Sustaining compliance with hand hygiene when resources are low: A quality improvement report.

BACKGROUND: Sustainability of hand hygiene is challenging in low resource settings. Adding ownership and goal setting to the WHO-5 multimodal intervention may help sustain high compliance. AIM: To increase and sustain compliance of nursing and medical staff with hand hygiene in a tertiary referral center with limited resources.
METHODS: A quality improvement initiative was conducted over two years (2016-2018). After determining baseline compliance rates, the WHO-5 multimodal intervention was implemented with staff education and training, system change, hospital reminders, direct observation and feedback, and hospital safety climate. Additionally, the medical staff was responsible for continuous surveillance of compliance (ownership) until rates above 90% were achieved and sustained (goal setting).
RESULTS: Of 2987 observations collected between August 2016 and April 2018, 1630 (54.5%) were before, and 1357 (45.5%) were after patient encounters. The average overall compliance with hand hygiene was sustained at 94% for nursing and medical staff. Two instances of drops below 90% were associated with incidence of nosocomial Rotavirus infections. There were no similar infections during intervention periods with compliance rates above the set goal. Analysis using p-charts revealed significant improvement in compliance rates from baseline (χ2 (1) = 7.94, p = 0.005).
CONCLUSION: Adding ownership and goal setting to the WHO-5 multimodal intervention may help achieve, and sustain high rates of compliance with hand hygiene. Involving health care workers in quality improvement initiatives is feasible, durable, reliable, and cheap, especially in settings with limited financial resources.

Introduction

Hospital-acquired infections have serious repercussions on patients’ morbidity and mortality, length of hospital stay, and health care expenditure [1-3]. Adequate hand hygiene remains the most effective single preventive intervention [4, 5], which makes it the main focus of quality improvement programs in hospitals worldwide [6, 7]. However, compliance among health care workers averages about 50% [8], representing a major challenge to hospital-acquired infection control. Health care workers’ compliance with hand hygiene is determined by knowledge and awareness about its importance, culture, memory and attention, and social influences [9]. Compliance with hand hygiene can be achieved with multimodal interventions such as the WHO-5 campaign, which has five components: system change, staff education and training, observation and feedback, hospital reminders, and hospital safety climate [10, 11]. Addition of goal setting, accountability, or reward incentives to WHO-5 may further increase compliance with hand hygiene [10].

This paper describes the journey of a pediatric department with limited human and financial resources to improve, and sustain health care workers’ compliance with hand hygiene, and reduce Rotavirus hospital-acquired infections. Our quality improvement initiative was designed to increase and sustain compliance above 90% for at least two years. Our intervention was based on the WHO-5 model, and was implemented by a team of three members: the head of the pediatric quality unit, a departmental administrator, and a quality officer from the Hospital Quality Department. Medical staff monitored the intervention implementation. Our working hypothesis was that involvement of the medical staff will improve staff accountability, and sustain high compliance rates.

Materials and methods

This project was mandated and approved by the Hospital Administration as a quality improvement initiative to address the reported Rotavirus nosocomial infections on the pediatric ward. Hence, it was exempt from review by the Institutional Review Board, and consent of patients and health care providers were not applicable in this case. This quality improvement initiative is reported in accordance with the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) [12].

Context

Our center is a 344-bed tertiary care, university hospital, with 100 beds dedicated to the general pediatric ward, a pediatric intensive care unit, a neonatal intensive care unit, a normal newborn nursery, and a children’s cancer center. The outpatient services provide primary and specialized care for 32,500 children each year. The Center has a well-established infrastructure for education, training and evaluation of staff in hand hygiene, and a well-advanced system change from this perspective. In 2015, the hospital Infection Control Office reported three nosocomial Rotavirus infections, which coincided with hospitalization of children with community-acquired Rotavirus gastroenteritis that were attributed to breaches of hand hygiene before, or after patient encounters.

Baseline data

Surveillance of physicians’ compliance with hand hygiene before and after patient contact was conducted by student volunteers during November and December 2015 in all pediatric outpatient units. Thirteen students from the Medical Research Volunteer Program at our University were trained on administering a short survey to parents of children after their ambulatory visits to their physicians. The survey included four questions about patient satisfaction with the visit, and one question that asked whether the physician performed hand hygiene by washing hands with soap and water, or using a hand sanitizer before, or after contact with the child. The overall compliance rates were 97% (180/185) for before patient encounters, and 95.5% (172/182) for after patient encounters.

