Journal of Hospital Infection (2001) 48: 222–227 doi:10.1053/jhin.2001.0983, available online at http://www.idealibrary.com on
Evaluation of a patient-empowering hand hygiene programme in the UK M. McGuckin*, R.Waterman*, J. Storr†, I.C.J.W. Bowler†, M. Ashby†, K.Topley† and L. Porten* *University of Pennsylvania, Philadelphia, PA, USA, and †Oxford-Radcliffe Hospitals, Oxford, UK
Summary: Partners in Your Care©, a patient education behavioral model for increasing handwashing compliance and empowering the patient with responsibility for their care was evaluated in an acute care hospital in Oxford, UK. A controlled prospective intervention study comparing medical and surgical patients was performed. Ninety-eight patients were eligible for the study. Thirty-nine patients (40%) agreed to participate in the programme Partners in Your Care by asking all healthcare workers who were going to have direct contact with them “Did you wash your hands?”. Compliance with the programme was measured through soap/alcohol usage and handwashings per bed day before and after its introduction. Partners in Your Care increased handwashing on average 50%. Healthcare workers washed hands more often with surgical patients than with medical (P:0.05). Alcohol gel was used on less than 1% of occasions. Sixty-two percent of patients in study felt at ease when asking healthcare workers “Did you wash your hands?” Seventy-eight percent received a positive response (washed hands). All patients asked nurses, but only 35% asked physicians. Partners in Your Care increased handwashing compliance in the UK. This programme empowers patients with responsibility for their care, provides infection control staff with a continuing means for providing handwashing education without additional staff and can save costs for a hospital. © 2001 The Hospital Infection Society
Keywords: Handwashing; patient empowerment; hand hygiene.
Introduction Handwashing is one of the most important issues in hospital infection control. Lack of compliance has been documented over the last two decades in several studies, all showing healthcare workers wash their hands less often and for a shorter time than recommended.1–3 Several reports have been
Received 18 May 2000; revised manuscript accepted 21 February 2001 ‘Partners in Your Care’ is copyrighted by The University of Pennsylvania. Presented at the 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections, Atlanta Georgia, 5–9 March 2000. Author for correspondence: Dr M. McGuckin, University of Pennsylvania School of Medicine, 422 Curie Blvd, 605-A, Stellar Chance, Philadelphia, PA 19104-6021 Tel.: +1 215-573-3066; Fax: +1 215-573-0826. E-mail:
[email protected]
0195-6701/01/030222;06 $35.00/0
published on the role of handwashing in reducing the transmission of potential pathogens on the hands,4,5 with subsequent reductions in morbidity and mortality for nosocomial transmission of infection.6–9 Handwashing education through interventions directed at the healthcare worker have been shown to have minimal long-term effects.10 A recent survey of infection control practitioners by our team found that ongoing handwashing education was lacking in 90% of infection control programmes.11 In 1997, McGuckin et al.12 developed a patienteducation model for increasing handwashing compliance and empowering patients with responsibility for their care. The programme Partners in Your Care© provides the infection control practitioners with a continuing means of handwashing education, monitoring outcomes and compliance with handwashing through soap/paper towel usage and © 2001 The Hospital Infection Society
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does not require additional time, staff or costs compared with the potential savings of preventing hospital-acquired infections. In the USA, the programme was shown to increase handwashing by at least 34% and could save a 300-bed hospital with 10 000 admissions yearly over $50 000 a year.12 The programme has now been evaluated in the UK and the results presented here. Methods The Partners in Your Care study was performed in one medical and one surgical in-patient ward at the Oxford-Radcliffe Hospitals NHS Trust, Oxford, UK. Each ward served as its own control. After approval was obtained from the Institutional Review Board of the University of Pennsylvania and the Applied and Qualitative Research Ethics Committee of Oxford Radcliffe Hospitals NHS Trust, all patients determined to be responsive (i.e. alert, could speak English, and could read and sign a consent form) by nursing staff were asked to participate in the Partners in Your Care handwashing intervention programme. After the programme was approved by the medical director and risk manager, a member of the housekeeping staff was identified for the collection of baseline soap/gel/paper towel usage. All soap/gel/paper towel dispensers located in each bay, utility room and nurses stations were emptied and new packets were placed in each dispenser. Usage was monitored for 6 weeks. During the baseline data collection period, the staff were not aware of the programme. Definitions
