FOCUS ON INFECTION PREVENTION A Systems and Behavioral Approach to Improve Hand Hygiene Practice Sharon Bradley INTRODUCTION Senior Infection Prevention Analyst Pennsylvania Patient Safety Authority Considerable efforts are being made to reduce healthcare-associated infections (HAIs) in Pennsylvania healthcare facilities.1 According to the Pennsylvania Department of Health, the incidence of HAIs in Pennsylvania hospitals has declined substantially ABSTRACT since the passage of Act 52 in 2007. However, the Pennsylvania Department of Health also reported that dramatic improvements in the incidence of hospital HAIs have Despite convincing evidence since the slowed, and in some cases, improvement regressed slightly from 2011 to 2012.2 From 1840s that improved hand hygiene 2010—the first full year of nursing home reporting to the Pennsylvania Patient Safety reduces infection rates, studies show Reporting System (PA-PSRS)—through 2013, there has been improvement in the HAI that healthcare worker compliance incidence of most nursing homes. However, in this same time period, the incidence of with hand hygiene is consistently sub- Clostridium difficile—associated diarrhea was unchanged and the reporting of influenza- optimal in many healthcare settings. like illnesses increased.1 Optimal hand hygiene is a critical component in any process focused on Since Semmelweiss discovered in the 1840s that handwashing prevented deaths from achieving and sustaining zero incidents puerperal sepsis, studies have continued to show convincing evidence that improved of healthcare-associated infections hand hygiene reduces infection rates.3,4 Good hand hygiene is recognized as the single (HAIs). Pennsylvania hospitals and most important method for preventing HAIs.5 Professional and regulatory agencies nursing homes have reported a slow expect infection control programs to emphasize healthcare worker adherence to hand but steady decline in HAIs through the hygiene practices.6-8 Hand hygiene practice standards have been embraced by the National Healthcare Safety Network Centers for Disease Control and Prevention, the World Health Organization (WHO), and the Pennsylvania Patient Safety the Joint Commission, the Society for Healthcare Epidemiology of America, and other Reporting System. Reliance on current expert organizations.5,9-11 methods to detect hand hygiene com- Despite professional and regulatory guidance, healthcare worker compliance with hand pliance—such as direct observation, hygiene is consistently suboptimal in many healthcare settings. For example, a 2010 hand hygiene product use measure- systematic review of hand hygiene compliance studies found a dismal overall compli- ment, and electronic monitoring—has ance rate of 40%.12 It remains critical for healthcare facilities to optimize basic hand been problematic. Implementation of hygiene as they strive for zero HAI incidents. Current regulations and guidelines pro- a credible hand hygiene program can vide few practical strategies to successfully motivate clinicians to improve hand hygiene be enhanced by integration of systems practices at the bedside.9 The inconsistency and lack of sustainability of methods to supporting hand hygiene activities motivate healthcare worker compliance suggests that hand hygiene behavior is complex. with an understanding of workflow However, implementation of a credible hand hygiene program can be enhanced by use and human behavior. Healthcare of systems that address healthcare delivery workflow and human behavior.13 facilities may improve hand hygiene practice by applying a multimodal HAND HYGIENE COMPLIANCE IN PENNSYLVANIA framework of system and behavioral strategies to investigate, understand, Pennsylvania Patient Safety Authority analysts queried the PA-PSRS database for and mitigate gaps in infrastructure events associated with hand hygiene for the 10-year period of June 2004 through and behavioral components of hand June 2014; the query returned 789 event reports. Analysts reviewed the reports to hygiene. (Pa Patient Saf Advis 2014 identify those associated with compliance. Pennsylvania healthcare facilities reported Dec;11[4]:163-7.) 