In January 2016 surveillance of the inpatient units was conducted. The nurse manager of each inpatient unit chose one nurse observer each day to conduct anonymous direct observations of physicians. One random observation was required for each physician daily. The physician’s compliance with hand hygiene was observed during his/her patient round based on the WHO My 5 Moments of Hand Hygiene. The overall compliance was 92% (152/165) before, and 85.7% (84/98) after patient encounter.

To better understand the root causes of the low compliance rate among physicians working in the inpatient units, they were surveyed about their perceived barriers to strict hand hygiene practice, and their suggestions for improvement. The survey identified the following barriers: malfunctioning sinks, insufficient hand sanitizers at the point of care, inadequate distribution of sanitizers, and skin irritation from the disinfectant. Physicians suggested having reminders and flyers about My 5 Moments of Hand Hygiene next to patient care areas and sinks, more and better distribution of sanitizers, timely and periodic maintenance of sinks, and changing to a more skin-friendly sanitizer. The pediatric quality unit team rounded on all inpatient units, and inspected the functioning of the sinks, the availability of sufficient hand sanitizers (alcohol-based hand rub) at critical patient care areas like near patient bed and at room entrances, the availability of disposable gloves, disposable protective garments, and one stethoscope for each patient in critical care areas.

Description of the intervention

In May 2016, the quality team decided on the WHO-5 plus as an intervention to improve hand hygiene compliance in the inpatient units, since baseline compliance rates in the outpatient units were above 90%. The intervention was a multi-component package that included staff education and training, system change, hospital reminders, direct observation and feedback, and hospital safety climate. Two other components were added: ownership and goal setting to sustain compliance above 90% in all inpatient units, for at least two years.

Education and training

The hospital’s Infection Control Office delivered two educational sessions for all pediatric faculty and resident staff. These sessions aimed at developing awareness, and a culture of hand hygiene among all pediatric physicians. The sessions covered application of standard precautions, My 5 Moments of Hand Hygiene, the institutional Hand Hygiene Policy, the correct technique of hand rubbing and handwashing, and information about disinfectant properties. The pediatric quality team delivered user-centered education and training using a standardized approach for new trainees, and for physicians and nurses who were reported not to correctly perform hand hygiene.

System change

Nurse Managers of the pediatric inpatient units inspected hand rub availability at the point of care, and the functioning of sinks daily; and attended to deficiencies immediately. Flyers about My 5 Moments of Hand Hygiene in English and Arabic languages were placed on bulletin boards of nursing stations, next to sinks and hand rub bottles. Frequent reminders to physicians and nurses about hand hygiene were done daily by one champion nurse. Health care workers who reported sensitivity to the hand rub were very few (n = 3). They were instructed to wash their hands with soap and water before and after patient contact, instead of using the hand rub. The Chairperson of the department supported the hand hygiene intervention as the departmental performance improvement initiative for the year 2016, and that daily anonymous surveillance would be conducted, with provision of immediate feedback for non-compliers, and incentives for units with high compliance rates.

Observation and feedback

Starting August 2016, daily surveillance of hand hygiene was implemented in all pediatric inpatient units. In each unit, one champion from the unit’s medical team was randomly chosen by the pediatric quality unit to conduct 20 anonymous direct observations over one week (average of three observations /day). The quality unit provided the champion with education and training about My 5 Moments of Hand Hygiene, and the correct way of hand rubbing and handwashing. Moreover, the champion was trained on how to record the observations on a data collection form developed for that purpose, and was instructed to email it to the quality officer as soon as the observation period was over. Non-compliers were sent emails by the Pediatric Quality Director about the details of the non-compliance incident, together with reminders about My 5 Moments of Hand Hygiene, and instructions about the correct technique of performing hand hygiene.

Hospital safety climate

Our hand hygiene quality improvement initiative was supported by the department chairperson, hospital administration, and the institutional Board of Trustees.

Ownership and goal setting

Ownership, our additional component to WHO-5 plus was implemented by having the medical staff be in charge of surveillance, and sharing with them compliance rates on quarterly basis. The set goal of achieving and sustaining compliance above 90% was disseminated to all health care workers in the inpatient units.

Study of the intervention

Compliance rates were tracked on monthly basis by the Quality Director and the quality officer. Quarterly reports were generated for all, as well as individual inpatient units that included their overall, before and after patient compliance rates. Additionally, the Infection Control Program shared results of hospital-acquired Rotavirus infection surveillance with the Chairperson and Quality Director for cross-validation of data generated by the medical staff involved in the quality improvement initiative.

