Use of hand hygiene on room entry and exit is shown in Figure 4 for surgeons, operating room staff, and anesthesia personnel. Segmented regression analysis showed no change corresponding to the time since the beginning of the studied intervention for surgeons (adjusted R2 = 0.01, mean change after intervention P = .61, rate of change after intervention P = .85) or for operating room staff (adjusted R2 = 0.03, mean change after intervention P = .47, rate of change after intervention P = .10). Data on anesthesia personnel, conversely, did show a modest effect of the intervention period (R2 = 0.36, mean change after intervention P = .012, rate of change after intervention P = .0002).
Potential confounders were tested for their relationship with hand hygiene frequency, and none was found significantly related. Hand hygiene per hour by certified registered nurse anesthetists versus residents did not differ (mean [95% CI], 3.5 [3.2–3.9] vs 3.1 [2.4–3.8]; P = .15). There was no relationship between hand hygiene per hour and surgical duration (R2 = 0.003, P = .08). Individual operating rooms did not vary overall (P = .055, no pairwise differences by Tukey test).
The results of this investigation demonstrate the feasibility of monitoring hand hygiene among anesthesia personnel at the individual provider level by a simple low-technology method that should be relatively easy to implement at modest cost. The accuracy of the measurements achieved by weighing the disinfectant containers used in this study, while not perfect, nevertheless, was sufficient to allow for global monitoring of institutional performance in hand hygiene quality improvement measures. Although this study utilized research assistants to gather the data, it may be possible to implement this methodology within the existing workflow by anesthesia technicians or other support personnel during room turnover at minimal incremental cost. In our institution, we have continued to estimate hand hygiene use weekly and we have used both dedicated quality data collectors who carry a room turnover pager and anesthesia technicians. The measurement typically takes <1 minute.
Hospital-acquired infections are a major source of patient morbidity16 and increase in health care costs.17 Hand hygiene use by medical personnel is considered a fundamental infection control process which is likely able to reduce hospital-acquired infections by ≥40%.18 In the operating room environment, measuring hand hygiene on room entry and exit only is simple but ignores the importance of the procedure by anesthesia personnel intraoperatively, who are in frequent contact with the patient from room entry to exit and do not themselves enter and leave the room frequently. Nonetheless, there is significant evidence that more frequent intraoperative hand hygiene performance by anesthesia personnel can reduce contamination of the work environment, and most importantly, the IV tubing and entry sites (eg, stopcocks), reducing patient exposure to potential pathogens.6,7,19,20 In some but not all such efforts, hand hygiene frequencies of 4–8 times per hour resulted in decreased hospital-acquired infections.6,7
Hand hygiene in the operating room poses unique challenges for anesthesia personnel. The anesthesia work environment becomes increasingly contaminated over the course of an operation.21,22 Anesthesia personnel constantly move between this area and the patient, and their hands can be a vector for pathogen transmission to medication syringes, IV tubing and stopcocks, and ultimately the patient.19,20,23 Application of the World Health Organization “five moments” criteria (before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching the patient’s surroundings) to perform hand hygiene would seem logical because they are designed to prevent just this sort of transmission. However, objective measurement of hand hygiene opportunities in the operating room environment according to the World Health Organization criteria leads to unrealistic and impractical hand hygiene requirements. For example, Biddle and Shah2 used trained nurse observers in the operating room and found up to 54 hand hygiene opportunities per hour for anesthesia personnel. Rowlands et al3 used video observation (which they felt was more robust and avoided bias from direct observations) and counted 149 ± 10.3 (mean ± SD) hand hygiene opportunities per hour. Performing hand hygiene this frequently (every 24 seconds), even under ideal circumstances, would leave no time for clinical care and is obviously impractical as a standard. This may explain why investigations of anesthesia clinicians’ actual hand hygiene use in the operating room reveal a substantially lower frequency than the World Health Organization opportunity count would suggest. Rowlands et al3 observed use of hand hygiene in just 2.3%–3.6% of all opportunities.3 Biddle and Shah2 found that 18% of their somewhat lower opportunity estimate was accompanied by hand hygiene use. Scheithauer et al5 used direct observation during a quality improvement project of anesthesia personnel limited to just the beginning of the surgical procedure and found only 2 episodes per case or 10% compliance at baseline was documented. In a series of studies, investigators at Dartmouth-Hitchcock Medical Center found very low rates of hand hygiene use before improvement interventions ranging from a mean of 0.15 to 0.57 events per hour.6,7,21 This is consistent with our findings of a median of 0 events per hour at baseline.