35 events related to hand hygiene compliance. A sampling of these reports included the following: — Handwashing was not performed before or after a postoperative dressing change procedure, and no gloves were worn for a dressing change. — A surgeon did not do a surgical scrub before gowning for the first case, then used foam soap before scrubbing for the second case and touched drapes on the sterile Scan this code table without being sterile. with your mobile — An x-ray tech ignored isolation precautions by not wearing gloves or sanitizing device’s QR reader their hands after touching the patient. to access the Authority's toolkit on this topic. Vol. 11, No. 4—December 2014 Pennsylvania Patient Safety Advisory Page 163 ©2014 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION — A nurse did not attempt to clean is problematic because of observer bias, monitoring eliminates observer bias their hands or wear gloves while expense, method validity, practicality, and but does not validate technique or compli- accessing a cancer patient’s port, lack of sustainable, effective strategies ance with performance of hand hygiene leaving the room twice and not per- to use the outcomes to change clinician opportunities at the WHO moments 2, forming hand hygiene or using clean behavior.9 Reliance on these methods has 3, and 5.9 Electronic monitoring is subject gloves either time. proved ineffective in hardwiring optimal to technical challenges and may require — An anesthesia provider suctioned hand hygiene behaviors. financial investment and ongoing main- a patient’s airway without gloves, Direct observation. This is the gold tenance. In contrast to room entry and wiped his hands on his jacket, and standard for assessing hand hygiene motion sensor methods of monitoring, a administered intravenous medica- compliance, but it is labor-intensive and recent study in two South Carolina hospi- tion without hand hygiene or gloves. subject to method variation. Observer tals demonstrated that observation via a The nurse offered him hand sanitizer bias, the Hawthorne effect, and technical 24-hour video monitoring system can be prior to medication administration, challenges may result in overlooking inci- used to validate performance of all of the but the physician refused. dents of contamination before and during WHO Five Moments for Hand Hygiene.16 — A nurse inserted a rectal suppository the patient encounter.9 in a patient and then performed a CLOSING THE HAND HYGIENE Product measurement. An increase in blood draw without washing their PRACTICE GAP the use of product does not verify tech- hands between procedures. nique or compliance with the WHO Five Rather than relying on measuring com- Moments for Hand Hygiene.9 See “WHO pliance or purchasing new products, it EFFECTIVENESS OF CURRENT may be more effective to focus available Five Moments for Hand Hygiene” for HAND HYGIENE METHODS more information. resources on implementation of systems Alcohol-Based Handrubs that address healthcare delivery workflow Electronic monitoring. Recent technolo- and human behavior.17 Current research The widespread provision of alcohol-based gies have been developed with room entry demonstrates that no single intervention handrubs (ABHRs) has been shown to and wearable motion sensor components can change long-standing patterns of improve hand hygiene compliance. ABHRs that record hand hygiene opportunities, behavior.18 A multimodal approach has improve the availability of the product at detect when hand hygiene dispensers are emerged as the best sustainable method the point of care, shorten the time neces- accessed, and/or use lights, vibration, or to improving hand hygiene compliance. sary to clean hands, and decrease skin audible alerts to prompt healthcare work- This approach consists of instituting a irritability with emollient-enriched formu- ers to perform hand hygiene. Electronic structured framework of strategies for las.5,9 Alcohol solutions containing 60% to 95% alcohol are the most effective hand hygiene antimicrobials, with the exception WHO FIVE MOMENTS FOR HAND HYGIENE of effectiveness against Clostridium difficile, which requires soap and water handwash- According to the World Health Organization (WHO), the five moments for hand ing to remove spores.5 Kendall et al. cite hygiene that will most effectively interrupt microbial transmission during patient care multiple studies from 2002 to 2012 dem- are as follows: onstrating improvement in hand hygiene 1. Before touching a patient: protects patients from harmful organisms on and decreases in HAI rates with implemen- healthcare workers’ hands tation of point-of-care ABHR dispensers.14 2. Before clean/aseptic procedures: protects patients from harmful organisms on Despite this improvement, a 12-month themselves or the healthcare