Hand Washing

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Clean-Hands

Abstract

Clean-Hands is a project that explores solutions to promote the hand hygiene in order to reduce cross-infection through contact. Research has shown that existing solutions succeed in some aspects but fail in others. The proposed solution is a combination of current methods, improved alternatives and a wearable device that keeps track of the health care workers' behavior.

Student: Szu-Chia Lu & Andy Wu

Budget Estimation (equipments)

  • Total: $301.95
  • Arduino: $39.95
  • Parallax RFID reader: $65
  • Speaker shield for Arduino: $32
  • Hand sanitizer: $15
  • automatic soap dispenserx3: $150

From HSI:

  • 17"~20" LCD monitor X 3
  • PC X 3
  • 1 big desk our booth
  • three small desks for LCD displays

Budget Execution

  • Total: $229.91
  • Arduino: $29.95 + battery holder $1.95 + speaker $1.95 +shipping $6.75 = $40.60
  • Parallax RFID reader: $64.02 + $10.18 shipping = $64.02
  • Speaker shield for Arduino: $32
  • Hand sanitizer: $9.07
  • automatic soap dispenserx4: $27.39+$21.99+$43.16 = $92.54
  • battery: $23.68

Schedule

Sun Mon Tue Wed Thu Fri Sat

week 0

29

Schedule ready

30
31

week 1

1
2
3

Literature Review Done

4
5

CHS visitors
Alternatives proposed; budget estimated

6
7

week 2

8
9
10

Solution refined; Presentation to class

11
12

Working on project

13
14

week 3

15
16
17

Working on project

18
19

Working on project

20
21

week 4

22
23
24

Mockup & Poster ready

25
26


Thanksgiving

27


Thanksgiving

28


Thanksgiving

week 5

29


Thanksgiving

30
12/1

Dry run

2
3

Working on project

4
5

week 6

6
7

Final report due

8
9
10

Open house

11
12

Issue

  • The purpose of hand washing in the health care setting is to remove pathogenic microorganisms ("germs") and avoid transmitting them.

Why people don't wash their hands?

  • I think my hands are clean. I don't bother finding facilities to wash hands.
  • The next thing I'm going to do will pollute my hands. Therefore, I consider washing my hands after that. (and after that...)
  • I use silverware. I don't touch my food directly. Why should I wash my hands?
  • I never get sick because of not washing my hands.
  • I can't find water and soap near me.
  • I have to stop that guy from bleeding. I have to check that woman's Xray. I have to report to someone's office in 3 minutes. Washing hand is not on the highest priority in my list.
  • I have objects in my hands. I can't wash my hands.


Why people don't wash their hands? (literature review)