Measurement of hand hygiene use by individuals over specific care episodes, such as anesthesia clinicians during individual operations, can be cumbersome. Human observation in the operating room has been used, primarily in research settings.2,5,7,9 Trained direct observation is time consuming, expensive, and may induce changes in clinician behavior due to the Hawthorne effect.2,24 Remote video monitoring is possible if installed in the operating rooms of interest,3 but it is similarly time consuming and expensive to install.10,25 The Dartmouth group used electronic devices installed in either wall-mounted product dispensers or individual waist-worn dispensers equipped with electronic timestamp counters of hand hygiene use.6,7 These devices are quite accurate but are not presently available on the market, and other electronic devices may be too costly for routine use,10–12,26 although any such calculation would have to consider the possible reduction in hospital-acquired infection. In the present investigation, we used a very inexpensive system based on weight change of individual hand hygiene dispensers placed in the anesthesia work environment. The hand hygiene product in our institution costs $2.46 per bottle or approximately $0.01 per use even assuming half-empty bottles were discarded. The scale used costs <$50 and each measurement required only a few seconds, making it possible to incorporate into standard room turnover activities with little to no incremental labor cost. Unlike conventional product consumption–based methods, our assessment of product use for a single case is not severely impacted by an inability to know who has used the container, the time course of the observed use, and other causes of inaccuracy.27
Our method is certainly not completely accurate. The experiments demonstrating variation in pump volume with plunger pressure, container volume, and operator likely reflect real-world variability in the delivered product from a given pump. Anesthesia personnel pushing partially or multiple times per hand hygiene episode could distort the estimated frequency derived from average volume and total volume dispensed. Furthermore, if >1 provider (eg, an attending physician and a resident) participated in the care of a given patient and each accessed the container, the weight change would overestimate the hand hygiene use for each practitioner. We did not correct for such events, which were relatively uncommon in our video validation sessions. In general, only 1 provider at a time interacted with the patient and the anesthesia work environment, and the attending physician was in the room a minority of the case duration. However, we recognize that if a colleague also in contact with the patient performed hand hygiene as well, this would be favorable with regard to the desired outcome of increasing hand disinfection for any provider who might be a source of contamination even if it overstated the quantitative estimate for the primary provider. Even given these sources of variability, the correlation between estimated and observed hand hygiene use during the validation observations was strong. Moreover, even if our methodology sometimes overestimated individual provider hand hygiene use, there is no reason to suspect that this phenomenon would have changed over the time course of the study period, and there was still an observed increase in overall hand hygiene use. While the uncertainty of who actually used the hand hygiene container is a limitation of our methodology, it also suggests that further research might be undertaken to statistically estimate this error in different circumstances as a further refinement. We believe, therefore, that our methodology is sufficiently accurate to support a quality improvement effort designed to augment hand hygiene performance frequency.
Our quality improvement program resulted in a significant improvement in hand hygiene frequency over the observed time period and achieved performance into the frequency range associated with reduced anesthesia workplace environment contamination and, in some cases, surgical site infections.6,7 Other hand hygiene monitoring (room entry and exit) obtained contemporaneously did not demonstrate changes among nonanesthesia personnel, so we do not believe that our results are the product of secular trends. While we cannot exclude the influence of unmeasured confounders, those that we were able to quantitate did not significantly influence hand hygiene use.
Published efforts to improve use of hand hygiene have ranged from simply making a disinfection product available at the anesthesia workstation,28 which was unsuccessful, to much more elaborate efforts such as those by the Dartmouth group, involving electronic dispenser/monitors for each anesthesia professional. The methods used in our intervention were relatively simple, including education, group and individual feedback on performance, and point-of-care reminders. We believe that the ability to monitor individuals’ performance and feedback, as in the work by the Dartmouth group, was key in driving compliance improvement. In addition, the intradepartmental peer nature of the feedback (as opposed to that from infection preventionists, outside monitors, or administrators) seemed to facilitate project acceptance and goal-directed behavior modification. Finally, the ability to establish an evidence-based, achievable goal distinct from the World Health Organization guidelines designed for a nonanesthetizing location environment was likely also important.
We certainly acknowledge that it would be possible for practitioners to “game” the system by deliberately wasting hand sanitizer, but we did not observe such activity during many hours of video observation performed at both the early and later phases of the project. The fact that container weights were obtained before room setup and during room turnover, and that it was unknown to the providers whether or not a given room or case was being audited at any particular time, perhaps makes this behavior less likely. We would hope that attitudes toward hand hygiene use may have changed over the time course of the project, although, of course, we cannot be certain since we did not measure opinion of anesthesia personnel. In addition, we did not monitor individuals at regular intervals, so we are not able to determine if there were particularly frequent or infrequent users with statistical rigor. This would certainly be a reasonable target for further investigation and quality improvement. While cultural barriers, time pressure, use of gloves instead of hand hygiene use, and other incompletely understood factors are common problems in hand hygiene improvement efforts,11,22,29 our results indicate that successful intraoperative hand hygiene quality improvement and monitoring is possible at modest effort and expense.
Name: Scott Segal, MD, MHCM.
Contribution: This author helped design the study, supervise the data collection, analyze the data, and prepare the manuscript.
Name: Hannah M. Harris, BS.
Contribution: This author helped collect the data, analyze the data, and revise the manuscript.
Name: Antonius Gunawan, BS.
Contribution: This author helped collect the data, analyze the data, and revise the manuscript.
Name: Roman Schumann, MD.
Contribution: This author helped design the study and revise the manuscript.
This manuscript was handled by: Richard C. Prielipp, MD, MBA.
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