Measures

Hand hygiene compliance rate was calculated as the number of compliant observations divided by the total number of observations (compliant and non-compliant). Observations collected by anonymous observers were reviewed by the quality officer, and checked for any missing or incomplete elements. When needed, the data were verified with the observer to ensure accuracy, and avoid false entries. Monthly data reports were generated and discussed with the Quality Director to monitor the progress of the intervention. Drops below the set goal of 90% were attributed to decreased compliance in a specific unit. They were promptly acted upon by the Quality Director by sharing the results with the Medical Director of the concerned unit, and discussion of potential causes that could explain the drop in compliance rates. Moreover, actions to address hand hygiene breaches or system change were discussed and agreed upon when needed.

Analysis

Quality control charts were used to monitor improvement in hand hygiene compliance over time. A p-chart was used to evaluate the overall compliance, as well as compliance in before and after patient encounters; nursing, and medical staff compliance. The upper and lower control limits (LCL) were set at 3ς, which equates to 3 standard deviations (SD). In the analysis, a run of eight consecutive points below or above the monthly average was considered a significant shift in the compliance rates (p <0.01) [13]. In addition, a χ2 analysis was done to determine whether there was a significant change in hand hygiene compliance between the baseline data of 2016, and the post-intervention data of 2018.

Ethical considerations

There were some ethical challenges encountered during implementation of the intervention. For example, few residents and medical students expressed concerns about reporting noncompliance of peers or faculty members, as this may create tension in the workplace. These concerns were addressed on one-to-one basis by the Quality Director. The concerned observers were reassured of the anonymity of their reports, and the importance of surveillance in promoting patient safety and quality care. Moreover, observers were offered the choice to continue, or decline participation in surveillance. Of 95 observer participants, only three opted to decline from participating in the surveillance. Another challenge was delayed observation submission due to the observers’ busy schedules. Delayed submissions were excluded from analysis for fear of recall bias. Observers who were late to submit their observations were counseled about the importance of timely submission to ensure data validity. Only three observation forms were excluded over 21 months of surveillance. The third challenge was how to handle repeated noncompliance by the same individual, without having to resort to extreme disciplinary actions. The quality team opted to copy the supervisors of the concerned non-compliers on the email notifications of the specific incident, and how to avoid it in the future. The Quality Director met with non-compliant individuals after three violations to review their noncompliance, discuss barriers to proper hand hygiene, and highlight its impact on patients and on the hospital environment. Interestingly, none of the repeated offenders exceeded three noncompliance reports.

Results

Between August 2016 and May 2018, a total of 2987 observations were collected: 1630 (54.5%) before, and 1357 (45.5%) after patient encounters. During the first year of the intervention (August 2016-August 2017), an average of 294 observations were conducted each month. The overall, as well as before patient encounter compliance were maintained above the 90% set goal (Figs 1 and 2).

Fig 1

Overall compliance with hand hygiene practice.

Solid bold line indicates the mean hand hygiene compliance. The dashed lines indicate upper and lower control limits, set at 3-ς.

Fig 2

Overall compliance with hand hygiene practice before patient encounters.

Solid bold line indicates the mean hand hygiene compliance. The dashed lines indicate upper and lower control limits, set at 3-ς.

After patient encounter compliance also reached to the set goal of 90% (Fig 3), except for three time points during which it dropped to 87% (November and December 2016, and August 2017). Despite these drops, the average compliance in the first year increased to 94% for all types of observations, as compared to baseline values (86% before, and 80% after patient encounter). Hence, the number of observations was reduced to an average of 57 per month starting August 2017.

Fig 3

Overall compliance with hand hygiene practice after patient encounters.

Solid bold line indicates the mean hand hygiene compliance. The dashed lines indicate upper and lower control limits, set at 3-ς.

During the second year (September 2017-May 2018), the overall, and after patient encounter compliance were sustained above 90% (Figs 1 and 3), with two drops in before patient encounter compliance reaching 88% in February and April 2018 (Fig 2). The average compliance during second year was 94% for both encounter types.

Analysis of compliance by health care worker discipline between November 2016 and May 2018 included 1067 observations on medical and 875 observations on nursing staff. Both disciplines achieved similar average compliance rates of 95%, for before, and after patient encounters. There was one drop in compliance to 85.2% for the nursing staff in November 2017 (Fig 4), the only drop below the LCL [13] after implementation of the intervention.

Fig 4

Nursing staff overall compliance with hand hygiene practice.

Solid bold line indicates the mean hand hygiene compliance. The dashed lines indicate upper and lower control limits, set at 3-ς.

The overall compliance of medical staff also decreased to 84.3% during April 2018 (Fig 5).

Fig 5

Medical staff overall compliance with hand hygiene practice.

Solid bold line indicates the mean hand hygiene compliance. The dashed lines indicate upper and lower control limits, set at 3-ς.