  • ([Guide: Improving Hand Hygiene ])
    • a lack of knowledge among personnel about the importance of hand hygiene in reducing the spread of infection and how hands become contaminated
    • lack of understanding of correct hand hygiene technique, understaffing and overcrowding, poor access to handwashing facilities, irritant contact dermatitis associated with frequent exposure to soap and water
    • lack of institutional commitment to good hand hygiene
  • Boyce, J. M., & Pittet, D. (2002). Guideline for hand hygiene in health-care settings—Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/ SHEA/APIC/IDSA Hand Hygiene Task Force. American Journal of Infection Control, 30(8), s1–s46 [for hand hygiene...]
    • Perceived barriers to adherence with hand-hygiene practice recommendations include
      • skin irritation caused by hand-hygiene agents
      • inaccessible hand-hygiene supplies
      • interference with HCW–patient relationships
      • priority of care (i.e., the patients’ needs are given priority over hand hygiene)
      • wearing of gloves
      • forgetfulness
      • lack of knowledge of the guidelines
      • insufficient time for hand hygiene
      • high workload and understaffing
      • the lack of scientific information indicating a definitive impact of improved hand hygiene on health-care–associated infection rates.
  • FACTORS INFLUENCING ADHERENCE TO HAND-HYGIENE PRACTICES (Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol 2000;21:381–6.)
    • Observed risk factors for poor adherence to recommended hand-hygiene practices
      • Physician status (rather than a nurse)
      • Nursing assistant status (rather than a nurse)
      • Male sex
      • Working in an intensive-care unit
      • Working during the week (versus the weekend)
      • Wearing gowns/gloves
      • Automated sink
      • Activities with high risk of cross-transmission
      • High number of opportunities for hand hygiene per hour of patient care
    • Self-reported factors for poor adherence with hand hygiene
      • Handwashing agents cause irritation and dryness
      • Sinks are inconveniently located/shortage of sinks
      • Lack of soap and paper towels
      • Often too busy/insufficient time
      • Understaffing/overcrowding
      • Patient needs take priority
      • Hand hygiene interferes with healthcare worker relationships with patients
      • Low risk of acquiring infection from patients
      • Wearing of gloves/beliefs that glove use obviates the need for hand hygiene
      • Lack of knowledge of guidelines/protocols
      • Not thinking about it/forgetfulness
      • No role model from colleagues or superiors
      • Skepticism regarding the value of hand hygiene
      • Disagreement with the recommendations
      • Lack of scientific information of definitive impact of improved hand hygiene on health-care–associated infection rates
    • Additional perceived barriers to appropriate hand hygiene
      • Lack of active participation in hand-hygiene promotion at individual or institutional level
      • Lack of role model for hand hygiene
      • Lack of institutional priority for hand hygiene
      • Lack of administrative sanction of noncompliers/rewarding compliers
      • Lack of institutional safety climate
  • Dorsey, S.T., Cydulka, R.K. and Emerman, C.L., 1996, Is Handwashing Teachable?: Failure to Improve Handwashing Behavior in an Urban Emergency Department, Academy of Emergency Medicine, 3(4): 360-5.
    • overwhelming in the ED where the physician must dash between multiple patients in the course of a shift.
    • sinks are located in awkward areas
  • Voss, A. and Widmer, A.F., 1997, No Time for Handwashing!? Handwashing Versus Alcoholic Rub: Can We Aðord 100% compliance?, Infect Control Hosp Epidemiol, 18(3): 205-8.
    • handwashing (40-80 seconds), and Alcoholic hand disinfection (20 seconds)
  • Cohen, H.A., Kitai, E., Levy, I. and Ben-Amitai, D., 2002, Handwashing Patterns in Two Dermatology Clinics, Dermatology, 205(4): 358-61.
    • The questionnaire results indicated that routine hand-washing, before or after every patient examination was practiced about 40% of the physicians. 37.3% physicians reported handwashing only following contact with suspected contaminants. Thus, handwashing is not routine procedure among dermatologists.
    • The second most common reason for noncompliance was sensitivity to the cleanser.
    • Several studies conducted in recent years have failed to demostrate the efficacy of education/biofeedback interventions and patients awareness program, or equipment improvements, on hand hygiene compliance. However, the introduction of a waterless alcohol-based handwashing antiseptic led to significantly higher handwashing rates among heath care worker.
  • Dorsey, S.T., Cydulka, R.K. and Emerman, C.L., 1996, Is Handwashing Teachable?: Failure to Improve Handwashing Behavior in an Urban Emergency Department, Academy of Emergency Medicine, 3(4): 360-5.
    • Results: A total of 252 situations requiring handwashing were observed, 132 pre-intervention and 120 post- intervention. Total handwashing, handwashing by each staff designation, and handwashing in each CDC recommendation category - except handwashing between contacts with different patients - all showed tendencies toward improvement, though none was significant ( p > 0.05). Both the NPs and the RNs demonstrated significantly higher adherence to recommended handwashing between patients after the intervention than did the EPs (85% vs 71% vs 31%, p < 0.01 and p < 0.05, respectively).
    • Conclusion: Despite a trend in improvement of compliance with CDC recommendations, handwashing among ED personnel remained unacceptably low.

