In October 2002, the Healthcare Infection Control

CE Article and Journal Club Feature HAND HYGIENE BEHAVIOR IN A PEDIATRIC EMERGENCY DEPARTMENT AND A PEDIATRIC INTENSIVE CARE UNIT: COMPARISON OF USE OF 2 DISPENSER SYSTEMS By Elaine L. Larson, RN, PhD, Sandra Albrecht, MPH, and Mary O Keefe, RN, MPH. From School of Nursing (ELL, SA) and Mailman School of Public Health (ELL), Columbia University, and Department of Epidemiology, New York-Presbyterian Hospital, Columbia University Medical Center (MO), New York, NY. BACKGROUND Adherence to hand hygiene standards is poor. Approaches and systems to improve hand hygiene practices warrant testing. OBJECTIVE To compare the frequency of use of manually operated and touch-free dispensers of sanitizer for hand hygiene. METHODS Manual and touch-free dispensers of alcohol sanitizer were placed in the emergency department and an intensive care unit of a large pediatric hospital for two 2-month periods for each type of dispenser. Counting devices installed in each dispenser and direct observations were used to determine actual frequency of and indications for hand hygiene. RESULTS The touch-free dispensers were used significantly more often than were the manual dispensers. The means for the number of episodes of hand hygiene per hour were 4.42 for the touch-free dispensers and 3.33 for the manual dispensers (P =.04); the means for the number of episodes per patient per hour were 2.22 and 1.79, respectively (P=.004); and the means for the number of uses of the dispenser per day were 41.2 and 25.6, respectively (P =.02). However, the overall compliance rate was 38.4% (2136 episodes of hand hygiene per 5568 indications for hand hygiene). CONCLUSIONS The type of dispensing system influenced hand hygiene behavior. Nevertheless, overall hand hygiene compliance remained low. In order for interventions to have a major effect on hand hygiene, multiple factors must be considered. (American Journal of Critical Care. 2005;14:304-312) CE Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your understanding of the following objectives: 1. Compare the frequency of use of manually operated and touch-free dispensers 2. Discuss limitations of the study and how future studies can avoid these limitations 3. Explain a way to increase hand hygiene compliance To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. In October 2002, the Healthcare Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention, issued Guideline for Hand Hygiene in Health-Care Settings. 1 Included in the material are recommended performance indicators for monitoring compliance with the guideline. One suggested method for monitoring compliance is periodical observations to document the number of episodes of hand hygiene of personnel per number of opportunities for hand hygiene, by ward or by service. However, several problems are associated with direct observations. First, direct observation is too costly and time-consuming to be used on any long-term basis. Second, only 1 or 2 staff members can be observed at a time, and generally open units are required to allow visualization of the staff members encounters with patients. Hence, the 304 AMERICAN JOURNAL OF CRITICAL CARE, July 2005, Volume 14, No. 4

representativeness of the data is limited. Finally, being observed may change a person s behavior, at least in the short-term, and may raise ethical and privacy concerns. In order to overcome such problems, feasible alternatives to direct observation are needed. A variety of esthetic and structural factors have been described because of their potential effect on hand hygiene behavior, including the fragrance and feel of products and the location of sinks and dispensers. 2,3 Although no evidence indicates that devices that must be manually pressed to dispense cleanser increase the risk of transferring microbes, healthcare staff may express concern about the safety of touching dispensers and may prefer dispensers that are more accessible and easier to use than the manual ones are. 4,5 Such concerns may be a deterrent to using manual dispensers. Therefore, the aim of this study was to compare the frequency of use of manually operated and battery-operated, touchfree dispensers of sanitizer for hand hygiene. Methods The study was a crossover intervention trial in which the manual and touch-free dispensers were used in 2 hospital units. The study was approved by the appropriate institutional review board. Setting and Sample The study was done in the emergency department and an intensive care unit (PICU) at a large pediatric hospital The emergency department had 17 beds, 21 sinks, and a total of 25 alcohol sanitizer and 21 soap dispensers. A total of 5 rooms in the emergency department were open and visible