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Physicians received a letter from the medical director announcing the programme and encouraging their support. All other healthcare workers received a flyer describing the programme and the role of the patient. Notification of the programme was one week prior to commencement. Each ward served as its own control, either before or after the 6-week intervention period. Patients were visited by the infection control nurse within 24 h of admission, to discuss the importance of handwashing by staff in preventing hospitalacquired infections. Patients admitted at the weekend were visited on Monday. Informed consent was obtained from patients who agreed to be part of the study. The patient education brochure, Partners in Your Care, which provided information on handwashing was given to the patient. Patients were asked to become Partners in Your Care, by asking all healthcare workers who had direct contact with them “Did you wash your hands?” As a reminder to ask and for patients who said they might be too shy to ask, patients were given prompting aids that said “Did you wash your hands?” (Figure 1). Two weeks after discharge all enrolled patients were contacted by the infection control nurse for a telephone interview. The following questions were asked: 1. Did you read the brochure? 2. Did you realize people get infections in the hospital? 3. Did you know the importance of handwashing? 4. Did you ask anyone? 5. Did you ask a nurse? 6. Did you ask a doctor? 7. Were you comfortable asking healthcare workers? 8. Did you receive a positive response?
Bed days were defined as the number of days a bed on a ward was occupied. Isolation days (i.e. those spent in a single room or during isolation precaution) were not counted in the total number of bed days. Soap usage and alcohol gel usage were defined in terms of units, each unit represented one packet of soap or 800 ml gel. Paper towel usage was defined in terms of packets, each packet representing 150 towels. Components of the Partners in Your Care Programme The following procedures were initiated prior to implementation.
Figure 1
Patient prompters for handwashing model.
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Data analysis Soap and alcohol gel usage/bed day were calculated by multiplying the number of packets of soap/gel used in a dispenser by the number of milliliters in a packet (800 ml) and this was divided by the number of bed days. The number of handwashings per bed-day was calculated by dividing soap/gel usage/ bed day by 1.7 ml for each handwashing. Paper towel usage/bed day was calculated by multiplying the number of packets of paper towels used by 150 and dividing by the number of bed days. The number of handwashings per bed day was calculated by dividing paper towels/bed day by three paper towels for each handwashing. A Poisson regression model was used to test the significance of the intervention.12 The number of soap/gel/paper towel packets used during the course of the study period was an example of ‘count data’ and Poisson regression was an appropriate modeling technique for these data. The model was designed to incorporate two facts: (1) that each inpatient had a different number of bed days and (2) that baseline handwashing practices were clearly different between the inpatients. The number of bed days was taken into account by adding an offset to the model.13,14 The potential impact of Partners in Your Care was modelled by using a dummy variable, which took the value “1” when an inpatient ward was undergoing the intervention and “0” when it was acting as control. Modelling the log of the number of soap/gel/paper towel packets meant that the relative, rather than absolute, change in soap/gel/paper towel usage was estimated.
Results Patient response Table I lists patient eligibility, compliance and responses for the study by type of ward. Ninety-eight patients were considered eligible for the study. Thirty-nine (40%) agreed to take part. Sixty one percent (24) of the patients in the study could be contacted following discharge. All patients asked nurses whether they had washed their hands, but only 35% asked physicians. Sixty-two percent of the patients were ‘comfortable’ (i.e. at ease) when asking and 78% received a positive response (washed hands) from the healthcare worker. Table II lists some of the responses the patients received to the question “Did You Wash Your Hands?”.
