Perform hand hygiene and the doors will open – the effectiveness of new system implementation on paediatric intensive care unit visitors’ handwashing compliance

Hand hygiene (HH) performance on entering intensive care units (ICUs) is commonly accepted but often inadequately performed. We developed a simple, inexpensive module that connects touchless dispensers of alcohol sanitiser (TDAS) to the automatic doors of a paediatric ICU, and assessed the impact of this intervention on HH compliance of hospital staff and visitors. A prospective observational study was conducted over a 3-week period prior to the intervention, followed by a 4-week period post intervention. HH performance was monitored by a research assistant whose office location enabled direct and video-assisted observation of the ICU entrance. A total of 609 entries to the ICU was recorded. Overall HH performance was 46.9% (92/196) before and 98.5% (406/413) after the intervention. Our findings suggest that HH performance on entering an ICU can be improved via a mechanism that makes operation of an automatic door dependent on use of a TDAS system, and thus contribute to infection control.

Hand hygiene (HH) is a universally recognised critical infection-control measure as efficient hand antisepsis reduces the incidence of outbreaks of health-care-associated infections (HCAIs), which can often be traced to poor practice of health-care workers (HCWs) [1]. Visitors may also be vectors for pathogen transmission in the ward and potentially import community-associated antimicrobial-resistant organisms [2]. In the paediatric setting, interventions to improve HH compliance among parents have been shown to reduce the incidence of viral HCAI in a neonatal intensive care unit (ICU) [3]. Although visitor restriction policies and practices vary in different paediatric facilities [4], the COVID-19 pandemic has raised general awareness of the importance of infection control measures. Increasing hospital staff engagement and HH compliance are therefore key measures for more effective infection control [5].

Technological solutions have been developed to enhance monitoring of HH compliance, but should be accompanied with educational tools [6]. Similarly, accessibility of hand-washing devices does not alone lead to perfect compliance [7], and educational campaigns and signage to inform visitors to hospitals of HH have also proved insufficient [8].

Our innovation connected the physical barrier to entering the paediatric ICU (PICU) (automatic electric doors) with readily accessible touchless dispensers of alcohol sanitiser (TDAS) to assess its impact on HH compliance of PICU visitors and staff before and after implementation of the intervention. A secondary aim was to evaluate the baseline compliance with local HH guidelines in different staff sectors.

The study was performed at the PICU of Kaplan Medical Centre (KMC), affiliated with the Hebrew University of Jerusalem, Israel. The six-bed PICU has four semi-open single rooms and two rooms for patients who need airborne isolation. The main entrance to the unit is through door A ( ) which can be opened automatically by staff key-card or by the guests' intercom system. Visitors first enter the lobby and then pass into the main area through door B. Alternatively, the visitor can enter the corridor where the staff offices and the parents’ resting rooms are located, and progress to the main area through door C. TDAS systems (Steripower©, Starnberg, Germany) were connected to the opening mechanism of doors B and C via an electronic module developed in-house which initiates automatic door opening after HH has been performed (Supplementary Fig. S1).

In order to evaluate the impact of the devices, the connection was not activated in the first stage of the study. Large signs located above the entrance doors instructed visitors to perform HH from dispensers adjacent to the automatic doors before entering the PICU. The PICU secretary, whose office is located in the unit lobby, served as a research assistant for the purpose of the study and monitored HH compliance by staff and visitors using hidden video cameras in the first study stage for 3 weeks. Only the research initiators and members of the institutional review board (IRB) were aware of the study, to prevent the ‘Hawthorne effect’ whereby people improve behaviour only because they are being observed. We included in the study all visitors to the PICU during morning shifts in the study period, and excluded the study authors. Each entry was recorded. In the second stage of the study the connections between the dispensers and the door mechanisms were activated, and HH compliance was monitored for an additional 4 weeks. Hospital staff retained the option to open the doors with a key-card, without activating the TDAS.

The primary outcome was defined as the proportion of individuals who performed HH before entering the PICU. ‘HH performance’ was completed if both of the entering individuals' hands were inserted into the TDAS device. The primary objective was to compare rates of HH compliance in different sectors during the first and second study stages for PICU staff, other hospital HCWs patients' parents and other visitors. Data were analysed for statistical significance by using the Fisher exact test.

During the 7-week study period, a total 609 entries to the PICU were recorded; 196 were logged in the first 3-week stage prior to the intervention, and 413 post intervention ( ). Overall HH performance was 46.9% (92/196) before, and 98.5% (406/413), after the intervention. PICU staff performed HH on 81.8% (27/33) of entries before the intervention and all (78) were compliant in the second stage. Notably, the nutritionists proved to be the most compliant with HH practice (100% (8/8)), followed by visiting physicians (65% (22/34)). By contrast, several other staff sectors such as X-ray technicians, ancillary and security staff failed to perform adequate HH before the intervention but only six entries of PICU visitors without HH performance were recorded after the intervention ( ).

