International Journal for Quality in Health Care, 2016, 28(1), 74–80 doi: 10.1093/intqhc/mzv097 Advance Access Publication Date: 30 November 2015 Article
Article
Hand-hygiene practices and observed barriers in pediatric long-term care facilities in the New York metropolitan area BORGHILD LØYLAND1, SIBYL WILMONT2, BEVIN COHEN2, and ELAINE LARSON2 1
Department of Nursing and Health Promotion, Oslo and Akershus University College, Oslo, Norway, and 2School of Nursing, Columbia University, New York City, NY, USA
Address reprint requests to: Elaine Larson, Columbia University School of Nursing, 617 W. 168th St. Room 330, Columbia University, New York City, NY, USA. Tel: +1 212-305-0723; Fax: +1 212-305-0722; E-mail:
[email protected] Accepted 26 October 2015
Abstract Objective: To describe hand-hygiene practices in pediatric long-term care ( pLTC) facilities and to identify observed barriers to, and potential solutions for, improved infection prevention. Design: Observational study using (i) the World Health Organization’s ‘5 Moments for Hand Hygiene’ validated observation tool to record indications for hand hygiene and adherence; and (ii) individual logs of subjective impressions of behavioral and/or systemic barriers witnessed during direct observation. Setting: Staff in three pLTC facilities (284 beds total) were observed by two trained nurses 1 day a week for 3 weeks in February and March 2015. Participants: Direct providers of health, therapeutic and rehabilitative care, and other staff responsible for social and academic activities for children with complex, chronic medical conditions. Main Outcome Measures: Hand-hygiene indications, adherence and barriers. Results: Hand hygiene was performed for 40% of the 847 indications observed and recorded. Adherence increased at one site and decreased in the other two sites during the study period. Adherence appeared to be influenced by individuals’ knowledge, attitudes, beliefs and work setting. Conclusions: Poor hand-hygiene adherence was observed overall. Specific barriers were identified, which suggest a contextual approach to the interpretation of results indicated in this uniquely challenging setting. We offer some practical suggestions for overcoming those barriers or mitigating their effect. Ultimately, an adaptation of the ‘5 Moments for Hand Hygiene’ may be necessary to improve infection prevention in pLTC. Key words: infection prevention, 5 Moments for Hand Hygiene, behavioral and systemic barriers, pediatric long-term care facilities
Introduction Largely neglected by the infection-prevention research community, children in pediatric long-term care ( pLTC) facilities are a vulnerable and growing population suffering from complex, chronic health conditions. Many are medically fragile, requiring around-the-clock, residential care and rehabilitation as well as psychosocial, academic and
therapeutic activities [1]. Clinical support often includes indwelling devices such as gastrostomy tubes, tracheostomies and also urinary and central venous catheters [2] that may increase the risk of infections [3–5]. Although they are at high risk of health-care associated infections (HAI), little hand-hygiene research has been conducted in this unique setting.
© The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved
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Hand-hygiene practices and observed barriers in pLTC • Quality Improvement Methods to evaluate hand hygiene vary from self-reporting and observation studies to electronic monitoring and counting of the use of hand-hygiene products [6, 7]. Monitoring and evaluating healthcare workers’ hand-hygiene performance (i.e. adherence/indications) is a standard practice in most health-care facilities in the USA as a key strategy to minimize HAI [8]. Direct observation is the ‘gold standard’ for hand-hygiene evaluation, according to guidelines from the World Health Organization (WHO) and the Society of Healthcare and Epidemiology of America [9–11]. The WHO has defined ‘5 Moments for Hand Hygiene’: (i) before touching a patient, (ii) before an aseptic/clean procedure, (iii) after body fluid exposure risk, (iv) after touching a patient and (v) after touching patient surroundings without touching a patient during the same care episode [12]. In addition, the WHO has developed and distributed a wide range of resources (e.g. observation tools, instructional leaflets and posters, training videos) to improve hand hygiene. Although observation studies are recommended and frequently used to measure and document hand-hygiene performance, observers affect their surroundings [13, 14] and their presence may influence the behavior of those they observe [15]. This Hawthorne effect is common in hand-hygiene adherence observation studies [16–20]. Despite this, observations may be important to validate whether the staff are doing what they are saying. As part of the baseline data collection for a federally funded project to reduce infections and improve the patient safety climate in pLTC (Keep It Clean for Kids: The KICK Project, R01HS021470), we reported suboptimal hand-hygiene practices in four pLTC facilities in 2013 [21]. In this parent study, we used a multimodal hand-hygiene improvement strategy based on key success factors for improving quality in healthcare published in recent years [22, 23]. We found that implementation of a number of interventions, such as staff education, installation of an electronic hand-hygiene monitoring system and introduction of new products, yielded minimal staff behavior change. To better understand the elements necessary to effect change in this setting, the aims of this observational study were to describe handhygiene practices in pLTC facilities and to identify observed barriers to, and potential solutions for, improve infection prevention.
