Effectiveness of an audible reminder on hand hygiene adherence

doi:10.1016/j.ajic.2011.05.023

American Journal of Infection Control

Volume 40, Issue 4, May 2012, Pages 320-323

https://doi.org/10.1016/j.ajic.2011.05.023 Get rights and content

Background

Multimodal interventions aim to improve health care workers’ adherence to hand hygiene guidelines. Visitors are not primarily targeted, but may spread epidemic infections. Effective interventions that improve the adherence of visitors to hand hygiene guidelines are needed to prevent the transmission of epidemic infections to or from health care environments.

Methods

An electronic motion sensor–triggered audible hand hygiene reminder was installed at hospital ward entrances. An 8-month preinterventional and postinterventional study was carried out to measure the adherence of hospital visitors and staff to hand hygiene guidelines.

Results

Overall hand hygiene adherence increased from 7.6% to 49.9% (P < .001). The adherence of visitors and nonclinical staff increased immediately from 10.6% to 63.7% and from 5.3% to 34.8%, respectively (P < .001). Adherence of doctors, nurses, and physiotherapists increased gradually from 4.5% to 38.3%, from 5.4% to 43.4%, and from 8.7% to 49.5%, respectively (P < .001). Improved adherence was sustained among visitors and clinical staff (P < .001), but not among nonclinical staff (P = .341).

Conclusions

The electronic motion sensor–triggered audible reminder immediately and significantly improved and sustained greater adherence of hospital visitors and clinical staff to hand hygiene guidelines. This is an effective addition to multimodal hand hygiene interventions and may help control epidemic infections.

Section snippets

Methods

We conducted a preinterventional and postinterventional study over an 8-month period in one hospital. Local infection prevention and control guidelines already promoted the use of alcohol-based hand rub by visitors and health care workers through the Intranet and posters. Two clinical researchers directly observed visitors and hospital staff entering and exiting wards via 4 separate doors to measure their adherence to hand hygiene guidelines using alcohol-based hand rub placed at each entrance.

Results

A total of 2,863 hand hygiene opportunities were observed during 54 periods over the entire 8-month study period, including 706 opportunities in the preintervention phase and 2,157 opportunities in the postintervention phase. Visitors were the most frequently observed subject group (Table 1).

Overall, hand hygiene adherence increased from 7.6% to 49.9% (P < .001). Adherence increased from 10.6% to 63.7% in visitors (P < .001), from 4.5% to 38.3% in doctors (P < .001), from 5.4% to 43.4% in

Discussion

This is the first report of the effectiveness of an electronic motion sensor–triggered audible reminder aimed at increasing the hand hygiene adherence of hospital ward visitors. This interventional study includes data on nearly 3,000 hand hygiene opportunities at the entrances to hospital wards. Before the intervention, the overall rate of hand hygiene adherence was 7.6%. After the intervention, the overall rate of hand hygiene adherence increased by 42.3%. Although this was a significant

Acknowledgment

We thank Amal Mohamed, clinical assistant at Charing Cross Hospital, for collecting data in the latter period of the study. We acknowledge the support of the Centre for Patient Safety and Service Quality, which is funded by the National Institute of Health Research, the Centre for Infection Prevention and Management, which is funded by the UK Clinical Research Collaboration and the Biomedical Research Centre at Imperial College London.