from the nurses station: 4 single rooms and 1 large treatment room that accommodated up to 5 children and could be viewed by a single observer. The PICU had 14 beds, 11 sinks, and 12 alcohol sanitizer and 11 soap dispensers. Of the 14 beds, 11 were in an open area so that several patients could be observed simultaneously. Procedure In both units, an alcohol-based hand sanitizer (Purell, GOJO Industries, Inc, Akron, Ohio) and regular handwashing soap (PROVON Mild Lotion Soap, GOJO Industries, Inc) were already in use. The locations of the dispensers were not changed for the data collection periods. Soap dispensers were manual and remained unchanged throughout the study. For manual and touch-free dispensers of alcohol sanitizer, data were collected for 2 months for each type, with a 1-month hiatus between changes in the type of dispenser. This hiatus allowed staff to become familiar with the new dispenser type and helped reduce bias introduced because of the novelty of the touch-free dispenser. In order to control for an order effect (ie, which type of dispenser was used first or second), a crossover design was used. During the first data collection period, staff in the emergency department used the touch-free dispensers and staff in the PICU used the manual type; the type of dispensers in each unit was reversed in the second data collection period. The frequency of hand hygiene episodes was measured by using both electronic counters and direct observation. Electronic counting devices were installed within each alcohol and soap dispenser throughout the 2 units. Dispenser uses ( hits ) were used as an indicator of hand hygiene episodes. At regular intervals, a member of the research team made rounds on the 2 study units and recorded the counter readings from each dispenser. Daily numbers of visits to patients (for the emergency department) and daily patient census (for the PICU) were obtained. Throughout the 4 months of the study, for approximately 15 h/wk at various intervals throughout the day and night shifts, 3 research assistants observed in 1- hour observation periods the number of actual episodes of hand hygiene and the number of opportunities for hand hygiene that occurred. The research assistants rotated between the 2 study units. For each observation in a unit, a research assistant assumed a position that allowed direct observation of the maximum number of contacts between staff members and patients. Generally, 2 to 5 patients and their environs were included in each observation period. During these observation periods, the research assistants also made sure that all dispensers were filled and functioning well. Instrument for Observations of Hand Hygiene The hand hygiene behavior of staff members whose activities could be directly observed was recorded without identifiers by using a hand hygiene observation instrument. On the basis of the 8 indications for hand hygiene listed in the recommendations of the hand hygiene guideline of the Centers for Disease Control and Prevention, 1 the research assistant noted when a hand hygiene episode was indicated and whether the staff member used either soap and handwashing or the alcohol sanitizer. Previous interrater reliability estimates of 0.94 to 0.98 were reported for an earlier version of this instrument. 6 Before the study began, interrater reliability was established between the research assistants and the investigators to ensure more than 95% agreement. Data Analysis To calculate statistical power for this study, we made several assumptions. Because we had no way of AMERICAN JOURNAL OF CRITICAL CARE, July 2005, Volume 14, No. 4 305

Table 1 Indications for hand hygiene, observed occurrences of hand hygiene with alcohol or soap products, and hand hygiene compliance rate in the emergency department and the pediatric intensive care unit Indication Before direct contact with a patient Before donning sterile gloves when inserting central venous catheters Before inserting invasive devices After touching a patient s intact skin After touching bodily fluids, wounds, nonintact skin Before moving from a contaminated site to a clean site in the same patient After contact with inanimate objects in a patient s vicinity After removing gloves Times indicated per hour, mean 4.89 0.47 0.69 3.61 0.49 0.09 Times occurred per hour, mean Alcohol Soap 1.45 0.37 0.05 0.04 0.14 0.02 1.24 0.47 0.16 0.15 0.03 0.03 Compliance rate, %* 39 17 26 46 64 55 3.01 1.58 0.38 0.42 0.12 0.19 16 41 *Number of episodes of hand hygiene with either alcohol or soap per number of indications for hand hygiene. knowing the degree to which use of the manual and touch-free dispensers would differ, we had to assume a numerical value to express the expected difference/ correlation (ie, an effect size) in order to determine an appropriate number of data points for analysis. For an effect size of 0.20 and a 90% chance of detecting that difference if the difference exists, 265 data points (ie, product uses) would be needed. The hours of observation for both dispenser types provided more than sufficient data points to detect this level of correlation. From the observational data, a hand hygiene compliance rate was calculated as the proportion of times a hand hygiene episode actually occurred after it was indicated (hand hygiene occurrence/hand hygiene indication). The means for the number of indications for hand hygiene were calculated according to indications per patient per hour and then compared between units and between dispenser types by using the Mann-Whitney nonparametric test. Comparisons of frequency of hand hygiene episodes between dispenser types were made for the alcohol dispensers only, because touch-free dispensers were not used for the soap dispensers. The means for the number of hand hygiene episodes per day for the manual and touch-free alcohol dispensers were estimated by averaging the total number of dispenser uses per unit per day. This mean number of episodes per day was divided by the daily patient census (for the PICU) or daily number of patient visits (for the emergency department) to determine the mean number of hand hygiene episodes adjusted by patient care day or patient visit. For the mean number of episodes per patient per hour, the mean number of episodes per day was divided by 24 (hours). This number controlled for variations in the number of patients. A t test or the nonparametric Mann-Whitney test was used to compare this adjusted hand hygiene frequency and number of dispenser hits between the 2 dispensing systems. Data were analyzed by using SPSS software (SPSS Inc, Chicago, Ill). All statistical tests were 2-tailed, and the results were considered statistically significant at P<.05. Results Direct Observation A total of 306 hours of observation (153 hours in the PICU and 153 hours in the emergency department) were completed. Most of the observations (272/306, 88.9%) occurred during the day shift; hours of observation were slightly greater for the manual dispenser (58.8%) than for the touch-free dispenser (41.2%). A mean of 2.68 (range 1-7) patients and a mean of 6.1 (range 1-29) different healthcare providers who cared for these patients were observed during each session. Although 5568 indications for hand hygiene occurred, a mean of 18.2 indications per hour (5568 per 306 hours), only 2136 episodes of hand hygiene occurred, a mean of 7.0 episodes per hour (2136 per 306 hours). The overall hand hygiene compliance rate was 38.4% (2136/5568), and in 79.4% (1696/2136) of the episodes, the alcohol sanitizer was used. The most frequent indications for hand hygiene were as follows: before direct contact with a patient, after touching a patient s intact skin, after contact with inanimate objects in a patient s vicinity, and after removing gloves (Table 1). The mean number of indications for hand hygiene per patient during the time the touch-free dispenser was in use did not differ signifi- 306 AMERICAN JOURNAL OF CRITICAL CARE, July 2005, Volume 14, No. 4

cantly from the mean number during the time the manual dispenser was in use (5.76 vs 5.47 indications, respectively; P =.23), but the mean number of indications for hand hygiene per patient was significantly greater in the PICU than in the emergency department (6.12 vs 5.16 indications, respectively; P =.02). Total compliance rates did not differ significantly between the emergency department and the PICU (35% vs 41%, respectively; P=.07). Based on the indications for compliance with the Centers for Disease Control and Prevention s guidelines for hand hygiene, this study found a 38% compliance rate for hand hygiene activities, with no difference between the emergency department and the pediatric intensive care unit. According to the observational data for both units combined, for the alcohol sanitizer, the touch-free dispensers were used significantly more often than the manual dispensers were (mean number of hand hygiene episodes per patient per hour 4.42 vs 3.33, respectively, P =.04) and significantly more often for hand hygiene episodes before direct contact with patients (1.58 vs 1.26, P=.003; Table 2). Use of Alcohol Dispensers Across both units, the mean number of hits per dispenser (both alcohol and soap) per day was 23.3 (range 7.9-48.7): a mean of 14.8 (range 7.9-25.8) for the emergency department and a mean of 31.7 (range 19.3-48.2) for the PICU. The mean number of daily dispenser hits for both types of dispensers, controlled for patient census, was significantly lower in the