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Lisa Pineles, D. Morgan, H. Limper, S. Weber, Kerri Thom, E. Perencevich, A. Harris, E. Landon (2014)Accuracy of a radiofrequency identification (RFID) badge system to monitor hand hygiene behavior during routine clinical activities.
American journal of infection control, 42 2
C. Fuller, Joanne Savage, S. Besser, A. Hayward, B. Cookson, B. Cooper, S. Stone (2011)“The Dirty Hand in the Latex Glove”: A Study of Hand Hygiene Compliance When Gloves Are Worn
Infection Control & Hospital Epidemiology, 32
D. Gould, D. Moralejo, N. Drey, J. Chudleigh (2017)Interventions to improve hand hygiene compliance in patient care.
The Cochrane database of systematic reviews, 9
J. Salman, S. Hani, N. Marcellis-Warin, Sister Isa (2015)Effectiveness of an electronic hand hygiene monitoring system on healthcare workers' compliance to guidelines.
Journal of infection and public health, 8 2
Gonzalo Bearman, Kristina Bryant, S. Leekha, Jeanmarie Mayer, L. Munoz-Price, Rekha Murthy, Tara Palmore, Mark Rupp, Joshua White (2014)Healthcare Personnel Attire in Non-Operating-Room Settings
Infection Control & Hospital Epidemiology, 35
Nai-Chung Chang, H. Reisinger, A. Jesson, M. Schweizer, D. Morgan, G. Forrest, E. Perencevich (2016)Feasibility of monitoring compliance to the My 5 Moments and Entry/Exit hand hygiene methods in US hospitals.
American journal of infection control, 44 8
S. Lydon, M. Power, J. McSharry, M. Byrne, C. Madden, J. Squires, P. O’Connor (2017)Interventions to Improve Hand Hygiene Compliance in the ICU: A Systematic Review
Critical Care Medicine, 45
D. Gould, D. Moralejo, N. Drey, J. Chudleigh (2015)Interventions to improve hand hygiene compliance in patient care (Review)
D. Pittet, B. Allegranzi, H. Sax, S. Dharan, C. Pessoa-Silva, L. Donaldson, J. Boyce (2006)Evidence-based model for hand transmission during patient care and the role of improved practices.
The Lancet. Infectious diseases, 6 10
M. McGuckin, J. Govednik (2015)A Review of Electronic Hand Hygiene Monitoring: Considerations for Hospital Management in Data Collection, Healthcare Worker Supervision, and Patient Perception
Journal of Healthcare Management, 60
J. Boyce, G. Potter-Bynoe, S. Opal, L. Dziobek, A. Medeiros (1990)A common-source outbreak of Staphylococcus epidermidis infections among patients undergoing cardiac surgery.
The Journal of infectious diseases, 161 3
S. Alsubaie, Abdallah Maither, Waddah Alalmaei, Ayshah Al-Shammari, M. Tashkandi, A. Somily, Abdulkareem Alaska, A. Binsaeed (2013)Determinants of hand hygiene noncompliance in intensive care units.
American journal of infection control, 41 2
M. McGuckin, J. Govednik (2012)Commentary: Electronic Hand Hygiene Compliance Interventions
American Journal of Medical Quality, 27
D. Pittet, P. Mourouga, T. Perneger (1999)Compliance with Handwashing in a Teaching Hospital
Annals of Internal Medicine, 130
M McGuckin, J Govednik (2012)Commentary: electronic hand hygiene compliance interventions: a descriptive guide for the infection prevention team
Am J Med Qual, 27
A. Marra, T. Camargo, Vanessa Cardoso, D. Moura, Emerson Andrade, Juliana Wentzcovitch, Alex Rocha, O. Santos, M. Edmond (2013)Hand hygiene compliance in the critical care setting: a comparative study of 2 different alcohol handrub formulations.
