Overall, engagement and compliance from the crowd-sourced hand hygiene observation program, Clean-In-Clean-Out (CICO), were similar between 2019 (96.6%) and 2020 (96.7%) despite fluctuations within 2020 that reflected our hospital's coronavirus disease 2019 (COVID-19) experience. Shared responsibility and just-in-time reminders can allow manual hand hygiene observation models to be sustainable

DiBiase, L.M.

Sickbert-Bennett, E.E.

Stancill, L.B.

Carolina Digital Repository

Concise CommunicationSustainability of a well-established hand hygiene program during thecoronavirus disease 2019 (COVID-19) pandemicLisa B. Stancill MPH1 , Emily E. Sickbert-Bennett PhD, MS, CIC1,2,3 and Lauren M. DiBiase MS, CIC1,31Department of Infection Prevention, University of North Carolina at Chapel Hill Medical Center, Chapel Hill, North Carolina, 2University of North Carolina GillingsSchool of Global Public Health, Chapel Hill, North Carolina and 3UNC School of Medicine, University of North Carolina, Chapel Hill, North CarolinaAbstractOverall, engagement and compliance from the crowd-sourced hand hygiene observation program, Clean-In-Clean-Out (CICO), were similarbetween 2019 (96.6%) and 2020 (96.7%) despite fluctuations within 2020 that reflected our hospital’s coronavirus disease 2019 (COVID-19)experience. Shared responsibility and just-in-time reminders can allow manual hand hygiene observation models to be sustainable.Keywords Hand hygiene; COVID-19(Received 10 October 2021; accepted 6 January 2022)Hand hygiene is a cornerstone of infection prevention and isroutinely tracked in hospital settings. During the coronavirus disease2019 (COVID-19) pandemic, the main focus has been on airborneand droplet transmission, but the importance of handhygiene has alsohad renewed emphasis. Severe acute respiratory coronavirus virus 2(SARS-CoV-2) can survive onhuman skin for∼9 hours, but it is easilyinactivated with an alcohol-based hand rub, reinforcing the role ofhand hygiene in limiting the COVID-19 spread.1To date, evaluations of hand hygiene in hospital settings duringCOVID-19 have focused on automated monitoring systems whichcollect compliance data through badge readers and/or dispenseruse, eliminating the need for staff to perform traditional handhygiene observations.2–4 By contrast, we sought to determinewhether UNC Medical Center’s Clean-In-Clean-Out (CICO) pro-gram,5 a well-established albeit manual method for hand hygieneobservations, was sustainable throughout a public health andhealthcare crisis. We also sought to determine whether theCOVID-19 pandemic had an effect on hand hygiene complianceby longitudinally examining key metrics of the CICO program.MethodsUNCMedical Center utilizes a crowd-sourced hand hygiene auditapplication, CICO, to track hand hygiene observations and com-pliance.5 Briefly, CICO can be accessed on any device on the hos-pital network via a web browser in all care settings. All staff areinvited to participate with a suggested 5 observations per month,and they are encouraged to provide real-time feedback (compli-ment or reminder) when performing observations.5,6During this evaluation, key hand hygiene metric data were que-ried from the CICO application regarding the following elements:(1) engagement, the absolute number of observations performedoverall and per 1,000 patient days; (2) compliance, hand hygienecompliance percentage; and (3) accountability, the percentage ofobservations with feedback from January 2019–December 2020across inpatient settings.Weekly counts of COVID-19 hospitalizedpatients were determined by the weekly average number ofCOVID-19 patients on the midnight census.Wemade several comparisons to assess changes in data across 3distinct periods. (1) Calendar year 2019 (baseline) was comparedto calendar year 2020. (2) Calendar year 2020 was stratified into4 periods based on the changing COVID-19 experience at ourfacility as follows: January–February was considered a prepan-demic phase, with no COVID-19 patients, high census, and height-ened awareness of COVID-19; March–June was characterized byCOVID-19 patients and decreased overall census; July–Septemberexperienced the first COVID-19 surge with a return to high census;October–December was marked by high, sustained COVID-19admissions along with high overall census. (3) To assess seasonalvariation in hand hygiene compliance, October–December 2020was compared to that from October–December 2019.The 95% confidence intervals (CIs) were calculated using the stan-dard formula for 95%CI for each of the periods andwere compared tothe 2019 baseline.7 Similarities were assessed by overlapping confi-dence intervals. Results are reported as mean with 95% CI.ResultsEngagement metric: observationsOverall, there were 97,429 observations in 2019 and 74,809 in 2020.Adjusting for the number of observations per 1,000 patient daysAuthor for correspondence: Lisa B. Stancill, MPH, Infection Prevention Department,1063 West Wing, NCMH, UNC Medical Center, 101 Manning Drive, Chapel Hill, NC27514. E-mail: Lisa.Stancill@unchealth.unc.eduCite this article: Stancill LB, Sickbert-Bennett EE, and DiBiase LM. (2022).Sustainability of a well-established hand hygiene program during the coronavirusdisease 2019 (COVID-19) pandemic. Antimicrobial Stewardship & HealthcareEpidemiology, https://doi.org/10.1017/ash.2022.13© The Author(s), 2022. