidelines.13 The frequency of hand hygiene was measured to determine whether hand hygiene was carried out, before and after six categorized nursing activities. The six nursing activities categorized to require hand hygiene were activities related to intravenous or intramuscular injection, respiratory ventilator care, care regarding excretion such as urine or stool, wound care, and nasogastric tube feeding. In total, 69 nursing activities required hand hygiene. The frequency of hand hygiene was calculated as ‘Number of hand hygiene activities conducted/Number of hand hygiene required × 100’ (%). The methods of hand hygiene were observed and scored based on the following: hand hygiene agent (0 for water, 1 for alcohol based gel or antiseptic soap), rubbing time (0 for less than 15 s, 1 for 15 s or more), area (0 for
Individual feedback on hand hygiene
711
Observation survey for hand washing frequency and method (n = 1194) Pre-education
Check-up of hand culture (n = 24) Survey of MRSA acquired incidence rate and MRSA colonization pressure
Education
Hand washing education programmes including individual feedback Group education for hand washing recommendation and effects Outcome of hand washing frequency and method Outcome of hand culture (n = 24)
1 week posteducation
Evaluation for hand washing frequency and method (n = 1152) Survey of MRSA acquired incidence rate and MRSA colonization pressure
Evaluation for hand washing freque ncy and method (n = 1176) 6 weeks posteducation
Survey of MRSA acquired i ncidence rate and MRSA colonization pressure
Figure 1. Study design.
less than three areas among palms, back of hands, wrists, fingers and finger tips, 1 for three or four areas, 2 for five areas) and drying method (0 for inadequate, 1 for paper towel usage after water and soap or waiting to dry after alcohol gel). The sum of the scores was used for evaluation. The investigator observed the hand hygiene performance of the nurses from approximately 1 m away from the patient’s bed twice a day during the time the nurse had the most frequent contact with patients (9:00 to 11:00 in the morning and 4:00 to 6:00 in the afternoon). Observations were completed at least 30 times on each nurse to ensure that every nurse was evaluated equally. The first observation was done 1 week after the group education to evaluate the immediate effect of individual feedback education on hand hygiene practices. The second observations were done 6 weeks after the education to evaluate the continuous effect of the group education as prior studies have shown that the performance of hand hygiene declined 3–4 weeks after the education (Fig. 1). Before education and after washing their hands, the right hand of every participant was cultured using a hand plate (Samlip general food, Gyeonggi-do, Korea) at a temperature of 30–35°C for 24–48 h in the incubator. A yellow zone around a colony indicates S. aureus. Individual reports of observed hand hygiene frequency, appropriateness of hand hygiene methods and hand culture results before education were handed out during
the group education. Hand plate photos of the hand culture results were also provided.
Hand hygiene education
Hand hygiene education was performed for the group, and personal feedback on the appropriateness and frequency of hand hygiene was provided individually. Group education included the proper methods of hand hygiene based on the guidelines released by the CDC1 and the World Health Organization,14 as well as the importance of hand hygiene, with study results regarding the effect of hand hygiene. Group education was performed with a PowerPoint presentation. The group education lasting about 30 min was conducted by the investigator at the end of the work day. It was repeated for 5 days to ensure all participants received the education. Individual feedback on the appropriateness and frequency of hand hygiene was provided for 10 min after the group education. Individual feedback was confidential.
MRSA screening
The MICU patients were screened for MRSA acquisition by nasal swab culture within 24 h of admission at the start of the study and then once a week thereafter. When the follow-up culture was positive in a patient with an initial negative culture, the patient was defined to have acquired MRSA.13 MRSA acquisition rate was calculated monthly © 2014 Wiley Publishing Asia Pty Ltd
H-K Chun et al.
712
Figure 2. MRSA acquired incidence rates in pre-education vs. post-education periods. ( ) No. patients acquired MRSA, ( ) MRSA acquisition rates (%), ( ) MRSA acquisition rates (per 1000 patient-days). Pre, pre-education; Post I, 1 week after education; Post II, 6 weeks after education.
as ‘Number of patients who acquired MRSA/Number of patient admitted to MICU and Number of patient days’, before and after the education. The MRSA colonization pressure was calculated as ‘Number of patients with positive culture for MRSA/ Current number of patients in MICU × 100’ (%). The MRSA colonization pressure indicates that more patients with positive MRSA culture surfaces, could translate into a higher chance of MRSA transmission. When the MRSA colonization pressure is 30% or higher, the risk of transmitting MRSA to an MRSA negative patient is very high.11,12 This was calculated before and 6 weeks after the education.
