Alexandra Ward, MA

In order to address barriers to hand hygiene (HH) compliance among health care workers (HCWs), we must first understand the behavior on an individual level, particularly in the intensive care unit (ICU) setting.

A team of investigators at the University of Louisville set out to gather data on HH compliance and patient contact time among ICU HCWs using an electronic sensor-based HH measurement system called Sanibit by Microsensor Labs. The wearable wristband works with location sensors throughout the hospital to track HH and HCW behavior, and then pairs with an app that analyzes individual performance. The data were presented in a poster at the 

Association for Professionals in Infection Control and Epidemiology (APIC) 2022 Annual Conference

, held June 13-15, 2022, in Indianapolis, Indiana.

“The takeaway from this study is really there is significant individual variation by day of the week, by hour of the day,” Jiapeng Huang, MD, PhD, professor and vice chairman of the Department of Anesthesiology & Perioperative Medicine at the University of Louisville, co-founder of Microsensor Labs, and study presenter, told 

Data were collected from 15 HCWs (12 nurses, 2 patient care assistants, and 1 secretary) at a 10-bed surgical ICU and analyzed to track HH compliance by day of the week, hour of the day, dispenser location, and patient care duration. A total of 27,692 interactions were recorded over a 6-month period.

Notably, investigators found that HH was performed more regularly upon exit from the patient room compared with entrance (37.3% vs 26.1%; 

 < .001). HH compliance rates varied widely among individuals but stayed relatively stable when comparing day of the week and hour of the day, except for weekends when compliance dipped.

Overall, investigators note that their findings reinforce the need for continuous education and reminders that are specific to HCWs, time, and location.

“Technology is just a tool,” Huang said. “If you just buy the technology, your HH will not improve. You have to have the entire package…The more we study HH, the more complex we realize it is.”

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The wearable wristband works with location sensors throughout the hospital to track HH and HCW behavior, and then pairs with an app that analyzes individual performance.

Digital Wristband Provides a Fuller Picture of Hand Hygiene Compliance in an Intensive Care Unit

Health care systems must get wound classification correct in order to paint an accurate picture of surgical site infection (SSI) rates, which, in turn, drive prevention efforts. However, some electronic medical records provide default wound classification that is not always accurate.

Infection preventionists can play a role in ensuring accurate wound classification in order to provide more precise SSI surveillance and reporting, according to a presentation at the 

, held June 13-15, 2022, in Indianapolis, Indiana.  

®, Emily Grohs, MPH, CIC, infection preventionist at Cincinnati Children's Hospital Medical Center, detailed her talk on a standardized approach to wound class and its impact on the surgical site infection rate. 

This transcript has been edited for clarity and length.

®: To start, can you talk about the importance of proper wound classification in general and what spurred you to pursue the research in this presentation?

Grohs: Every procedure should have a wound classification assigned to it that's usually assigned by the surgeon or the surgical team. For infection preventionists, we use that for surgical site infection (SSI) surveillance and for reporting. Depending on how you report your SSIs, you may have to report by wound class.

®: What is the current state of wound classification and what challenges exist?

Grohs: I can't speak for everybody, but for our institution…specifically, for wound class, our biggest challenges right now are getting the correct wound classification. We are trying to be with technology…we have an electronic medical record that will actually default a wound classification, so trying to be one step ahead. One less thing to think about while you're in the operating room. But we found that it's not always accurate and really also requires that human factor. That piece is kind of missing. Our surgical team really relies heavily on the default part, so when an IP is doing surveillance, we’ll usually go and find that the correction is not always there.

®: Can you walk us through the research you conducted?

Grohs: I started SSI surveillance for the institution about a year ago. We went through our whole process as I was learning this and found that there are gaps in our current process that can possibly affect the rate that we are believing is true. We did a retrospective review of all SSIs over the past 3 years and looked at the wound classes for both the default wound class, also [how] the infection preventionist was classifying the wounds and, from there, came up with 3 different SSI rates and just showing how, depending on where you pull your data from, it does have an effect on your SSI rate.

We found that the biggest takeaway is that, of all the SSIs we culled over that 3 years, about 42% of them required a wound class change by an infection preventionist. So, assuming that the IP is following your wound class policy, 42% of them were not correct, and then a little over half of the ones that we did change were changes that would have an effect on our SSI rate, which was kind of a shocking result.

