Hand Hygiene Compliance in the ICU: A Systematic Review.

OBJECTIVES: To synthesize the literature describing compliance with World Health Organization hand hygiene guidelines in ICUs, to evaluate the quality of extant research, and to examine differences in compliance levels across geographical regions, ICU types, and healthcare worker groups, observation methods, and moments (indications) of hand hygiene. DATA SOURCES: Electronic searches were conducted in August 2018 using Medline, CINAHL, PsycInfo, Embase, and Web of Science. Reference lists of included studies and related review articles were also screened. STUDY SELECTION: English-language, peer-reviewed studies measuring hand hygiene compliance by healthcare workers in an ICU setting using direct observation guided by the World Health Organization's "Five Moments for Hand Hygiene," published since 2009, were included. DATA EXTRACTION: Information was extracted on study location, research design, type of ICU, healthcare workers, measurement procedures, and compliance levels. DATA SYNTHESIS: Sixty-one studies were included. Most were conducted in high-income countries (60.7%) and in adult ICUs (85.2%). Mean hand hygiene compliance was 59.6%. Compliance levels appeared to differ by geographic region (high-income countries 64.5%, low-income countries 9.1%), type of ICU (neonatal 67.0%, pediatric 41.2%, adult 58.2%), and type of healthcare worker (nursing staff 43.4%, physicians 32.6%, other staff 53.8%). CONCLUSIONS: Mean hand hygiene compliance appears notably lower than international targets. The data collated may offer useful indicators for those evaluating, and seeking to improve, hand hygiene compliance in ICUs internationally.

Guided Reflection Interventions Show No Effect on Diagnostic Accuracy in Medical Students.

Background: Guided reflection interventions, in an effort to reduce diagnostic error, encourage diagnosticians to generate alternative diagnostic hypotheses and gather confirming and disconfirming evidence before making a final diagnosis. This method has been found to significantly improve diagnostic accuracy in recent studies; however, it requires a significant investment of time, and psychological theory suggests the possibility for unintended consequences owing to cognitive bias. This study compared a short and long version of a guided reflection task on improvements in diagnostic accuracy, change in diagnostic confidence, and rates of corrected diagnoses. Methods: One hundred and eighty-six fourth- and fifth-year medical students diagnosed a series of fictional clinical cases, by first impressions (control condition) or by using a short or long guided reflection process, and rated their confidence in their initial diagnostic hypothesis at intervals throughout the process. In the "short" condition, participants were asked to generate two alternatives to their initial diagnostic hypothesis; in the "long" condition, six alternatives were required. Results: The reflective intervention did not elicit more accurate final diagnoses than diagnosis based on first impressions only. Participants who completed a short version of the task performed similarly to those who completed a long version. Neither the short nor long form elicited significant changes in diagnostic confidence from the beginning to the end of the diagnostic process, nor did the conditions differ on the rate of corrected diagnoses. Conclusions: This study finds no evidence to support the use of the guided reflection method as a diagnostic aid for novice diagnosticians, who may already use an analytical approach to diagnosis and therefore derive less benefit from this intervention than their more experienced colleagues. The results indicate some support for a shorter, less demanding version of the process, and further study is now required to identify the most efficient process to recommend to doctors.

Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review.

BACKGROUND: Diagnostic error incurs enormous human and economic costs. The dual-process model reasoning provides a framework for understanding the diagnostic process and attributes certain errors to faulty cognitive shortcuts (heuristics). The literature contains many suggestions to counteract these and to enhance analytical and non-analytical modes of reasoning. AIMS: To identify, describe and appraise studies that have empirically investigated interventions to enhance analytical and non-analytical reasoning among medical trainees and doctors, and to assess their effectiveness. METHODS: Systematic searches of five databases were carried out (Medline, PsycInfo, Embase, Education Resource Information Centre (ERIC) and Cochrane Database of Controlled Trials), supplemented with searches of bibliographies and relevant journals. Included studies evaluated an intervention to enhance analytical and/or non-analytical reasoning among medical trainees or doctors. FINDINGS: Twenty-eight studies were included under five categories: educational interventions, checklists, cognitive forcing strategies, guided reflection, instructions at test and other interventions. While many of the studies found some effect of interventions, guided reflection interventions emerged as the most consistently successful across five studies, and cognitive forcing strategies improved accuracy and confidence judgements. Significant heterogeneity of measurement approaches was observed, and existing studies are largely limited to early-career doctors. CONCLUSIONS: Results to date are promising and this relatively young field is now close to a point where these kinds of cognitive interventions can be recommended to educators. Further research with refined methodology and more diverse samples is required before firm recommendations may be made for medical education and policy; however, these results suggest that such interventions hold promise, with much current enthusiasm for new research.