Drops in compliance necessitated reminder sessions for physicians and nurses about proper hand hygiene. Cross-validation of the effectiveness of our intervention with the Infection Control Office data revealed no nosocomial Rotavirus infections during 2016 and 2018, and four such infections during 2017: two in January, one in May, and one in August, coinciding with drops in overall compliance with after patient encounters to levels at, or below the set goal of 90% (Fig 3). Except for the nursing staff data (Fig 4), p-charts revealed no significant shifts in data points above or below the mean following the implementation of the intervention in November 2016 (Figs 1–3 and 5). Hence, we considered the process to be In Control [13]. In addition, the χ2 test of independence suggested significant improvement in compliance rates between 2016 baseline data and 2018 data (χ2 (1) = 7.94, p = 0.005).

Discussion

This quality improvement initiative demonstrated that implementation of the WHO-5 multimodal intervention in addition to ownership and goal setting increased and sustained hygiene compliance above the 90% set goal for twenty months in our inpatient units, a rate that is quite challenging to achieve and sustain. It has been shown that implementing accountability, reward incentives, or goal setting may help sustain high compliance rates [10, 14]. However, few studies reported on ownership of hand hygiene surveillance by physicians or nurses, all revealing a significant positive impact on compliance rates [15-19], The sustainability of high compliance rates in our setting may be attributed to the motivated physicians in charge of surveillance who may have felt that it was their responsibility to achieve the set goal. Physicians are the least involved in quality improvement initiatives, mainly because of time constraints and other work priorities. Hence recruiting them as internal champions may enhance success of quality improvement initiatives, especially if there is a supportive hospital leadership [16, 20]. Also, adding ownership to the WHO-5 multi-modal intervention did not mandate additional financial costs as it was integrated with the daily activity of our staff, making proper hand hygiene part of their daily routine, thus slowly changing their behavior.

We provided real-time performance feedback to non-compliers to raise their awareness of the importance of compliance for patient safety, a strategy that helped raise compliance after every drop, such as seen in November and December 2016, and August 2017. Several previous studies have shown that provision of real-time individual or group feedback was associated with improvement and sustainability of high compliance rates [21-24], as well as reduction in serious nosocomial infections such as central line-associated blood stream infections [25].

There are some limitations to our intervention. First, assigning surveillance ownership to health care workers would add additional tasks to their daily routine. This burden however can be reduced by increasing the pool of staff members participating in similar initiatives, as previously reported by Linam et al. [26]. Yet, it may be challenging to replicate this strategy in small hospitals where human resources is an issue. Resorting to volunteers, such as medical students may be helpful in such settings. In our case, we trained volunteer medical students on proper hand hygiene and how to conduct direct observations of doctors and nurses. We found this experience to be useful since it saves on institutional human resources, is reliable, and sensitizes the students to the importance of proper hand hygiene for patient safety early on in their career. Rees et al. [27] and Ghee & Kowdley [17] also depended on volunteer medical students to implement their hand hygiene initiatives with similar success. A second limitation of our initiative is that some health care workers may be uncomfortable in reporting non-compliant colleagues or supervisors, especially in units with a small number of staff. Having video cameras for surveillance, instead of human observers can help avoid this concern. Automatic video monitoring has been used in auditing hand hygiene initiatives and providing real-time feedback to individual users [28]. Video surveillance can also reduce observer bias as reported by Sharma et al [29]. A third limitation is that sustainability of surveillance by hospital staff may be interrupted under certain circumstances, such as with new incoming staff, or periods in between academic years in teaching centers, which we faced during the month of June, and compelled us to temporarily withhold surveillance by the medical staff. This problem can also be overcome by using video monitoring. Finally, our data may be biased by the Hawthorne effect where doctors and nurses may have modified their behaviors because they knew they were being observed. However, cross-validation of our data against the hospital’s Infection Control Office data on nosocomial Rotavirus infection revealed that the infections occurred with drops in after patient encounter compliance, suggesting that the Hawthorn effect on the validity of our data was minimal if any.

Conclusions

Adding ownership and goal setting to the WHO-5 multimodal intervention may help achieve, and sustain high rates of compliance with hand hygiene. Involving health care workers in quality improvement initiatives is feasible, durable, reliable, and cheap. This strategy may be especially useful in settings with limited financial resources. Further study is needed to assess the feasibility of hospital-wide implementation of this strategy.

Anonymized pre-intervention data set.

(XLSX)

Click here for additional data file.

Anonymized post-intervention data set.

(XLSX)

Click here for additional data file.

22 Jul 2020

PONE-D-20-06452

Sustaining compliance with hand hygiene when resources are low: a quality improvement report.