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Nudges may play an important role in improving infection prevention and control (IPC) in hospitals. However, despite the novelty of the framework, their objectives, strategies and implementation approaches are not new. This review aims to provide an overview of the methods typically used by nudge interventions in IPC in hospitals targeting healthcare workers (HCWs). The initial search in PubMed yielded nine hits. Consequently, the search criteria were broadened and a second search was conducted, introducing ‘nudge sensu lato’ which incorporates insights from sources beyond the traditional nudge framework while maintaining the same objectives, strategies and approaches. During the second search, PubMed, Epistemonikos, Web of Science and PsycInfo were searched in accordance with the PRISMA guidelines. Abstracts were screened, and reviewers from an interdisciplinary team read the full text of selected papers. In total, 5706 unique primary studies were identified. Of these, 67 were included in the review, and only four were listed as nudge sensu stricto, focusing on changing HCWs' hand hygiene. All articles reported positive intervention outcomes. Of the 56 articles focused on improving hand hygiene compliance, 71.4% had positive outcomes. For healthcare equipment disinfection, 50% of studies showed significant results. Guideline adherence interventions had a 66.7% significant outcome rate. The concept of nudge sensu lato was introduced, encompassing interventions that employ strategies, methods and implementation approaches found in the nudge framework. The findings demonstrate that this concept can enhance the scientific development of more impactful nudges. This may help clinicians, researchers and policy makers to develop and implement effective nudging interventions.
Qualitative interview study exploring frontline managers’ contributions to hand hygiene standards and audit: Local knowledge can inform practice
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Citation Excerpt :
Those in charge of wards reported that their endeavors to encourage visitors to use alcohol handrub had been successful. The use of automated prompts at ward entrances can increase hand hygiene adherence among staff and visitors.27 Such devices might be of particular value on the wards where we collected data because of the very high levels of traffic.
Frontline managers promote hand hygiene standards and adherence to hand hygiene protocols. Little is known about this aspect of their role.
Qualitative interview study with frontline managers on 2 acute admission wards in a large National Health Service Trust in the United Kingdom.
Managers reported that hand hygiene standards and audit were modeled on World Health Organization guidelines. Hand hygiene outside the immediate patient zone was not documented but managers could identify when additional indications for hand hygiene presented. They considered that audit was worthwhile to remind staff that hand hygiene is important but did not regard audit findings as a valid indicator of practice. Managers identified differences in the working patterns of nurses and doctors that affect the number and types of hand hygiene opportunities and barriers to hand hygiene. Ward managers were accepted as the custodians of hand-hygiene standards.
Frontline managers identified many of the issues currently emerging as important in contemporary infection prevention practice and research and could apply them locally. Their views should be represented when hand hygiene guidelines are reviewed and updated.
Effectiveness of the CareCentre<sup>®</sup> at improving contact precautions: randomized simulation and clinical evaluations
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An audible reminder that incorporated feedback improved hand hygiene at doorways in an intensive care unit by 77.9% to 87.9% in an interrupted time-series study.18 An audible reminder without feedback improved hand hygiene at the doorways to hospital wards by 42.3% to 63.7% in a before-and-after study.19 Also, a conspicuous sign improved hand hygiene at the doorway to a ward by 38% to 62% in another before-and-after study.20
Bedside hygiene is important to reduce healthcare-associated infection rates. The CareCentre^® is an end-of-hospital-bed table, housing: alcohol-based hand rub, gloves, aprons, waste bin, and an ergonomic writing surface.
To determine the effectiveness of the CareCentre at improving bedside hygiene.
In the randomized cross-over simulation evaluation, 20 participants used the CareCentre and standard conditions to perform common bedside tasks. In the randomized cross-over clinical evaluation, nine pairs of acute adult hospital ward bays received CareCentres and standard conditions for one week each. Researchers measured adherence to the World Health Organization's ‘my five moments for hand hygiene’ and donning and disposing of gloves and aprons at the bedside.
Adherence to hand hygiene guidelines improved from 48% to 67% (P = 0.04) in the simulation and from 14% to 40% (P < 0.001) in the clinical evaluation. Donning and disposing of gloves at the bedside improved from 19% to 79% (P < 0.001) in the simulation and from 30% to 65% (P = 0.014) in the clinical evaluation. Donning and disposing of aprons at the bedside improved from 14% to 78% (P < 0.001) in the simulation and from 10% to 53% (P = 0.180) in the clinical evaluation.
The CareCentre improved bedside hygiene and might help reduce healthcare-associated infection rates as part of a multimodal strategy.
