Jocelyn A. Srigley

Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study

Background The Hawthorne effect, or behaviour change due to awareness of being observed, is assumed to inflate hand hygiene compliance rates as measured by direct observation but there are limited data to support this. Objective To determine whether the presence of hand hygiene auditors was associated with an increase in hand hygiene events as measured by a real-time location system (RTLS). Methods The RTLS recorded all uses of alcohol-based hand rub and soap for 8u2005months in two units in an academic acute care hospital. The RTLS also tracked the movement of hospital hand hygiene auditors. Rates of hand hygiene events per dispenser per hour as measured by the RTLS were compared for dispensers within sight of auditors and those not exposed to auditors. Results The hand hygiene event rate in dispensers visible to auditors (3.75/dispenser/h) was significantly higher than in dispensers not visible to the auditors at the same time (1.48; p=0.001) and in the same dispensers during the week prior (1.07; p<0.001). The rate increased significantly when auditors were present compared with 1–5u2005min prior to the auditors’ arrival (1.50; p=0.009). There were no significant changes inside patient rooms. Conclusions Hand hygiene event rates were approximately threefold higher in hallways within eyesight of an auditor compared with when no auditor was visible and the increase occurred after the auditors’ arrival. This is consistent with the existence of a Hawthorne effect localised to areas where the auditor is visible and calls into question the accuracy of publicly reported hospital hand hygiene compliance rates.

Hand hygiene monitoring technology: a systematic review of efficacy.

Electronic and video monitoring systems (EMS/VMS) may improve hand hygiene by providing feedback, real-time reminders or via the Hawthorne effect. The aim of this systematic review was to assess the efficacy of EMS/VMS in improving hand hygiene or reducing the incidence of healthcare-associated infection (HCAI). Experimental and quasi-experimental studies were included if they measured any hand hygiene outcome and/or HCAI incidence. Of the studies included, seven used system-defined compliance (SDC) (N = 6) or hand hygiene event rate (N = 1) as their outcome. SDC differed for all systems. Most (N = 6) were single ward studies. Two uncontrolled pretest‒post-test studies evaluating EMS that provided voice prompts showed increases in SDC, but risk of bias was high. Two uncontrolled time-series analyses of VMS that provided aggregate feedback demonstrated large, sustained improvement in SDC and were at moderate risk of bias. One non-randomized controlled trial of EMS with aggregate feedback found no difference in hand hygiene frequency but was at high risk of bias. Two studies evaluated EMS providing individual feedback and real-time reminders. A pretest‒post-test study at high risk of bias showed an increase in SDC. An RCT at low risk of bias showed 6.8% higher SDC in the intervention arm partially due to a fall in SDC in the control arm. In conclusion, the overall study quality was poor. The study at lowest risk of bias showed only a small increase in SDC. VMS studies at moderate risk of bias showed rapid and sustained increases in SDC. Data were insufficient to recommend EMS/VMS. Future studies should prioritize testing of VMS using stronger study designs including control arms and validated, system-independent measures of hand hygiene.

Using behavior change frameworks to improve healthcare worker influenza vaccination rates: A systematic review.

BACKGROUNDnInfluenza vaccination of healthcare workers (HCW) is important for protecting staff and patients, yet vaccine coverage among HCW remains below recommended targets. Psychological theories of behavior change may help guide interventions to improve vaccine uptake. Our objectives were to: (1) review the effectiveness of interventions based on psychological theories of behavior change to improve HCW influenza vaccination rates, and (2) determine which psychological theories have been used to predict HCW influenza vaccination uptake.nnnMETHODSnMEDLINE, EMBASE, CINAHL, PsycINFO, The Joanna Briggs Institute, SocINDEX, and Cochrane Database of Systematic Reviews were searched for studies that applied psychological theories of behavior change to improve and/or predict influenza vaccination uptake among HCW.nnnRESULTSnThe literature search yielded a total of 1810 publications; 10 articles met eligibility criteria. All studies used behavior change theories to predict HCW vaccination behavior; none evaluated interventions based on these theories. The Health Belief Model was the most frequently employed theory to predict influenza vaccination uptake among HCW. The remaining predictive studies employed the Theory of Planned Behavior, the Risk Perception Attitude, and the Triandis Model of Interpersonal Behavior. The behavior change framework constructs were successful in differentiating between vaccinated and non-vaccinated HCW. Key constructs identified included: attitudes regarding the efficacy and safety of influenza vaccination, perceptions of risk and benefit to self and others, self-efficacy, cues to action, and social-professional norms. The behavior change frameworks, along with sociodemographic variables, successfully predicted 85-95% of HCW influenza vaccination uptake.nnnCONCLUSIONnVaccination is a complex behavior. Our results suggest that psychological theories of behavior change are promising tools to increase HCW influenza vaccination uptake. Future studies are needed to develop and evaluate novel interventions based on behavior change theories, which may help achieve recommended HCW vaccination targets.