Statistical analysis Windows SPSS version 12.0 (Chicago, IL, USA) was used for statistical analysis. The chi-square test was used for frequency measurement of hand washing before and after group education. One-way ANOVA and Dunnett’s multiple comparisons were used for methods of hand washing. The chi-square and Fisher’s exact tests were used to examine the MRSA acquisition rate and the colonization pressure. A P-value < 0.05 was considered statistically significant.
RESULTS Twenty-four nurses participated in the study. The group consisted of 23 female participants (95.8%) and their mean age was 32.9 ± 7.9 years. Their mean working period was 7.6 ± 8.1 years, with a mean of 2.9 ± 1.9 years of ICU working experience. © 2014 Wiley Publishing Asia Pty Ltd
A total of 1194 hand hygiene observations were made before the group education, 1152 hand hygiene observations were made 1 week after the education (first time post-education) and 1176 observations were made 6 weeks after the group education (second time posteducation).
Frequency of hand hygiene The overall frequency of hand hygiene increased from 46.8% before the educational sessions to 71.4% after the first education and to 64.9% at the second group education observations (P = 0001) (Fig. 2). Table 1 shows changes in the hand hygiene frequency by nursing activities before and after the group education, and was seen to have increased. When nurses came in contact with known MRSA isolated patients, vancomycin-resistant enterococci and imipenem-resistant Acinetobacter baumannii, the frequency of hand hygiene increased from 53.1% at pre-education to 74.1% and 71.7% at the first and second time of observations, respectively (P = 0.001).
Methods of hand hygiene The mean score for hand hygiene methods was 2.84 before the group education, and increased to 3.65 and 3.89 at the first and second posteducation observations, respectively (P = 0.001). The score for the hand hygiene agent increased from 0.99 to 1.00 at the first and second posteducation observation periods (P = 0.013 and 0.053). The score for hand hygiene time, hand hygiene area and drying methods were also increased (Table 2).
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Table 1 Hand hygiene frequency by nursing activity Activity
Pre-education No (%)
Posteducation I No (%)
P†
Posteducation II No (%)
P‡
Related to intravenous/injection therapy Related to respiratory therapy Related to excretory management Related to wound dressing and drainage Related to nutritional support and oral medication Casual contact with patient Overall nursing activities
95/280 (33.9) 145/252 (57.5) 38/88 (43.2) 12/40 (30) 9/22 (40.9) 260/512 (50.8) 559/1194 (46.8)
171/260 (65.8) 255/334 (76.3) 69/92 (75.0) 27/52 (51.9) 5/10 (50.0) 296/404 (73.3) 823/1152 (71.4)
0.001 0.001 0.001 0.035 0.631 0.001 0.001
186/318 (58.5) 196/262 (74.8) 69/108 (63.9) 21/48 (43.8) 17/22 (77.3) 274/418 (65.6) 763/1176 (64.9)
0.001 0.001 0.004 0.185 0.014 0.001 0.001
†
Chi-square test: pre-education/posteducation I (1 week after education). ‡ Chi-square test: pre-education/posteducation II (6 weeks after education). No (%), No. hand hygiene/No. activity for which hand hygiene is recommended (hand hygiene frequency rate). Table 2 Comparison of content scores for each hand hygiene method Content (total score)
Hand hygiene agent (1) Hand hygiene time (1) Hand hygiene area (2) Drying method (1) Total score of hand hygiene method (1)
Pre-education
Posteducation I
N
Mean ± SD
N
Mean ± SD
559 559 559 559 559
0.99 ± 0.08 0.26 ± 0.44 0.78 ± 0.62 0.78 ± 0.42 2.84 ± 1.12
823 823 823 823 823
1.00 ± 0.00 0.63 ± 0.48 1.14 ± 0.55 0.87 ± 0.34 3.65 ± 1.11
P†§
0.013 0.001 0.001 0.001 0.001
Posteducation II N
Mean ± SD
763 763 763 763 763
1.00 ± 0.36 0.74 ± 0.44 1.20 ± 0.57 0.95 ± 0.22 3.89 ± 0.99
P‡§
0.053 0.001 0.001 0.001 0.001
†
Comparison between pre-education and posteducation (1 week after education). ‡ Comparison between pre-education and posteducation II (6 weeks after education). § One-way ANOVA with Dunnett’s t-test (two sided) as a control and comparison of all other groups. Each was regarded as independent. N, number of hand hygiene.
The score for hand hygiene methods after nursing care for patients with multiple drug resistance (MDR) microorganisms was increased from 1.52 ± 1.68 at pre-education, to 2.76 ± 1.91 and 2.79 ± 1.97 at first and second time posteducations periods (P = 0.001).