Methods Sample and settings This observational study was conducted in three pLTC facilities located in the New York metropolitan area, which at the time provided residential care for a total of 284 children, who ranged in age from newborn to 21 years, with lengths of stay spanning 1 day to 21 years. The mean and range lengths of stay among the three facilities were ∼60 days (90–120 days), 556 day (1 day-21 years) and 1022 days (7 days-8 years). Most children in these facilities had severe congenital anomalies or developmental disabilities, and they were dependent on staff for virtually all their care. A majority was non-ambulatory, had feeding tubes and tracheostomies, and a growing number were ventilator-dependent. In addition to comprising ∼120 resident rooms, each facility featured independently administered schools with 4 to 14 classrooms. Direct-care staff included registered nurses; certified nurse assistants; physicians; respiratory, physical, speech, occupational, child life, and recreational therapists; teachers and teachers’ aides; and volunteers. Approval for this study was obtained from the Columbia University Medical Center Institutional Review Board.
Observations Two trained nurses from the Columbia University School of Nursing research team—one was a doctorally prepared faculty member and the
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other was a registered nurse enrolled in a graduate public health nursing degree program—observed staff hand-hygiene behaviors at each of the three facilities 1 day a week for 3 weeks in late February and early March 2015. To cover staff shift changes, observations were conducted at each site from 10 am to 3 pm during the first two visits and from 3 pm to 7 pm on the third visit. Hand-hygiene observation sessions varied from 15 to 45 min during those periods. While on site, the observers took note of and recorded possible barriers to handhygiene adherence presented by staff members’ individual behaviors and routines, physical settings and environments, and/or workflow patterns. The observers used the WHO ‘5 Moments for Hand Hygiene’ validated observation tool to record hand-hygiene indications and staff adherence, defined as ‘hand cleansing using alcohol-based handrub or handwashing with soap and water’ [12]. The two observers were trained by a senior member of the KICK research team with previous experience using the ‘5 Moments’ tool during the initial baseline data collection period [21]. At site visits in January 2015, before commencement of the study period, she supervised practice sessions in which the two observers conducted inter-rater reliability testing and, using actual case-based examples, discussed decision rules until they reached agreement. Observation session locales were selected on-site according to children’s whereabouts. As unobtrusively as possible, observers situated themselves in areas where children were seen interacting with directcare providers, following the children as they moved throughout the facilities. These areas included, but were not limited to, their own rooms, the nursery, classrooms and shared dining/recreational spaces. When situated, observers recorded hand-hygiene indications and adherence within their viewable areas. Some group settings often included multiple residents and staff members. As directed by the ‘5 Moments’ tool, observers indicated whether or not hand hygiene was performed for each recorded indication, the type of staff member observed (e.g. registered nurse, teacher) and the location of the observation (e.g. classroom, nursery).