emergency department than in the PICU (10.3 uses per patient visit per day vs 71.1 uses per patient census per day, respectively, P <.001). For both units combined, the mean number of daily hits for the alcohol sanitizer was significantly greater for the touch-free dispensers than for the manual dispensers (41.2 and 25.6, respectively, P=.02; Table 2). Discussion Hand Hygiene Practices and Dispensing Systems Kampf 7 recently noted that one prerequisite for improving compliance with hand hygiene is convenient, readily accessible dispensers. Our finding that the number of hand hygiene episodes overall was higher for Table 2 Daily uses of alcohol dispenser by type of dispenser Type of dispenser Count No. of uses per dispenser per day, mean (SD)* No. of episodes of hand hygiene per patient per hour, mean (SD) Manual 25.6 (19.6) 3.33 (2.7) Touch-free 41.2 (26.9) 4.42 (2.8) No. of episodes of hand hygiene before contact with a patient per hour, mean (SD) 1.26 (1.74) *Measured by using installed counters. Measured by using direct observation. 1.58 (1.59) the touch-free dispenser than for the manual dispenser is consistent with the hypothesis that the delivery system has an effect on behavior and that a touch-free dispenser may be preferred by healthcare professionals. Hand hygiene episodes were more frequent with the touch-free dispenser than with the manual dispenser. Although some have reported that hand hygiene compliance improved after the installation of alcohol dispensers, 8-10 Muto et al 11 found that compliance did not improve when alcohol dispensers were placed by every patient s door in 2 units. That study 11 was done, however, before publication of the hand hygiene guideline of the Centers for Disease Control and Prevention, and only manual dispensers were tested. The results of Muto et al are comparable to those of several other studies, 12,13 in which investigators found that simply increasing the number of handwashing sinks did not increase the frequency of hand hygiene. An alternative dispensing system that has been successful in increasing the frequency of hand hygiene is individual, pocket-sized bottles of alcohol sanitizer. 10,14,15 Use of this system seems to be more widespread in Europe than in the United States and to our knowledge has not been widely adopted in the United States as part of an overall hand hygiene program. A potential barrier to its use is the extra cost that would occur if staff members carried bottles of sanitizer with them out of the institution. Nevertheless, use of individual bottles may be cost-effective in the long run, and further economic analyses of various delivery systems are indicated. Measurement of compliance, however, would be more complicated if a combination of wall-mounted and individual dispensers were available. P.02.04.003 AMERICAN JOURNAL OF CRITICAL CARE, July 2005, Volume 14, No. 4 307

Table 3 Proposed method for calculating a unit-specific hand hygiene compliance rate Parameter Number of indications for hand hygiene Number of actual episodes of hand hygiene Hand hygiene compliance rate Ongoing monitoring Method of assessment 1. Directly observe personnel long enough to observe approximately 200 indications 2. Divide the total number of indications by the total time observed to obtain a mean number of indications for hand hygiene per hour 3. Multiply the value obtained in step 2 by 24 to get the mean number of indications per day. 4. Obtain the patient census for the period the observations were made. 5. Calculate mean number of indications for hand hygiene per day per patient by dividing mean number of indications per day by the census value. 1. Obtain data on volume of hand hygiene products (soap and alcohol) used per month for the unit* 2. Divide the total volume used by the amount of product dispensed with each hit 1. Compute number of indications per month by multiplying indications for hand hygiene per day per patient by the number of days in the month by the mean monthly patient census 2. Obtain a hand hygiene compliance rate by dividing the total number of hits by the total number of indications for that month 1. Repeat baseline observations if evidence indicates that patterns of hand hygiene have changed or if a hand hygiene intervention is planned Example 200 indications for hand hygiene were observed during a period of 5 hours 200/5 = 40 indications per hour 40 x 24 = 960 indications per day Patient census for day of observation was 30 960/30 = 32 indications for hand hygiene per day per patient 12 000 ml of product used per month 12 000 ml/1.5 ml per hit = 8 000 total hits/month 32 indications x 30 days x 32 mean monthly census = 30 720 indications in that month 8000/30720 = 26.0% compliance rate Not applicable *This step