Positive deviance: a new strategy for improving hand hygiene compliance.

OBJECTIVE: To evaluate the effectiveness of a positive deviance strategy for the improvement of hand hygiene compliance in 2 adult step-down units. DESIGN: A 9-month, controlled trial comparing the effect of positive deviance on compliance with hand hygiene. SETTING: Two 20-bed step-down units at a tertiary care private hospital. METHODS: The first phase of our study was a 3-month baseline period (from April to June 2008) in which hand hygiene episodes were counted by use of electronic handwashing counters. From July to September 2008 (ie, the second phase), a positive deviance strategy was implemented in the east unit; the west unit was the control unit. During the period from October to December 2008 (ie, the third phase), positive deviance was applied in both units. RESULTS: During the first phase, there was no statistically significant difference between the 2 step-down units in the number of episodes of hand hygiene per 1,000 patient-days or in the incidence density of healthcare-associated infections (HAIs) per 1,000 patient-days. During the second phase, there were 62,000 hand hygiene episodes per 1,000 patient-days in the east unit and 33,570 hand hygiene episodes per 1,000 patient-days in the west unit (P < .01 ). The incidence density of HAIs per 1,000 patient-days was 6.5 in the east unit and 12.7 in the west unit (p = .04). During the third phase, there was no statistically significant difference in hand hygiene episodes per 1,000 patient-days (P = .16) or in incidence density of HAIs per 1,000 patient-days. CONCLUSION: A positive deviance strategy yielded a significant improvement in hand hygiene, which was associated with a decrease in the overall incidence of HAIs.

Controlled trial measuring the effect of a feedback intervention on hand hygiene compliance in a step-down unit.

OBJECTIVE: To evaluate hand hygiene compliance in 2 adult step-down units (SDUs). DESIGN: A 6-month (from March to September 2007), controlled trial comparing 2 SDUs, one with a feedback intervention program (ie, the intervention unit) and one without (ie, the control unit). SETTING: Two 20-bed SDUs at a tertiary care private hospital. METHODS: Hand hygiene episodes were measured by electronic recording devices and periodic observational surveys. In the intervention unit, feedback was provided by the SDU nurse manager, who explained twice a week to the healthcare workers the goals and targets for the process measures. RESULTS: A total of 117,579 hand hygiene episodes were recorded in the intervention unit, and a total of 110,718 were recorded in the control unit (P = .63). There was no significant difference in the amount of chlorhexidine used in the intervention and control units (34.0 vs 26.7 L per 1,000 patient-days; P = .36) or the amount of alcohol gel used (72.5 vs 70.7 L per 1,000 patient-days; P = .93). However, in both units, healthcare workers used alcohol gel more frequently than chlorhexidine (143.2 vs 60.7 L per 1,000 patient-days; P < .001). Nosocomial infection rates in the intervention and control units, respectively, were as follows: for bloodstream infection, 3.5 and 0.79 infections per 1,000 catheter-days (P = .18); for urinary tract infection, 15.8 and 15.7 infections per 1,000 catheter-days (P = .99); and for tracheostomy-associated pneumonia, 10.7 and 5.1 infections per 1,000 device-days (P = .13). There were no cases of infection with vancomycin-resistant enterococci and only a single case of infection with methicillin-resistant Staphylococcus aureus (in the control unit). CONCLUSIONS: The feedback intervention regarding hand hygiene had no significant effect on the rate of compliance. Other measures must be used to increase and sustain the rate of hand hygiene compliance.