Related Work/Existing Solutions

  • Hand washing in wikipedia
  • NIC Clean Pocket
  • Hand washing signs - [sign]
  • multi-purpose disinfectant [Virkon] -> cannot be used as a hand-washing liquid
  • Hand Sanitizer - [sanitizer]
  • Drying methods: Paper towels and roll -> Decrease of 24% on Bacterial Count; Hot-air drier -> Increase of 117% on Bacterial Count
  • Wearing gloves during patient care is an additional intervention to help reduce transmission of infectious agents in high-risk situations. However, gloves must be used properly. Gloves can become contaminated during care and must be removed or changed when moving from a contaminated site to a clean site on the same patient. Gloved hands can also become contaminated due to tiny punctures in the glove material or during glove removal; therefore, hand hygiene must be performed immediately after glove removal. Consequently, use of gloves is an important adjunct to, but not a replacement for, proper hand hygiene practice.
  • The following four components of the hand hygiene intervention package are critical aspects of a multidimensional hand hygiene program. Glove use is included in this package because proper glove use is inextricably linked to effective hand hygiene.
  1. Clinical staff, including new hires and trainees, understand key elements of hand hygiene practice (demonstrate knowledge)
  2. Clinical staff, including new hires and trainees, use appropriate technique when cleansing their hands (demonstrate competence)
  3. Alcohol-based hand rub and gloves are available at the point of care (enable staff)
  4. Hand hygiene is performed at the right time and in the right way and gloves are used appropriately as recommended by CDC’s Standard Precautions (verify competency, monitor compliance, and provide feedback)
  • Bischoff et al. found that compliance by health care workers was significantly greater when dispensers for alcohol-based hand rub were adjacent to each patient’s bed than when there was only one dispenser for every four beds. In critical care, availability of alcohol-based hand rub at the point of care proved to minimize the time constraint associated with hand hygiene during patient care and to predict better compliance. (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.)
  • In a study of hand hygiene among physicians, Pittet et al. found that easy access to an alcohol-based hand rub was an independent predictor of improved hand hygiene compliance.(Pittet D, Hugonnet S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet. 2000;356:1307-1312.;Hugonnet S, Perneger TV, Pittet D. Alcohol-based hand rub improves compliance with hand hygiene in intensive care units. Arch Int Med. 2002;162:1037-1043.;Pittet D, Simon A, Hugonnet S, et al. Hand hygiene among physicians: Performance, beliefs, and perceptions. Ann Intern Med. 2004;148:1-8.)
  • IHI's suggestions: Form a team -> set an aim -> measure periodically
    • Placing dispensers for alcohol-based hand rub and boxes of clean gloves of various sizes near the point of care, such as:
      • Next to each patient’s bed o Attached to the frame of patient beds
      • Near the door to each patient’s room (either adjacent to the door in the corridor or just inside the door)
      • At nursing stations or on medication carts o Supplied as portable (pocket or belt) individual dispensers for personal use
    • Installing alcohol-based hand rub dispensers in locations that are compliant with local and federal fire safety regulations
    • Assigning responsibility for checking alcohol-based hand rub dispensers and glove boxes on a regular basis to assure that:
      • Dispensers and glove boxes are not empty
      • Dispensers are operational
      • Dispensers provide the correct amount of the product
    • Evaluating the design and function of dispensers before selecting a product for use since poorly functioning dispensers may adversely affect hand hygiene compliance rates
  • CDC Guideline for Hand Hygiene in Health-Care Settings. These recommendations include
    • Washing hands with plain soap or with antimicrobial soap and water, as follows:
      • When hands are visibly dirty or contaminated with proteinaceous material or with blood or other body fluids
      • Before eating o After using the restroom o After caring for patients colonized with Clostridium difficile
    • If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in the following situations:
      • Before direct contact with patients
      • Before donning sterile gloves when inserting a central intravascular catheter
      • Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices
      • After direct contact with a patient’s skin
      • After contact with body fluids, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled
      • When moving from a contaminated body site to a clean body site during patient care
      • After contact with inanimate objects in the immediate vicinity of the patient
      • After removing gloves
    • If there has been any contact with the patient or the patient’s environment, hands should be decontaminated when leaving the patient’s bedside or room
  • Barriers That May Be Encountered
    • Reluctance to change, tolerance of the status quo: All change is difficult. The antidote is knowledge about the deficiencies of the present process and optimism about the potential benefits of a new process. The rate of compliance in most institutions is woeful, and dramatic improvement is possible.
    • Lack of leadership commitment and follow-through: Hard work and good intentions cannot produce dramatic, long-term change without leadership buy-in and support.
    • Failure to educate and communicate: Staff must understand the rationale for hand hygiene and glove practices, the danger of non-compliance to themselves and their patients, and the effectiveness and tolerability of hand hygiene products.
    • Failure to tailor product selection to staff preferences: Staff should test products before they are introduced.
    • Lack of staff self-efficacy and empowerment: Staff must believe that they have the ability and power to make major improvements.
    • Failure to make compliance a social norm and establish a culture of safety: Staff must be empowered to remind other caregivers, regardless of rank or position, to practice hand hygiene. This should be reinforced by patients.
    • Failure to provide real time feedback of performance data: Performance data should be communicated regularly and properly. Post trended data prominently.
    • Lack of a cohesive approach to behavior change: A multi-factorial, creative approach to behavior change is essential.
    • Lack of physician buy-in: Opinion leaders, role models, and physician champions, armed with educational materials and evidence, are essential.
  • The majority of alcohol-based hand antiseptics contain either isopropanol, ethanol, n-propanol, or a combination of two of these products. Alcohol solutions containing 60%–95% alcohol are most effective, and higher concentrations are less potent because proteins are not denatured easily in the absence of water.
  • PROPOSED METHODS FOR REDUCING ADVERSE EFFECTS OF AGENTS(Antimicrobial substances that are applied to the skin to reduce the number of microbial flora. Examples include alcohols, chlorhexidine, chlorine, hexa- chlorophene, iodine, chloroxylenol (PCMX), quaternary ammonium compounds, and triclosan)
    • reducing the frequency of exposure to irritating agents
      • One strategy for reducing the exposure of personnel to irritating soaps and detergents is to promote the use of alcohol-based hand rubs containing various emollients.
      • Hand lotions and creams often contain humectants and various fats and oils that can increase skin hydration and replace altered or depleted skin lipids that contribute to the barrier function of normal skin.
      • barrier creams have been marketed for the prevention of hand-hygiene–related irritant contact dermatitis. Such products are absorbed to the superficial layers of the epidermis and are designed to form a protective layer that is not removed by standard handwashing-whether barrier creams are effective in preventing irritant contact dermatitis among HCWs remains unknown.
    • replacing products with high irritation potential with preparations that cause less damage to the skin
    • educating personnel regarding the risks of irritant contact dermatitis
    • providing caregivers with moisturizing skin-care products or barrier creams
  • STRATEGIES FOR SUCCESSFUL PROMOTION OF HAND HYGIENE IN HOSPITALS
    • Education
    • Routine observation and feedback
    • Engineering control
    • Make hand hygiene possible, easy, and convenient
    • Make alcohol-based hand rub available (at least in high-demand situations)
    • Patient education
    • Reminders in the workplace
    • Administrative sanction/rewarding
    • Change in hand-hygiene agent
    • Promote/facilitate skin care for health-care–workers’ hands
    • Obtain active participation at individual and institutional level
    • Improve institutional safety climate
    • Enhance individual and institutional self-efficacy
    • Avoid overcrowding, understaffing, and excessive workload
    • Combine several of above strategies