will require coordination with the purchasing department. The amount of product dispensed with each hit may vary according to the type of product or dispenser. Other researchers have discussed the importance of ensuring that dispensers are functioning and well maintained; in one study, 4 dispensers were often either nonfunctional or empty. Nonfunctional or empty dispensers were not a problem in our study because the dispensers were monitored routinely. Hence, differences in dispenser use could not be attributed to the functioning of the dispensers. Of note, although the cost of touch-free dispensers may be comparable to that of other dispensers, the touch-free devices require batteries for operation. Although the battery life is purported to be 2 years and a warning light on the dispenser makes it possible for housekeepers to readily detect the need for refill or battery change, the additional cost for battery operation may be a consideration in some settings. Further, we found that the hands-free dispensers were more complicated than the traditional manual units, and additional training of housekeeping staff in appropriate use and maintenance of the touch-free dispensers was needed. Regardless of any improvement associated with use of the touch-free dispensers, hand hygiene was clearly suboptimal in both units in our study. This finding is consistent with the results of previous studies 10,16,17 in which adherence to hand hygiene guidelines was poor. Practical Methods for Monitoring Hand Hygiene Compliance On the basis of our results, we suggest that a feasible unit-specific performance monitoring system for hand hygiene can be developed. In our study, we used electronic counters installed in each alcohol and soap dispenser, as is sometimes done in the food service industry. One potential monitoring system is use of a smaller number of counters and extrapolation of the number of uses of the dispensers with those counters to represent the number of uses of all dispensers in a clinical unit or even a whole facility. A manageable compliance program could be designed around ongoing use of these counters. Electronic counters installed in dispensers may be a practical way of monitoring hand hygiene compliance. A second alternative for monitoring hand hygiene is to use the volume of hand hygiene products used as an indicator of the number of hand hygiene episodes. 308 AMERICAN JOURNAL OF CRITICAL CARE, July 2005, Volume 14, No. 4

Two baseline parameters would be needed to develop a performance monitoring system to assess appropriate hand hygiene practice: the number of indications for hand hygiene and the number of actual occurrences of hand hygiene. The volume of product used could be determined for known values of these 2 parameters and could be used as a comparative value. Table 3 summarizes the calculations necessary to use product volume as an indicator to determine a hand hygiene compliance rate. Limitations Our study had several limitations. First, the touchfree dispensers were placed in the same location as the manual dispensers, which was high on the walls. In high-traffic areas and when staff inadvertently entered the sensor zone, product was dispensed. As might be expected, because of this inconvenience, some staff members were dissatisfied with the system. As noted by Ibrahim and Smith, 18 dispensers of products for hand hygiene should be placed at waist height to ensure delivery of the products into the palm of the hand. Other researchers 10,19 also reported significant variations in hand hygiene practices according to location in the hospital, type of activity, and type of healthcare professional. Further, we used each hit of a soap or an alcohol dispenser as an indication of an episode of hand hygiene. Some staff members might have used multiple hits for a single episode of hand hygiene, and counting hits of a dispenser would result in an overestimation of the number of hand hygiene episodes. However, the electronic counters we used had a built-in delay circuit to compensate for multiple deliveries of product to a single user. Further, the dispensers automatically shut off if 5 dispensing cycles occurred within 15 seconds. Because this study was conducted in a pediatric emergency department and a PICU, the results may not be generalizable to other hospital settings. Further, hand hygiene activity only reflected those beds that could be directly observed and may not have been representative of practices on the entire unit. Another limitation of the study is that most observations were made during the day, and as in all observational studies, behavioral changes among the persons being observed are possible. Finally, the time frame of the study was just a few months. Because hand