Abstract
Hand hygiene (HH) is essential to prevent hospital-acquired infections. To determine whether providing real-time feedback on a simplified HH action improves compliance with the World Health Organization's "5 Moments" and the quality of the HH action. This open-label, cluster randomized, stepped-wedge clinical trial was conducted between June 1, 2017, and January 6, 2018 (with a follow-up in March 2018), in a geriatric hospital of the University of Geneva Hospitals, Switzerland. All 12 wards and 97 of 306 eligible health care workers (HCWs) volunteered to wear a novel electronic wearable device that delivered real-time feedback on duration of hand rubbing and application of a hand-sized customized volume of alcohol-based handrub (ABHR). This study had 3 sequential periods: baseline (no device), transition (device monitoring without feedback), and intervention (device monitoring and feedback). The start of the transition period was randomly allocated based on a computer-generated block randomization. The primary outcome was HH compliance, according to the direct observation method during intervention as compared with baseline. Secondary outcomes included the volume of ABHR and duration of hand rubbing measured by the device during intervention as compared with transition. All wards and respective HCWs were evenly assigned to group 1 (26 participants), 2 (22 participants), 3 (25 participants), or 4 (24 participants). Twelve HCWs did not fully complete the intervention but were included in the analysis. During 759 observation sessions, 6878 HH opportunities were observed. HH compliance at intervention (62.9%; 95% CI, 61.1%-64.7%) was lower than at baseline (66.6%; 95% CI, 64.8%-68.4%). After adjusting for covariates, HH compliance was not different between periods (odds ratio, 1.03; 95% CI, 0.75-1.42; P = .85). Days since study onset (OR, 0.997; 95% CI, 0.994-0.998; P < .001), older age (OR, 0.97; 95% CI, 0.95-0.99; P = .015), and workload (OR, 0.29; 95% CI, 0.20-0.41; P < .001) were independently associated with reduced HH compliance. The median (interquartile range) volume of ABHR and duration of hand rubbing in transition and intervention increased from 1.12 (0.76-1.68) mL to 1.71 (1.01-2.76) mL and from 6.5 (4.5-10.5) seconds to 8 (4.5-15.5) seconds, respectively. There were no serious adverse events. The use of this device did not change HH compliance, but increased the duration of hand rubbing and volume of ABHR used by HCWs. isrctn.org Identifier: ISRCTN25430066.
Highlights
hand hygiene (HH) compliance at intervention (62.9%; 95% CI, 61.1%-64.7%) was lower than at baseline (66.6%; 95% CI, 64.8%-68.4%)
There were no serious adverse events. The use of this device did not change HH compliance, but increased the duration of hand rubbing and volume of alcohol-based handrub (ABHR) used by health care workers (HCWs)
It is hypothesized that these changes could lead to an increase in the quality of the HH action performed by health care workers (HCWs).[13,16]
Summary
Health care–associated infections (HAI) and the spread of antimicrobial resistance are major public health concerns[1,2] that are largely avoidable in health care by effective implementation of infection prevention and control best practices.[3,4] The World Health Organization (WHO) recommends that performing hand hygiene (HH) correctly (“How to Handrub”) at the correct time (“5 Moments”) is the most effective measure to prevent HAI.[5,6] The appropriate HH action is crucial to assure proper antimicrobial efficacy.[7,8,9] HH compliance remains suboptimal,[10] and new strategies are needed to improve its implementation.A number of studies suggest that the HH action, as endorsed by the WHO, could be simplified without compromising efficacy. Proposed changes include shortening duration of hand rubbing to 15 seconds (instead of 30 seconds)[11,12,13,14] and changing the number or order of steps (“3 steps” or “fingertips-first” instead of the “6 step” technique).[15,16,17] standardization of the hand-size (“palm full”) concept recommended by the WHO has been proposed.[18,19] It is hypothesized that these changes could lead to an increase in the quality of the HH action performed by health care workers (HCWs).[13,16] In addition, some small-sized studies have suggested that a simplified HH action could improve compliance with the “5 Moments.”[13,16]
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