Design Alternatives

Using Active Ads

An LCD display to remind people washing hands by using

  • statistical facts, e.g. 40 percent of people exiting bathrooms fail to wash their hands...
  • interesting signs
  • video clips
pro
  • easy to deploy and update
  • can be used for other health promotions
  • can catch people's eye
con
  • cost: LCD monitor and computer (optional: wireless connection)
  • need power supply
  • just a reminder
  • cannot hang/place everywhere

Hand bacteria detector and display

  • a piece of skin detector showing how soiled the hands are when person touch the device to enforce the motivation of washing hands
pro
  • people will know they need to wash their hands clearly
  • enforce the psychological motivation to wash hands
con
  • still just a reminder
  • technology might not be available yet
  • People have no idea the safe number of bacteria allowed.
discussion
  • These are evolved versions of a conventional sign.
  • We can add sensors to these devices. So that, they show messages when people are close to them.
  • We can add speakers to them.

Wearable Device

An RFID reader attached to the suit of physicians and nurses. When they are close to tagged places (exam rooms), objects (medical records), facilities (washing basins)... the device sends reminders or dispenses hand sanitizer.

pro
  • Tag any objects with RFID tags
con
  • Cost
  • Everyone needs to carry this device.
discussion

Hand Sanitizer Everywhere

Install as many sanitizers as we can. In exam rooms, next to nursing stations, at the door... This device detects the approach of human and dispenses sanitizer. For example: when you turn a door knob, it squeezes sanitizer onto your hands.

pro
  • Don't have to bring with you but still in reachable place
  • We are forced to wash our hands
con
  • Can't be really "everywhere"
  • If people ignore them, still no use.
  • We are forced to wash our hands-what if I have something in my hands?
discussion
  • Sanitizers with speakers-> "Hey, wash your hands!"

Portable Sanitizer

Nap Sanitizer, portable sanitizers

pro
  • go with you to everywhere
  • easy to deploy to everyone
con
  • have to carry it all the time
discussion

Reducing Infections Spread by Contact

pro
con
discussion

Analysis

Radar chart of our analysis Comparison.png

Terminologies

  • HCW: Health-Care Worker

Showcase Figures

  • RFID tag (CleanHands Buzzer Card)

CleanHandsBuzzerCard.png

  • CleanHands Buzzer

CleanHandBuzzer1.jpg

CleanHandBuzzer2.jpg

  • CleanHands Map

FloorPlan.png

  • Poster

File:Clean-hands small.pdf

  • brochure

Brochure1.png

Brochure2.png

  • videos

The video played in dynamic display

Final Report

File:FinalreportCleanHands.pdf