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Table I Patient compliance with Partners in Your Care handwashing programme Surgical patients Medical patients No. of patients eligible for study No. of patients who agreed to participate No. of patients contacted by phone
54 22 (41%) 15 (70%)
44 17 (40%) 9 (53%)
Response rates to questions 1. Did you read the brochure? 2. Did you realize people get infection in the hospital? 3. Did you know the importance of handwashing? 4. Did you ask anyone? 5. Did you ask a nurse? 6. Did you ask a doctor? 7.Were you comfortable asking? 8. Did you receive a positive response?
93%
100%
100%
78%
100% 33% 100% 20% Yes 60%
78% 44% 100% 50% Yes 66.6%
Yes 80%
Yes 66.6%
Soap, alcohol gel, paper towel, handwashings per bed day A total of 39 patients enrolled in the study. Both wards had an increase in soap usage during the 6-week intervention period. Of interest is the fact that at baseline (before the intervention) soap or gel usage per bed day was 69% higher for the surgical ward than the medical ward (P:0.05). This represents three handwashings for medical patients versus eight handwashings for surgical patients per bed day. Soap usage and handwashings increased by an average of 50% (P:90.05) during the programme. Alcohol gel was not widely used on either the medical or surgical ward. In fact, it was used on less than 1% of occasions. There was no significant increase in alcohol gel usage after the intervention. Table III shows the effect of Partners in Your Care on soap/gel and paper towel usage during the baseline, control and intervention periods. There was a 37% increase in soap and gel usage for the baseline versus control, 50% for baseline vs. intervention and 10% for control versus intervention. The change in paper towel usage was 23% for baseline vs. control, 24% for baseline vs. intervention and 0.4% for control vs. intervention. Discussion Handwashing is central to preventing the spread of infection in hospitals. In the USA, the Joint Commission on Accreditation of Hospitals
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Table II Some of the comments made by patients when interviewed by telephone about their experiences when asking staff whether they had washed their hands Surgical
Medical
The nurses laughed when I asked them. Didn’t ask the doctors – didn’t have much to do with them When I asked the doctor he looked at me as if I had two heads. I thought I was going to have a heart attack but forced myself to ask
Everyone wore gloves anyway! Comfortable asking most One care assistant said she always wore gloves to protect herself — but didn’t change them between patients — I explained to her why she should Very positive responses from nurses
The person who takes the blood didn’t wash hands between three patients. I asked them to, before taking my blood — didn’t feel comfortable asking Some nurses washed their hands, but some said they’d put gloves on instead Didn’t have to ask — because they saw the leaflet They saw the brochure
I asked one doctor Doctors and nurses responded well Was not comfortable asking doctors as they were always in a group Nurses always washed their hands when prompted Didn’t ask doctors because I noticed doctors did wash hands
I think infections are mostly from long nails — it’s important to keep nails short Got a positive response from most — not the doctor. Doctor didn’t wash his hands before taking blood I asked two nurses — both said they’d already washed their hands
Table III
Effect of Partners in Your Care on soap, gel and paper towel usage
Baseline* vs. control† Baseline vs. intervention‡ Control vs. intervention Medical ward vs surgical ward
Soap and gel usage (units)
Percent increase
P
Paper towel usage (boxes)
Percent increase
P
12.3 vs. 15.6 12.3 vs. 18.5 15.6 vs. 16.5 (15.4 vs. 21.7)
37% 50% 10% 69%
90.05 90.05 90.05 :0.05
10.5 vs. 12.9 10.5 vs. 13.0 12.9 vs. 13.0
23.0 24.0 0.4
90.05 90.05 90.05
*Baseline:pre-Partners in Your Care period; †Control:test period (no intervention); ‡Intervention:test period (Partners in Your Care period). A unit of soap is one pack, a unit of gel is 800 ml.
