PRACTICE IMPROVEMENT

KEEP IT CLEAN: A VISUAL APPROACH TO REINFORCE HAND HYGIENE COMPLIANCE IN THE EMERGENCY DEPARTMENT Authors: Lynn L. Wiles, PhD, MSN, RN, CEN, Chris Roberts, BSN, RN, CEN, and Kim Schmidt, BSN, RN, Norfolk and Virginia Beach, VA

Problem: Although hand hygiene strategies significantly reduce

health care–associated infections, multiple studies have documented that hand hygiene is the most overlooked and poorly performed infection control intervention. Methods: Emergency nurses and technicians (n = 95) in a 41-bed

emergency department in eastern Virginia completed pretests and posttests, an education module, and two experiential learning activities reinforcing hand hygiene and infection control protocols.

rates improved at the conclusion of the project and 3 months after the study (F (2, 15) = 9.89, P = .002). Implications for Practice: Interfaces with staff as they

completed the interactive exercise, as well as anecdotal notes collected during the study, identified key times when compliance suffered and offered opportunities to further improve hand hygiene and, ultimately, patient safety.

Results: Posttest scores were significantly higher than pretest

Keywords: Infection control; UV light technology; Experiential learning; Hand hygiene

and hygiene (HH) is considered the most crucial measure for preventing the spread of infection, yet studies document that HH is the most overlooked and poorly performed infection control intervention, 1 with a median compliance rate of 40%. 2 Health care–associated infections (HAIs) claim more lives annually than do AIDS, breast cancer, and motor vehicle crashes combined. 3 HAIs occur during the course of receiving treatment in health care settings 4 and affect 5% of all hospitalized patients 5 or 1.7 million people annually, resulting in 99,000 deaths. 6 In

2008, HAIs were classified as preventable complications that preclude hospitals from receiving reimbursement from the Centers for Medicare and Medicaid Services. 7 The reduction of HAIs is a major objective outlined in The Joint Commission’s Center for Transforming Healthcare report. 8 This report, along with documented low national HH compliance rates and unacceptable HAI rates, establishes the need for ongoing staff education and compliance monitoring. It has been suggested that “a multi-faceted intervention, including use of feedback, education, the introduction of alcohol-based hand wash, and visual reminders” may effectively improve HH compliance. 9 A pilot study implemented by investigators in the University of California, San Francisco, neurological ICU used video surveillance monitors and tickertape feedback to improve HH. Findings indicate that HH compliance in the rooms with the near–real-time feedback significantly exceeded the HH compliance in rooms that were not monitored. 10 Because almost 40% of hospital admissions stem from the patients who make approximately 119 million annual ED visits, 11 ED staff have a unique opportunity to decrease HAI rates by improving HH compliance. Compliance can be improved by implementing Centers for Disease Control and Prevention (CDC) infection control guidelines as patients enter the health care system. The purpose of this project was to increase staff awareness about HH guidelines and improve HH compliance rates in the emergency department.

scores (t (108) = –6.928, P = .048). Hand hygiene compliance

H

Lynn L. Wiles, Member, Tidewater Chapter, is Assistant Professor, Old Dominion University School of Nursing, Norfolk, VA, and Per-diem Staff Nurse, Sentara Virginia Beach General Hospital, Virginia Beach, VA. Chris Roberts, Member, Tidewater Chapter, is Nurse Manager, Sentara Virginia Beach General Hospital, Virginia Beach, VA. Kim Schmidt, Member, Tidewater Chapter, is Director of Emergency Services, Sentara Virginia Beach General Hospital, Virginia Beach, VA. This research project was supported in part by a grant from the Old Dominion University Research Foundation, Norfolk, VA. For correspondence, write: Lynn L. Wiles, PhD, MSN, RN, CEN, 4608 Hampton Blvd, Norfolk, VA 23529; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.11.012