PLOS ONE

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Reviewer #1: Dear authors, thank you for the opportunity to Review your article. I do have some Major concerns regarding your study:

1) There is no Ethical vote, though you stated that physicians and parents took part in a Survey.

2) Introduction line 59-60: I miss a Hygiene expert who performs the Training of the M5M of HH.

3) Methods: Your mehtods are a mix of methods and results. Furthermore, you only performed compliance measurements of two indications, mainly, before and after Patient contact. There are important HH indications missing. You mentioned a surveillance of physicians and parents, however, there are no results presented in dtail. In line 92 you mention low compliance rates, however, in the hole manuscript I do not find any very low compliance rate, they are rather high, in my eyes too high! You also mention 20 anonymous observations, how can Observation be like that when physicians receive Feedback after an Observation? Actually, I do not understand your methodological Approach, it is described in an unclear way. Line 159: Did you only collect data on before and after Patient contact?

4) Results: As you stated in two years 2987 observations were performded, which included only two indications! So patients never received an Infusion from a physician or nurses never had contact with Body fluid or the near Patient surrounding? Also the number of observations seems rather low. Did you also observe others (i.e.. dietology, physical therapy,..)? Overall, compliance rates seems rather high and 3 indications are missing. There are no surveillance data presented.

5) The discussion is poor and is lacking of recent literature (mostly between 2002 and 2013).

Kind regards

Reviewer #2: The manuscript provides an interesting insight into the implementation of the WHO-multimodal strategy to improve and sustain hand hygiene compliance rates in a setting with limited resources. Data provided are sound and analysis was performed in a rigorous way. However, some minor revisions are required.

INTRODUCTION

1. The authors reported that their quality improvement initiative was designed to increase and sustain compliance above 90% for at least two years. How did they identify such a threshold? Is there any evidence to identify as meaningful a cut-off of 90% and not below or above, like 85% or 95%? Please explain it.

METHODS

2. How did the nurse manager choose the observer each day? Alphabetic order, random order based on sequence, …? Besides, using such a high number of observers could lead to important differences. How was the inter-observer reliability tested? Were they trained? And how much time passed between conducting the observation and filling out the questionnaire? Was a recall bias possible?

3. “Non-compliers were sent emails by the Paediatric Quality Director about the details of the non-compliance incident, …”: does it mean that the observed healthcare worker’s name was disclosed in the observation form? Why?

RESULTS

4. Several papers in the literature have pointed out that hand hygiene compliance may vary across professional categories and in relation to several factors (i.e., shifts, types of interaction between patients and healthcare workers). Is any other information available from your study to support or dismiss these hypotheses?

DISCUSSION

5. “This quality improvement initiative demonstrated that adding ownership and goal setting to the WHO-5 multimodal intervention increased, and sustained hygiene compliance …”. I am not sure that this study really proved what the authors claim. We don’t know what would have happened if the interventions were carried out without these newly added components. It would be safer to say that the implementation of the whole strategy led to an increase in hand hygiene compliance rates.

6. In the baseline data, the authors report that “the overall compliance was 92% before, and 86% after patient encounter”. This result is worth a proper elaboration, as it seems to be in contrast with other findings where after patient’s contact the hand hygiene compliance rates were significantly lower, probably because hand hygiene was usually performed for self-protection.

7. I would say that real-time feedback to non-compliers is likely to be the main factor responsible for the successful campaign conducted in this hospital. Several other studies discuss the difficulty in maintaining a high rate of adherence to recommended practice over time and the importance of providing educational reinforcement and performance feedback to HCWs so that improvements can be sustained (for instance, see: Baccolini V, D'Egidio V, de Soccio P, Migliara G, Massimi A, et al. Effectiveness over time of a multimodal intervention to improve compliance with standard hygiene precautions in an intensive care unit of a large teaching hospital. Antimicrob Resist Infect Control. 2019; 8:92). I wonder what happened when the campaign stopped, and if would not have been appropriate to conduct a few observations after a few months. This could be added as an important limitation of the study.

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Reviewer #1: No

Reviewer #2: No

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5 Sep 2020

Response to Reviewer #1

Thank you for taking the time to review our manuscript. We greatly appreciate your comments and suggestions. Kindly find below our response.

1. There is no ethical vote, though you stated that physicians and parents took part in a survey.

Answer: The following paragraph is added to the beginning of the Methods section: “This project was mandated and approved by the Hospital Administration as a quality improvement initiative to address the reported Rotavirus nosocomial infections on the pediatric ward. Hence, it was exempt from review by the Institutional Review Board, and consent of patients and health care providers were not applicable in this case”.