American journal of infection control, 41 2
J. Vries, W. Baas, K. Ploeg, A. Heesink, J. Degener, J. Arends (2006)Outbreak of Serratia marcescens Colonization and Infection Traced to a Healthcare Worker With Long-Term Carriage on the Hands
Infection Control & Hospital Epidemiology, 27
D Pittet, P Mourouga, TV Perneger (1999)Compliance with handwashing in a teaching hospital
Infection Control Program Ann Intern Med, 130
A. Han, Laurie Conway, C. Moore, Liz McCreight, K. Ragan, Jannice So, E. Borgundvaag, Michael Larocque, B. Coleman, A. McGeer (2016)Unit-Specific Rates of Hand Hygiene Opportunities in an Acute-Care Hospital
Infection Control & Hospital Epidemiology, 38
Background: Hand hygiene (HH) compliance remains low in many intensive care units (ICU). Technology has been suggested to improve HH compliance. We describe the introduction of an electronic HH surveillance and intervention system into the general ICU of a tertiary care teaching hospital, the obstacles to success and reasons for the system’s ultimate failure and removal. Methods: The system was based on radiofrequency transmitters in patient areas, on HH dispensers, and individual personal bracelets. The transmitters were connected to a central computer. The system was designed to detect entry and exit from patient areas and provide real time alerts of missed HH performance. A staff satisfaction questionnaire was administered followed by validation of system accuracy. Electronic data were compared to human observer data collected during defined observation periods. Results: Data from 41 questionnaires revealed low satisfaction rate (21/41, 51%). Low system accuracy (31/41, 76%) and inconvenience (18/41, 44%) being the most frequent reasons. During 44 one hour observation periods the observer recorded more HH opportunities and performances than the electronic system (mean number of HH opportunities/hour 10.9 ± 7.6 vs 6.8 ± 6.9, p < 0.001, correlation r = 0.75, p < 0.001, and performances/hour 8.7 ± 3.9 vs 6.0 ± 3.1, p < 0.001, correlation r = 0.60, p < 0.001, respectively). Correlation between observer and HH electronic system was very low (correlation coefficient r = 0.03, p = 0.91). Conclusions: The electronic HH system was not accepted by ICU staff principally due to inaccuracy and inconvenience. Inaccuracies were verified by direct observations. In order for an electronic HH system to succeed we suggest it must be highly accurate and comfortable to use. Keywords: Hand hygiene, Surveillance, Electronic HH system Background through lectures, (3) evaluation and feedback (4) posters Hand hygiene (HH) compliance remains appallingly low etc. that are directed at a wide audience but are not spe- in intensive care units (ICUs) [1–4] and probably leads cific to the individual, and (5) an improved culture of to the spread of bacteria which can be involved with quality and safety [8, 9]. Fostering individual account- subsequent hospital acquired infections [5–7]. ability or personal “ownership” of the HH issue is diffi- Attempts to improve HH are generally based on five cult using these tools. Possibly for these reasons, or due main elements: (1) improving access to HH facilities (2) to the high intensity of HH training including educational messages delivered required during care of ICU patients (up to 11.4 ± 2.1 times per hour, or approximately every 5.5 min ), HH interventions are generally met with only limited or * Correspondence: Benenson@hadassah.org.il transient success . Unit for infection Prevention and Control, Department of Clinical Recently attempts have been made to exploit technol- Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, POB 12000, 9112001 Jerusalem, Israel ogy to personalize and thus improve HH compliance Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Levin et al. Antimicrobial Resistance and Infection Control (2019) 8:43 Page 2 of 5 with variable success . A prerequisite for such phone text message to each staff member with their per- systems is that they be accepted by the ICU staff, and sonal HH compliance percentage) and monthly HH that the data they provide are accurate. compliance reports including specific data on all staff We describe the process surrounding the introduction members sent to managers. of an electronic HH surveillance and intervention sys- Prior to the introduction of the HH system in to the ICU, tem into the ICU. We present the results of a question- staff education sessions were performed on several occa- naire relating to staff satisfaction regarding the system, sions. The technical basis of the system was also described, and report a comparison of the incidence of HH oppor- and the importance of improving HH repeatedly presented. tunities, performance and compliance as recorded by the This led to considerable enthusiasm for using the system. system and by an observer. Questionnaire Methods Staff satisfaction with the HH system was measured In October 2013 an electronic HH surveillance and using a questionnaire. The questionnaire was delivered intervention system was introduced into the 13 bed to physicians and nurses anonymously. The key question General ICU of a tertiary academic medical center, for relating to satisfaction concerning the system was “To clinical use. what extent are you satisfied with the electronic HH sys- This report describes a questionnaire to identify causes tem?” 1 – not satisfied at all to 5 extremely satisfied. of satisfaction/dissatisfaction with the electronic HH sys- This question was followed by: “Please list three advan- tem, and a prospective assessment of the system’s accur- tages associated with use of the system” and “Please list acy. Both parts of the study were performed