Handwashing compliance: Going beyond ‘monitor and forget’

New research from Olin Business School at Washington University in St. Louis shows that motivating compliance with standard processes via electronic monitoring can be a highly effective approach, despite concerns about employee backlash.

handwash_south_park(2)However, the research also highlights that managers cannot simply “monitor and forget,” and that a long-term plan for supporting the retention of monitoring is critical. The findings were published online May 5 in Management Science.

Hengchen Dai, assistant professor of organizational behavior at Olin, along with co-authors Bradley A. Staats and David Hofmann from the University of North Carolina at Chapel Hill and Katherine L. Milkman from the University of Pennsylvania’s Wharton School, studied compliance with hand-hygiene guidelines among more than 5,200 caregivers at 42 hospitals for more than three years.

They collaborated with Proventix, a company that uses a radio frequency-based system to track whether health-care workers wash their hands. More than 20 million hand-hygiene opportunities — incidents when hand hygiene is expected — were captured; each with the potential to prevent, or spread, a hospital-borne illness or infection.

“Maintaining high compliance with standard processes is a challenge for many industries,” Dai said. “We examined hand-hygiene compliance in hospitals because this is a setting where consistent compliance is extremely important in an effort to eliminate hospital-acquired infections. This is an area where improvements can, and should, be made.”

Dai and her co-authors found that on average, electronic monitoring resulted in a large increase in hand-hygiene compliance during their study period. Interestingly, compliance initially increased, and then gradually declined, after approximately two years. When electronic monitoring was stopped, hand-washing rates dropped, suggesting that hand-hygiene habits weren’t formed.

In fact, researchers discovered that compliance rates for hand-washing dropped to below the levels seen before the monitoring began, a finding that is surprising to both the researchers and health-care practitioners.

“While we thought decreased compliance after the monitoring could perhaps be a possible outcome, we were still somewhat surprised to see the result,” Dai said. “We based our prediction on past research about ‘crowding out,’ whereby caregivers’ internal motivation for compliance may have been replaced by external forces associated with monitoring, such as the fear of penalties or punishments for not washing their hands.

“When the external stimulus of monitoring was removed, their compliance behavior declined below the initial level as both the external forces and internal motivations were gone,” she said. “We do not have the data to get into the underlying psychology, but it is certainly worth examining in future research.”

While the findings focused on the health-care profession, Dai said all managers should take note, no matter their field. While electronic monitoring is an important motivation and compliance tool, it’s a single piece of a larger strategy.

“Individual electronic monitoring is one tool managers can use to dramatically improve standardized process compliance, but that it is not a panacea,” Dai said. “Managers looking to build process compliance must think about how electronic monitoring fits within a broader system encompassing not only technology, but also norms, culture and leadership.

“Managers should not ‘monitor and forget,’ ” Dai said.

Try harder: UK petting farm ‘doing all it can’ after E. coli outbreak

The owners of a petting farm at the centre of a parasitic disease outbreak that has left dozens ill said they are working with the local authority to investigate its cause.

swithern.farmIan and Angela Broadhead, who run Swithens Farm, in Rothwell, Leeds, have reassured visitors that their “health, safety and welfare” is of “utmost importance” to them as they continue to work with public health experts.

The petting farm has been linked to 29 cases of cryptosporidiosis, and two cases of E.coli O157.

The Broadhead family said: “As a small family-run business the health, safety and welfare of our visitors is of utmost importance to us all.

handwash.UK_.petting.zoo_.09Between January and May 2015 around 130 people were affected by outbreaks of cryptosporidiosis linked to petting farms in England.

PHE has advised all visitors to wash their hands after touching animals.

Handwashing, however, is never enough.

A table of petting zoo outbreaks is available at http://barfblog.com/wp-content/uploads/2016/05/Petting-Zoo-Outbreaks-Table-5-5-16.xlsx

Best practices for planning events encouraging human-animal interations

Zoonoses and Public Health 62:90-99

Erdozain , K. KuKanich , B. Chapman and  D. Powell, 2015

http://onlinelibrary.wiley.com/doi/10.1111/zph.12117/abstract?deniedAccess

Educational events encouraging human–animal interaction include the risk of zoonotic disease transmission. ‘It is estimated that 14% of all disease in the USA caused by Campylobacter spp., Cryptosporidium spp., Shiga toxin-producing Escherichia coli (STEC) O157, non-O157 STECs, Listeria monocytogenes, nontyphoidal Salmonella enterica and Yersinia enterocolitica were attributable to animal contact. This article reviews best practices for organizing events where human–animal interactions are encouraged, with the objective of lowering the risk of zoonotic disease transmission.

