Christopher Fuller

The Feedback Intervention Trial (FIT) — Improving Hand- Hygiene Compliance in UK Healthcare Workers: A Stepped Wedge Cluster Randomised Controlled Trial

Introduction Achieving a sustained improvement in hand-hygiene compliance is the WHO’s first global patient safety challenge. There is no RCT evidence showing how to do this. Systematic reviews suggest feedback is most effective and call for long term well designed RCTs, applying behavioural theory to intervention design to optimise effectiveness. Methods Three year stepped wedge cluster RCT of a feedback intervention testing hypothesis that the intervention was more effective than routine practice in 16 English/Welsh Hospitals (16 Intensive Therapy Units [ITU]; 44 Acute Care of the Elderly [ACE] wards) routinely implementing a national cleanyourhands campaign). Intervention-based on Goal & Control theories. Repeating 4 week cycle (20 mins/week) of observation, feedback and personalised action planning, recorded on forms. Computer-generated stepwise entry of all hospitals to intervention. Hospitals aware only of own allocation. Primary outcome: direct blinded hand hygiene compliance (%). Results All 16 trusts (60 wards) randomised, 33 wards implemented intervention (11 ITU, 22 ACE). Mixed effects regression analysis (all wards) accounting for confounders, temporal trends, ward type and fidelity to intervention (forms/month used). Intention to Treat Analysis Estimated odds ratio (OR) for hand hygiene compliance rose post randomisation (1.44; 95% CI 1.18, 1.76;p<0.001) in ITUs but not ACE wards, equivalent to 7–9% absolute increase in compliance. Per-Protocol Analysis for Implementing Wards OR for compliance rose for both ACE (1.67 [1.28–2.22]; p<0.001) & ITUs (2.09 [1.55–2.81];p<0.001) equating to absolute increases of 10–13% and 13–18% respectively. Fidelity to intervention closely related to compliance on ITUs (OR 1.12 [1.04, 1.20];p = 0.003 per completed form) but not ACE wards. Conclusion Despite difficulties in implementation, intention-to-treat, per-protocol and fidelity to intervention, analyses showed an intervention coupling feedback to personalised action planning produced moderate but significant sustained improvements in hand-hygiene compliance, in wards implementing a national hand-hygiene campaign. Further implementation studies are needed to maximise the intervention’s effect in different settings. Trial Registration Controlled-Trials.com ISRCTN65246961

The National One Week Prevalence Audit of Universal Meticillin-Resistant Staphylococcus aureus (MRSA) Admission Screening 2012

Introduction The English Department of Health introduced universal MRSA screening of admissions to English hospitals in 2010. It commissioned a national audit to review implementation, impact on patient management, admission prevalence and extra yield of MRSA identified compared to “high-risk” specialty or “checklist-activated” screening (CLAS) of patients with MRSA risk factors. Methods National audit May 2011. Questionnaires to infection control teams in all English NHS acute trusts, requesting number patients admitted and screened, new or previously known MRSA; MRSA point prevalence; screening and isolation policies; individual risk factors and patient management for all new MRSA patients and random sample of negatives. Results 144/167 (86.2%) trusts responded. Individual patient data for 760 new MRSA patients and 951 negatives. 61% of emergency admissions (median 67.3%), 81% (median 59.4%) electives and 47% (median 41.4%) day-cases were screened. MRSA admission prevalence: 1% (median 0.9%) emergencies, 0.6% (median 0.4%) electives, 0.4% (median 0%) day-cases. Approximately 50% all MRSA identified was new. Inpatient MRSA point prevalence: 3.3% (median 2.9%). 104 (77%) trusts pre-emptively isolated patients with previous MRSA, 63 (35%) pre-emptively isolated admissions to “high-risk” specialties; 7 (5%) used PCR routinely. Mean time to MRSA positive result: 2.87 days (±1.33); 37% (219/596) newly identified MRSA patients discharged before result available; 55% remainder (205/376) isolated post-result. In an average trust, CLAS would reduce screening by 50%, identifying 81% of all MRSA. “High risk” specialty screening would reduce screening by 89%, identifying 9% of MRSA. Conclusions Implementation of universal screening was poor. Admission prevalence (new cases) was low. CLAS reduced screening effort for minor decreases in identification, but implementation may prove difficult. Cost effectiveness of this and other policies, awaits evaluation by transmission dynamic economic modelling, using data from this audit. Until then trusts should seek to improve implementation of current policy and use of isolation facilities.

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

Ward procurement of hand hygiene consumables is a proxy measure of hand hygiene compliance. The proportion of this due to use of alcohol hand rub (AHR) at ward entrances, and bedside use of consumables by patients and visitors, is unknown. Thirty-six hours of direct observation of bedside hand hygiene behaviours by healthcare workers (HCWs), patients and visitors on 27 wards in nine hospitals was undertaken. AHR containers from ten ward entrances were collected for four days. Mean daily volume used was compared with mean daily volume procured. Only 4% of bedside soap and AHR use was by visitors. Patients used neither. An average 21% (range 7—38%) of all AHR procured by wards was used at ward entrances. Non-HCW use of soap or AHR at the bedside is low. Ward entrance use of AHR is modest but varies. Hand hygiene intervention studies using consumables as an outcome should assess and adjust for such usage.

What Is the Optimal Period for Measuring Hand Hygiene Compliance: Are Longer Periods Better than 20-Minute Periods?

Better than 20-Minute Periods? Author(s): Sheldon Stone, MD; Chris Fuller, MSc; Susan Michie, PhD; John McAteer, PhD; Andre Charlett, PhD Source: Infection Control and Hospital Epidemiology, Vol. 33, No. 11 (November 2012), pp. 1174-1176 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/668017 . Accessed: 28/06/2014 18:11