three disadvantages associated with use of the system”. approximately three months after the introduction of the system. The hospital ethics committee approved per- Observer data formance of the study (0576–13-HMO) with agreement An observer was trained by an infection control nurse to to cooperate being taken as consent to participate. identify HH opportunities and the use of HH products. A HH opportunity was defined as entrance or exit from an in- Electronic hand hygiene system description dividual patient’sarea – either the patient’s individual room The electronic HH system was designed to identify en- or the area close to the patient’s bed including their personal trance and exit from patient areas, regardless of whether equipment in the open plan area. Although the WHO five there was contact with the patient . This is the moments of HH includes other opportunities, the electronic standard operating procedure in our ICU. The system system was designed to identify entrance and exit from pa- was based on sensors connected to radio-frequency tient areas only. Thus to ensure comparability, the observer transmitters linked to a central computer. The sensors was trained to identify similar opportunities. The length of were widely distributed throughout the ICU, above every time hands were rubbed together during use of HH prod- bed and on HH-product dispensers (both alcohol hand ucts was also recorded by the observer. Adequacy of training rub and 4% chlorhexidine gluconate soap dispensers). was checked by the infection control nurse making parallel Each staff member was assigned a specific individual observation during an assessment period. bracelet that was worn during working hours in the During each observation period a staff member (either ICU. The bracelets were able to communicate with the a physician or a nurse) was asked to wear a “study brace- sensors so that proximity to the patients’ beds (i.e. en- let” in addition to the clinical bracelet worn at all times. trance and exit from an individual patient’s care area) The study bracelet was used to collect electronic data and use of HH products could be monitored. All data for comparison with the observer data for the particular were transmitted to the central computer. Real time in- observation period only. The “clinical bracelet”continued formation about whether HH was required or had been to function as normal. Two dedicated “study bracelets” performed was then transmitted back to the staff mem- were used during the observation periods. Each observa- bers bracelet. If HH was required but had not been per- tion period lasted one hour. A count of HH opportun- formed (defined as entrance and exit from a patient ities and HH performance was recorded for each area), the bracelet vibrated and displayed a screen mes- observation period. The observer counts represented the sage. The system also measured adequacy of HH per- gold standard for comparison to the same data provided formance by measuring the time that hands were rubbed by the electronic system for the same time periods. together – the bracelets included a motion sensor. Al- though greater than 15 s of hand rubbing was recom- Data analysis mended, the system was designed to “accept” more than Due to technical limitations (known in advance), the three seconds as adequate. In addition the system pro- electronic HH system was able to report only the total vided personal weekly reports (in the form of a cell count of HH opportunities and the total count of HH Levin et al. Antimicrobial Resistance and Infection Control (2019) 8:43 Page 3 of 5 performances for each individual one-hour observation A total of 44 matched (observer and electronic) period. These data did not describe whether HH had one-hour observation periods were analysed. During the been performed in response to a specific opportunity observation periods a total of 613 HH opportunities and and thus compliance could not be reported per individ- 487 HH performances were recorded by the observer vs ual one-hour observation period. The system was, how- 372 HH opportunities and 330 HH performances by the ever, able to provide compliance data for all observation electronic system. The mean number of HH opportun- periods performed during one week based on aggrega- ities/hour was higher for the observer than the elec- tion of multiple individual observation periods. This data tronic system (10.9 ± 7.6 vs 6.8 ± 6.9, p < 0.001) as was was provided as a compliance rate per week only. the mean number of HH performance events/hour (8.7 The mean number of HH opportunities and HH per- ± 3.9 vs 6.0 ± 3.1, p < 0.001). Correlation between num- formance per one-hour observation period were com- ber of HH opportunities and performances per observa- pared for observer data and electronic data both tion period for the observer and electronic system are graphically (Pearson correlation coefficient) and numer- shown graphically in Fig. 1 (Correlation coefficient: Ob- ically (Students t-test). The weekly aggregate compliance server vs electronic: number of HH opportunities/hour: rates were also compared. SAS 9.4 (Cary, NC, USA) was r = 0.75, p < 0.001; number of HH performance events/ used for all statistical comparisons and significance was hour: r = 0.60, p < 0.001). defined as two tailed p < 0.05. Due to a technical limitation of the electronic HH sys- tem, measured compliance data were available only Results weekly, rather than for each one-hour observation A total of 41 questionnaires were filled out – 26 by nurses period. Weekly aggregation of data from the two study (out of 56, 46%) and 15 by doctors (out of 15, 100%). Satis- bracelets used yielded 14 weekly compliance data