Table 1.

Before interventionAfter interventionP-valueHH (N)%No HH (N)%Total beforeHH (N)%No HH (N)%Total afterPICU staff2781.8618.23378100.000.0780.0005PICU visitors (HCWs)Physicians2264.71235.3347598.711.376<0.0001Nurses523.81676.22141100.000.041<0.0001X-ray technicians00.04100.044100.000.040.0286Housekeeping workers325.0975.0126100.000.060.009Kitchen workers325.0975.0121493.316.7150.0008Nutritionists8100.000.0815100.000.0151Porters00.05100.052392.028.0250.0001Maintenance workers00.010100.01016100.000.016<0.0001Educational staff746.7853.31544100.000.044<0.0001Pharmacists114.3685.7710100.000.0100.0006Security staff00.01100.01375.0125.040.4Ventilation technicians00.02100.02266.7133.330.4Other visitors432.7555.6910100.000.0100.0108Total HCWs (visitors)5337.98762.114026397.862.2269<0.0001Patients' parents1252.21147.82366100.000.066<0.0001Total (visitors and staff)9246.910453.119640798.561.5413<0.0001Open in a separate window

Previous studies have reported variable HH compliance rates among ICU staff. Nishimura et al. used video camera monitoring of HH compliance rates of all visitors entering an ICU over a 7-day period and reported rates of 71% for ICU staff, 74% for other staff and 95% for patients’ visitors [9]. By comparison, only 34% of hospital personnel in two US hospitals were reported to comply with HH performance according to the WHO's standardised method [10].

Our hospital policy requires all HCWs and visitors to perform HH before entering the ICU. Surprisingly, only half of the patients' parents (12/23) did so prior to the study intervention. Indeed, compliance rates as low as 10% by hospital visitors, despite proper signage and easy access to alcohol dispensers, has been reported. Similarly, as recorded here and by others [10], compliance of other HCWs was less than that of patients' parents (37.9% of entries) [10].

The prevalence of HCAI remains high even in developed countries with stringent infection-control measures. Most nosocomial pathogens are transmitted via the hands of health-care personnel and caregivers, from contaminated surfaces or equipment in the hospital environment [11]. The introduction of HH institutional policies has been proven to reduce HAIs and to be cost-effective [12], and the placing of barriers with mandatory HH performance should be a component of this policy.

Barriers to adherence with HH recommendations include structural aspects, knowledge gaps and especially a lack of time in daily routine practice. The latter issue is pivotal [9] as HH performance using TDAS can be measured in seconds. Similarly, siting a mandatory TDAS usage barrier at the entrance to the PICU should not directly affect compliance with the ‘five moments for hands hygiene’ model but is complementary to the process. This intervention reminds visitors that they are entering a ‘clean zone’ and diminishes baseline hand contamination with minimal time investment.

Our study has some limitations. First, the pre-post study design can be affected by unexpected biases. We made our best effort to keep the study secret. Second, the connection of the door entry mechanism to the TDAS may allow groups of people to enter at the same time without all performing HH. Third, the study wasn't planned to assess the impact of the intervention on the incidence of HAIs, and the load of potentially pathogenic bacteria on the hands of visitors was not evaluated. Nevertheless, this study shows how readily HH compliance can be achieved. The groups (before and after the intervention) differed in size, as we wished to ensure that the effect was sustainable, and data collection was therefore continued for a longer-than-planned period of time. Occasional changes in volume of PICU activity also increased the number of observations between pre- and post-intervention periods. Moreover, data collection was performed only during the day-shifts and not on weekends, because of the logistical issues.

In conclusion, our study shows that significant improvement of HH performance on entering the PICU by hospital staff and other visitors was achieved subsequent to implementation of the intervention. The improvement was surprisingly high in hospital staff, since personnel could use key-cards to open the doors. Our findings suggest that HH performance on entering any healthcare facility can be dramatically improved by installing this inexpensive and easy-to use module, and could be extended to out of hospital platforms as part of the global effort to prevent the spread of infectious diseases.

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How to Reduce Surface Contamination with Automatic Hospital Doors

Hospital entrance doors play a pivotal role in maintaining the hygiene and safety of healthcare environments. As the primary gateway where countless individuals – from medical staff to patients and visitors – pass through daily, hospital doors are not merely physical barriers but are instrumental in controlling the spread of contaminants.

In this blog post, we will delve into the specific designs and functionalities of sliding doors and other healthcare doors used in hospitals. Hygienic automatic doors, through advanced technologies and stringent operational protocols, significantly lower the risk of contamination in healthcare facilities.

Infection control in healthcare environments

The arrival of COVID-19 has taught us many things – not the least of which is the need to exercise more caution when it comes to modes of disease transmission.

Indeed, infectious diseases have always been around, with some of them surging seasonally as in the case of poliomyelitis, measles and flu. However, the high mortality rate attributed to the new coronavirus has forced health experts and scientists to reassess how we have been living with various microbes in our surroundings.