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A seminal study conducted almost a decade ago suggested that “clean” activities such as taking vital signs, shaking hands, or touching an area higher in organism growth like the groin can contaminate nurses’ hands with 100 to 1000 colonyforming units of Klebsiella species. 12 Similarly, one study documented health care records as a source of bacterial transmission; investigators found that bacteria can survive on paper for up to 4 days and be transferred from paper to hands to clean paper. 13 Another study suggested that 63% of nurses’ uniforms were contaminated with pathogens, including antibiotic-resistant microorganisms. 14 Moreover, 92% of the curtains in patient rooms in ICUs and medical/surgical units were contaminated within 7 days of being washed and harbored potential pathogens, including methicillin-resistant Staphylococcus aureus (21%), vancomycin-resistant enterococcus (42%), and other gram-negative rods, including enterococcus species or S aureus (66%). 15 During each patient encounter, health care workers are exposed to organisms that can be transmitted from patient to patient or health care worker to health care worker if proper HH recommendations are not followed. Traditional education and social pressures to perform HH have not provided sustained improvements in HH compliance. Educational interventions that provoke fear for personal safety or disgust may be the most effective method to improve HH compliance. 16 Kolb’s experiential learning theory served as the theoretical framework for this study because it focuses on using concrete, skill-based learning experiences to reinforce didactic content. 17 Based on Kolb’s tenets, the experiential learning activity was designed with the expectation that simulation of spreading microorganisms would allow ED staff to immediately see the spread they caused. We believe that this approach has a more lasting impact than didactic learning alone because this strategy significantly improves nursing students’ understanding of and compliance with HH protocols. 18

3.What

changes in HH compliance occur as a result of the learning activities?

This project took place in the 41-bed emergency department of a 276-bed acute care hospital that is accredited in trauma, stroke, and cardiac care. The hospital is located in a resort city in the mid-Atlantic region of the United States. All 95 ED RNs and technicians were invited to take part. Participation was voluntary, and no demographic data were collected. Completion of the online pretest implied consent. Human subjects’ protection approval was obtained prior to the project. Baseline HH knowledge was established using a 25-question online pretest. Next, volunteers participated in an experiential learning activity in which they applied Glo Germ lotion (Glo Germ Company, Moab, UT) 19 to their own hands and, after it dried, performed HH as per their usual routine. Researchers then shined an ultraviolet (UV) light on the participants’ hands, providing a visual representation of the effectiveness of their HH and the spread of the Glo Germ throughout the hand-washing area. As needed, researchers reinforced the HH guidelines for staff who did not comply with CDC recommendations. In addition, during selected shifts, researchers placed a small amount of microsphere powder (Cospheric LLC, Santa Barbara, CA) 20 in common locations (eg, telephone, computer mouse area, point of care testing machines, and fax machine) throughout the emergency department (Figure 1). After 2 to 4 hours, the ED spaces and equipment were photographed using UV light. At the next monthly staff meeting, staff viewed a presentation that showed the spread of the microsphere powder throughout the emergency department and reinforced the need to comply with HH guidelines. Proper

Methods

The purpose of this descriptive pretest-posttest quality improvement project was to evaluate the impact of an experiential hand-washing learning activity and simulated infectious disease spread activity on ED clinical staff’s knowledge of HH guidelines and adherence to HH protocols in an ED work environment. The following specific research questions were asked: 1.What

is the baseline knowledge of the ED staff related to HAIs and the CDC HH guidelines? 2.What changes in the knowledge of the ED staff related to HAIs and the CDC HH guidelines occur after the learning activities?

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FIGURE 1 Ultraviolet photograph showing the spread of microsphere powder on a mouse and mouse pad.

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techniques for using alcohol-based foam/gel and HH practices were again reviewed. Finally, participants completed the online posttest that was identical to the pretest. Two measures were used for this study: the pretest/ posttest knowledge assessment and the hospital’s audit tool used to collect HH compliance data. Pretest and posttest questions were developed from content found on the public domain CDC Web site and the University of Miami-Jackson Memorial Hospital Center Web site (used with permission). This 25-item survey included 22 true/false statements and 3 multiple-choice items about HH, HAI, standard precautions, and transmission-based precautions. HH compliance data are routinely collected by hospital staff internal and external to the emergency department. These audits covered all shifts, including weekdays and weekends. Auditors categorize HH opportunities as soap and water or alcohol foam events and document whether the correct procedure was followed. SPSS software version 21 (IBM Corp, Armonk, NY) was used to analyze the data. Only aggregate group comparisons were used to indicate the organizational changes that occurred. The number of subjects from the pretest and posttest were described as counts and measures of central tendency for the test items. The Assessment Score Reliability (KR-20) was 0.63 for the pretest and 0.70 for the posttest. The change in scores between pretest and posttest was analyzed using an independent t test for the entire cohort. Testing for statistical significance of HH compliance data was performed using analysis of variance (ANOVA) comparing baseline, end of study, and 3-month follow-up data. Ninety-five percent confidence intervals were calculated for key parameters.