®: Armed with these data, where do you go from here?

Grohs: Now that we have all that data, which is nice to have when you're presenting to perioperative leadership or other people who have a stake in the game and care about SSIs and want to do anything to target efforts to prevent SSIs…we have that data and we have presented it to perioperative leadership. They have a few different interventions that we're looking to try. Obviously, re-education is one of them, putting wound class back at the forefront of the education for new employees, recertification. We've also talked about possibly removing the default aspect of the wound class. That's a less popular option. We're trying to do a few different interventions before we actually go there, but those are the ones that we've started so far.

“Of all the SSIs we culled over that 3 years, about 42% of them required a wound class change by an infection preventionist,” Emily Grohs, MPH, CIC, tells ICT®.

How Wound Classification Impacts Surgical Site Infection Rate

Hospitals rely heavily on portable medical equipment, including workstations on wheels (WOWs). However, these machines are prone to contamination by health care worker (HCW) hands and could potentially serve as fomites in the transmission of health care–associated infections (HAIs).

In an effort to glean more knowledge into potential contamination associated with WOWs, a team of investigators at Central Texas Veterans Healthcare System conducted a longitudinal assessment of contamination patterns on the equipment. Findings were presented in a poster at the 

“Periodic disinfection of equipment is required in most hospitals, but multiple surfaces on an equipment may not be adequately disinfected all the time. In addition, the complexity of demands on staff may limit their ability to properly disinfect an equipment,” the research team reported. “The purpose of this study was to determine if current disinfection practices were effectively managing bioburden on WOWs on our hospital wards.”

Using press plates, investigators collected bioburden data from 10 WOWs on each of the 3 units in the hospital over a 4-week period, assigned at random. Samples were taken 4 consecutive days per week (Monday-Thursday) at 3 different time points (9AM, noon, and 3PM). Specific WOW areas sampled included the keyboard, mouse, arm, and tray. Investigators calculated aerobic bacterial colony counts after 24 hours of incubation and used Bayesian multilevel models to estimate the mean bioburden and compare it across locations sampled.

Technicians planned to collect a total of 480 samples, although 28 were lost because the portable medical equipment was in use at the time or unable to be found. After modeling, the estimated mean colony count and 95% UI for press plates takes from WOWs was 29.2 (range, 16.1–51.1) counts.

Estimated mean colony counts were much higher for the arm of the WOW (58.8 [range, 35.2–91.2]) compared with the keyboard (24.7 [range, 14.5–37.2]), the tray (17.0 [range, 10.0–26.4]), and the mouse (12.5 [range, 7.4–19.3]).

“The IRRs for keyboard compared to arm was 0.43 (0.32–0.55), for tray compared to arm was 0.29 (0.22–0.38), and for mouse compared to arm was 0.22 (0.16–0.29),” investigators reported.

The bioburden disparities among the various locations sampled could mean a number of things. It could mean HCWs are not practicing proper hand hygiene before using or moving WOWs. It could also reflect the number of touches, a discrepancy in cleaning methods, or differences in where individual users touch WOWs the most.

“It is also possible that the differences in bioburden levels among these locations is due to the sampling process rather than the result of the bioburden accumulation process, as the keyboard and mouse may be more difficult to sample with a press plate,” the research team concluded. “The correlation of bioburden to HAI transmission was not studied here so the significance of bioburden alone in the absence of HAI monitoring is uncertain.”

Articles

The bioburden disparities among the various locations sampled could mean HCWs are not practicing proper hand hygiene before using or moving WOWs. It could also reflect the number of touches or a discrepancy in cleaning methods. 

Workstations on Wheels: Contamination Patterns Show Arm Used for Moving Carries Highest Bioburden

Hand hygiene (HH) compliance experienced a bump during the COVID-19 pandemic when the practice came under the microscope, but health care worker (HCW) adherence remains low nationwide. To gain a more accurate understanding of why, a 3-hospital network in Illinois conducted a HCW survey and presented the results at the 

Infection prevention and quality investigators across the 3 health care facilities—Advocate Christ Medical Center in Chicago, Illinois; Advocate Trinity Hospital in Chicago; and Advocate Aurora Healthcare in Mokena, Illinois—developed a 14-item anonymous survey comprising Likert, Yes/No, and open-ended questions. The goal was to gain more insight into HCW’s current HH practices and perceived barriers to compliance in order to identify opportunities for improvement. The team set a goal outcome of 3 potential interventions that could be implemented across the network.