Analyses Observations of hand-hygiene indications and performance were coded and entered into a spreadsheet (Microsoft Excel, 2010). Descriptive analyses were performed using SAS version 9.3 (SAS Institute, Cary, NC, USA). We calculated the frequency of hand-hygiene indications and the proportion for which staff performed different methods of hand hygiene—hand rub, soap and water, and/or gloves—alone, and/ or in combination. We analyzed hand-hygiene adherence across types of personnel and facility locations, by site visit days and according to the ‘5 Moments’ indications using Pearson’s χ 2 tests for independence. An important approach that we adapted from Corbin and Strauss and grounded theory is that when you are doing observations the concepts drive the research process [15]. Hence the observers maintained individual logs of subjective impressions of behavioral and/or systemic barriers they witnessed while conducting direct observations. Although they did not use a formal guide to identify potential barriers, they applied their clinical experience with infection prevention as nurses and ended every session with a debriefing session and discussion of their notes. This educated exchange of impressions helped to inform the next day’s observations and clarify their ideas for possible solutions to identified behavioral and systemic problems. This analytic process was iterative and interactive over a period of weeks, and observers sometimes included the KICK team’s expertise. They compared logs and categorized key barriers, discussed potential solutions of education and intervention, and interpretations with the rest of the KICK research team.
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Results A total of 847 observations of hand-hygiene indications and adherence were recorded at sites one (N = 209), two (N = 237), and three (N = 401). Hand hygiene was performed for 40% (N = 336) of all observed indications. Adherence differed significantly by location within the facility (P < 0.001) and the type of personnel observed (P < 0.001). Adherence was greatest among registered nurses (60%) and when residents were in their rooms (57%; Table 1). The most commonly observed indications for hand hygiene were before (41%) and after (36%) patient contact (Fig. 1). Adherence was significantly different across the five indications, with the highest adherence (61%) after contact with body fluid and lowest adherence (16%) before aseptic procedures (P < 0.001). Figure 2 shows differences in hand-hygiene adherence by observation day at the three sites. Observed adherence suggests a progressive increase at one site and a progressive decrease at the other two.
Table 1 Differences in hand-hygiene adherence across the type of personnel and location within facilitya
Location Resident room Shared space School Personnelc Nurses Therapists School staff Nursing assistants Therapeutic activities staff Volunteers/visitors Housekeeping staff Total
N
% (n) performed hand hygiene
313 316 218
57 (177) 32 (101) 27 (58)
207 101 198 205 105 13 10 847
60 (124) 47 (47) 35 (69) 29 (59) 29 (30) 23 (3) 0 (0) 40 (336)
Observers’ impressions of behavioral and/or systemic barriers to hand-hygiene performance included those directly witnessed as well as those communicated to them by staff members. The barriers fell into three categories, namely staff, settings and workflow (Table 2), and were consistent with the observers’ subjective perceptions of some direct-care providers as ‘washers’—those who habitually cleaned their hands—and others as ‘non-washers’, who almost never cleaned their hands. Performance appeared to be influenced by individuals’ knowledge, attitudes and beliefs; their particular work setting; and the general workflow of the facility. In some cases, all but one direct-care provider working together as a team performed hand hygiene. Some staff members stated they felt there was a pervasive lack of awareness about the relative effectiveness of hand washing with soap and water versus using waterless hand sanitizer. They also noted confusion about their roles in implementing isolation precaution protocols. Regarding work setting, we observed that some members of school and recreational staff supervising ambulatory children in school and play areas routinely did not perform hand hygiene. Ambulatory children mingled and freely touched each other and staff members during transport or meal times, for example, largely without hand hygiene. Observations of staff members working with groups of children revealed poor hand-hygiene performance overall.
Discussion Numerous studies have reported observations of hand-hygiene behavior, but our work adds new knowledge about infection prevention practices in pLTC, an under-researched but critically important healthcare setting. We have identified specific challenges to infection prevention and barriers to hand hygiene, some of which are common across sites and some that are unique to this population. Three issues are highlighted below: the relevance and feasibility of the WHO ‘5 Moments’ in pLTC, the striking variation in hand-hygiene practices among different types of personnel and the differing responses to direct observation.
a
Chi-square tests significant for independence between indications, locations and types of personnel (all P < 0.0001). b Indication not observed for n = 5 observations. c Observations of physician (n = 1), technicians (n = 2) and administrators (n = 5) excluded from analysis.
