American Journal of Infection Control 41 (2013) 1107-8
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American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Variability in hand hygiene practices among internal medicine interns Lauren Block MD, MPH a, *, Robert Habicht MD b, Fareedat O. Oluyadi BA c, Albert W. Wu MD, MPH d, e, Sanjay V. Desai MD d, Timothy Niessen MD, MPH d, Kathryn Novello Silva MD b, Nora Oliver MD, MPH f, Leonard Feldman MD d a
Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY Department of Medicine, University of Maryland School of Medicine, Baltimore, MD c Icahn School of Medicine at Mount Sinai, New York, NY d Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD e Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD f Department of Medicine, University of Maryland Medical Center, Baltimore, MD b
Key Words: Graduate medical education Patient safety Quality of care Prevention
Hand hygiene compliance remains suboptimal among physicians despite quality improvement efforts. We observed hand hygiene compliance among 29 medicine interns at 2 large academic institutions. Overall compliance was 75%. Although 4 interns averaged <40% compliance, 14 averaged at least 80%. Given variability observed among individuals in the same training programs, targeting those with poor performance may be important in improving overall compliance. Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Hand hygiene is the most cost-effective measure in preventing health care-associated infections, but health care worker compliance remains suboptimal, on the order of 30%-75% in observational studies.1e4 Whereas hand hygiene quality improvement initiatives are associated with improved compliance and lower rates of nosocomial infections, attending physicians have been shown to have lower levels of compliance than other health care professionals.1,3,5 Targeting quality improvement programs at physician trainees may be an important piece of professional training. We sought to evaluate hand hygiene practices among medical interns as well as factors associated with compliance. METHODS We conducted a direct observational study at 2 large academic medical centers in Baltimore, MD, during January 2012. Twentynine post-graduate year one residents (interns) from 2 internal medicine residency programs provided informed consent to participate. Participants were observed as part of a larger observational study and were not informed that hand hygiene was among the behaviors being observed. The Institutional Review
* Address correspondence to Lauren Block, MD, MPH, Hofstra North Shore-LIJ School of Medicine, 2001 Marcus Ave, Lake Success, NY 11042. E-mail address: [email protected]
(L. Block). This work was supported by The Osler Center for Clinical Excellence at Johns Hopkins and the Johns Hopkins Hospitalist Scholars Fund. Conﬂict of interest: None to report.
Board at site 1 approved the study and the Institutional Review Board at site 2 deemed it not human subjects research. Twenty-two trained undergraduate students served as observers for this study. Observers were required to achieve 85% concordance with researchers in a mock observation setting before collecting data. Observers followed interns for the entire shift, day or night, and through all shifts in the call cycle during 21 consecutive days. A dichotomous response for compliance with hand hygiene opportunities was recorded. We deﬁned an opportunity for hand hygiene as each time an intern entered or exited a patient’s room.6 We deﬁned compliance as any attempt to wash hands or use alcohol-based hand rub. Data were entered in real time using iScrub (University of Iowa, Iowa City, IA), an application for the iPod Touch (Apple Inc, Cupertino, CA), and exported at the end of each shift. Independent variables included residency program, sex of the intern, number of patients cared for, and new admissions. Data were analyzed using c2 tests and multilevel regression analysis adjusted for clustering at the intern and observer levels using STATA 11IC (Stata Corp, College Station, TX). We performed a sensitivity analysis to determine if hand hygiene compliance improved during the second half (latter 10 days) of our study, which might indicate that interns discovered that hand hygiene was being observed and changed behaviors accordingly. RESULTS A total of 1,678 hand hygiene opportunities were recorded during 117 intern shifts. Interns were observed an average of 58
0196-6553/$36.00 - Copyright Ó 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2013.03.303
L. Block et al. / American Journal of Infection Control 41 (2013) 1107-8
Table 1 Rates of hand hygiene compliance Encounters n
Entry to room Exit from room
Site 1 Site 2
Male intern Female intern
Day Night Admitting shift Non-admitting shift
Compliance, % 75
*P < .05 in unadjusted analysis. P < .05 in analysis adjusted for clustering at the intern and observer levels.