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America. This is an Open Access article, distributed under theterms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the originalarticle is properly cited.Antimicrobial Stewardship & Healthcare Epidemiology (2022), 2, e34, 1–3doi:10.1017/ash.2022.13showed no statistically significant difference between 2019 (318.4;95% CI, 276.7–360.1) and 2020 (258.1; 95% CI, 229.1–287.1).Notably, total observations decreased below baseline levels duringboth the July–September (221.0; 95% CI, 203.0–239.0) andOctober–December periods (206.2; 95% CI, 190.1–222.4).Hand hygiene observations followed the same trend (sharpincrease followed by stabilization) as COVID-19 hospitalizationsfrom March through July 2020, when the number of COVID-19hospitalizations reached its first peak (Fig. 1). After mid-July,the number of observations stabilized and began decreasing withincreasing hospitalizations. Hand hygiene observations neverrecovered to the spring 2020 level.Accountability metric: feedbackAlthough observations with feedback fluctuated month tomonth (Fig. 2), the feedback for 2020 (61.3%, 59.0-63.6%)was similar to feedback during all of 2019 (62.4%; 95% CI,60.1%–64.6%). In October–December 2019, feedback was atthe lowest yearly level, but it increased each month duringthe first quarter of 2020. However, this increase was not signifi-cantly different than the October–December 2019 baselineperiod (64.6%; 95% CI, 64.0%–65.1%). The percentage of obser-vations with feedback only significantly decreased beyond base-line during one period, July–September 2020 (57.0%; 95% CI,54.5%–59.5%).Compliance metric: complianceHand hygiene compliance as assessed by CICO was statisticallysimilar in 2019 (96.6%; 95% CI, 96.3%–97.0%) and 2020 (96.7%;95% CI, 96.0%–97.3%) (Fig. 2). However, across 2020 there wasa statistically significant increase during March–June 2020(97.7%; 95% CI, 97.6%–97.9%). However, compliance duringOctober–December 2020 (95.1%; 95% CI, 94.7%–95.6%) decreasedfrom the 2019 baseline and compared to October–December 2019(96.3%; 95% CI, 95.7%–97.0%).DiscussionNot only was the Clean-In-Clean-Out model sustainable througha public health and healthcare crisis, initial increases in engage-ment and compliance metrics were identified. Although not atstatistically significant levels, observations and feedbackincreased with COVID-19 media attention, prior to cases occur-ring in North Carolina or at our facility. These increases may be areflection of staff proactively engaged in COVID-19 infectionprevention efforts. Feedback and compliance increased againwhen our facility began seeing COVID-19 patients, even in theabsence of active reminders and campaigns from infectionprevention staff.A statistically significant increase in hand hygiene compliancewas observed during one period, March–June 2020, which corre-sponded with the admission of the first COVID-19 patient at ourfacility, shelter-in-place orders community-wide, and lowinpatient volumes. In July, patient volumes started to return topre–COVID-19 levels while our facility also began treating a highernumber of COVID-19 patients. In addition, the hospital startedexperiencing staff shortages. The decrease in engagement observedwith higher patient volume and patient-to-staff ratios is furtherevidence that operating at high capacity is not beneficial for patientsafety.8–10 This trend was further demonstrated by the decrease inhand hygiene compliance from October through December 2020,when our facility had high, sustained COVID-19 admissions aswell as a normal non–COVID-19 patient volume.This study had several limitations. We evaluated hand hygieneat a single, large academicmedical center, and these results may notbe generalizable to other settings or hand hygiene programs.However, the results were similar to findings published onCOVID-19 and automated hand-hygiene monitoring systemsin which compliance increased with lower patient volume, espe-cially early in the pandemic.2,3 CICO is a novel hand hygieneprogram and is subject to selection and measurement bias.However, CICO provides benefits of real-time feedback