Big mother? Prompts spur hand-washing compliance
ICAAC studies focus on hand washing
A voice-prompt machine designed for Alzheimer’s patients dramatically improved hand washing and lowered infection rates on a surgical intermediate care unit, researchers reported in San Diego at a recent Interscience Conference on Anti-microbial Agents and Chemotherapy (ICAAC). Designed by Amron Corp. in McLean, VA, the system uses motion detectors and computer-activated recordings in both male and female voices.
"It was actually used in patients with Alzheimer’s to help remind them to wash their hands after they use the bathroom and also remind them to take their medications," said Sandra Swoboda, RN, MS, a senior clinical research program coordinator at Johns Hopkins University Medical School in Baltimore. "The computer activates the voices, which are actually recordings of people. There are six different messages, [including, for example,] Please wash your hands after leaving room 22.’"
The electronic monitoring study in the nine-room, 14-bed unit was conducted in three phases: baseline observation, intervention with voice prompts, and post-intervention observation. Nosocomial infection rates decreased in the active intervention phase and stayed at lower levels in the post-intervention period.1
"The system was complex in the sense that it had motion sensors for room entry and exit and sensors on sink and foam dispensers," said Pamela Lipsett, MD, lead researcher on the project and associate professor of surgery, anesthesiology, and critical care medicine at Johns Hopkins. "So we could tell whether you had left or entered a room and whether you had washed your hands inside or outside the room. There was a 40% improvement in hand hygiene and about a 29% decrease in infection rates if you combine phase two and phase three. This was statistically significant."
How did health care workers react to the electronic surveillance and prompting? "The nurses found it empowering because it was a way to help remind the physicians to wash their hands," said Swoboda. "The families also found it empowering for them as well to help remind people to wash their hands. [Remember,] if there is proper washing behavior, you didn’t hear a message."
Physicians resent the prompting
The physicians found little empowerment in electronic monitoring of their hand hygiene behavior. "There is really no question that physicians are a big problem in doing a very simple activity [hand washing]," Lipsett said. "They just don’t do it, and it is not clear to me why. But this helped. They thought it was Draconian and neo-Nazi-like, but they responded to it nonetheless. I’m not sure we have to be embarrassed about the techniques if the techniques work."
Lipsett also found an interesting trend in the study that suggests an inverse relationship between educational level and hand washing compliance. Alzheimer’s patients and nurses’ aides showed the greatest improvement in compliance. Nurses improved as well, but the grudgingly compliant physicians scored the least improvement. Overall, the 40% improvement in compliance pushed the baseline hand hygiene rate from 19% to 27%. The improvement held in subsequent three-month follow-up when the prompt was not used.
"I not sure if people were afraid they going to [get prompted], but whatever the reason, it lasted three months," she said.
The data still are under analysis, but the magnitude of the effect certainly justifies continuing use of the system, she said. It may be that episodic or occasional prompts may be most effective in instilling compliance in health care workers, Lipsett said. "Maybe a month here or a week here might be exactly the way to really make a substantial improvement in this." While the cost of such a device will have to be resolved with the manufacturer, she said it could have practical applications in ward settings. "It is extremely practical for at least monitoring. It is a terrific way to monitor overall compliance. Once the system is in place, I don’t expect it will have large costs, even if it were only used for monitoring. I think it is applicable, certainly, in an era of patient safety when we have to do everything we can to do our best. And we are clearly far from doing that right now, so we can justify using it from this point on."
Other studies focus on rubs
While the study did not focus on alcohol hand rubs — the newly recommended approach to hand washing problems — other ICAAC studies did address the hot topic. In one study, researchers showed that operating room staff favored an alcohol rub over povidone-iodine solution.2
"The alcohol-based products had a rapid onset of action and a very wide spectrum of action," said C. Gupta, MD, an epidemiologist at the St. John Health System in Detroit. "An overwhelming majority of our participants liked the alcohol-based waterless rub. We feel that alcohol-based scrubs may be acceptable as an alternative to iodine-based scrubs for use in ORs."
The study compared the effectiveness and acceptability of an alcohol-based waterless rub, an alcohol-based product that is "water-aided," and a standard iodine brush-based surgical scrub. Health care volunteers were enrolled from the surgical services of the hospital. Participants were randomized to study phases lasting five consecutive days, in which they used one of the products for all scrubs. Samples for culture were collected immediately prior to, immediately post-scrub, and at six hours post-scrub, on days one, two, and five. A questionnaire was used to evaluate product acceptability. The mean reduction in colony counts was similar for all products within one minute of scrub on day one. The products yielded similar results until day five, when a three-log reduction in colony counts was found only with the waterless alcohol-based rub. The workers also favored that product.
"I have to say that data are totally consistent with the data we found, too," said Elaine Larson, PhD, moderator of the ICAAC session and a professor of pharmaceutical and therapeutic research at Columbia University School of Nursing in New York City. "I think this may be one of the first tests of the water [aided] product, so it needs to get out there in the literature very quickly. A lot of people are asking about this."
Another study at the ICAAC session found that there was a marked decrease in vancomycin-resistant enterococci and a smaller decrease in methicillin-resistant Staphylococcus aureus after an alcohol-based hand rub was made available in a hospital.3 "We looked at all the variables associated in our program and could see no other cause other than implementation of the [alcohol-based rubs]," said Maureen Schultz, RN, infection control coordinator at Veterans Affairs Medical Center in Washington, DC.
Whether infection reductions will be duplicated in other studies with larger numbers of patients remains to be seen. Though the anecdotal evidence is compelling, it is actually no easy task to tie a hand washing practice directly to infection rates, Larson said. "It has always been hard to show any effect of hand hygiene on infection rates, and I don’t expect it will be easier with alcohols than it has been with anything else," she told Hospital Infection Control. "I would be surprised to find dramatic enough results to show a difference."
Larson receives funding through a grant from the National Institutes of Health to test the efficacy of both traditional hand washing and alcohol hand rubs in neonatal intensive care units. "The study is half over, and I don’t really know what we are going to find. It is a big study. We are going to have over 3,000 infants in the study. So I hope that if there is a difference, we will be able to find it."
References
1. Swoboda S, Lane S, Strauss K, et al. The evidence: Hand hygiene impacts nosocomial infection rates. Abstract: K-1098. Presented at the 42nd Interscience Conference on Antimicrobial Agents and Chemotherapy. San Diego; September 2002.
2. Gupta C, Czubatyj AM, Briski LE. Comparison of two alcohol-based scrubs to an iodine-based scrub for pre-surgical antiseptic effectiveness in operating rooms at a community hospital. Abstract K-1100. Presented at the 42nd Interscience Conference on Antimicrobial Agents and Chemotherapy. San Diego; September 2002.
3. Schultz M, Huber R, Gill J, et al. Decrease in new nosocomial cases of resistant bacteria associated with hospitalwide use of an alcohol-based hand rub. Abstract K-1099. Presented at the 42nd Interscience Conference on Antimicrobial Agents and Chemotherapy. San Diego; September 2002.