Inappropriate use of antibiotics and Clostridium difficile infection

We assessed appropriateness of preceding and concurrent antibiotics in 126 consecutive patients with hospital-associated Clostridium difficile infection. In 93 (73.8%) episodes, at least 1 preceding course of antibiotics was inappropriate. We provided feedback on concurrent antibiotics on the day of diagnosis during the final 8 months: 17 of 74 (23.0%) patients were on inappropriate antibiotics. Our recommendations were well received. Reviewing C difficile-infected patients allowed for identification of opportunities to improve antibiotic utilization and potentially improved patient outcomes.

Examination of staphylococcal stethoscope contamination in the emergency department (pilot) study (EXSSCITED pilot study).

INTRODUCTIONnThe objective of this study was to determine the prevalence of Staphylococcus-contaminated stethoscopes belonging to emergency department (ED) staff and to identify the proportion of these that were Staphylococcus aureus or methicillin-resistant Staphylococcus aureus (MRSA).nnnMETHODSnWe conducted a prospective observational cohort study of bacterial cultures from 100 ED staff members stethoscopes at three EDs. Study participants were asked to complete a questionnaire.nnnRESULTSnFifty-four specimens grew coagulase-negative staphylococci and one grew methicillin-susceptible S. aureus. No MRSA was cultured. Only 8% of participants, all of whom were nurses, reported cleaning their stethoscope before or after each patient assessment. Alcohol-based wipes were most commonly used to clean stethoscopes. A lack of time, being too busy, and forgetfulness were the most frequently reported reasons for not cleaning the stethoscope in the ED.nnnCONCLUSIONSnThis study indicates that although stethoscope contamination rates in these EDs are high, the prevalence of S. aureus or MRSA on stethoscopes is low.

Applying psychological frameworks of behaviour change to improve healthcare worker hand hygiene: a systematic review

BACKGROUNDnDespite the importance of hand hygiene in preventing transmission of healthcare-associated infections, compliance rates are suboptimal. Hand hygiene is a complex behaviour and psychological frameworks are promising tools to influence healthcare worker (HCW) behaviour.nnnAIMn(i) To review the effectiveness of interventions based on psychological theories of behaviour change to improve HCW hand hygiene compliance; (ii) to determine which frameworks have been used to predict HCW hand hygiene compliance.nnnMETHODSnMultiple databases and reference lists of included studies were searched for studies that applied psychological theories to improve and/or predict HCW hand hygiene. All steps in selection, data extraction, and quality assessment were performed independently by two reviewers.nnnFINDINGSnThe search yielded 918 citations; seven met eligibility criteria. Four studies evaluated hand hygiene interventions based on psychological frameworks. Interventions were informed by goal setting, control theory, operant learning, positive reinforcement, change theory, the theory of planned behaviour, and the transtheoretical model. Three predictive studies employed the theory of planned behaviour, the transtheoretical model, and the theoretical domains framework. Interventions to improve hand hygiene adherence demonstrated efficacy but studies were at moderate to high risk of bias. For many studies, it was unclear how theories of behaviour change were used to inform the interventions. Predictive studies had mixed results.nnnCONCLUSIONnBehaviour change theory is a promising tool for improving hand hygiene; however, these theories have not been extensively examined. Our review reveals a significant gap in the literature and indicates possible avenues for novel research.

Bordetella holmesii, an Emerging Cause of Septic Arthritis

ABSTRACT Bordetella holmesii is a well-described pathogen in asplenic and immunocompromised patients. Here we report the first two published cases of septic arthritis caused by B. holmesii documented in apparently immunocompetent patients and unaccompanied by bacteremia.