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Really? CDC campaign reminds docs, nurses that “Clean Hands Count”

Today (yesterday), World Hand Hygiene Day, the U.S. Centers for Disease Control is launching the new “Clean Hands Count” campaign urging healthcare professionals, patients, and patients’ loved ones to prevent healthcare-associated infections by keeping their hands clean.

handwash_south_park(2)Although hand contact is known to be a major way germs spread in medical facilities, studies show that some healthcare professionals don’t follow CDC hand hygiene recommendations. On average, healthcare professionals clean their hands less than half of the times they should.

“Patients depend on their medical team to help them get well, and the first step is making sure healthcare professionals aren’t exposing them to new infections,” said CDC Director Tom Frieden, M.D., M.P.H. “Clean hands really do count and in some cases can be a matter of life and death.”

Part of the new campaign promotes healthcare provider adherence to CDC hand hygiene recommendations by addressing some of the myths and misperceptions about hand hygiene. For example, some people wrongly believe that using alcohol-based hand sanitizer contributes to antibiotic resistance and that it is more damaging to hands than washing with soap and water. Alcohol-based hand sanitizer kills germs quickly and in a different way than antibiotics, so it does not cause antibiotic resistance, and it causes less skin irritation than frequent use of soap and water.

The initiative also encourages patients and their loved ones to ask their healthcare team to clean their hands if they don’t see them do so before providing care.

“We know that patients can feel hesitant to speak up, but they are important members of the health care team and should expect clean hands from providers,” said Arjun Srinivasan, M.D., CDC’s associate director for healthcare-associated infection prevention programs. “We know that healthcare providers want the best for their patients, so we want to remind them that the simple step of cleaning their hands protects their patients.”

That’s right, it’s up to the dying and preoccupied family to ensure medical types wash their damn hands.

visit: www.cdc.gov/handhygiene.

Over 1200 sick: Campaign launched to fight Norovirus infection in Philippines

It’s gonna to more than edumacation to “effectively prevent and control the spread of the viral infection in Manila.

dude.wash.handsCity Health Officer Dr. Rodel Agbulos said his office has been saturating the different communities with varied information, education and communication (IEC) materials, through health centers and places of convergence in the different barangays.

Through the declaration, the CHO and other concerned offices and agencies and all health institutions in the city have been directed to institute, undertake and implement curative and proactive measures to effectively address and eradicate the outbreak.

CHO Epidemiology Division Chief Dr. Ivy Iturralde said the aggressive campaign will be focused on the practice of hand washing and proper hygiene.

It’s all in the friction: Hand dryers are germ-flinging BS

The benefits of paper towels versus conventional blow dryers for drying after handwashing are well-documented.

handwash_south_park(2)But what about those high-tech – and expensive – Dyson thingies that seem to be popping up everywhere.

I say, show me the data.

Caroline Weinberg writes that a study published in the Journal of Applied Microbiology showed that Dyson jet air dryers can fling germs as far as 10 feet from the device.

For the experiment, researchers dipped their gloved hands in a suspension of the bacteriophage MS2 (similar in structure to the contagious enteric viruses transmitted in poop). The hands were then dried by one of three methods. First up were Dyson jet air dryers, which are designed to push water off of your hands in 10 seconds with roughly the force of a jet engine. Next were warm air dryers, which blow warm air downwards and supposedly remove water via evaporation. The final competitor was paper towels, which use absorbent paper to remove water from your hands (and actually leave them dry).