2. Introduction, Line 59-60: I miss a hygiene expert who performs the training of the M5M of HH.

Answer: The Departmental quality unit works closely with the Hospital Infection Control Office whenever such training is planned. We stated in the Education and training section that the training was done by the Infection Control Office: “The hospital’s Infection Control Office delivered two educational sessions for all pediatric faculty and resident staff. These sessions aimed at developing awareness, and a culture of hand hygiene among all pediatric physicians. The sessions covered application of standard precautions, My 5 Moments of Hand Hygiene, the institutional Hand Hygiene Policy, the correct technique of hand rubbing and handwashing, and information about disinfectant properties”.

3. Methods: Your methods are a mix of methods and results. Furthermore, you only performed compliance measurements of 2 indications, mainly, before and after Patient contact. There are important HH indications missing.

Answer: In reporting our Methods, we followed the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) [Reference 12]. Some subsections (such as Baseline data) require that we report the findings in this subsection rather than in the Results.

We agree with the kind reviewer that there are more HH indications than the before and after patient contact. However, for the purpose of this departmental quality improvement project we decided to focus on these 2 indicators only since they are by far the most commonly performed indications (as compared to procedures for example), and to minimize overwhelming our medical staff observers with less commonly performed indications that are routinely monitored/audited by the Infection Control Office.

4. Methods: You mentioned a surveillance of physicians and parents, however, there are no results presented in detail.

Answer: Yes. This surveillance was done in the pilot phase in the outpatient units to obtain baseline data. Since the overall before and after patient compliance in the outpatient units was above 90%, it was decided not to include it in the planned intervention since there was no problem there. We added the following sentence to summarize the results of the outpatient surveillance: “The overall compliance rates were 97% (180/185) for before patient encounters, and 95.5% (172/182) for after patient encounters”. As for the inpatient pre-intervention surveillance, we added the following sentence: “The overall compliance was 92% (152/165) before, and 85.7% (84/98) after patient encounter”.

5. Methods: In line 92 you mention low compliance rates, however, in the whole manuscript I do not find any very low compliance rate. They are rather high, in my eyes too high!

Answer: Yes. In the inpatient units, the before patient compliance was high at 92%, However since the after patient compliance of 86% was below our set goal of 90%, we decided to proceed with our intervention in the inpatient units. At the time this quality improvement was planned, the hospital was to undergo an assessment by the Joint Commission International (JCI) for accreditation. Hence, as part of the hospital preparation for this accreditation, the Administration asked each department to upgrade the standards of their quality indicators. In view of the Rotavirus nosocomial infections reported to us by the Infection Control Office, we elected to go for the set goal of 90% compliance.

6. Methods: You also mention 20 anonymous observations, how can Observations be like that when physicians receive feedback after an observation? Actually, I do not understand your methodological approach. It is described in an unclear way.

Answer: The identities of the physicians conducting the observations were not revealed to the observed staff (kept anonymous). However, because the multimodal intervention included ‘Feedback’ to non-compliers, we requested that the observers record only the name(s) of the non-complier(s), and the details of the specific violation(s) so we can give them feedback, as well as retrain them on the proper HH practice.

7. Methods, Line 159: Did you only collect data on before and after Patient contact?

Answer: Yes. We revised this sentence to become clearer for the reader: “Quarterly reports were generated for all, as well as individual inpatient units that included their overall, before and after patient compliance rates”.

8. Results: As you stated in 2 years 2987 observations were performed, which included only 2 indications! So patients never received an infusion from a physician or nurses never had contact with body fluid or the near patient surrounding?

Answer: Patients did have a variety of procedures. However, as we mentioned in our reply to comment #3 above, for the purpose of this departmental quality improvement project we decided to focus only on these 2 indicators since they were by far the most commonly performed indications (as compared to procedures for example), and to minimize overwhelming our medical staff observers with less commonly performed indications that are routinely monitored/audited by the Infection Control Office.

9. Results: Also the number of observations seems rather low. Did you also observe others (i.e. dietology, physical therapy..)?

Answer: We specifically targeted the medical and nursing staff since it would be easier for the observers to conduct their observations in their teams. However there were very few observations done on other staff like those working in the cleaning services which are not included in this study. Luckily we had no violations among them. The Hospital Infection Control Office monitors/audits the HH practice of all kinds of hospital staff.

As for the number of the total observations being on the low side, we decided on 20 observations per week initially because we did not want to overwhelm the observers with too many observations that would interfere with their daily responsibilities, and might tempt them to withdraw from participation in the QI.