Feasibility of ‘5 Moments’ The WHO’s ‘5 Moments for Hand Hygiene’ tool is designed to be easily learned, logical, applicable in a wide range of settings, and
Figure 1 Observed adherence to the WHO’s ‘5 Moments for Hand Hygiene’ in three pLTC facilities.
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Figure 2 Hand-hygiene adherence differed significantly by indication (Pearson’s χ2 test of independence, P < 0.001).
interwoven with the natural workflow of care [24]. It has been tested and used in hospitals and acute-care facilities around the world [22, 25]. It has not, however, been widely tested or used in long-term or residential care settings, whose challenges and priorities differ considerably from those of acute-care settings. The primary goal in pLTC is to provide children with high-quality care to promote the best possible quality of life. This involves engaging them in group activities at school and play, which present challenges for infection preventionists. For example, as we have observed, two or three direct-care providers may be responsible for 10 or more wheelchair-bound and/or ambulatory children at a time. They often move from one child to the next without performing hand hygiene, because, in most cases, it is either extremely inconvenient or, in the case of safety, simply impossible. Imagine a therapist interrupting a game of ‘patty cake’ to clean her and the child’s hands between claps. Or cleaning puzzle pieces each time a different child touches one, or cleaning their hands as they toss a ball to one another. Imagine a teacher wiping a child’s nose and letting a second child hit himself with a book while she washes her hands in the sink. These are the daily activities that may render the ‘5 Moments’, designed for acute care, unsuitable for pLTC, in which children are, nevertheless, at high risk for infection. A recent study reported that the ‘5 Moments’ do not apply in overcrowded conditions [26]. Its authors suggested a modification to help mitigate the impact of overcrowding such that hand-hygiene practices focus on events presenting the greatest risk of microbial transmission. The WHO has developed several context-specific hand-hygiene guidelines, including one for residential care facilities that removes the requirement to perform hand hygiene following contact with patient surroundings [27]. So, this adaptation still does not address problems we identified in pLTC facilities, such as barriers to hand hygiene during educational group activities. During our site visits, staff members and facility leaders expressed interest in developing adaptations to the ‘5 Moments’ specifically addressing their needs.
consistently performed hand hygiene as often as feasible and indicated. ‘Non-washers’ rarely did so, regardless of the circumstances or the awareness that they were being observed. For example, in a room in which four staff members worked together as a team—knowing they were being observed—three performed appropriate hand hygiene during the entire observation session, but one did not perform hand-hygiene at all. This is neither a new phenomenon, nor it is unique to this study. In fact, Chassin et al. [28] identified 41 different causes of hand-hygiene non-compliance in eight hospitals, reporting that key causes varied considerably across hospitals. To improve practice, each hospital customized their own set of interventions relevant to the specific issues identified at their site. The result was a sustained, statistically significant improvement in performance; compliance increased from 47.5 to 81.0% (P < 0.001). Although the intervention in the Chassin study was implemented at the institutional level, it is likely that it will also be necessary to identify specific causes of non-compliance at the individual staff member level in order to implement effective interventions. Since causes of noncompliance may vary widely amongst individuals—lack of skill regarding when and how to perform hand hygiene, disbelief about its efficacy, lack of mindfulness in a given situation, competing priorities, dislike of product options or simply disregard for rules—it is not surprising that any single, generic intervention would fail for some staff members. A combination of a multi-faceted approach as recommended by WHO along with attention to individual staff member needs and opinions is likely essential for success. In fact, Lee et al. [29] found that a hand-hygiene promotion campaign not only significantly improved compliance but also resulted in a significantly more positive perception among physicians and nurses toward hand hygiene. This is encouraging because it suggests that such individualized and multi-faceted approaches may be beneficial even among staff members with little interest, incentive or concern about infection prevention.