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A very important finding from the study by Jang et al13 was other HCWs considered their role models to be physicians. This was a significant finding when studies have shown physicians to have the lowest hand hygiene compliance rates compared with other HCWs.14-17 Bandura's social cognitive theory served as the foundation to address the problem of hand hygiene compliance among HCWs.
Good hand hygiene is the single most important strategy used to prevent health care–associated infections (HAIs); however, health care workers' (HCWs') hand hygiene compliance rates range between 25% and 51%. This study aims to determine if a multimodal strategy using the World Health Organization's (WHO's) My 5 Moments for Hand Hygiene methodology increases HCWs' compliance with handwashing and awareness of the importance of good hand hygiene in the prevention of HAIs.
A quasi-experimental, 1-group pre-post survey design was used to test awareness and knowledge. A simple interrupted time series methodology at baseline and 3 months was used to monitor hand hygiene compliance.
Overall, HCWs' hand hygiene compliance increased from 51.3% to 98.6%, with an odds ratio of 71.10. The pre-post survey demonstrated HCWs were aware and knowledgeable of the importance of good hand hygiene. Eight postsurvey questions focusing on the strategies used to promote hand hygiene demonstrated statistical significance using a 1-sample t test, with P values ranging from .000-.024.
A multimodal approach using the WHO's My 5 Moments for Hand Hygiene does increase HCWs' hand hygiene compliance and awareness and knowledge of the importance of hand hygiene in the prevention of HAIs. Using this approach can produce a positive social change by reducing preventable disease and decreasing HAIs not only within a facility but also in the community.
A study of the efficacy of flashing lights to increase the salience of alcohol-gel dispensers for improving hand hygiene compliance
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These lights can be rapidly and easily deployed and replaced, are inexpensive, and are immediately effective. Our intervention is 10-fold less expensive than the audible reminder system that costs at least US$500 and takes half a day to install.4 The use of an intense, flashing red light might not be suitable for all hospital locations.
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Baseline hand hygiene compliance was 12.4%. Our intervention increased compliance to 23.5% during cold weather and 27.1% during warm weather. Overall, our pooled compliance rate increased to 25.3% (P < .0001).
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Effects of Audio-Visual Stimulation on Hand Hygiene Compliance among Family and Non-Family Visitors of Pediatric Wards: A Quasi-Experimental Pre-post Intervention Study
2019, Journal of Pediatric Nursing
Citation Excerpt :
Non-family visitors likely showed a higher HHC rate because they paid attention to unfamiliar surroundings including signage and audible directions. Fakhry, Hanna, Anderson, Holmes, and Nathwani (2012) reported visitors showed higher persistence of HHC than healthcare providers to an audible hand hygiene reminder. Furthermore, it could be a consequence of family members' need for reminders through various methods to increase their HHC.
This study aimed to identify the differences in interventional effects on hand hygiene compliance (HHC) among families and visitors in pediatric wards.
A total of 2787 family and non-family visitors entering through the glass sliding door of 6 pediatric wards at a university children's hospital were observed for 4 h, respectively, before and after interventions between April 27 and May 20, 2018. In the first intervention, a visual stimulus emphasized the location of the hand sanitizer. In the second intervention, an additional auditory stimulus transmitted a cue through a motion sensor speaker.
During the preliminary observation, the HHC rates of family and non-family visitors were 0.0% and 1.5%, respectively; after the visual stimulus, they were 0.6% and 5.4%, and after the audio-visual stimulus, 1.8% and 8.2%. There was a significant increase in the overall HHC with the visual (OR, 5.22; 95% CI, 1.76–20.90) and audio-visual (OR, 8.67; 95% CI, 3.08–33.70) stimuli (Fisher's exact test, p < .05).
The HHC of family and non-family visitors entering pediatric wards was very low and the audio-visual stimulus was found to be more effective than was the visual stimulus alone.
To reduce healthcare-associated infection, pediatric wards must actively implement effective interventions. Using audio-visual stimulation to increase HHC among visitors will provide advantages. Follow-up research should examine the current state of HHC among visitors in various locations and conditions.

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: Conflict of interest: None to report.

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Major articleEffectiveness of an audible reminder on hand hygiene adherence

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Acknowledgment

J Hosp Infect

J Hosp Infect

Am J Infect Control

Lancet

J Hosp Infect

Am J Infect Control

WHO guidelines on hand hygiene in healthcare. First global patient safety challenge: clean care is safer care

Guideline for hand hygiene in health care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee, HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

Morb Mortal Wkly Rep

WHO guidelines for hand hygiene in healthcare (advanced draft)

Use of alcohol hand rub (AHR) at ward entrances and use of soap and AHR by patients and visitors: a study in 27 wards in nine acute NHS trusts

J Infect Prev

Major article
Effectiveness of an audible reminder on hand hygiene adherence