worker multicenter collaboration focused on ABHRs demonstrated that overall hand 3. After body fluid exposure risk: protects the healthcare worker and the environment from the patient’s harmful organisms hygiene adherence remains low across the country.12,15 4. After touching a patient: protects the healthcare worker and the environment from the patient’s harmful organisms Compliance Monitoring 5. After touching patient surroundings: protects the healthcare worker and the Current methods to detect compliance environment from the patient’s harmful organisms include direct observation, product Source: World Health Organization. Five moments for hand hygiene [online]. [cited 2014 Nov 3]. measurement, and electronic monitor- http://www.who.int/gpsc/tools/Five_moments/en ing. However, reliance on these methods Page 164 Pennsylvania Patient Safety Advisory Vol. 11, No. 4—December 2014 ©2014 Pennsylvania Patient Safety Authority hand hygiene compliance with the addi- — Institute a multidisciplinary team behavioral motivators have been docu- tional focus on the internal and external to coordinate implementation. mented in the literature.13,18,20-22 determinants of behavior changes.11,19 — Determine the effectiveness of Strategies to enhance staff behavior beliefs A tool to facilitate mapping strategies preventive strategies with ongoing that hand hygiene prevents HAIs include to specific staff beliefs and behaviors, monitoring and timely feedback the following:14 entitled Decision-Making Map to Improve about HAI rates and hand Hand Hygiene Behavior, is available on — Explain the rationale and science hygiene compliance. the Authority’s website at http://patient behind the WHO Five Moments for — Implement methods to reinforce Hand Hygiene. safetyauthority.org/EducationalTools/ behavior and accountability, PatientSafetyTools/Pages/home.aspx. — Require that a clinical role model including education, reminders, provide hand hygiene education that and support for appropriate hand COMPONENTS OF A is specific to the various staff mem- hygiene behavior. MULTIMODAL APPROACH bers’ job tasks. These components are consistent with Assess Barriers to Hand Hygiene — Use visual aids, such as a fluore- the WHO key elements of a hand scent marker to demonstrate organ- A robust hand hygiene improvement hygiene program, which include system ism transfer. program begins with assessment of barri- changes and strategies to ensure available ers to optimal practice. A facility-specific resources, training, monitoring, perfor- — Define administrative goals and tar- assessment targets hand hygiene systems mance feedback, workplace reminders, gets for hand hygiene for all staff. problems, workplace reminders, safety cli- and institution of a safety climate.11 — Institute persuasive communication mate, training, evaluation, and feedback moments, such as one-to-one point- on resources, knowledge, compliance, and Map Specific Strategies for of-care conversations by leadership leadership. A sample of a barrier assess- Hand Hygiene Compliance on the value of proper hand hygiene. ment, Hand Hygiene Self-Assessment to Behaviors — Post intranet screensavers and vari- Framework 2010, is available on the ous changeable visual reminders by Valuable strategies to improve hand WHO website at http://www.who.int/ the sinks, mirrors, doors, or charts. hygiene behaviors correlate with individ- gpsc/country_work/hhsa_framework.pdf. — Provide feedback, at staff meetings or ual beliefs that influence the intention to perform hand hygiene.21 The behav- group sessions, on successful hand Survey Hand Hygiene Behaviors hygiene efforts as well as episodes of ioral determinants of intention include and Beliefs the following: patient harm from HAIs. It is critical to assess healthcare workers’ Strategies to enhance the belief that hand — The person believes that hand beliefs about hand hygiene to target hygiene compliance is valued and expected hygiene at the point of care prevents internal motivators (such as attitude, by administrators, role models, peers, and the spread of organisms and patient social norms, perceived control, and patients include the following:13 intentions) and external motivators (such harm from HAIs. as the activity level in the work setting and — The person believes that hand — Engage staff and physicians as active the location of hand hygiene stations). hygiene compliance is expected role models. An example of a behavior belief survey, and valued by peers, supervisors, — Require