The first part of the experiment looked at how many bacteria are blown back on you during the drying process. Researchers erected a vertical board roughly 16 inches away from each dryer and counted the viral particles that landed on it. Overall, the jet dryer dispersed 60 times more particles than the warm air dryer and 1,300 more than the paper towel. 70 percent of particles hit the board between 2.5 and 4.5 feet—roughly chest or stomach level on an woman of average height, or right at the face level of a small child. At the highest density point, the jet air dryer dispersed 167 times as many viral particles as the warm air dryer and 8,340 times as many as a paper towel.

dyson.air-blade-thumb-468x369-147704For the second part of the experiment, researchers studied air dispersal, or how much of the bacteria is spread into the air around the machine or towel. Airborne virus counts were consistently higher around the jet dryer both over time and distance. The jet dryer dryer propelled the virus as far as 10 feet away, with high levels recorded a full 15 minutes after use. There was no significant difference in air dispersal between warm air dryers and paper towels.

This isn’t a perfect study: Because it was done in a lab setting, researchers could not account for individual behaviors or real world differences. They also only tested one example of each hand drying device (Dyson is taking the heat here, but they are not the only makers of jet air dryers) and did so over a small number of trials. Critics of the study also rightfully point out that most people don’t dip their hands in bacteria prior to using the hand dryers: they wash their hands first. And it’s true that if one were to stick perfectly clean hands into a dryer, there would not be germs to blow around.

Unfortunately, here in the real world, 95% of people using public restrooms fail to adequately wash their hands. Sure, a small percentage may use the scientifically vetted, 42-second-long, six-step hand washing process that most effectively rids your hands of all the filthy germs you’ve picked up in the bathroom and world at large. The rest of them (OK, us) are doing a quick scrub or, worse, simply passing their hands under a running faucet for a few seconds for the illusion of cleanliness. So while the hands most people place in the dryer aren’t drenched in germs, they are likely carrying, among other things, poop particles. Poop particles that the machine then proceeds to blow all over the room, including back on the very hands you just cleaned.

handwashing.blow.dryer.09This isn’t the first time a study has suggested that hand dryers are germ cannons, either. A 2014 study published in the Journal of Hospital Infection also supports this finding—but it was dismissed by Dyson as funded by Big Paper Towel (in their defense, that study was literally funded by Big Paper Towel, i.e. the European Tissue Symposium,). Dyson would direct us, instead, to 2011 study published in the Journal of Applied Microbiology that found their air dryers to be more effective at preventing the spread of germs than warm air dryers. Now it was Big Paper Towel’s turn to cry foul—that study was funded by Dyson Limited. The current study in question is funded independently by the researchers’ university (though the lead author has worked with the European Tissue Symposium in the past) lending it a hopefully uncontaminated air of legitimacy.

A few months ago, shortly after this study was published, Dyson posted an ominously narrated attack ad of sorts titled “Paper’s Dirty Secret.” Don’t listen to Big Jet Dryer’s propaganda (well, maybe listen to it, because the video is hilarious—but don’t believe it). It is true that a 2012 pilot study found unused paper towels to be contaminated with small amounts of bacteria. But paper towels have been repeatedly shown to be efficient, effective, and—perhaps most importantly—not responsible for flinging extra poop germs through the air.

 

Going public: 167 people with the runs in Iowa

That moment happened.

Usually it takes until puberty, but it happened.

diarrhea.toiletMy 7-year-old daughter, who was in a local Dettol commercial, which I had nothing to do with (that’s her, at the end, second row from the bottom, far rightin the pic below; I’ve always shamelessly promoted my children).

Yet this morning, she was too embarrassed to answer what number 1 meant, and number 2, while watching some other video this morning before school, something about poop.

And it happened.

Sure, kids find me hilarious until about 11-years-old, then it’s embarrassment for 10 years, then they come around.

Maybe the folks in Dubuque County, Iowa feel the same way, maybe they have state laws limiting what they can say.

But when 167 people have diarrhea since Oct 1, public health has to step in (not in the #2).

Seriously, no public announcement until April 11, 2011, on an outbreak that started Oct. 1, 2015?

 “This is a high number of diagnosed cases that we have had,” said Patrice Lambert, executive director of the Dubuque County Health Department.

Shigellosis is a disease caused by the bacterium shigella, which causes watery and sometimes bloody diarrhea, according to Lambert.

 “Wash your hands with soap and water,” Lambert said. “That’s the easiest thing to do, not only for shigellosis but for all communicable diseases.