Led by John P. Delano, MPH, CIC, manager of infection prevention at Advocate Christ Medical Center in Chicago, Illinois, investigators distributed the survey via email beginning in July 2021, allotting 2 weeks for HCW completion. Some of the items on the survey included “clarity of HH education received, perceived HH effectiveness, willingness to provide and/or receive real-time feedback, assessment of potential perceived barriers, and evaluation of effectiveness of potential targeted interventions,” according to the poster.

The resulting data were analyzed and results were provided in a Microsoft Excel sheet in August 2021.

In all, 1001 HCWs completed the survey. HCWs acknowledged the benefits of proper HH, with 92% responding that HH is “very effective” at preventing patients and self from acquiring infections and 93% saying they would be receptive to someone asking them to perform HH if they were seen not doing so.

However, only 45% of HCW surveyed admitted that they would “always” remind a team member to perform HH if he or she forgot to do so.

When it comes to barriers, only 15% of HCWs surveyed said that availability of HH products (ie, dispensers are often empty) either always, most of the time, or some of the time contributed most to them not performing proper HH. More than 80% of those surveyed felt supplementing the network’s existing secret shopper HH auditing program with real time feedback and coaching would be somewhat or very effective at boosting HH compliance.

Armed with the survey data, investigators developed an action plan, presented it to leadership, implemented interventions, and then audited via a secret shopper program in December 2021.

During a 4th quarter audit conducted post-intervention, HH compliance scores increased for 2 out of the 3 hospitals in the network, with 1 hospital registering a > 20% improvement in HH compliance.

“Survey and preliminary HH audit results suggest that interventions aimed at improving the availability of [alcohol-based hand rub], encouraging peer-to-peer reminders, and supplementing existing auditing processes with real time feedback and coaching may have greater impact on HH compliance than education alone,” investigators concluded.

Health care worker hand hygiene compliance ticked up during COVID, but levels remain low nationwide. A 3-hospital network in Illinois wanted to know why.

Barriers to Hand Hygiene Include Availability of Products, Lack of Feedback

The infection preventionist’s (IP’s) role in vaccine compliance has traditionally centered on influenza shots, but that all changed with SARS-CoV-2. Encouraging vaccination and assisting with vaccine acceptance was a role that fell partly on the IP’s shoulders in many health care systems, including at Emory University Hospital.

, held June 13-15, 2022, in Indianapolis, Indiana, Jessica Tarabay, MPH, MHR, CIC, manager of infection prevention at Emory University Hospital, shared how the team at Emory built trust to implement interventions that boosted SARS-CoV-2 vaccine compliance and resulted in more than 1000 employees successfully completing the vaccine series. She detailed the process in a video interview with 

®: Can you discuss the role of trust and how that factors into vaccination decisions in general?

Tarabay: I feel like with trust, it's really building those rapports with your frontline teams, all the departments, and people [who] have very big influence within your organization. Building that partnership…goes along the same lines as building that trust. Ultimately, I look at our department and infection prevention as a relationship department. We are a support department, and so having the trust within our teams really helps us to do the work. WE can’t do that without those rapports.

®: Can you discuss the role of the IP in vaccination compliance prior to SARS-CoV-2?

Tarabay: Especially around flu, we give a presentation during new employee orientation on why it's so important, but really hitting the whys behind why vaccine compliance is so important. And I feel that with SARS-CoV-2, really just understanding the hesitancy within certain groups within health care and the communities as a whole, and really just learning to listen, that was one of the biggest components of building that trust.

What we did is we went to departments, specifically those that have very low compliance, and we just learned. We wanted to see what was truly going on, we learned part of it was that transportation was a barrier. We also learned that some people just really didn't have the resources that if they were to go into the emergency room for some reason, they couldn't pay that copay. There are a lot of questions that, as an organization, we weren't able to answer right away, and just building those rapports—sitting and listening—that's where we were really truly able to deliver on some of those frequently asked questions that really helped increase compliance.

®: What were some of the barriers to vaccine compliance that were encountered once SARS-CoV-2 vaccination was made mandatory?