10. Overall, compliance rates seem rather high and 3 indications are missing. There are no surveillance data presented.

Answer: We addressed these issues in our reply above: for high compliance rates please see reply to comment #5, for the 3 missing indications please see reply to comments #3 and #8, and for the surveillance data please see reply to comment #4.

11. The discussion is poor and is lacking recent literature (mostly between 2002 and 2013).

Answer: The Discussion section is now revised with the addition of 9 new recent references published between 2016 and 2020 (highlighted in yellow).

Response to Reviewer #2

Thank you for your critical review of our manuscript and the valuable comments. Please find below our point by point response.

1. Introduction: The authors reported that their quality improvement initiative was designed to increase and sustain compliance above 90% for at least 2 years. How did they identify such a threshold? Is there any evidence to identify as meaningful a cut-off of 90% and not below or above, like 85% or 95%? Please explain it.

Answer: When we designed this PI project, our literature review did not yield a specific recommended set goal by the CDC or the WHO. However, most of the papers in the literature used the 90% set goal (e.g. references #7, #17, #22; Omar et al. International Journal of Risk & Safety in Medicine. 2020 Jun 04; Linam et al. Pediatric Quality & Safety. 2017 Jul-Aug ;2(4):e035; and many papers from the older literature). Also, our Hospital Infection Control Office uses the same set goal. The Hospital’s rationale for this threshold was based on the fact that historically, the compliance in some of the hospital units was low ranging between 40% and 50%. Hence, to increase those pre-intervention low rates to rates high enough to secure patient safety, the 90% goal was chosen because it would almost double the low compliance rates and would be an achievable target, whereas the 100% compliance rate would be unachievable.

2. Methods: How did the nurse manager choose the observer each day? Alphabetic order, random order based on sequence,..? Besides, using such a high number of observers could lead to important differences. How was the inter-observer reliability tested? Were they trained? And how much time passed between conducting the observation and filling out the questionnaire? Was a recall bias possible?

Answer: The choice of the nurse observer in each unit was left to the nurse manager’s judgement based on the available nursing resources and the equity level of that unit. We did not interfere in their decisions or impose a specific system on them. Some units that had a good number of nurses chose the champion nurse from their pool of nurses who were never cited by the Infection Control Office to have had violations in hand hygiene practice (i.e. committed to good HH practice). The remaining units chose their champion nurse based on seniority and good audit training.

We did not do inter-observer reliability testing since the task to be observed was very simple, which is performing good hand rubbing with the hand sanitizer before and/or after patient contact. However, during training of all observers, each physician demonstrated to the quality officer how to properly perform good HH. Once this skill was mastered the physician was considered competent enough to recognize a HH violation when he/she observes one.

The observers were requested to record their observations as soon as they could do so in privacy, and before their shift was over. The possibility of recall bias of course cannot be completely ruled out, but since the shifts did not exceed 12 hours, this possibility is quite low. To note, log sheets that were submitted late were cancelled to avoid this bias. Only three observation forms were excluded over 21 months of surveillance.

3. Methods: “Non-compliers were sent emails by the Pediatric Quality Director about the details of the non-compliance incident..”. Does it mean that the observed health care worker’s name was disclosed in the observation form? Why?

Answer: The identities of the physicians conducting the observations were not revealed to the observed staff (kept anonymous). However, because the multimodal intervention included ‘Feedback’ to non-compliers, we requested that the observers record only the name(s) of the non-complier(s), and the details of the specific violation(s) so we can give them specific feedback relating to their violation, as well as retrain them on the proper HH practice. There were no disciplinary measures.

4. Results: Several papers in the literature have pointed out that hand hygiene compliance may vary across professional categories and in relation to several factors (i.e. shifts, types of interaction between patients and health care workers). Is any other information available from your study to support or dismiss these hypotheses?

Answer: We specifically targeted the medical and nursing staff since it would be easier for the observers to conduct their observations in their teams. However there were very few observations done on other staff like those working in the cleaning services. Luckily we had no violations among them, and these were excluded from this report. The reason for limiting the surveillance to nursing and medical staff is that we did not want to overwhelm the observers with too many observations as this would interfere with their daily responsibilities, and might tempt them to withdraw from participation in the QI. Our results revealed that medical and nursing staff had similar compliance rates, which is somehow different from the literature that report better HH compliance among nurses as compared to physicians.

5. Discussion: “This quality improvement initiative demonstrated that adding ownership and goal setting to the WHO-5 multimodal intervention increased, and sustained hygiene compliance..”. I am not sure that this study really proved what the authors claim. We don’t know what have happened if the interventions were carried out without these newly added components. It would be safe to say that the implementation of the whole strategy led to an increase in hand hygiene compliance rates.

