American Journal of Infection Control 42 (2014) 926-8

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American Journal of Infection Control

American Journal of Infection Control

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Brief report

Influence of signal colored hand disinfectant dispensers on hand hygiene compliance at a medical intensive care unit Simone Scheithauer MD, PD a, b, *, Helga Häfner MD a, Jörg Schröder MD c, Katharina Nowicki a, Sebastian Lemmen MD a a b c

Central Institute of Infection Control and Infectious Diseases, University Hospital Aachen, RWTH Aachen, Aachen, Germany Central Institute of Infection Control and Infectious Diseases, University Medicine Göttingen, Göttingen, Germany Department of Medicine I, University Hospital Aachen, RWTH Aachen, Aachen, Germany

Key words: Compliance Hand hygiene Infection control Novel technologies

To assess the influence of signal colors on hand disinfectant dispenser activities, health care workers (HCWs) at a medical intensive care unit were analyzed for a total of 20 weeks with 8 weeks before and 12 weeks after exchange to signal color. No significant increase in hand rubs (HRs) per patient day (PD) was observed (about 40 HRs/PD); however, HCW-adjusted compliance showed a 6% increase with signal colored devices. Therefore, colored devices may help to improve hand hygiene compliance. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Improvement of hand hygiene (HH) compliance in medical settings is crucial to patients’ welfare, and a multifaceted approach is generally advocated.1,2 Beyond classical strategies to raise awareness, such as hands-on teaching, proactive campaigns, and work audits to measure the level of compliance and amount of disinfectant usage, novel strategies and devices are regarded as potentially useful tools to improve HH compliance.3-8 To date, novel devices can be divided into 2 main categories: special types of disinfectant dispensers and electronic devices aimed at reminding health care workers (HCWs) about HH regulations.3 In general, the appliance of novel devices or technologies to standard wards and even intensive care units (ICUs) has been shown to yield improvements in HH compliance.3-8 However, it still remains questionable whether such improvements are caused by the implementation of novel devices or technologies or by reminding HCWs about the importance of best practice standards. In this article, we assess the influence of the introduction of signal colored red hand disinfectant dispensers at an already perfectly equipped ICU with well-trained staff and report on the

* Address correspondence to Simone Scheithauer, MD, PD, Department of Infection Control and Infectious Diseases, University Hospital Aachen, RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany. E-mail address: [email protected] (S. Scheithauer). Presented at the 2nd International Conference on Prevention and Infection Control, June 25-28, 2013, Geneva, Switzerland. The study has been partly funded by Ophardt Hygienetechnik. Conflict of interest: Dr. Scheithauer has received speakers fees from Ophardt Hygienetechnik. The rest of the authors have nothing to report.

number of dispenser activities before and after the introduction of these novel devices for each HCW present. MATERIAL AND METHODS The study was performed at a medical ICU at the University Hospital RWTH Aachen, Aachen, Germany, a tertiary care center. The ICU is a 14-bed ward caring predominantly for patients with cardiological disorders. The investigation was performed from April to September 2012. Years before we started this study, the ICU was already fully equipped with hand disinfectant dispensers located at each patient bed and in the corridors and the HCWs had been fully instructed and trained in HH compliance from 2009 onward according to the World Health Organization’s My 5 Moments for Hand Hygiene concept. Moreover, for the last 9 years, we have actively monitored ward-specific hand disinfectant usage and analyzed these data in patient days (PDs). After a baseline phase of 8 weeks, we exchanged all conventional dispensers for signal colored ones (N ¼ 25; Ophardt Hygiene-Technik, Issum, Germany) and continued to monitor hand disinfectant dispenser activities for a further 12 weeks. The dispensers were all colored in a warning color red. In detail, dispenser activities were documented for each individual dispenser daily and on a weekly basis. The endpoint of interest was the number of hand disinfectant dispenser activities and HRs per PD. Two hand disinfectant dispenser activities equal 1 HR. The calculation was performed on a daily level and to identify possible time trends and offer more stable data; the major analysis

