Electronic Hand Hygiene Monitoring and ICU Infection Rates (HANDS)

A Pragmatic Crossover Cluster Randomised Study of Electronic Compliance Monitoring of Staff Hand Sanitisation in Critical Care (HANDS Study)

If patients acquire a new infection whilst in hospital this can cause significant morbidity, prolonged hospitalisation and even death. Indeed, there is much public concern about infections such as MRSA. Patients who require intensive care are probably at the greatest risk.

Appropriate hand hygiene by healthcare workers can reduce infection rates and is a key goal of many patient safety initiatives. Worldwide, hand hygiene compliance has been estimated at only 38.7% despite the intervention being simple and cheap. Reasons for poor compliance include lack of time, skin irritation, lack of facilities, intensity of workload and forgetfulness. Furthermore, since cross infection may not be apparent for some days, staff may not associate their (lack of) actions with having caused harm.

Measuring compliance levels enables staff to understand whether they could improve. Direct observation of staff is labour intensive and is not continuous or universal. We will monitor hand hygiene compliance with a newly developed electronic system (MedSense, General Sensing Inc.). We will use the data to provide feedback to the staff in several ways. We hypothesise that comprehensive personalised feedback will reduce healthcare associated infections. We will undertake the study in three intensive care units.

Study Overview

• Status: Completed
• Conditions: Cross Infection
• Intervention / Treatment: Other: Weekly poster of unit performance; Other: Daily email of personal feedback; Other: Active reminder from badge

Detailed Description

All patients admitted to three intensive care units will be monitored for healthcare associated infections. In parallel the units will be cluster randomised to implement the electronic compliance monitoring in three different ways:

• Unit level feed back every week of current compliance for each of three staff groupings (doctors, nurses, allied health professionals)
• Personalised feedback in the form of an email at the end of a shift stating an individuals performance relative to the average for their professional grouping.
• Real time feedback in the form of a badge worn by the healthcare worker that vibrates when the system thinks they have missed or are about to miss an opportunity for hand hygiene.

All healthcare workers will receive the level of feedback defined in the randomisation for the duration of the three intervention periods. The units will cross-over with an interventing two week wash out period.

All personal feedback will be confidential and private to the individual.

• Study Type: Observational
• Enrollment (Actual): 1065

Contacts and Locations

Study Locations

• United Kingdom
  • London, United Kingdom
    • Royal Brompton and Harefield NHS Foundation Trust

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

All patients admitted to the ICU during the study period.

Description

Inclusion Criteria:

• All patients admitted to the intensive care units
• All healthcare workers caring for the patients on the intensive care units.

Exclusion Criteria:

• Healthcare workers with skin sensitivity to both alcohol hand rub and soap

Study Plan

How is the study designed?

Number of groups / cohorts

3

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
ICU Cluster 1; Adult Intensive Care Unit - Royal Brompton Hospital	Other: Weekly poster of unit performance; Weekly feedback is provided to the ICU about current levels of hand hygiene compliance amongst doctors, nurses, and allied healthcare professionals; Other: Daily email of personal feedback; Healthcare workers receive private and personal feedback via email regarding their individual performance benchmarked against the average performance for their professional grouping.
ICU Cluster 2; Paediatric ICU - Royal Brompton Hospital	Other: Weekly poster of unit performance; Weekly feedback is provided to the ICU about current levels of hand hygiene compliance amongst doctors, nurses, and allied healthcare professionals; Other: Daily email of personal feedback; Healthcare workers receive private and personal feedback via email regarding their individual performance benchmarked against the average performance for their professional grouping.; Other: Active reminder from badge; The badge the healthcare worker is wearing vibrates if opportunities to perform hand hygiene are missed
ICU Cluster 3; Adult Intensive Care Unit - Harefield Hospital	Other: Weekly poster of unit performance; Weekly feedback is provided to the ICU about current levels of hand hygiene compliance amongst doctors, nurses, and allied healthcare professionals; Other: Daily email of personal feedback; Healthcare workers receive private and personal feedback via email regarding their individual performance benchmarked against the average performance for their professional grouping.; Other: Active reminder from badge; The badge the healthcare worker is wearing vibrates if opportunities to perform hand hygiene are missed

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Composite health care infection rate	One of the following three: Bacteriological proven infection at a normally sterile site. The sterile sites vein considered are a prior defined as blood, broncho-alveolar lavage, urine sampled from a catheter, chest drain fluid, and surgical wounds. Blood cultures that grow normal skin commensals will be included Endotracheal secretions that culture organisms other than normal upper respiratory tract flora Clostridium difficult related diarrhoea	Until the end of the second calendar day following ICU discharge

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence of central line associated blood stream infections	CDC definition	Until the end of the second calendar day following ICU discharge
Incidence of catheter associated urinary tract infections	CDC definition	Until the end of the second calendar day following ICU discharge
Incidence of ventilator associated pneumonia	CDC definition	Until the end of the second calendar day following ICU discharge
Incidence of surgical site infection	Public Health England definition	Until the end of the second calendar day following ICU discharge
Incidence of clostridium difficult diarrhoea	Public Health England definition	Until the end of the second calendar day following ICU discharge
Incidence of acquisition of new methicilllin resistant staphylococcus aureus		Until the end of the second calendar day following ICU discharge
Incidence of secondary blood stream infections	CDC definition	Until the end of the second calendar day following ICU discharge
Incidence of antibiotic resistance infections	Pre-defined as Acinetobacter baumanii, Pseudomonas aeroginosa (Extended-Spectrum Beta Lacatamase [ESBL] producing), Klebsiella penumoniae (ESBL producing), Escherichia coli (ESBL producing), Stenotrophomonas maltophilia, Serratia marcescens, Clostridium difficile, or MRSA.	Until the end of the second calendar day following ICU discharge
Adverse event rate		24 weeks

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Staff attitudes to electronic compliance monitoring	Quantitative and qualitative analysis of questionnaire data	0 and 24 weeks
Surrogate measures of hand hygiene compliance	Alcohol hand rub usage, Soap usage and visual compliance monitoring	24 weeks

Collaborators and Investigators

• Sponsor: Royal Brompton & Harefield NHS Foundation Trust
• Investigators: Principal Investigator: Patricia Cattini, MSc, Royal Brompton and Harefield NHS Foundation Trust

Publications and helpful links

General Publications

• Cheng VC, Tai JW, Ho SK, Chan JF, Hung KN, Ho PL, Yuen KY. Introduction of an electronic monitoring system for monitoring compliance with Moments 1 and 4 of the WHO "My 5 Moments for Hand Hygiene" methodology. BMC Infect Dis. 2011 May 26;11:151. doi: 10.1186/1471-2334-11-151.

Study record dates

Study Major Dates

• Study Start: November 1, 2013
• Primary Completion (Actual): July 1, 2014
• Study Completion (Actual): July 1, 2014

Study Registration Dates

• First Submitted: November 26, 2013
• First Submitted That Met QC Criteria: July 27, 2015
• First Posted (Estimate): July 30, 2015

Study Record Updates

• Last Update Posted (Estimate): July 30, 2015
• Last Update Submitted That Met QC Criteria: July 27, 2015
• Last Verified: July 1, 2015

More Information

Terms related to this study

• Keywords: Critical care; Feedback
• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Iatrogenic Disease; Infections; Cross Infection
• Other Study ID Numbers: 2013IC004B