Answer: Thank you for the suggestion. We revised this sentence as follows: “This quality improvement initiative demonstrated that implementation of the WHO-5 multimodal intervention in addition to ownership and goal setting increased and sustained hygiene compliance above the 90% set goal..”.

6. Discussion: In the baseline data, the authors report that “the overall compliance was 92% before and 86% after patient encounter”. This result is worth a proper elaboration, as it seems to be in contrast with other findings where after patient’s contact the hand hygiene compliance rates were significantly lower, probably because hand hygiene was usually performed for self-protection.

Answer: We agree with the kind reviewer about this finding for which we have no explanation. We found only one report of a similar trend (Deshommes T, et al. A quality improvement initiative to increase hand hygiene awareness and compliance in a neonatal intensive care in Haiti. Journal of Tropical Pediatrics. 2020 June 28). In that paper, post-intervention hand hygiene was most likely to happen before, rather than after patient contact. We elected not to elaborate on why our pre-intervention after patient contact rate was lower than the before patient contact rate because we could not speculate about the reason, and because this trend did not persist post-intervention. We realize that this is opposite to what has been reported in the literature.

7. Discussion: I would say that real-time feedback to non-compliers is likely to be the main factor responsible for the successful campaign conducted in this hospital. Several other studies discuss the difficulty in maintaining a high rate of adherence to recommended practice over time and the importance of providing educational reinforcement and performance feedback to HCWs so that improvements can be sustained (for instance, see Baccolini et al., 2019). I wonder what happened when the campaign stopped, and if it would not have been appropriate to conduct a few observations after a few months. This could be added as an important limitation of the study.

Answer: Yes, we agree with the kind reviewer that sustaining a high compliance rate is challenging. This is well-documented in the literature (thank you for the reference). In the provided reference (Baccolini et al., 2019), surveillance continued for 17 months only (November 2016- April 2018), whereas our surveillance continued for 21 months (August 2016- May 2018) in order to monitor sustainability. During the 21 months we continued to have high compliance rates which may be due to the real-time feedback to non-compliers, as per your suggestion. However, one cannot rule out the importance of other elements such as ownership which we believe is another major factor in the success of the intervention. In multi-component interventions, it is hard to dissect the individual contribution of each component. In June 2018 we stopped the HH surveillance by physician observers since the hospital was moving towards having electronic health record system using EPIC, and all hospital staff’s time (including physicians and nurses) was dedicated for training on EPIC. HH surveillance continued to be done by the Hospital’s Infection Control Office as usual. We were hoping to resume conducting our QI within 2 years however we were hit by the COVID-19 Pandemic similar to all other countries, which led to strict adherence to HH by all HCWs, patients and visitors.

We hope we have addressed all the comments of the kind reviewers in a clear manner, and revised the manuscript accordingly.

Thank you again for the thorough review of our paper.

Yours sincerely,

Mona Nabulsi, MD, MSc

Professor of Clinical Pediatrics

Department of Pediatrics and Adolescent Medicine

Faculty of Medicine

American University of Beirut

Beirut-Lebanon

P.O.Box: 113-6044/C8

Fax: 961-1-370781

961-1-744464

E-mail: mn04@aub.edu.lb

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

20 Oct 2020

Sustaining compliance with hand hygiene when resources are low: a quality improvement report.

PONE-D-20-06452R1

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Reviewer #1: Dear authors, thank you very much for answering my comments. However, you discuss the WHO 5 multimodal model and Focus only on two indications. I cannot Support your opinion, that in a low resource Hospital there is no time for the other three indications. As this should represent a quality initiative I miss a comprehensive approach. It is the Patient which should be protected and it is the staff which should protect themselves. I am not convinced of this study at all.

Kind regards

Reviewer #2: all comments have been addressed. No further revision is required. The manuscript is clear and writtein in an intelligible fashion.

Reviewer #3: At the beginning of the method section you stated that the project was mandated and approved by the Hospital Administration, was exempt from IRB. This meant that participants had no choice. Why do you have a section on ethical considerations? Although strictly QI activities usually do not require IRB oversight, this particular QI initiative followed tenets of research, which include a hypothesis and some basic statistical analysis; as such an IRB review would have been appropriate. In addition, some ethical challenges were reported by few residents and medical students.The issue of anonymity even though addressed remains questionable; given that for non-compliers the quality team opted to copy their supervisors on emails which meant confidentiality between participants and the quality team was breached. Were there any penalties imposed on non-compliers?

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23 Oct 2020

PONE-D-20-06452R1

Sustaining compliance with hand hygiene when resources are low: a quality improvement report

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