Tarabay: I think the barriers of like, when something is forced, and once it became that mandate, really understanding who then are those key influential team members in a department and if it's a leader that is completely hesitant, that's going to be our first source, right? So if a leader of an entire department is vaccine non-compliant, it does set the stage and it cascades down to their team. And so I think it just starts with listening to them and truly just being observant of what's going on within your organization. Town Halls don't do anything because we truly weren't reaching the people that needed to hear it the most.

®: Your poster details different methods that were tried out to increase compliance. Can you talk us through some of those?

Tarabay: So it's going into department huddles and just listening. It was literally one-on-one conversations with staff members, all the way from [environmental services] to director level and just truly understanding. We even have team members who would go down whenever we were offering on-site vaccination. We went down, each of us, and we held the hands of certain team members and we waited through…the 15-minute or 30-minute wait time [post-vaccine] just depending on certain risks levels. And that, honestly, cascaded down. We did it with one person and they went and told another team member and they told another team member and then it just became like this camaraderie and that's really how we saw that vaccine compliance increase.

Also just partnering with our management engineers and nursing colleagues, very respected people in the organization who were able to deliver roving carts around the hospital itself to each department, and really just trying to get a group there so we're coming to you, you're not going to have to come to us. It took a bit, I will say it took many months to get there. But I will say that, ultimately, it's not the complete topic of conversation anymore. It was because we did what we needed to do.

Tarabay: The departments with the lowest compliance, even getting them to 80% compliance rate or 70% when they're coming from 40%, those are huge, huge results. Ultimately, we did have a mandatory vaccination that we had to have results met by October 1, and so we did see instrumental impact with that with each of those methods.

The IP’s role in vaccine compliance has traditionally centered on influenza shots, but that all changed with SARS-CoV-2.

Infection Preventionists Spearhead SARS-CoV-2 Vaccine Efforts as Trusted Leaders

A free mobile application drastically improved and streamlined hand hygiene observation collection at a pediatric hospital in south Texas, boosting both the number of audits completed and eliminating certain staff roles in the process, according to a poster presented at the 

“The impetus behind this [poster] was, there is growing interest in new technology around this sort of data collection, largely these electronic hand hygiene monitoring systems that use RFID technology to track health care worker movements around the facility,” Danielle J. Durant, PhD, MBA, MS, assistant professor of health sciences at Texas A&M University and poster presenter, told 

® in a video interview. “There’s this social consciousness around, ‘we should be getting these systems in our facilities.’ [In] the hospital I was working with on this project, the infection prevention and control department kind of got the same directive from executive leadership” to explore some new methods to modernize the data collection process.

Durant and colleagues led the interventional, pre-post study at a 191-bed pediatric hospital in south Texas, which compared a free mobile application called iScrub with traditional pen and paper methods of hand hygiene observation collection. Previously, staff were conducting on-the-floor observations, as per the Joint Commission gold standard, and recording the data manually. Using the app instead of pen and paper streamlined the collection process.

“[The app] works like any other kind of app on your phone…You open it up and you can start a data collection session. On the screen, there are options to collect the normal data you would collect during an observation What kind of health care worker am I observing? Is it a doctor? Is it a nurse? You can indicate whether or not they used a wash or a rub, [did they] wash at a hand hygiene station or use a sanitizer rub? Did they wear the appropriate [personal protective equipment]?” Durant explained. “The mobile app just replaces the pen and paper booklets. We were kind of shocked at how that little process change allowed this entire process to become a lot more efficient.”

Trained observers relied on the app for hand hygiene observation collections between June 18 and November 30, 2021, and logged a 140% increase in observations collected, from 3082 pre- to 7388 post-app. Other benefits included the ability to record additional information and comments for each observation, less time spent collecting each observation, and automated transmission of observation data to the infection preventionist, which eliminated observers having to remember to “hand in” observation booklets to the administrative staff for manual processing.

Durant and colleagues hypothesize that, over time, use of the mobile app could also reduce operational costs, since it eliminates the need for the physical booklets, an administrative staff member to input data, and a decision support analyst for additional analysis.

Staff members at the study site found the app easy to use and convenient.

"As a quality champion, I'm not going down to the department to pick up little booklets; I'm also not having to drop them off. It just makes the whole process easier," Durant said.

Trained observers at a pediatric hospital in south Texas relied on the app for hand hygiene observation collections between June 18 and November 30, 2021, and logged a 140% increase in observations collected.