Results

Fifty-nine clinical staff members completed the pretest, and 51 completed the posttest. Staff demographics were not collected to help maintain anonymity. Scores for the pretest ranged from 60 to 95 with a mean of 82.6 (standard deviation [SD] = 8). Posttest scores ranged from 80 to 100 with a mean of 91.7 (SD = 5.5). An independent-samples t test was conducted to evaluate the hypothesis that pretest scores would be different than posttest scores. The test was significant, with t (108) = –6.928 and P = .048 using Levene’s test of inequality to compensate for unequal sample sizes. Compared with baseline knowledge, clinical staff knowledge about current CDC HH guidelines increased significantly after completing the learning activities. HH compliance rates were also compared. The mean HH compliance rates in this emergency department were higher than the nationwide mean at baseline (70%), the conclusion of the study (84%), and 3 months after the study (81%). A one-



way ANOVA was conducted to evaluate the relationship between HH compliance rates prior to the study, at the conclusion of the study, and 3 months after the study. This finding was significant (F (2, 15) = 9.89, P = .002). Follow-up tests were conducted to evaluate pairwise differences among the means. The Tukey HSD test showed a statistically significant increase in both baseline to end of study HH compliance rates (P = .002) and baseline and follow-up HH compliance rates (P = .0012). The difference between the end of study and follow-up HH compliance rates (P = .645) were not significant, suggesting that postintervention HH compliance was sustained 3 months after completion of the project. In addition to the increase in overall HH compliance, documented spikes in HH compliance were linked with the 2 experiential learning activities (Figure 2). The first spike occurred as the staff participated in the Glo Germ HH activity that included visual reinforcement of hand and sink area contamination. The second spike, and one that produced sustained HH compliance rates, occurred after the microsphere powder photographs showing contamination throughout the emergency department (Figures 3, 4, and 5) were shared at the staff meetings. The increase in HH compliance after visual reinforcement of gaps in HH practices supports the study premise that a multifaceted intervention with visual reminders would be more effective at producing results than didactic education and verbal reminders alone. Overall, HH compliance rates for this emergency department exceeded national averages; however, better than average HH compliance is not our goal. Providing a safe environment and minimizing patient harm (ie, reducing HAIs) require more than 80% compliance with CDC guidelines. Nurses who collected HH data made anecdotal comments identifying breaks in HH compliance. One gap repeatedly observed was that staff did not follow HH protocols when removing equipment (eg, IV carts or rolling laptops) or specimens from patients’ rooms. Because alcohol foam soap dispensers are located outside patient rooms, HH monitors were able to track staff activities until the equipment was returned to its proper location and to look for HH completion at that time, as well as when the staff exited the room. Auditors also noted that when staff used soap and water, often the length of time they spent hand washing did not comply with CDC recommendations, and staff were observed turning off water with their clean hands rather than with a dry paper towel. A final behavior observed was that nurses with fewer than 5 years of experience were more likely than the more experienced nurses to demonstrate correct soap and water procedures and to verbalize the superior effectiveness of alcohol foam over soap and water in most patient care instances. The necessity of using soap and water for patients with actual or suspected Clostridium difficile was

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FIGURE 2 Hand hygiene (HH) compliance compared with visual reinforcement activities.