hygiene behavior is ingrained and difficult to change, the full effect of the intervention may not have been achieved during the study period. Summary and Recommendations In 2 pediatric units, for use of an alcohol sanitizer, the mean number of hand hygiene episodes per hour and the mean number of hand hygiene episodes per indication for hand hygiene were greater for touch-free dispensers than for manual dispensers. Hence, the dispensing system clearly is an important factor in hand hygiene compliance. Nevertheless, the rate of hand hygiene continues to be extremely low. Clearly, efforts to improve hand hygiene will require a multifaceted approach, including system and environmental changes as well as educational and motivational strategies. Our results are encouraging and suggest that changes in dispenser technology are an element of leverage to improve hand hygiene. Finally, we recommend 2 feasible methods to monitor hand hygiene compliance: use of electronic counters or use of unit-specific data on the volume of hand hygiene product used. ACKNOWLEDGMENTS This study was funded in part by GOJO Industries, Inc, Akron, Ohio. We are grateful to the nursing, medical, and environmental services staff of the study units and to the data collectors, Amy Edelstein and Annie Xu, for their collaboration and helpful participation. Commentary by Mary Jo Grap (see shaded boxes). REFERENCES 1. Boyce JM, Pittet D. Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Am J Infect Control. 2002;30:S1-S46. Also available at: http://www.cdc.gov/mmwr/ preview/mmwrhtml/rr5116a1.htm. Accessed March 29, 2005. 2. Boyce JM, Kelliher S, Vallande N. Skin irritation and dryness associated with two hand-hygiene regimens: soap-and-water hand washing versus hand antisepsis with an alcoholic hand gel. Infect Control Hosp Epidemiol. 2000;21:442-448. 3. Boyce JM, Pearson ML. Low frequency of fires from alcohol-based hand rub dispensers in healthcare facilities. Infection Control Hosp Epidemiol. 2003;24:618-619. 4. Kohan C, Ligi C, Dumigan DG, Boyce JM. The importance of evaluating product dispensers when selecting alcohol-based handrubs. Am J Infect Control. 2002;30:373-375. 5. Boyce JM. Antiseptic technology: access, affordability, and acceptance. Emerg Infect Dis. 2001;7:231-233. 6. O Boyle CA, Henly SJ, Larson E. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control. 2001;29:352-360. 7. Kampf G. The six golden rules to improve compliance in hand hygiene. J Hosp Infect. 2004;56(suppl 2):S3-S5. 8. Girard R, Amazian K, Fabry J. Better compliance and better tolerance in relation to a well-conducted introduction to rub-in hand disinfection. J Hosp Infect. 2001;47:131-137. 9. Bischoff WE, Reynolds TM, Sessler CN, Edmond MB, Wenzel RP. Handwashing compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med. 2000;160: 1017-1021. 10. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med. 2004;141:1-8. 11. Muto CA, Sistrom MG, Farr BM. Hand hygiene rates unaffected by installation of dispensers of a rapidly acting hand antiseptic. Am J Infect Control. 2000;28:273-276. 12. Lankford MG, Zembower TR, Trick WE, Hacek DM, Noskin GA, Peterson LR. Influence of role models and hospital design on hand hygiene of healthcare workers. Emerg Infect Dis. 2003;9:217-223. 13. Vietri NJ, Dooley DP, Davis CE Jr, Longfield JN, Meier PA, Whelen AC. The effect of moving to a new hospital facility on the prevalence of methicillin-resistant Staphylococcus aureus. Am J Infect Control. 2004;32:262-267. AMERICAN JOURNAL OF CRITICAL CARE, July 2005, Volume 14, No. 4 309

14. King S. Provision of alcohol hand rub at the hospital bedside: a case study. J Hosp Infect. 2004;56(suppl 2):S10-S12. 15. Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol. 2000;21:381-386. 16. Cohen B, Saiman L, Cimiotti J, Larson E. Factors associated with hand hygiene practices in two neonatal intensive care units. Pediatr Infect Dis J. 2003;22:494-499. 17. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Ann Intern Med. 1999;130:126-130. 18. Ibrahim T, Smith M. The dangers of wall-mounted hand gel dispensers. J Hosp Infect. 2003;54:82. 19. Raboud J, Saskin R, Wong K, et al. Patterns of handwashing behavior and visits to patients on a general medical ward of healthcare workers. Infect Control Hosp Epidemiol. 2004;25:198-202. 310 AMERICAN JOURNAL OF CRITICAL CARE, July 2005, Volume 14, No. 4