a signed contract or the Perception Survey for Health-Care and patients. commitment to formulated hand Workers, is available on the WHO website — The person believes that they have hygiene goals. at http://www.who.int/gpsc/5may/tools/ control over the resources necessary — Develop, distribute, and practice evaluation_feedback/en. to comply with hand hygiene and peer-to-peer talking points. can remove barriers to performance. — Provide visible praise, encourage- Institute a Hand Hygiene The results of a behavior, belief, and/or ment, and/or material rewards in “Bundle” barrier assessment will indicate which recognition of successes. Key components of a bundle of motivators need to be targeted. Studies — Include hand hygiene compliance/ hand hygiene interventions include have shown that mapping specific inter- performance evaluations in annual the following:18 ventions to these internal and external performance and competency — Integrate administrative and leader- motivators of behavior can increase evaluations. ship support with the healthcare healthcare worker hand hygiene perfor- — Make hand hygiene compliance a facility quality improvement effort. mance. Multiple strategies to address these credentialing requirement. Vol. 11, No. 4—December 2014 Pennsylvania Patient Safety Advisory Page 165 ©2014 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION — Empower patients to speak up using Intervene to Address CONCLUSION patient report cards. Disruptive Behaviors Healthcare facilities may fall short of goals — Have staff wear the Joint Commis- If hand hygiene compliance is not achieved to improve hand hygiene compliance if sion’s “Ask me if I’ve washed my after application of all of the previously that improvement is dependent solely hands” buttons.10 mentioned strategies, closer investigation on the availability of ABHR stations, Strategies to increase the person’s belief may uncover that systems or belief barri- the deployment of current monitoring that they have control over resources for ers remain. If noncompliance appears to methods, and compliance with regula- good hand hygiene performance include be the result of reckless or unprofessional tory and professional standards and the following:13 behavior, then an alternative approach guidelines. Implementation of a credible may be necessary to manage the behavior. hand hygiene program can be enhanced — Ensure availability of ABHR or handwashing stations at the point of A graduated intervention scale entitled by using systems that target healthcare care in all patient care areas. the disruptive behavior pyramid has been delivery workflow with strategies that described as an effective measure to cur- influence healthcare worker behaviors — Develop a system to ensure soap, tail reckless hand hygiene behaviors when and integrate handwashing into patient ABHR stations, and towels are other methods have failed.23 This scale care activities. Studies have shown that stocked, functional, and convenient. focuses on four escalating interventions: mapping specific interventions to internal — Install a touchless hand lotion dis- and external motivators of behavior can (1) informal conversation for a single penser in all work areas to prevent skin improve healthcare worker hand hygiene incident of not performing hand hygiene, irritation from multiple handwashings. performance. A multimodal framework (2) nonpunitive awareness interventions — Practice integrating missed oppor- if a pattern of poor hand hygiene exists, of system and behavioral strategies is vital tunities for hand hygiene into (3) leader-developed action plans for per- to investigate, understand, and mitigate high-workload situations. sistent noncompliance with hand hygiene, gaps in hand hygiene compliance; remove — Demonstrate methods to integrate and (4) if all other strategies have been obstacles to hand hygiene performance; hand hygiene into workflows and exhausted and the individual has been and convince healthcare workers that to keep up with the workload while educated and coached but noncompliance hand hygiene compliance is valued, maintaining good hand hygiene. continues, corrective action to hold the expected, and important. healthcare worker accountable for reckless hand hygiene behavior. NOTES 1. Pennsylvania Patient Safety Authority. 5. Boyce JM, Pittet D. Guideline for hand 9. Ellingson K, Haas JP, Aiello AE, et al. Pennsylvania Patient Safety Authority hygiene in health-care settings: recom- Strategies to prevent healthcare-associated annual report 2013 [online]. 