Handwashing is never enough.

 

Medium and message: Need to frequently change handwashing signs to be effective

I’m a food safety voyeur.

Supermarkets, farmers markets, restaurants – fancy or not – kitchens, farms, I’ve been professionally watching people for 20 years.

surprise-01Chapman likes to recount how he was invited to the GFSI Consumer Goods Forum as a last minute replacement speaker in 2013 to talk about food safety infosheets and how we evaluated them.  He said that the literature shows surprise matters when it comes to communicating risks – and a message that is up all the time, like a hand washing sign, probably doesn’t do much after the day it was posted (when it is surprising to the food handler).

The level of surprise in a message determines how successfully the information is received. In 1948, the Bell Telephone Company commissioned a study on communication as a mathematical theory to aid in the design of telephones.  In a study of brain function, Zaghloul and colleagues (2009) also showed the brain’s sensitivity to unexpected or surprising information plays a fundamental role in the learning and adoption of new behaviors.

During the Q&A session at the end of the session someone from a German retail store asked Chapman if he was suggesting that that they take down all the handwashing posters they had up, and Chapman said, yes, unless they plan on changing them every couple of days. The audience had an audible gasp.

We’ve found that posting graphical, concise food safety stories in the back kitchens of restaurants can help reduce dangerous food safety practices and create a workplace culture that values safe food.

It was the first time that a communication intervention such as food safety information sheets had been validated to work using direct video observation in eight commercial restaurant kitchens and was published in the  Journal of Food Protection.

hand_sanitizer_hospital_11We found that infosheets decreased cross-contamination events by 20 per cent, and increased handwashing attempts by 7 per cent.

Based on observations of more than 5,000 patrons at a hospital-based cafeteria, we showed that an evidence-based informational poster can increase attempts at hand hygiene.

So we gladly welcome new work on food safety messages and media in poultry processing facilities.

Signs can provide repetitive training on specific food safety practices for multicultural food processing employees. Posted signs for workers in many food processing facilities tend to be text-heavy and focus specifically on occupational hazard safety. The purpose of this study was to evaluate the effectiveness of newly-developed hand washing pictograms on employees’ hand washing behavior using video observation.

Five employee hand washing behaviors (soap use, wash completeness, wash time, complete rinsing, and towel use) were evaluated with (a) no intervention, company signs posted and considered the baseline; and compared to (b) hand washing behavior the next day (short term) and two weeks (long term) after experimental hand washing signs were displayed at a raw poultry slaughter facility (Facility A) and a poultry further processing facility (Facility B).

sponge.bob.handwashingBoth facilities showed a significant increase (p < 0.05) in soap use after the new sign was introduced at both short and long term time periods. There was a significant increase (p < 0.05) in washing, time of washing, and rinsing observed by Facility B employees, when baseline data was compared to the short term. This indicates that a new sign could increase hand washing compliance at least in the short term. Sign color also had a significant effect (p < 0.05) on employee behavior for washing and time of washing. Behavior for four of the five variables (soap, wash, time of wash, and towel use) was significantly different (p < 0.05) between baseline and either experimental observation period.

While signs can be a useful tool to offer as recurring food safety training for food processing employees, employees tend to revert back to old habits after several weeks.

Evaluation of how different signs affect poultry processing employees’ hand washing practices

Food Control, Volume 68, October 2016, Pages 1–6

Matthew Schroeder, Lily Yang, Joseph Eifert, Renee Boyer, Melissa Chase, Sergio Nieto-Montenegro

http://www.sciencedirect.com/science/article/pii/S0956713516301244

 

Nebraska health board recommends no bare hands for restaurants

The No. 1 cause of what people often call food poisoning is not spoiled food. It is a flu-like illness called norovirus that comes with diarrhea and vomiting.

handwash_south_park(2)And the No. 1 cause of norovirus is people who have the virus on their hands touching food without gloves.

To help prevent outbreaks of the virus, a health-related advisory group to the Lincoln-Lancaster County Health Department has recommended the city tighten restaurant rules, seriously limiting when staff can touch ready-to-serve food with their bare hands.