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.2014.05.021

S. Scheithauer et al. / American Journal of Infection Control 42 (2014) 926-8

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Fig 1. Hand rubs (HRs) per patient day (PD) stratified according to hand disinfectant dispenser localization before and after exchange of hand disinfectant dispensers from standard to signal colored ones (arrow).

was performed weekly within the baseline and intervention period (SigmaStat 3.1.1, Systat, San Jose, CA). No additional dispensers were introduced, no other intervention was performed during this time, and use of gown pocket dispensers was prohibited during the entire investigation. The investigation was performed as a part of a quality improvement project; all HCWs were informed about and agreed to participate in the investigation. RESULTS During the investigation, a total of 81,654 dispenser activities were documented, translating to 40,827 HRs. Most of these (58,852 dispenser activities, 29,426 HRs; 72%) occurred at dispensers located at individual patients’ beds. Interestingly, within the 8-week baseline phase and 12-week postexchange phase, a different trend for HH compliance was not observed. There was no major change during the 20-week study of the recorded weekly dispenser activities, which ranged from 6,119 to 8,026. In addition, when calculating the number of HRs per PD, no significance increase was observed (ie, 39 vs 41 for pre- and postexchange phases) (Fig 1). However, the nurse-to-patient ratio decreased during the postexchange phase by 8.5% (Fig 2). Therefore, taking this into consideration and analyzing the staffcorrected HR rate (number of HRs divided by PDs and then divided by the number of HCWs) revealed around a 6% increase in the HR rate after the introduction of signal colored hand disinfectant dispensers. DISCUSSION Several novel devices aiming at improving HH compliance have been recently investigated.4-9 Moreover, some studies have demonstrated promising results after the introduction of novel devices in regard to increased HH compliance in everyday medical

scenarios.3,6 For example, Cheng et al6 compared the HH compliance rate determined by direct observation with that determined by HH count devices and offered indication- and time-specific rates. However, the authors did not specifically investigate the effect of introducing novel devices on HH compliance. Helder et al7 concluded that automated electronic HH count devices provide useful information on frequency, time, and time trends regarding HRs, and both Morgan et al4 and Marra et al5 also suggested that such electronic counters more accurately define HH compliance than direct human observation. Specifically, Morgan et al reported a 7%-23% increase in the number of HRs at 2 ICUs by a feedback intervention with posters using secret shoppers.4 In a previous study, we documented an almost 50% increase in HH compliance at a medical ICU after the introduction of touchless hand disinfectant dispensers.8 However, the question arises on whether the introduction of the novel device itself was the true cause of this observed increase in HH compliance. It is of interest whether signal colors draw users’ attention and, therefore, improve compliance with hand disinfection. To address this question, we initiated our study at an already perfectly equipped medical ICU with highly trained staff. In this hospital setting, the exchange of standard hand disinfectant dispensers for signal colored ones produced no increase in the number of HRs per PD. Notably, the mean number of HRs per PD already exceeded the 75th percentile of the national benchmark (38 HR/PD for medical ICUs in 2013, thereby demonstrating an already high compliance.10 Moreover, when taking into consideration the lower staff-topatient ratio during the 12-week signal colored dispenser period, HR activities per PD and HCW day increased by around 6%. It has to be questioned if this effect was driven by the dispenser exchange. The medical ICU was already fully equipped with dispensers and had also taken part in a previous investigation on HH compliance that included annual work audits defining compliance and disinfectant consumption measurements for the last 3 and

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Fig 2. Staff-corrected hand rub rates taking into consideration the number of health care workers (HCWs) and patient days (PD) before and after exchange of hand disinfectant dispensers from standard to signal colored ones (arrow); numbers of PDs and HCWs indicated at the left, the ratio of HCWs to PDs indicated at the right axis.