Organization has created examples to emphasize the importance of handwashing and the need to empower patients with responsibility for their care.15 Similar direction has been proposed by the UK Department of Health, Handwashing Liaison Group in its Information for Chief Executives on hospital-acquired infections.16 This states, that “educational programmes should be aimed at the empowerment of patients.”16 Handwashing compliance has been studied by researchers since the era of Semmelweis17 and
during the past two decades it has been shown that health care workers wash hands on less than 50% of possible occasions18 and that physicians are the least compliant.19,20 Pittet et al.3 reported that handwashing decreased with higher workload and higher risk patients. In 1988, Miller and Farr surveyed hospitalized patients and reported that 70% were concerned about the risk of hospital acquired infections and 57% were willing to pay an average of $7.14 per day to ensure that their hospital had an effective infection
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control programme.21 Ten years later, we documented that 95% of hospital patients know patients acquire infections in the hospitals and realize the importance of handwashing.12 Partners in Your Care empowers the patient with responsibility for their care by having them remind healthcare workers to wash their hands. The patient becomes the source of constant reinforcement. Although the percentage of patients willing to ask healthcare workers “Did you wash your hands?” was lower in UK than the U.S.12 (40% vs. 60%), the increase in handwashing per bed day was the same. This was probably due to patients in UK study being in bays (four patients) rather than in private or semi-private rooms as in the US study. Healthcare workers entering a bay would not be able to determine which patients agreed to be in the study and might therefore be more likely to wash for all patients. As one patient during the phone interview said, “I did not have to ask, the nurse saw the brochure.” It is also interesting to note that the announcement and support of the programme by the medical director to physicians and flyers sent to other healthcare workers, increased handwashing by 50% from the baseline period. This was probably due to three factors: (1) awareness of a programme, (2) non-awareness of control versus test ward and (3) support from administration on the importance of the programme. The fact that there was only a 10% increase from the control versus the intervention period is probably due to the fact that increased compliance began when the programme was announced and therefore, patients asking was a reinforcement of behavior that was already being practiced. Paper towel usage showed a low percentage increase, perhaps due to the difficulty in determining the number of paper towels used for a handwashing. However, percentage change was similar to that found with soap and gel usage in the control period and indicated an increase in handwashing. It has been proposed that improvements in handwashing should focus on the quality of handwashing, continuous education of the healthcare worker and various controls that will validate handwashing, but these are all costly and labour intensive for the infection control practitioner.16 Partners In Your Care is a cost-saving programme that provides continuous handwashing education by using the patients as a daily handwashing prompter and provides the infection control practitioner with outcomes and cost effectiveness data.12 Once introduced
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by the infection control team the programme can be implemented by the patient and staff on the ward as a continuing activity. Following a 6-week testing period of the programme in Norway, the infection control practitioners delegated the daily activity to the ward nursing staff. They showed that handwashing increased by 40% during the 6-week test period and quarterly monitoring for one year showed a sustained increase of 20%.22 The limitations of our study include the small sample size representing only two wards. However, these wards were representative of a medical and surgical ward with a spectrum of patients and the increase in handwashings per bed day was similar to that of the multi-centre USA study.12 Although we did not assess handwashing technique, we did determine that alcohol gel is not widely used as a handwashing agent even when readily available. Finally, as with all intervention studies, the possibility exists that patients will give answers intended to please the interviewer rather than reflecting the truth. In summary, Partners in Your Care has now been shown to also increase handwashing frequency in the UK by at least 50%. In addition, we have also shown that administrative support through letters sent to physicians and flyers to other staff members increased compliance before the start of the intervention and that the intervention provided continuous reinforcement to the healthcare worker. This programme empowers patients with responsibility for their care, provides the hospital epidemiologist and infection control staff with a continuing means for handwashing education, and allows for an objective outcome measurement of handwashing compliance. All these benefits are achieved without additional staff and can provide cost-savings for a hospital. Acknowledgments The authors thank Dr Christopher Bunch, Medical Director, and Mary Burrows, Director of Risk Management, Oxford-Radcliffe Hospitals NHS Trust and the Housekeeping Staff on wards 6F/7F, in particular, Laurie Blissett (Domestic Supervisor) and Len Porter, Computer Department at OxfordRadcliffe Hospitals NHS Trust and acknowledge the support of Liz Bowley, DEB Ltd and Per Brohagen, SCA Hygiene. This study was supported in part by a grant from DEB Ltd. and SCA Hygiene.
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