opportunities each. Fifty-one percent of these observations took place on entering a patient’s room. The overall rate of compliance was 75% (Table 1). Compliance varied by hospital site and by sex of the intern. Interns at site 1 were more compliant than interns at site 2 (80% vs 71%, P < .01), and men were more compliant than women (80% vs 72%, P < .01). Interns complied with hand hygiene rules more often upon exiting the room than entering (84% vs 67%, P < .01). Compliance did not vary by time of day or whether the intern was admitting patients during the shift. In adjusted analysis, only being a man and exiting the room were associated with signiﬁcantly higher compliance rate. Hand hygiene compliance was higher during the ﬁrst half of data collection than the second, but this difference did not reach statistical signiﬁcance (77% vs 73%, P ¼ .06). Among the 29 participants in our study, the average compliance rate per intern was 72% (range 24%-100%). Four interns averaged <40% compliance, whereas 14 averaged at least 80% compliance. There was not a signiﬁcant correlation between compliance rate and number of new patients admitted (Pearson’s correlation coefﬁcient <0.01; P ¼ .99) or total number of patients cared for by an intern (Pearson’s correlation coefﬁcient ¼ 0.17; P ¼ .07). DISCUSSION During this 3-week observational study, interns complied with hand hygiene on 75% of occasions, but hand hygiene varied substantially at the individual level. Although several interns attempted to decontaminate their hands on fewer than 40% of opportunities, nearly half practiced hand hygiene on at least 80% of occasions. Because patient care practices learned during residency training are often maintained during one’s career, it is important to instill good habits during training.7 Interns at both sites received mandatory annual infection control training, yet levels of hand hygiene compliance varied. Given the differences among individuals within the same programs, targeting poor performers may be an important intervention to improve overall compliance. General quality improvement programs in hand hygiene have been successful and produced sustainable results, but it is unclear if these programs improve practice among individuals with the lowest compliance rates.4,5,8,9
Strengths of our study include multiple observations of the same individuals over the course of several shifts, which allowed us to examine consistency both within and among study participants. Our observers followed interns into patient rooms, allowing for observation of hand hygiene that took place both outside and within patient rooms. We recorded data at 2 hospitals and observed a variety of shifts and times of day. Interns were not aware that we were observing their hand hygiene compliance, and the sensitivity analysis suggests that compliance rates did not increase with length of time the interns were observed. Our observation tool allowed for direct export of data, minimizing errors in transcription. Limitations of the study included only recording compliance with hand hygiene opportunities when entering or exiting a patient’s room, which we believed would encompass the majority of the World Health Organization-recommended Five Moments of Hand Hygiene.6 We did this for simplicity and to maximize interrater reliability, but we may have missed hand hygiene opportunities occurring outside patient rooms.6 Use of nonmedical observers may lead to observer bias and measurement error, which we attempted to mitigate through training in hand hygiene protocol and data analysis with adjustment for clustering at the observer level. Findings may differ by geographic location, medical specialty, and time of year. Although hand hygiene is a simple practice supported by a strong evidence base, several interns observed in our study performed this behavior <40% of the time. This may reﬂect gaps in individual knowledge, attitudes, or awareness. Individualized report cards that lead to targeted educational interventions or incentive plans aimed at individuals with suboptimal hand hygiene compliance should be investigated as ways to improve patient safety practices across the board. Acknowledgments The authors thank Sara Cosgrove, MD, MS, and Lisa Maragakis, MD, MPH, for help with editing. References 1. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physcians: performance, beliefs, and perceptions. Ann Intern Med 2004;141:1-8. 2. Harris AD, Samore MH, Nafziger R, DiRosario K, Roghmann MC, Carmeli Y. A survey on hand hygiene practices and opnions of healthcare workders. J Hosp Infect 2000;45:318-21. 3. Duggan JM, Hensley S, Khuder S, Papadmios TJ, Jacobs L. Inverse correlation between level of professional education and rate of hand hygiene compliance in a teaching hospital. Infect Control Hosp Epidemiol 2008;29:534-8. 4. Van de Mortel T, Bourke R, McLoughlin J, Nonu M, Reis M. Gender inﬂuences handwashing rates in the critical care unit. Am J Infect Control 2001;29:395-9. 5. Conrad C. Increase in hand alcohol consumption among medical staff in a general hospital as a result of introducing a training program and visualization test. Infect Control Hosp Epidemiol 2001;22:41-2. 6. Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D. My Five Moments for Hand Hygiene: a user-centered design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 2007;67:9-21. 7. Martin GJ, Curry RH, Yarnold PR. The content of internal medicine residency training and its relevance to the practice of medicine. J Gen Intern Med 1989;4: 304-8. 8. Armellino D, Hussain E, Schilling ME, et al. Using high-technology to enforce low-technology safety measures: the use of third-party remove video auditing and real-time feedback in healthcare. Clin Infect Dis 2012;54:1-7. 9. Ventakesh AJ, Landford MG, Rooney DM, Blachford T, Watts CM, Noskin GA. Use of electronic alerts to enhance hand hygiene compliance and decrease transmission of vancomycin-resistant Enterococcus in a hematology unit. Am J Infect Control 2008;36:199-205.