Wide variations in individual practice
Differing responses to direct observation
An additional complexity regarding hand hygiene observed in this study was the identification of ‘washers’ and ‘non-washers’ across various direct-care providers. ‘Washers’ were individuals who
Although hand-hygiene monitoring by direct observation is still the ‘gold standard’ in most US healthcare facilities [8], more consideration should be given to the possibility of biased results and what direction
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Table 2 Observed barriers to hand hygiene and infection prevention and suggestions for facilitating change
Staff
Observation
Potential solution
Some staff always performed HH appropriately, but others frequently missed opportunities
Education: anonymously target re-education to staff requiring additional training. Intervention: game of ‘telephone’ in which staff who receive additional education pass an HH message onto a peer, and so on until all staff have received it. Education: discuss importance of inanimate objects as vectors and discourage use/ transportation of personal items between rooms. Intervention: make antimicrobial wipes available at room exits. Education: emphasize importance of protecting residents from pathogens Intervention: post signage in areas where feeding takes place. Education: provide evidence-based information demonstrating that residents are more vulnerable to infection than healthy staff. Intervention: create a slogan competition for buttons/stickers to be worn by staff, emphasizing their role in patient safety (e.g. ‘I protect!’) Education: review procedures for all types of isolation precautions and the rationale behind each step. Intervention: posts signs at all points of care when isolation precautions are indicated, displaying both the type of precautions and the steps to be followed. Education: inform supervisors that the goals of HH observation are assessment and improvement, not punishment. Intervention: encourage supervisors to turn ‘observer alerts’ into frequent reminders for all staff (e.g. announce ‘Wash like somebody is watching!’). Education: inform staff that the goals of HH observation are assessment and improvement, not punishment. Intervention: alter any potentially punitive programs to focus instead on merit for continuous improvement. Education: focus on the WHO ‘Moment’ to perform HH after touching patient surroundings, and emphasize rationale. Intervention: affix point-of-touch reminder stickers (e.g. ‘After you touch me, please clean your hands!’. Education: review protocols for cleaning and replacement of soiled supplies and equipment. Intervention: place antimicrobial wipes and replacement supplies near points of care. Education: engage in bidirectional education, in which teachers and therapists communicate residents’ developmental needs and infection prevention staff communicate importance of HH and PPE; discuss risks and benefits of prioritizing psychosocial development over IP. Intervention: develop tailored infection prevention protocols to meet residents’ needs in educational and therapeutic settings. Education: encourage staff to bring portable sanitizer dispensers to point of care before beginning group activities. Intervention: position sanitizer dispensers on rolling poles or pedestals that can be transported to point of care. Education: review specific responsibilities and protocols for cleaning different types of toys and equipment. Intervention: use dedicated toys and equipment for each resident and/or ensure they are used by only one resident at a time; designate a staff member to be in charge of cleaning toys/equipment after an activity has ended. Education: review when curtains and other materials should be laundered or changed. Intervention: designate specific rooms for isolation precautions, and/or increase space between residents when infections occur; launder curtains on a regular basis and more frequently when infections occur. Education: discuss importance of avoiding contact with other residents while caring for a resident on isolation precautions, if possible; review protocols for PPE. Intervention: assign designated staff to rooms on isolation precautions. Education: encourage staff to discuss importance of PPE and HH with visitors, explain how and when to use, and offer reminders during visits. Intervention: develop take-home materials tailored for families and visitors. Education: provide the same infection prevention training for volunteers as for staff. Intervention: incorporate infection prevention training into volunteer orientations and hold re-training sessions periodically. Education: work with staff to develop realistic workflow models to efficiently incorporate more hand hygiene in group settings. Intervention: work with administrators and supervisors to increase staff-to-resident ratios and/or reorganize staff placement during group activities.
Staff used cell phone in room on contact precautions, then used it in other residents’ rooms Staff cleaned residents’ hands, but not their own, during feedings. Some staff said they and their families were most vulnerable to infection, and infection prevention measures were designed for their own safety Some staff expressed confusion about which PPE should be worn for different types of isolation precautions, donning/doffing procedures and rules concerning entering/exiting rooms Supervisor alerted unit staff of observer presence.