thatdirectly affects practices.5,6Fig. 1. Count of inpatient hand hygiene observations each week along with average COVID-19 patient census since UNC Medical Center began seeing patients with COVID-19 inMarch–December 2020.2 Lisa B. Stancill et alHand hygiene compliance remained high, >90%. Key CICOmetrics demonstrated that although a manual rather than auto-mated monitoring tool requires extra effort from staff, it is stilla viable model. Unlike automated systems, CICO provides theopportunity for just-in-time reminders. Stangerup et al4 found thathand hygiene compliance decreased when hand-hygiene datasharing stopped. Furthermore, the crowd-sourced component ofCICO allows all staff to complete observations and providereal-time feedback as time permits rather than further burdeninginfection prevention staff or specific designees whowere inundatedwith competing priorities.The COVID-19 pandemic has caused healthcare staff tojuggle numerous responsibilities with quality improvementand patient safety projects often being deprioritized and/ordelayed. In the midst of this environment, it was encouragingto see that this CICO manual hand hygiene program was stillactively utilized at comparable levels to the pre-COVID-19baseline and that overall compliance and feedback provideddid not significantly decline. In addition, the sustainabilityand success of the CICO program allowed UNC MedicalCenter to replicate this model of shared responsibility for mon-itoring mask compliance in contrast to more labor-intensivemethods.11 In the midst of a global pandemic, sustainable handhygiene programs remain foundational to the success of infectionprevention.Acknowledgments. We would like to acknowledge the Infection Preventiondepartment as well as all the healthcare personnel who continued to contributeto our hand hygiene program throughout the pandemic.Financial support. No financial support was provided relevant to this article.Conflicts of interest.All authors report no conflicts of interest relevant to thisarticle.References1. Hirose R, Ikegaya H, Naito Y, et al. Survival of SARS-CoV-2 and influenzavirus on the human skin: importance of hand hygiene in COVID-19. ClinInfect Dis 2021;73:e4329–e4335.2. Hess OCR, Armstrong-Novak JD, Doll M, et al. The impact of coronavirusdisease 2019 (COVID-19) on provider use of electronic hand hygiene mon-itoring technology. Infect Control Hosp Epidemiol 2021;42:1007–1009.3. Moore LD, Robbins G, Quinn J, Arbogast JW. The impact of COVID-19pandemic on hand hygiene performance in hospitals. Am J Infect Control2021;49:30–33.4. Stangerup M, Hansen MB, Hansen R, et al. Hand hygiene compliance ofhealthcare workers before and during the COVID-19 pandemic: a long-term follow-up study. Am J Infect Control 2021;49:1118–1122.5. Sickbert-Bennett EE, DiBiase LM, Schade-Willis TM, Wolak ES, Weber DJ,Rutala WA. Reducing health care-associated infections by implementing anovel all hands on deck approach for hand hygiene compliance. Am J InfectControl 2016;44 suppl 5:e13–e16.6. Sickbert-Bennett EE, DiBiase LM, Teal LJ, Summerlin-Long SK, Weber DJ.The holy grail of hand hygiene compliance: just-in-time peer coaching thatleads to behavior change. Infect Control Hosp Epidemiol 2020;41:229–232.7. Andreas Stang, Charles Poole, Oliver Kuss. The ongoing tyranny ofstatistical significance testing in biomedical research. Eur J Epidemiol2010;25:225–230.8. Chang N, Schweizer M, Reisinger H, et al. The impact of workload on handhygiene compliance: is 100% compliance achievable? Infect Control HospEpidemiol 2021. doi: 10.1017/ice.2021.179.9. Fridkin SK, Pear SM, Williamson TH, Galgiani JN, Jarvis WR. The role ofunderstaffing in central venous catheter-associated bloodstream infections.Infect Control Hosp Epidemiol 1996;17:150–158.10. Vicca AF. Nursing staff workload as a determinant of methicillin-resistantStaphylococcus aureus spread in an adult intensive therapy unit. J HospInfect 1999;43:109–113.11. Datta R, Glenn K, Pellegrino A, et al. Increasing face-mask compliance amonghealthcare personnel during the coronavirus disease 2019 (COVID-19) pan-demic. Infect Control Hosp Epidemiol 2021. doi: 10.1017/ice.2021.205.Fig. 2. Inpatient hand hygiene compliance and percentage of observations with feedback provided for UNC Medical Center measured through the Clean-In-Clean-Out handhygiene program from 2019 to 2020.Antimicrobial Stewardship & Healthcare Epidemiology 3

Sustainability of a well-established hand hygiene program during the coronavirus disease 2019 (COVID-19) pandemic

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Sustainability of a well-established hand hygiene program during the coronavirus disease 2019 (COVID-19) pandemic

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