Nursing News

Immediate Feedback About Hand Hygiene Improves Compliance

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By Debra Wood, RN, contributor 

November 3, 2012 - Despite everything known about good hand hygiene preventing transmission of infection, compliance on hospital units remains dismal. A British team recently found some success improving hand hygiene in intensive care units using observation and an immediate feedback intervention, which is something that a few United States hospitals are doing already.

Hand Hygiene
Gina Pugliese, RN, MS, indicated studies show observation plus immediate feedback improves hand hygiene compliance, but it is labor intensive.

“The literature points to immediate feedback if you want to change behavior,” said Gina Pugliese, RN, MS, vice president of Premier Safety Institute, part of Premier, a health care alliance in Charlotte, N.C. “When you are observing you can look at the quality of how they washed, if they were complying with policies.”

Greenville Hospital System began using immediate feedback last year, as part of a multifaceted campaign to change health care workers’ hand-hygiene practices to conform to the World Health Organization’s guidelines. They have experienced “phenomenal success” with it, said Sue Boeker, RN, BSN, CIC, an infection preventionist leader at the Greenville, S.C., hospital. 

The World Health Organization (WHO) recommends health care providers practice Five Moments for Hand Hygiene, by cleaning their hands: (1) before patient contact; (2) after contact with blood or body fluids; (3) after touching possibly contaminated surfaces in the patient surroundings; (4) before invasive procedures, and; (5) after removing gloves. Yet only 25-40 percent of health care workers consistently follow those guidelines.

Hand Hygiene
Sue Boeker, RN, BSN, CIC, reported phenomenal success with Greenville Hospital’s campaign to improve workers’ hand hygiene.

“Learning how to do the hand hygiene following the World Health Organization’s Five Moments is a change in thinking for most health care workers, a change in culture, and it helps with the culture change to get immediate feedback,” Boeker said. “The Five Moments is the way we need to go for helping to prevent infections in our patients and not take anything home to families or give it to ourselves.” 

Greenville Hospital increased its compliance to 93.2 percent in September 2012, up from 53.8 percent at baseline in 2009. Their campaign included education about the WHO guidelines, posters to remind staff about the Five Moments, and monitoring of soap and alcohol rub quantities used. At first, full-time, trained observers just watched, but workers asked for the feedback, so they could learn.

At the end of the patient encounter, the observer hands the worker a card that either says “Congratulations” or “Whoops,” presenting an opportunity for improvement. Those receiving a card saying their hand-hygiene was correct can enter a quarterly drawing for prizes.

Many hospitals have launched such hand-hygiene campaigns, but few long-term studies exist to demonstrate their effectiveness. A 2010 review study from the Netherlands concluded that noncompliance with hand hygiene guidelines is a universal problem, and a 2010 Cochrane Review called the quality of the intervention studies it reviewed “disappointing. Although multifaceted campaigns with social marketing or staff involvement appear to have an effect, there is insufficient evidence to draw a firm conclusion.”  

Researchers at University College-London (UCL), in partnership with the Health Protection Agency, set out to change that and conducted the first “randomized controlled trial evidence showing which interventions improve hand-hygiene compliance in modern hospitals.”

The team completed a three-year study on 60 hospital units to determine whether a feedback intervention was more effective in improving hand-hygiene compliance than the United Kingdom’s national “Clean your hands” campaign, which reported in 2012 that the initiative resulted in sustained increases in the use of alcohol rubs and soaps, an indication of increased hand-hygiene compliance.

The UCL intervention included trained observers watching nurses and other care providers for 20 minutes. The observers provided immediate follow up. Those who washed their hands consistently were praised and received a certificate placed in their annual performance review file. They helped nurses who did not perform good hand-hygiene formulate an action plan for improved behavior.

The team found that the intervention cohort increased compliance by up to 18 percent on intensive care units and 13 percent on the general acute-care wards. The study was published in PLOS ONE.

“Although audit and feedback is often suggested as a way of improving hand hygiene, this study puts its use on a firmer footing than previous nonrandomized studies, providing the strongest evidence yet that this is an effective way to improve hand hygiene when coupled with a repeating cycle of personalized goal setting and action planning,” said co-author Sheldon Stone, at the UCL Medical School at the Royal Free Hospital, in a written statement.

Stone called the intervention a powerful tool, which could be included in infection control teams’ audit and appraisal systems in order to reduce the burden of health care-associated infection on hospital wards. However, the authors wrote in the paper that it would be premature to recommend routine clinical use of the intervention.

Greenville Hospital, however, is pleased with the results of its investment in observation with immediate feedback.

Pugliese cautioned though that human observation and feedback is labor intensive. As an alternative or supplementary tool, a number of electronic monitoring systems are available.

North Shore University Hospital in Manhasset, N.Y., reported in the journal Clinical Infectious Diseases that “remote video auditing combined with feedback produced a significant and sustained improvement in hand hygiene.” The system from Arrowsight of Mount Kisco, N.Y., combines motion-activated cameras with a digital video recorder and time stamp. Independent auditors reviewed the video.

While human and electronic surveillance and immediate feedback appears to improve compliance, ultimately, Pugliese said, hospitals need to change the culture to make hand hygiene a priority and to overcome behaviors learned while growing up.

“All of the studies have shown you need more than one approach to get people to wash their hands,” Pugliese said. That may include posters, role models, placing alcohol rub containers in convenient positions, and patient campaigns to speak up and to report on caregiver hand hygiene. A Premiere study found involving patients was successful. But some caregivers are offended when patients ask them to wash up, she added.

“You need a variety of strategies,” Pugliese said. “Not one single strategy will work in all situations.”



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