common knowledge for ED nurses but not for the ED technicians. These identified gaps in knowledge and practice were addressed with all staff during the debriefing meetings when study results and photographs were shared. In the debriefing meetings, staff stated that the most effective components of this intervention were the visual ones. The HH activity where individuals viewed their hands after performing soap and water HH showed staff where potential bacteria lingered—especially in rings, around fingernails, and on their wrists. Several staff had Glo Germ spread to their faces from touching their skin or from water splashes while washing. When visualizing the sink area using the UV light, staff noted that the soap dispensers and

sink handles were covered with Glo Germ and that there was residual splash on the side and back walls and, on one occasion, on the top of an empty pizza box 2 feet away on the same counter. Likewise, the photographs showing the biosphere spread that occurred during the study made staff feel “filthy,” “gross,” “disgusted,” and “contaminated.” Some staff members got up during the presentation to wash their hands. These comments and actions reinforce the premise that educational interventions that provoke fear for personal safety or disgust may be the most effective method to improve HH compliance 16 and support Kolb’s experiential learning theory that visual reminders that show the

FIGURE 3 Ultraviolet photograph showing the spread of microsphere powder to an ED i-stat machine.

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FIGURE 4 Ultraviolet photograph showing the spread of microsphere powder to an ED keyboard.

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convenience of staff in the high noncompliance areas revealed during this study. Additionally, based on the identified ease with which organisms can spread, other options are being explored. For example, the emergency department has purchased 3 washable keyboards that can be submerged or wiped with Virex wipes(Virex MSDS, Sturtevant, Wisconsin). Keyboard covers have been placed on all nonwashable keyboards and will be used until these keyboards can be replaced. Staff are encouraged to wipe down the keyboards, as well as phones and other pieces of equipment, at each shift change. All new clinical staff will participate in the Glo Germ HH experience and complete HH computer-based training module available on the hospital Web site. Continued visual reinforcement with Glo Germ and the microsphere powder will be used as needed by analyzing HH data routinely collected by the Quality Improvement Committee. FIGURE 5 Ultraviolet photograph showing the spread of microsphere powder to a ED computer mouse.

impact of HH noncompliance on personal health and safety are very effective educational tools. Limitations of this study included the use of a convenience sample, and thus caution should be used relative to generalizing study results to the larger nursing and ED technician population. Although pretests and posttests were anonymous, some staff may have chosen not to participate in the study based on the belief that they could be identified. An unequal number of staff completed the pretest and posttest, and researchers cannot verify that the same staff completed both assessments. Finally, because the sample was limited to clinical staff, findings cannot be generalized to other providers.

Conclusion

HH compliance has a direct impact on patient safety and thus, in combination with infection control practices, is a focus of The Joint Commission’s Center for Transforming Healthcare report. The increase in HH compliance after this project supports use of multifaceted interventions to produce increased HH compliance rates. As the portal for nearly 40% of admitted patients, the emergency department and ED staff have a key role in implementing effective HH practices when patients enter health care systems. Providing education, identifying gaps in practice, and brainstorming solutions to address department-specific challenges are key strategies for improving HH compliance in a fast-paced environment. Acknowledgments

Implications for Practice

This project reveals several opportunities to improve HH compliance. Decreased compliance rates were observed when staff entered and exited the rooms while transporting equipment. Specimen bags have been placed on the IV cart, which permits staff to place specimens in bags prior to leaving the bedside. This approach frees staffs’ hands to perform HH when exiting patients’ rooms. The Cal Stat Plus alcohol-based gel dispensers (Steris Corp, Mentor, OH) cannot be placed on the rolling laptops because of life safety standards set forth by the Det Norske Veritas (DNV) accrediting body but will be added to all rolling carts (eg, IV, gynecologic, central line, and suture) to facilitate HH. Additional dispensers have been placed throughout the emergency department for the



We thank Dr Mona Wicks for her guidance and review of the manuscript and Dr Miyong Kim for her statistical analysis assistance. REFERENCES 1. Son C, Chuck T, Childers T, et al. Practically speaking: rethinking hand hygiene improvement in health care settings. Am J Infect Control. 2011;39:716-724. 2. Erasmus V, Daha T, Brug H, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010;31(3):283-294. 3. Patient Safety Focus. Patient safety: current statistics. http://www. patientsafetyfocus.com/patient-safety-current-st.html. Accessed December 12, 2014.

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Keep it clean: a visual approach to reinforce hand hygiene compliance in the emergency department.

Although hand hygiene strategies significantly reduce health care-associated infections, multiple studies have documented that hand hygiene is the mos...
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