JOURNAL CLUB ARTICLE DISCUSSION POINTS In a journal club, research articles are reviewed and critiqued. General and specific questions help to aid journal club participants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications for practice. When critically appraising this issue s AJCC journal club article, Hand Hygiene Behavior in a Pediatric Emergency Department and a Pediatric Intensive Care Unit Using 2 Dispenser Systems, consider the questions and discussion points listed below. Study Synopsis: The purpose of this study was to compare the frequency of hand hygiene practices in a pediatric emergency department and a pediatric intensive care unit (PICU) using manually operated or touch-free dispensers. A crossover study design was used with the emergency department and PICU using both types of dispensers, each during different data collection intervals. During two 2-month periods, total hand hygiene episodes per hour were monitored using manual and touch-free dispensers for alcohol sanitizer. Direct observations were used to determine indications for hand hygiene and electronic counting devices installed in each dispenser provided a count of hand hygiene episodes per hour. The study results revealed that there were significantly more total hand hygiene episodes per hour with the touch-free dispensers compared with the manual alcohol dispensers (P=.04). The most frequent indications for hand hygiene were before direct contact with patient, after touching patient s intact skin, after contact with inanimate objects in patient vicinity, and after removing gloves. The results indicate that the dispensing system is an important factor in hand hygiene. Yet, the overall hand hygiene compliance rate was low (38.4%), indicating that other efforts to improve hand hygiene need exploration. A. Description of the Study What was the purpose of the research? Why is the problem significant to nursing? B. Literature Evaluation What has previous research on hand hygiene measures explored? C. Methods and Design Describe the procedure used to collect data on frequency of hand hygiene episodes, episodes of actual hand hygiene, and number of hand hygiene opportunities. What would be the rationale for the use of a crossover study design? D. Results What were the findings of the research? What were the most frequent indications for hand hygiene? What indications for hand hygiene had the higher compliance rates? F. Clinical Significance What are implications of the study for clinical nursing? Information From the Authors: Elaine Larson, RN, PhD, lead author of this journal club article, provided additional information about the study. Larson explained that the idea for the study came about from examining the literature on previous research on hand hygiene. She reported, Adherence to hand hygiene is generally poor in every study conducted. Although alcohol hand hygiene products have been shown to improve adherence, it is still poor. We wanted to assess the impact of an equipment change on adherence. Larson explained that the study was designed to specifically compare staff use of alcohol sanitizer using a manually operated or touch-free dispenser. Larson added, Staff were informed of the study both verbally and with written posters and announcements placed in the units. She shared that the decision was made to test use of the 2 dispensers at different time frames and added, In previous work, we have noted that some dispensers, because of their location, are used considerably more than others, so it would not have been possible to, for example, use dispensers in every other site. Another option might have been to put the 2 types of dispensers side by side and let staff choose. However, that would have meant considerable more expense and disruption in already busy and high risk units. Also, the walls would have needed to be repainted or touched up after removing one or both dispensers, so the hospital requested that we simply replace one dispenser type with the other in the same location. Hence, there were practical and cost considerations, but also we avoided confounding the study by not changing the dispenser location. Implications for Practice: According to the study results, the use of touch-free alcohol dispensers resulted in significantly more hand hygiene episodes per hour, and more dispenser use per day. Larson reported that the most surprising finding of the study was the low rate of hand hygiene compliance (38.4%). She explained, Even though hand hygiene improved with the touch-free dispenser and even though staff knew that observations were being made, hand hygiene frequency was still so low. It becomes evident that additional research is needed to examine factors influencing hand hygiene behaviors. Larson concluded, Even the best products and equipment have little chance of improving patient outcomes if they are not used! Journal Club feature commentary is provided by Ruth Kleinpell. AMERICAN JOURNAL OF CRITICAL CARE, July 2005, Volume 14, No. 4 311