The City Council likely will hold a public hearing on the no-bare-hands policy April 11. The Health Department advisory board approved it in early March. 

The idea behind the policy is that once food is cooked, no staffer should touch it before a customer eats it, said Scott Holmes, manager of the Environmental Health Division with the local health department. 

The proposed rule does allow some exceptions.

Staff can touch ready-to-eat food before it’s cooked, garnish beverages and wash fruits and vegetables with bare hands.

Some eating establishments already follow a no-bare-hands policy, including those that serve vulnerable or high-risk populations — people in custodial care, assisted-living facilities, hospitals, nursing homes and senior centers, for example.

And many chain restaurants already have such policies, Holmes said.

The local proposal follows a national model, with some exceptions. The committee that developed the Lincoln policy eliminated a few of the rules, ones that created the most controversy in other communities.

They said loads: reducing cross-contamination via hands

Hand washing and glove use are the main methods for reducing bacterial cross-contamination from hands to ready-to-eat food in a food service setting. However, bacterial transfer from hands to gloves is poorly understood, as is the effect of different durations of soap rubbing on bacterial reduction.

handwashing.loadsTo assess bacterial transfer from hands to gloves and to compare bacterial transfer rates to food after different soap washing times and glove use, participants’ hands were artificially contaminated with Enterobacter aerogenes B199A at ∼9 log CFU. Different soap rubbing times (0, 3, and 20 s), glove use, and tomato dicing activities followed. The bacterial counts in diced tomatoes and on participants’ hands and gloves were then analyzed.

Different soap rubbing times did not significantly change the amount of bacteria recovered from participants’ hands. Dicing tomatoes with bare hands after 20 s of soap rubbing transferred significantly less bacteria (P < 0.01) to tomatoes than did dicing with bare hands after 0 s of soap rubbing. Wearing gloves while dicing greatly reduced the incidence of contaminated tomato samples compared with dicing with bare hands. Increasing soap washing time decreased the incidence of bacteria recovered from outside glove surfaces (P < 0.05).

These results highlight that both glove use and adequate hand washing are necessary to reduce bacterial cross-contamination in food service environments.

Adequate hand washing and glove use are necessary to reduce cross-contamination from hands with high bacterial loads

Journal of Food Protection®, Number 2, February 2016, pp. 184-344, pp. 304-308(5)

Robinson, Andrew L.; Lee, Hyun Jung; Kwon, Junehee; Todd, Ewen; Rodriguez, Fernando Perez; Ryu, Dojin

http://www.ingentaconnect.com/content/iafp/jfp/2016/00000079/00000002/art00016

Does your state suck at food safety? CDC releases prevention status reports

CDC has just released the latest Prevention Status Reports (PSRs), which highlight the status of state-level policies and practices to prevent or reduce problems affecting public health. The PSRs cover 10 public health topics—including food safety—and rate states on their implementation of recommended policies and practices. 

 

skippy.burger skippy.burgerThe reports include a new measure on state adoption of selected provisions in the 2013 Food and Drug Administration (FDA) Food Code. The Food Code is a science-based model code that states can use to develop or update their food safety rules to better prevent foodborne illness and outbreaks.

CDC identified four Food Code provisions especially important in reducing outbreaks in restaurants and other retail food establishments:

  • exclude ill food service staff from working until at least 24 hours after symptoms, such as vomiting and diarrhea, have ended;
  • prohibit bare hand contact with ready-to-eat food;
  • require at least one employee in a food service establishment to be a certified food protection manager; and,
  • require food service employees to wash their hands.

The other two measures continue from the 2013 Prevention Status Reports. High scores for these two measures enable efficient detection and investigation of outbreaks:

  • speed of DNA fingerprinting using pulsed-field gel electrophoresis (PFGE) testing for all reported cases of Shiga toxin-producing E. coli O157; and,
  • completeness of PFGE testing of Salmonella.

The PSR website has been enhanced to include an interactive map that leads directly to topic reports for each state. The website also includes State Summary tables that outline the full set of policy and practice ratings for each state; a National Summary that gives aggregate ratings across states and rating comparisons for 2013 and 2015; the PSR Quick Start Guide; a fact sheet; answers to frequently asked questions; and a link to the 2013 PSRs.