Effect of Frequency of Changing Point-of-Use Reminder Signs on Health Care Worker Hand Hygiene Adherence: A Cluster Randomized Clinical Trial

Abstract

Importance: Although hand hygiene (HH) is considered the most effective strategy for preventing hospital-acquired infections, HH adherence rates remain poor.

Objective: To examine whether the frequency of changing reminder signs affects HH adherence among health care workers.

Design, setting, and participants: This cluster randomized clinical trial in 9 US Department of Veterans Affairs acute care hospitals randomly assigned 58 inpatient units to 1 of 3 schedules for changing signs designed to promote HH adherence among health care workers: (1) no change; (2) weekly; and (3) monthly. Hand hygiene rates among health care workers were documented at entry and exit to patient rooms during the baseline period from October 1, 2014, to March 31, 2015, of normal signage and throughout the intervention period of June 8, 2015, to December 28, 2015. Data analyses were conducted in April 2018.

Interventions: Hospital units were randomly assigned into 3 groups: (1) no sign changes throughout the intervention period, (2) signs changed weekly, and (3) signs changed monthly.

Main outcomes and measures: Hand hygiene adherence as measured by covert observation. Interrupted time series analysis was used to examine changes in HH adherence from baseline through the intervention period by group.

Results: Among 58 inpatient units, 19 units were assigned to the no change group, 19 units were assigned to the weekly change group, and 20 units were assigned to the monthly change group. During the baseline period, 9755 HH opportunities were observed at room entry and 10 095 HH opportunities were observed at room exit. During the intervention period, a total of 15 855 HH opportunities were observed at room entry, and 16 360 HH opportunities were observed at room exit. Overall HH adherence did not change from baseline compared with the intervention period at either room entry (4770 HH events [48.9%] vs 3057 HH events [50.1%]; P = .14) or exit (6439 HH events [63.8%] vs 4087 HH events [65.2%]; P = .06). In units that changed signs weekly, HH adherence declined from baseline at room entry (-1.9% [95% CI, -2.7% to -0.8%] per week; P < .001) and exit (-0.8% [95% CI, -1.5% to 0.1%] per week; P = .02). No significant changes in HH adherence were observed in other groups.

Conclusions and relevance: The frequency of changing reminder signs had no effect on HH rates overall. Units assigned to change signs most frequently demonstrated worsening adherence. Considering the abundance of signs in the acute care environment, the frequency of changing signs did not appear to provide a strong enough cue by itself to promote behavioral change.

Trial registration: ClinicalTrials.gov Identifier: NCT02223455.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Forrest reported serving as the local site investigator in a study funded by Pfizer outside of the submitted work. Dr Morgan reported receiving grants from the National Institutes of Health, Agency for Health Research and Quality, and US Centers for Disease Control and Prevention (CDC); reimbursement for travel fees from the Lown Institute, Infection Disease Society of America, and Society for Healthcare Epidemiology of America; and honoraria from Springer Nature. Dr Bittner reported receiving grants from the CDC. No other disclosures were reported.

Figures

Figure 1.. CONSORT Diagram of Unit Recruitment and Randomization

Figure 2.. Hand Hygiene (HH) Adherence Rates at Room Entry

Solid lines prior to the break indicate observed HH adherence rates prior to the intervention; solid lines after the break, observed HH adherence rates based on the intervention; dashed lines, predicted HH adherence rates if the intervention was not implemented; and dots, aggregate HH adherence rates per week.

Figure 3.. Hand Hygiene (HH) Adherence Rates at Room Exit

Solid lines prior to the break indicate observed HH adherence rates prior to the intervention; solid lines after the break, observed HH adherence rates based on the intervention; dashed lines, predicted HH adherence rates if the intervention was not implemented; and dots, aggregate HH adherence rates per week.