Staff expressed fear of punishment and job insecurity for poor HH performance and infection prevention practices Staff frequently touched monitors, IV poles, bedrails, equipment and used supplies without performing HH afterwards Supplies (e.g. suction catheter) that had fallen to floor were used without cleaning or replacement Teachers and therapists expressed concern that strict adherence to contact precautions prevents interaction and touch necessary for residents’ rehabilitation and development
Settings
Staff expressed that the use of wall-mounted dispensers or sinks is impractical while working with groups of residents Cleaning of toys and equipment was inconsistent
Residents with infections shared small, curtain-divided rooms with other residents; reaching residents frequently required staff to brush against curtains. Staff attended to residents on isolation precautions as well as other residents.
Workflow
Parent had close contact (e.g. kissing, coddling) with resident on isolation precautions but did not wear PPE or perform HH Volunteer working with a group of residents touched multiple children without performing HH Staff expressed that HH was particularly challenging when working alone with groups of residents
Table continued
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Table 2 Continued Observation Teachers used methods and games that pass equipment from child to child and use hand-to-hand contact (e.g. ‘pattycake’) Staff expressed that aside from nursing, workflow in other disciplines (e.g. housekeeping) did not change during isolation precautions
Potential solution Education: engage in bidirectional education to harmonize residents’ educational and infection prevention needs. Intervention: work with teachers and recreational therapists to adapt teaching methods to allow for appropriate HH. Education: target education to each group of personnel that focuses on their specific workflow and include discuss rationale for all protocols. Intervention: reorganize workflow and inter-room travel of non-clinical staff (e.g. housekeeping and administration) to accommodate isolation precautions.
such biases might take. In this study, we used identical procedures, the same observers and observed for the same time periods in three different facilities. Nevertheless, during the 3-week data collection period, adherence increased at one site and decreased in the other two. During our observations, we noted several factors that may have contributed to this phenomenon. In one facility, we observed a supervisor alerting staff that they were being observed. As expected, hand-hygiene rates increased during that particular observation period when compared with other time periods. In the sites where frequency of hand hygiene waned over time, it was clear that staff recognized the observers and became accustomed to their presence. At one site there was an outbreak during the first observation period; this occurred concurrently with the highest frequency of hand hygiene. Others have questioned the validity of hand-hygiene monitoring data, primarily because of variations in data collection processes and definitions [7, 30]. But our observations clearly indicate that even with standardized protocols and well-trained observers, variations in adherence rates may be associated with a number of temporal and sociocultural factors and should be interpreted in context.
to change. Accordingly, we have suggested potential approaches to mitigating or minimizing their impact. This study clarified our understanding of prevalent staff dilemmas, especially the conflict between prioritizing safe infection prevention practices above psychosocial care in these facilities. Applying the WHO’s ‘5 Moments for Hand Hygiene’ to pLTC is challenging. Modifications to these guidelines that take into account the unique characteristics of these facilities, and their residents and staff may be needed.
Acknowledgements We acknowledge and deeply appreciate the collaboration and positive input and support of the leaders, administrators and staff of the participating sites.
Funding This work was supported by the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services (Keep It Clean for Kids: The KICK Project, R01HS021470).
Limitations Data collection for this study was limited to three settings over a period of 3 weeks, and even when observers were present it is likely that some observations were missed. We are assuming that the observations were somewhat representative of actual practice, but clearly the presence of observers generally has an impact on staff behavior. The barriers identified were based on the direct, but subjective, observations of two professional nurses. Variations in their individual interpretations of observations are possible, despite their simultaneous training in the WHO ‘5 Moments’ and the establishment of inter-rater reliability. Additionally, although both were familiar with a variety of clinical settings, neither had worked in a pLTC facility. This raises the likelihood that their observations may have been colored by their own previous experiences and preconceptions, which may have been a double-edged sword. They may have seen things somewhat more objectively, with ‘new eyes’. On the other hand, they may have missed important mitigating circumstances or challenges. Finally, we did not rate the quality or duration of hand-hygiene events.
Conclusion Hand-hygiene adherence in pLTC is important because children in these facilities are uniquely vulnerable to infection and in constant need of high-quality care. In this study, we observed poor overall adherence to hand hygiene, and identified several barriers to infection prevention. Some of these barriers, such as the patient population and workflow patterns, inevitably affect staff behavior and are difficult
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