points. faction with the electronic HH system was low or very Correlation of mean weekly compliance between obser- low for 21 of 41 staff members (51%). System inaccuracy ver and HH electronic system is presented in Fig. 2.The (false positive notifications, or lack of notifications when correlation was found to be very low (correlation coeffi- required) represented the most common reason for dissat- cient r = 0.03, p = 0.91). isfaction (31/41, 76%) followed by inconvenience of wear- ing the bracelet (18/41, 44%). The main advantages Discussion recorded were increased awareness and improved HH Despite initial enthusiasm for the electronic HH system, compliance (31/41, 76%), followed by organized uniform this soon changed to disappointment and subsequently supervision for the entire staff (5/41, 12%). to unwillingness to continue with use of the system. The Fig. 1 Correlation between observer and electronic system data for individual one-hour observation periods for the number of hand hygiene opportunities and performance Levin et al. Antimicrobial Resistance and Infection Control (2019) 8:43 Page 4 of 5 is not primarily to evaluate the staff performance accur- ately but rather to improve HH in order to prevent cross transmission of pathogens. It is possible that a relatively inaccurate system will still achieve this goal and benefit the patients. Two main obstacles stand before this ap- proach however. First, in qualitative comments, the staff stated that if their performance was being scored, they felt they had the right to be scored accurately, and were disappointed when the system clearly “felt” inaccurate. Second, outside the ICU we are used to an extremely high level of technological performance – smartphones, tablets and laptops are extremely reliable, fast and accur- ate. The HH technology did not approach this level of function, and although it might have provided benefit, the frustration that resulted from imperfect function proved to be a major obstacle to acceptance. It is interesting to note that the ICU staff was exquis- itely sensitive to HH opportunities and performance. Within a short time they identified that the system was inaccurate giving false alarms and missing HH oppor- tunities. Given that the staff seemed to be able to iden- tify HH opportunities more accurately than the Fig. 2 Correlation between observer and electronic system data for aggregate weekly hand hygiene compliance data electronic system, one cannot avoid asking why overall HH compliance was only 65% as recorded by the ICU staff appreciated the need for HH improvement observer. (noted by 76% to be an important goal of system intro- Using the electronic HH system required staff mem- duction), but equally were disappointed by the system’s bers to wear a bracelet around their wrists. This is in poor performance (76%) and the inconvenience of wear- contravention of the “bare below the elbows” approach, ing the required bracelet (44%). In terms of accuracy,  which is mandated in the United Kingdom in order staff dissatisfaction may have been justified, as the sys- to ensure that the hands can be decontaminated tem consistently underestimated HH opportunities and throughout the duration of clinical work (in addition to HH performance when compared to direct observation removing wrist and hand jewellery etc.). This practice is and occasionally provided false alerts. Further, the based on biological plausibility, but the incremental in- weekly summary of HH compliance provided to staff fection prevention impact to inpatient care is unknown was largely inaccurate. The number of HH opportunities and mentioned as “may be considered” only in the per hour recorded by the observer in our study was guidelines published by the Society for Healthcare Epi- similar to that reported elsewhere supporting the validity demiology of America (SHEA) . The bracelet used in of the observer data . our study, could be cleaned using antibacterial wipes, al- The ability to monitor movements using technology cohol or even washed with antibacterial soap. Further, it seems attractive as a means of evaluating whether HH is is possible that improving HH is an objective of suffi- performed properly and there are several commercial cient importance that may justify this infraction of the systems available today. These use radio-frequency bare below the elbow practice. transmission, cameras or and/or other sensors . All Our research has several limitations. The electronic these systems have been tested in simulated ICU envi- HH data represented the sum of data for one hour of ronments but rarely in the real life situations – where observation periods and not single events. Therefore, we the beds are close to one another, where there is little could not directly compare individual HH opportunities room between patient areas and where work load is or events between the observer and the technology, but high. For example Pineles et al.  studied the accuracy only numerical sums for each hour’s observation. Add- of “nGage” systems (a system based on radio-frequency itionally, the system was unable to provide individual and badges) and showed that the system had 88.5% ac- compliance data per one-hour observation period. How- curacy in a simulated setting but during real-life clinical ever, compliance between observer and system could be activities the system’s accuracy dropped to 50%. compared based on available weekly aggregated data. Is imperfect accuracy a sufficient reason for not using We have chosen not to identify the specific technology an electronic HH system? The goal of using the system used in this study as we did not directly measure Levin et al. Antimicrobial Resistance and Infection Control (2019) 8:43 Page 5 of 5 whether the technology actually performed its task – to Received: 11 October 2018 Accepted: 13 February 2019 improve HH performance. Rather we looked at the rea- sons that the system ultimately failed and was removed References from our ICU in order to suggest improvements re- 1. Fuller C, Savage J, Besser S, et al. "the dirty hand in the latex glove": a study of hand hygiene compliance when gloves are worn. Infect Control Hosp quired for acceptance. Epidemiol. 