Interventions to improve patient hand hygiene: a systematic review

Nosocomial pathogens may be acquired by patients via their own unclean hands, but there has been relatively little emphasis on patient hand hygiene as a tool for preventing healthcare-associated infections (HCAIs). The aim of this systematic review was to determine the efficacy of patient hand hygiene interventions in reducing HCAIs and improving patient hand hygiene rates compared to usual care. Electronic databases and grey literature were searched to August 2014. Experimental and quasi-experimental studies were included if they evaluated a patient hand hygiene intervention conducted in an acute or chronic healthcare facility and included HCAI incidence and/or patient hand hygiene rates as an outcome. All steps were performed independently by two investigators. Ten studies were included, most of which were uncontrolled before-after studies (N=8). The majority of interventions (N=7) were multi-modal, with components similar to healthcare worker hand hygiene programmes, including education, reminders, audit and feedback, and provision of hand hygiene products. Six studies reported HCAI outcomes and four studies assessed patient hand hygiene rates; all demonstrated improvements but were at moderate to high risk of bias. In conclusion, interventions to improve patient hand hygiene may reduce the incidence of HCAIs and improve hand hygiene rates, but the quality of evidence is low. Future studies should use stronger designs and be more selective in their choice of outcomes.

Hand hygiene monitoring technology: protocol for a systematic review

BackgroundHealthcare worker hand hygiene is thought to be one of the most important strategies to prevent healthcare-associated infections, but compliance is generally poor. Hand hygiene improvement interventions must include audits of compliance (almost always with feedback), which are most often done by direct observation - a method that is expensive, subjective, and prone to bias. New technologies, including electronic and video hand hygiene monitoring systems, have the potential to provide continuous and objective monitoring of hand hygiene, regular feedback, and for some systems, real-time reminders. We propose a systematic review of the evidence supporting the effectiveness of these systems. The primary objective is to determine whether hand hygiene monitoring systems yield sustainable improvements in hand hygiene compliance when compared to usual care.Methods/DesignMEDLINE, EMBASE, CINAHL, and other relevant databases will be searched for randomized control studies and quasi-experimental studies evaluating a video or electronic hand hygiene monitoring system. A standard data collection form will be used to abstract relevant information from included studies. Bias will be assessed using the Cochrane Effective Practice and Organization of Care Group Risk of Bias Assessment Tool. Studies will be reviewed independently by two reviewers, with disputes resolved by a third reviewer. The primary outcome is directly observed hand hygiene compliance. Secondary outcomes include healthcare-associated infection incidence and improvements in hand hygiene compliance as measured by alternative metrics. Results will be qualitatively summarized with comparisons made between study quality, the measured outcome, and study-specific factors that may be expected to affect outcome (for example, study duration, frequency of feedback, use of real-time reminders). Meta-analysis will be performed if there is more than one study of similar systems with comparable outcome definitions.DiscussionElectronic and video monitoring systems have the potential to improve hand hygiene compliance and prevent healthcare-associated infection, but are expensive, difficult to install and maintain, and may not be accepted by all healthcare workers. This review will assess the current evidence of effectiveness of these systems before their widespread adoption.Study registrationPROSPERO registration number: CRD42013004519

Measurement of Patient Hand Hygiene in Multiorgan Transplant Units Using a Novel Technology: An Observational Study

OBJECTIVEnHealthcare worker hand hygiene is known to prevent healthcare-associated infections, but there are few data on patient hand hygiene despite the fact that nosocomial pathogens may be acquired by patients via their own unclean hands. The purpose of this study was to measure patient hand hygiene behavior in the hospital after visiting a bathroom, before eating, and on entering and leaving their rooms.nnnDESIGNnCross-sectional study.nnnSETTINGnAcute care teaching hospital in Canada.nnnPATIENTSnConvenience sample of 279 adult patients admitted to 3 multiorgan transplant units between July 2012 and March 2013.nnnMETHODSnPatient use of alcohol-based hand rub and soap dispensers was measured using an ultrasound-based real-time location system during visits to bathrooms, mealtimes, kitchen visits, and on entering and leaving their rooms.nnnRESULTSnOverall, patients performed hand hygiene during 29.7% of bathroom visits, 39.1% of mealtimes, 3.3% of kitchen visits, 2.9% of room entries, and 6.7% of room exits.nnnCONCLUSIONSnPatients appear to perform hand hygiene infrequently, which may contribute to transmission of pathogens from the hospital environment via indirect contact or fecal-oral routes.