6 years, respectively.11 In other words, information and training on HH compliance regulations were already widely available to the HCWs; as early as 2008, we measured HH compliance by direct observation to be 72%, which subsequently increased to about 85% (Scheithauer and Lemmen personal data; not published). Beyond the introduction of new electronic technologies to better help measure HH compliance, new electronic tools (eg, touchless dispensers) have been previously shown to increase compliance.8 However, in times of limited human resources, not only increasing the number of HRs, but also decreasing the number of hand rub opportunities by optimizing workflows, will also be of ultimate benefit as has already been shown in several settings (eg, anesthesia working area).12 Limitations The limitations of this study are as follows: there was only 1 center setting, the setting took place in an ICU, there was only a short-time effect, and there was only a slight effect. In conclusion, signal colored hand disinfectant dispensers may be a useful tool for increasing HH compliance. Moreover, when taking the issue of understaffing into consideration (HRs divided by patient days and number of HCWs), our study showed about a 6% increase in staff-adjusted compliance. However, this effect is small and only visible with regard to the data of understaffing. Future studies should be performed to evaluate whether the introduction and what type of novel devices would fit other medical settings, especially in cases where there is relative low HH compliance.

References 1. World Health Organization. WHO guidelines for hand hygiene in health care. Geneva, Switzerland: WHO; 2009. p. 1-262. 2. Helms D, Dorwal S, Laurent PS, Winter M. Improving hand hygiene compliance: a multidisciplinary approach. Am J Infect Control 2010;38:572-4. 3. Boyce JM. Measuring healthcare worker hand hygiene activity: current practices and emerging technologies. Infect Control Hosp Epidemiol 2011;32: 1016-28. 4. Morgan DJ, Pineles L, Shardell M, Young A, Ellingson K, Jernigan JA, et al. Automated hand hygiene count devices may better measure compliance than human observation. Am J Infect Control 2012;40:955-9. 5. Marra AR, Moura DF, Paes AT, dos Santos OF, Edmond MB. Measuring rates of hand hygiene adherence in the intensive care setting: a comparative study of direct observation, product usage, and electronic counting devices. Infect Control Hosp Epidemiol 2010;31:796-801. 6. Cheng VC, Tai JW, Ho SK, Chan JF, Hung KN, Ho PL, et al. Introduction of an electronic monitoring system for monitoring compliance with Moments 1 and 4 of the WHO “My 5 moments for hand hygiene” methodology. BMC Infect Dis 2011;11:151. 7. Helder O, van Goudoever J, Hop W, Brug J, Kornelisse RF. Hand disinfection in a neonatal intensive care unit: continuous electronic monitoring over a one-year period. BMC Infect Dis 2012;12:248. 8. Scheithauer S, Schwanz T, Koch A, Haefner H, Krizanovic V, Lemmen S. Increase of alcoholic hand disinfection usage due to new touchless dispensers. Hyg Med 2011;36:494-6. 9. Higgins A, Hannan M. Improved hand hygiene technique and compliance in healthcare workers using gaming technology. J Hosp Infect 2013;84: 32-7. 10. KISS Krankenhaus-Infektions-Surveillance-System. Available from: http:// www.nrz-hygiene.de/fileadmin/nrz/module/hand/199701_201304_HAND_S_ reference.pdf). [in German]. Accessed January 4, 2014. 11. Scheithauer S, Haefner H, Schwanz T, Schulze-Steinen H, Schiefer J, Koch A, et al. Compliance with hand hygiene on surgical, medical, and neurologic intensive care units: direct observation versus calculated disinfectant usage. Am J Infect Control 2009;37:835-41. 12. Scheithauer S, Rosarius A, Rex S, Post P, Heisel H, Krizanovic V, et al. Improving hand hygiene compliance in the anesthesia working room work area: more than just more hand rubs. Am J Infect Control 2013;41:1001-6.

Influence of signal colored hand disinfectant dispensers on hand hygiene compliance at a medical intensive care unit.

To assess the influence of signal colors on hand disinfectant dispenser activities, health care workers (HCWs) at a medical intensive care unit were a...
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