2011;32:1194–9. 2. Alsubaie S, Maither A, Alalmaei W, et al. Determinants of hand hygiene noncompliance in intensive care units. Am J Infect Control. 2013;41:131–5. Conclusions 3. Marra AR, Camargo TZ, Cardoso VJ, et al. Hand hygiene compliance in the Staff dissatisfaction with the electronic system seemed to critical care setting: a comparative study of 2 different alcohol handrub result primarily from inaccurate identification of HH op- formulations. Am J Infect Control. 2013;41:136–9. 4. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a portunities and performance. The staff dissatisfaction teaching hospital. Infection Control Program Ann Intern Med. 1999;130:126– seemed justified by direct observation of the electronic system. We suggest that for HH technology to be suc- 5. de Vries JJ, Baas WH, van der Ploeg K, et al. Outbreak of Serratia marcescens colonization and infection traced to a healthcare worker with long-term cessfully introduced into the ICU it must be both highly carriage on the hands. Infect Control Hosp Epidemiol. 2006;27:1153–8. accurate and comfortable to use. 6. Boyce JM, Potter-Bynoe G, Opal SM, et al. A common-source outbreak of Staphylococcus epidermidis infections among patients undergoing cardiac Abbreviations surgery. J Infect Dis. 1990;161:493–9. HH: Hand hygiene; ICU: Intensive care unit 7. Pittet D, Allegranzi B, Sax H, et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Acknowledgements Infect Dis. 2006;6:641–52. Not applicable. 8. http://www.who.int/gpsc/5may/tools/WHO_IER_PSP_2009.02_eng.pdf?ua= 1(accessed 3 Oct 2017). Funding 9. Lydon S, Power M, McSharry J, et al. Interventions to improve hand hygiene No funding was received for the performance of this research. compliance in the ICU: a systematic review. Crit Care Med. 2017;45:e1165– Availability of data and materials 10. Han A, Conway LJ, Moore C, et al. Unit-specific rates of hand hygiene The datasets used and/or analyzed during the current study are available opportunities in an acute-care hospital. Infect Control Hosp Epidemiol. 2017; from the corresponding author on reasonable request. 38:411–6. 11. Gould DJ, Moralejo D, Drey N, et al. Interventions to improve hand hygiene Authors’ contributions compliance in patient care. Cochrane Database Syst Rev. 2017;9 Cd005186. PDL: This author conceived and designed the study, participated in data 12. McGuckin M, Govednik J. A review of electronic hand hygiene monitoring: collection, performed the data analysis, interpreted the data, wrote the considerations for Hospital Management in Data Collection, healthcare manuscript and has approved the publication of this version. He is worker supervision, and patient perception. J Healthc Manag. 2015;60:348– accountable for the accuracy and integrity of the work. RR: This author participated in the data collection, interpreted the data, wrote the 13. Al Salman JM, Hani S, de Marcellis-Warin N, et al. Effectiveness of an manuscript and has approved the publication of this version. CS: This author electronic hand hygiene monitoring system on healthcare workers' participated in the data collection, data analysis, writing of the manuscript compliance to guidelines. J Infect Public Health. 2015;8:117–26. and has approved the publication of this version. CS: This author participated 14. Chang NC, Reisinger HS, Jesson AR, et al. Feasibility of monitoring in study design, oversight and manuscript preparation and has approved the compliance to the my 5 moments and entry/exit hand hygiene methods in publication of this version. AEM: This author participated in study design, US hospitals. Am J Infect Control. 2016;44:938–40. oversight and manuscript preparation and has approved the publication of 15. McGuckin M, Govednik J. Commentary: electronic hand hygiene this version. SB: This author conceived and designed the study, participated compliance interventions: a descriptive guide for the infection prevention in data collection, performed the data analysis, interpreted the data, and team. Am J Med Qual. 2012;27:540–1. wrote the manuscript. He has approved the publication of this version and is 16. Pineles LL, Morgan DJ, Limper HM, et al. Accuracy of a radiofrequency accountable for the accuracy and integrity of the work. All authors read and identification (RFID) badge system to monitor hand hygiene behavior approved the final manuscript. during routine clinical activities. Am J Infect Control. 2014;42:144–7. 17. https://www.nice.org.uk/guidance/cg139/chapter/1-Guidance#standard- Ethics approval and consent to participate principles. (accessed 10 Feb 2019). The hospital ethics committee approved performance of the study (0576–13- 18. Bearman G, Bryant K, Leekha S, et al. Healthcare personnel attire in non- HMO) with agreement to cooperate being taken as consent to participate. operating-room settings. Infect Control Hosp Epidemiol. 2014;35:107–21. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Unit for infection Prevention and Control, Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, POB 12000, 9112001 Jerusalem, Israel. Department of Anesthesiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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