MRSA colonization pressure The MRSA colonization pressure was initially 39.5%, but was reduced to 28.8% at the first posteducation observation (P = 0.038) and to 8.6% at second postsession (P = 0.001) (Fig. 3).
MRSA acquisition rate
DISCUSSION
The MRSA acquisition rate decreased from 11.1% (5 patients) before the education to 2.7% (1 patient) (P = 0.215) at first group education and to 0% (0 patients) after the second round of observations (P = 0.014) (Fig. 2). The MRSA acquisition rate was 13.3 per 1000 patientdays before education and decreased to 2.6 and 0 per 1000 patient-days after the first and second observations, respectively (P = 0.118 and P = 0.071) (Fig. 2).
Hand hygiene is the easiest and most fundamental method to prevent health care-associated infections. It removes microorganisms acquired during nursing care for patients with an infection or a colonization of microorganisms. Hand hygiene also helps to prevent cross-infection between patients and HCWs.15 Nurses have a higher chance of direct contact with patients as compared with other HCWs, and therefore, proper hand hygiene for nurses is very effective in © 2014 Wiley Publishing Asia Pty Ltd
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Figure 3. MRSA colonization pressure in pre-education vs. the posteducation period. Pre, pre-education; Post I, 1 week after education; Post II, 6 weeks after education.
preventing the propagation of health care-associated infections. The reason for conducting a single-group intervention in this study was that there were three shifts of nurses working in the MICU. As such, conducting two group interventions was not possible. The study period was fall and winter, with no new interns and residents in the hospital. Therefore, the reduction of the MRSA acquisition rate and the colonization pressure was considered an effect of the reduction of cross-infection due to an increase in the hand hygiene implementation rate. In one Korean study, the implementation rate of hand washing was 33.5% in a surgical ICU before improving hand washing programme.2 Pittet et al. reported that the frequency of hand hygiene increased from 48% to 66% after applying a multidimensional programme, including seven education sessions, promotion for hand sanitizers and feedback.16 Jeong and Choe has reported that hand hygiene promotion increased the implementation of hand hygiene from 33.5% to 58.4% in a surgical ICU.2 In the present study, the individual feedback given after a group education for hand hygiene improved the frequency of hand hygiene. This result indicated that individual feedback increased the awareness for hand hygiene, as well as improving the methods of hand hygiene. Some studies have reported that the effect of a hand hygiene improvement programme lasted less than 4 weeks.10,17 In the present study, the frequency of hand hygiene at the second posteducation observation period © 2014 Wiley Publishing Asia Pty Ltd
decreased compared with the first, but increased significantly when compared with its original state (P = 0.001). The score for hand hygiene was even higher for the second session, which showed more prolonged effect than previous studies. During the 4 month study, the MRSA acquisition rate decreased from 11.1% at the first posteducation observation period to 0% after the second posteducation. Although there was no significant difference in the statistics, the MRSA acquisition rate corrected during ICU admissions tended to decrease from 13.0/1000 patientdays prior to the education to 0/1000 patient-days after the second posteducation period. In Kim and Choi’s study, as hand hygiene frequency showed an increase from 15.6% to 46.9%, MRSA nasal colonization decreased from 42.8% to 18.6%.3 In Jeong and Choe’s study, for the 5 months of the hand hygiene period, there was no difference in the incidence of infection.2 To identify the effect of hand hygiene on the prevention of health careassociated infections, the improvement of hand hygiene should be maintained for a long period of time and thus, hand hygiene education for HCWs should be carried out persistently. If MRSA colonization pressure is greater than 30%, there is a high probability for MRSA cross-infection within the area.12,18 Before the education, the MRSA colonization pressure was 39.5%, but decreased to 28.8% and 8.6% at the first and second posteducation observations. As the
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MRSA colonization pressure decreased, the probability of MRSA cross-infection also decreased. Before the education, the hand hygiene frequency and methods were observed without prior information. However, after the group education and individual feedback data, nurses became aware that their hand hygiene would be observed and they would need to wash their hands more frequently and properly. However, we found that the individual feedback provided improved both frequency and methods of hand hygiene, and the effect persisted longer than seen in previous studies. This indicates that health care-associated infections can be decreased by maintaining proper hand hygiene.
Conclusion Hand hygiene education and individual feedback of hand hygiene frequency and method were effective in increasing hand hygiene frequency and improving nurses’ methodology scores of hand hygiene. Also, it was proven to decrease MRSA acquisition rate and MRSA colonization pressure. This study was conducted only with targeted ICU nurses, so further study would be helpful on the effect of individual feedback for hand hygiene to HCWs including doctors, paramedics and technicians on the incidence of health care-associated infections.
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