In healthcare settings where the possibility of disease transmission is high, hospital and clinical personnel follow strict protocols to minimise the spread of infection. These measures include following prescribed assessment and treatment procedures, the proper disposal of medical waste, restricting certain sections to authorised personnel, requiring the use of PPEs, and the regular disinfection of instruments, machines and other hospital appliances.

Hospital settings during COVID-19

With the COVID-19 pandemic, healthcare facilities in high-case countries have been constantly overwhelmed by the rise in cases, so the fear of hospital-acquired infections (HAIs) is much higher.

In the United States, where there are now nearly 14 million cases and over 270,000 deaths on record, over 900 medical front liners have succumbed to COVID-19 as of August 2020.

In the UK, places like Wales have reported an increase in hospital transmissions, while a four-month study in England revealed that at least 10% of COVID-19 cases were due to HAIs.

This is why today it is more important than ever to ensure hygiene standards and guidelines are continually being observed to prevent the spread of disease from patients to health workers and other patient rooms.

In Australia, where COVID-19 cases and mortality rates are relatively lower, medical professionals follow the NHMRC issued guidelines.

The guidelines include instructions on the specific clinical management and care of people with suspected or confirmed COVID-19 infection, including procedures to be followed based on the patient’s life stage or age. This, coupled with more ideal medical situations where there is no overcrowding has helped to control the spread of the new coronavirus within hospitals.

Aside from the importance of protecting patients and processes in managing hygiene and reducing intra-hospital disease transmissions, there are also engineering controls in place to control infection.

One of the key aspects of engineered control mechanisms that promote safety in medical centres is healthcare doors. Since healthcare doors function as entrance and exit points, they are considered high-touch areas where disease-causing germs can stay alive for hours or days.

The role of contaminated surfaces in disease transmission

A University of Leeds study back in 2015 revealed that intra-hospital disease transmissions occur when infected patients’ bacteria or viruses end up on surfaces. When uninfected people touch these surfaces, they can get sick themselves or spread the germs to others who are more susceptible to infection.

In the case of the new coronavirus, research has shown that the duration of its viability depends on what type of surface it is left on.

For example, earlier studies showed it can survive for five days on glass and metal surfaces such as jewellery, door hardware and silverware, four days on wooden surfaces, and two to three days on various plastic laminate products.

However, according to a newer study published in the Virology Journal, the new coronavirus can survive on surfaces (e.g. phone screens, paper money and stainless steel) for as long as 28 days. It can also survive much longer at lower (colder) temperatures and on smooth, non-porous surfaces like glass and stainless steel.

Since hospital doors (and commercial automatic doors in general) are usually made of metal and glass, hospital door manufacturers are now offering medical establishments a chance to reduce surface contamination by using automated hospital entrance doors – whether it’s by retrofitting public entrances or installing new corridor doors, toilet doors or any type of hospital door for the healthcare facility.

Touchless automatic doors for better hygiene

To address concerns regarding disease transmission, establishments in Perth and the rest of Western Australia are adopting touchless automatic door technology.

This technology enables people to utilise access points without the need to touch shared surfaces that can get contaminated with bacteria, viruses and other types of germs. Referred to as ‘fomites’ in medical terminology, inanimate objects that can facilitate disease transmission in hospital settings include the door frame, push plates, door handles, doorknobs, keypads, buttons and intercoms.

Now that COVID-19 health protocols continue to ease and more people venture out, it is paramount for public and private institutions to make their spaces safe and hygienic for everyone.

Aside from improving hygiene by eliminating the need to touch a door or knob, touchless automatic doors also provide other benefits, such as:

• Energy efficiency: The automated mechanism of automatic sliding doors ensures the rapid opening and closing of entryways. This helps to maintain a room’s ideal temperature and improves insulation.
• Access control: Depending on the model you choose, hospital doors become seamless entry and exit points, as all you need to do is wave your hand or arm to open them.
• Noise control: Installing door sensor technology effectively eliminates creaking sounds that are produced when opening and closing conventional doors.

The hygiene component of touchless doors, such as revolving doors, is enhanced as airtight seals that work as barriers against different airborne debris, allergens, pollution and odours.

What’s more, even if you have existing hospital swing doors, Go Doors can retrofit your healthcare facility so you can begin enjoying the benefits of door sensor technology. Hospitals using push-button access can be retrofitted with new Go Doors touchless sensors – no matter the hospital door width, too.

Hygienic secure doors from Go Doors

Ensure safety and hygiene are maintained in your hospital or healthcare facility by adopting touchless and secure hospital entrance doors.

Go Doors is the sole Western Australia sales agent of globally renowned RECORD Automatic Doors – the Swiss maker of precision automatic door operators used in toilets for the handicapped, hospitals, shopping malls and international airports. Get in touch with Go Doors today!