CE Test Test ID A051404: Hand Hygiene Behavior in a Pediatric Emergency Department and a Pediatric Intensive Care Unit: Comparison of Use of 2 Dispenser Systems. Learning objectives: (1) Compare the frequency of use of manually operated and touch-free dispensers. (2) Discuss limitations of the study and how future studies can avoid these limitations. (3) Explain a way to increase hand hygiene compliance. 1. For how long was the study conducted? a. 2 months b. 3 months c. 4 months d. 5 months 2. How did the researchers control for order effect? a. Crossover design b. Direct observation c. Ongoing monitoring d. Electronic counters 3. How was the frequency of hand hygiene episodes measured? a. Electronic counters only b. Direct observation only c. Direct observation and electronic counters d. Electronic counters and staff reports 4. According to this study, when were staff members most compliant in hand hygiene? a. After restroom use b. Before patient contact c. After touching bodily fluids d. Before inserting invasive devices 5. How was a hand hygiene compliance rate calculated? a. Proportion of times a hand hygiene episode occurred after it was indicated b. Hand hygiene indications per patient per hour c. Averaging the total number of dispenser uses per day d. Mean number of hand hygiene episodes per day per daily census 6. How was the mean number of hand hygiene episodes calculated? a. Average number of hand hygiene episodes divided by daily census b. Averaging total number of dispensers per unit per day c. Average number of hand hygiene episodes per day divided by 24 hours d. Average number of hand hygiene episodes adjusted per patient visit 7. What is one prerequisite for improving compliance with hand hygiene? a. Multiple sinks b. Several different types of sanitizers c. Frequent education d. Convenient, readily accessible dispensers 8. What do researchers suggest doing to correct one limitation of their study? a. Placing dispensers high on the wall b. Placing dispensers low on the wall c. Placing dispensers at waist level d. Placing dispensers in patients rooms by sink 9. Rates of hand hygiene episodes were higher for touch-free dispensers than for manual dispensers in which of the following areas? a. Mean number of hand hygiene episodes per hour and indication b. Mean number of hand hygiene episodes per day and patient c. Mean number of hand hygiene episodes per occurrence and patient d. Mean number of hand hygiene episodes per dispenser and unit 10. What do the researchers suggest as a feasible method for monitoring hand hygiene compliance? a. Direct observation b. Use of electronic counters c. Self-reporting d. Weekly interviews with hospital staff 11. According to the researchers, what problems are associated with direct observation studies? a. The need for multiple observers and subjects b. Direct observation is costly and time-consuming c. Sophisticated analytic software is required d. Direct observation is difficult with diverse patient populations Test Answers: Mark only one box for your answer to each question. You may photocopy this form. 1. a 2. a 3. a 4. a 5. a 6. a 7. a 8. a b b b b b b b b c c c c c c c c d d d d d d d d 9. a b c d 10. a b c d 11. a b c d Test ID: A051404 Form expires: July 1, 2007. Contact hours: 2.0 Fee: $12 Passing score: 8 correct (73%) Category: A Test writer: Kathy Rodgers, RN, MSN, CNS, CCRN, CEN. Program evaluation Name Member # Objective 2 was met Yes No Objective 1 was met Objective 3 was met Address City State ZIP Content was relevant to my Country Phone E-mail address Mail this entire page to: nursing practice My expectations were met RN License #1 State AACN This method of CE is effective RN License #2 State 101 Columbia for this content The level of difficulty of this test was: Payment by: Visa M/C AMEX Check Aliso Viejo, CA 92656 easy medium difficult To complete this program, Card # Expiration Date (800) 899-2226 it took me hours/minutes. Signature

Hand Hygiene Behavior in a Pediatric Emergency Department and a Pediatric Intensive Care Unit: Comparison of Use of 2 Dispenser Systems Elaine L. Larson, Sandra Albrecht and Mary O'Keefe Am J Crit Care 2005;14 304-311 Copyright 2005 by the American Association of Critical-Care Nurses Published online http://ajcc.aacnjournals.org/ Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=permissiondirect Subscription Information http://ajcc.aacnjournals.org/subscriptions/ Information for authors http://ajcc.aacnjournals.org/misc/ifora.xhtml Submit a manuscript http://www.editorialmanager.com/ajcc Email alerts http://ajcc.aacnjournals.org/subscriptions/etoc.xhtml The American Journal of Critical Care is an official peer-reviewed journal of the American Association of Critical-Care Nurses (AACN) published bimonthly by AACN, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright 2016 by AACN. All rights reserved.