2014 Apr 30 mendations of the Healthcare Infection infections through hand hygiene. Infect [cited 2014 Nov 3]. http://patientsafety Control Practices Advisory Committee Control Hosp Epidemiol 2014 Aug;35(8): authority.org/PatientSafetyAuthority/ and the HICPAC/SHEA/APIC/IDSA 937-60. Pages/AnnualReports.aspx Hand Hygiene Task Force [online]. 10. Joint Commission. Measuring hand 2. Pennsylvania Department of Health. MMWR Morb Mortal Wkly Rep 2002 hygiene adherence: overcoming the chal- Healthcare-associated infections in Oct 25 [cited 2014 Nov 3]. http://www. lenges [online]. 2009 [cited 2014 Nov 3]. Pennsylvania [online]. 2012 [cited 2014 Nov cdc.gov/mmwr/PDF/rr/rr5116.pdf http://www.jointcommission.org/ 3]. http://www.portal.state.pa.us/portal/ 6. Office of Disease Prevention and Health assets/1/18/hh_monograph.pdf server.pt/document/1417904/pennsylvania Promotion. US Department of Health 11. Pittet D, Allegranzi B, Boyce J. The World haireport2012_2014-05-19_pdf and Human Services. National action Health Organization Guidelines on Hand 3. Pittet D, Allegranzi B, Sax H, et al. plan to prevent health care-associated Hygiene in Health Care and their consen- Evidence-based model for hand transmis- infections: road map to elimination sus recommendations. Infect Control Hosp sion during patient care and the role of [online]. [cited 2014 Nov 3]. http://www. Epidemiol 2009 Jul;30(7):611-22. improved practices. Lancet Infect Dis 2006 health.gov/hai/prevent_hai.asp#hai_plan 12. Erasmus V, Daha TJ, Richards JH, et al. Oct;6(10):641-52. 7. Joint Commission. 2014 and 2015 Systematic review of studies on compli- 4. Allegranzi B, Pittet D. Role of hand National Patient Safety Goals [online]. ance with hand hygiene guidelines in hygiene in healthcare-associated infec- [cited 2014 Nov 3]. http://www.joint hospital care. Infect Control Hosp Epidemiol tion prevention. J Hosp Infect 2009 commission.org/standards_information/ 2010 Mar;31(3):283-94. Dec;73(4):305-15. npsgs.aspx 13. Huis A, van Achterberg T, de Bruin M, 8. 42 CFR § 482.12 (2008). Also available et al. A systematic review of hand hygiene at http://www.access.gpo.gov/nara/cfr/ improvement strategies: a behavioural waisidx_08/42cfr482_08.html approach. Implement Sci 2012 Sep 14;7:92. Page 166 Pennsylvania Patient Safety Advisory Vol. 11, No. 4—December 2014 ©2014 Pennsylvania Patient Safety Authority 14. Kendall A, Landers T, Kirk J, et al. Point- 17. De Wandel D, Maes L, Labeau S, et al. of planned behaviour. Psychol Health of-care hand hygiene: preventing infection Behavioral determinants of hand hygiene Med 2002;7(3):311-26. behind the curtain. Am J Infect Control compliance in intensive care units. Am J 21. O’Boyle CA, Henley SJ, Larson E. 2012 May;40(4 Suppl 1):S3-10. Crit Care 2010 May;19(3):230-9. Understanding adherence to hand 15. McGuckin M, Waterman R, Govednik 18. Pincock T, Bernstein P, Warthman S, et hygiene recommendations: the theory of J. Hand hygiene compliance rated in the al. Bundling hand hygiene interventions planned behavior. Am J Infect Control 2001 United States--a one-year multicenter col- and measurement to decrease health care- Dec;29(6):352-60. laboration using product/volume usage associated infections. Am J Infect Control 22. Whitby M, Pessoa-Silva CL, McLaws measurement and feedback. Am J Med 2012 May;40(4 Suppl 1):S18-27. ML, et al. Behavioural considerations for Qual 2009 May-Jun;24(3):205-13. 19. Boyce J, Larson EL, Pittet D. Foreword: hand hygiene practices: the basic building 16. Diller T, Kelly JW, Blackhurst D, et al. emerging trends in hand hygiene: infec- blocks. J Hosp Infect 2007 Jan;65(1):1-8. Estimation of hand hygiene opportunities tion prevention on our way to 2020. Am J 23. Hickson GB, Pichert JW, Webb LE, et al. on an adult medical ward using 24-hour Infect Control 2012 May;40(4 Suppl 1):S2. A complementary approach to promoting camera surveillance: Validation of the 20. Jenner EA, Watson PWB, Miller L, professionalism: identifying, measuring, HOW2 Benchmark Study. Am J Infect et al. Explaining hand hygiene practices: and addressing unprofessional behav- Control 2014 Jun;42(6):602-7. an extended application of the theory iours. Acad Med 2007 Nov;82(11):1040-8. Vol. 11, No. 4—December 2014 Pennsylvania Patient Safety Advisory Page 167 ©2014 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 11, No. 4—December 2014. 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