Smartphone application : useful tool in hand hygiene adherence control

Department of Biology and Pharmacy, Medicine School, University of Santa Cruz do Sul, Rio Grande do Sul, Brazil Hospital Infection Control Committee, Hospital Santa Cruz, Rio Grande do Sul, Brazil Strictu sensu Postgraduate Program in Health Promotion, University of Santa Cruz do Sul, Rio Grande do Sul, Brazil Nursing School, University of Santa Cruz do Sul Department of Biology and Pharmacy – Pharmacy School, University of Santa Cruz do Sul, Rio Grande do Sul, Brazil Professor of the Department of Biology and Pharmacy – Medicine School, University of Santa Cruz do Sul. International Journal of Infection Control ISSN 1996-9783 www.ijic.info


Introduction
Hand hygiene (HH) is the most significant measure to prevent the cross-transmission (CT) of microorganisms, being an important component of patient safety. 1 However, the lack of adherence by health professionals (HPs) is a dilemma identified worldwide, despite being a professional ethical responsibility.² In 2016 in Brazil, the Healthcare-Associated Infections (HAIs) in an Adult Intensive Care Unit (ICU) showed an incidence density rate (50th percentile) of 3.3/1000 patient-days in primary bloodstream infection associated with central venous catheter use; 3.9/1000 patient-days in urinary tract infections associated with long-term indwelling urinary catheters; and 12/1000 patient-days in not for citation purposes  Data collection was computed using an electronic standardized form (Google forms®), 5 through which observers, when arriving at the ICU, waited for the first opportunity for the direct observation of care identifying which HP category it was. Thus, they maintained the observation until the end of patient care, filling out a form to verify HH adherence. All the results were monthly sent to the heads of the unit by e-mail and, thus, the results were disseminated in monthly meetings with the staff.
To quantify the amount of alcohol used in the HH process, the indicator was used in millilitres of alcohol/patient-days/ICU unit and, thus, the monthly quantification could be estimated, since the section has a known stock of the product.
The study outcome was the overall prevalence of HH adherence and adherence at each of the 5 moments.
To calculate adherence, the number of opportunities for HH and those actually performed were assessed in person by the evaluator in the unit during the practices. The association of the professional category of the evaluated professional and the work shift were not assessed in relation to the adherence rates in this study.
Statistical analysis of the data was carried out using the SPSS® Program, version 23.0 (Statistical Package for the Social Sciences, IBM, Armonk, NY, USA). Initially, the adherence versus non-adherence comparison was performed at each of the 5 moments, during the four months of data collection. An analysis was performed to verify the prevalence of outcomes and their association with the professional category (doctors, nurses, nursing technicians, others). The category "others" consisted of physical therapists, psychologists, dentists, nutritionists, pharmacists, and audiologists/speech therapists. The chi-square test was used in all statistical analyses, with the significance set at p <0.05.
The study was approved by the hospital's ethics committee.

Discussion
The overall rate of HH adherence found in this study was low, and lower when compared to two other not for citation purposes Hand hygiene adherence monitoring Basso et al.  studies, both performed in Kuwait, which found, respectively, adherence rates of 43% and 69.1%. 6,7 Regarding the HH moments, one can infer that the low adherence at M1, when compared to M3, M4 and M5, reflects the concern of HP with self-care and neglect with patient safety. 2 This situation is not justified, since there are no major structural obstacles for the effective performance of HH in the ICU. The availability and placement of the alcohol dispensers and the presence of posters in each bed, recalling the importance of HH, were certified and all the HPs periodically participate in institutional training.
The prospective analysis from September to December of the monthly isolated HH adherence moments disclosed a significant increase in adherence rates at all moments, except for M2. This was due to the reduced number of opportunities, such as in October, which had a total of one opportunity. Possibly, an increase in sample size will solve this problem with such an indicator. However, the adherence rates at the other moments -especially the M4 and M5, which showed the highest significant increase -as well as the monthly overall adherence rates, confirm that the direct observation and periodic feedback are effective strategies in increasing HP involvement with HH. 8 The control of HH adherence through answers in an application installed in a smartphone work as a tool to facilitate the study and generate automatic data to send feedback -without the introduction of interventionist means, which has been well-demonstrated in other studies. 6,9 This is characterized as a key strategy for developing countries that find it difficult to establish HH adherence, since the app is free, easy to operate and is a very useful tool for collecting data, which is then transformed into interventions that improve adherence.
When analysing the professional categories, there was no significant difference between the adherence rates. However, it is known that the adherence rates among the nursing staff are usually significantly higher than not for citation purposes Hand hygiene adherence monitoring Basso et al.
those found among the medical staff, and it may be due to the activity that offers more HH opportunities. 7 This study also showed the HH adherence rates among healthcare undergraduate students, due to the fact that the hospital is directly linked to university-level education, which showed a low indicator, although similar to the HPs, such as the technical nursing staff. The quantification of alcohol consumption was adequate according to the WHO standardization. 4 Finally, the observation of HH opportunities was characterized by a constant feeling of reaffirming the empathy values in the health services, so that the professionals can establish a positive habit based on their concern for the patient. Moreover, the previously undertaken actions should be immediately redirected and expanded, aiming to permanently transform behaviour and, thus, generate commitment within a network of positive attitudes, with increasingly higher adherence rates.