In light of the COVID-19 pandemic, health care workers (HCWs) and the public at large have been reminded of the importance of hand hygiene to prevent the spread of disease. However, the Centers for Disease Control (CDC) reports that many HCWs clean their hands less than half of the time they should. Scenario-based simulation training can be used to help healthcare providers and staff practice and hone good hand hygiene habits, so they become second nature, thereby improving patient safety and the quality of care they receive.
Hospital-acquired infections (HAI) are a significant cause of morbidity and mortality. In American hospitals alone, about 1 in 31 hospital patients have an HAI, and about 72,000 patients die from an HAI. Infections are commonly spread via the hands, so maintaining good hand hygiene habits is vital to preventing the spread of disease.
Good hygiene is a habit
For that reason, the World Health Organization (WHO) launched the SAVE LIVES: Clean Your Hands global hand hygiene campaign in 2009. The campaign aims to increase awareness about the importance of hand hygiene in preventing the spread of hospital-acquired infections.
Studies have shown that continually assessing, practicing, and monitoring hand hygiene protocols increases compliance by as much as 92% . However, compliance decreases when either senior staff or hospital administration does not consistently emphasize these practices.
Although care providers and staff are aware of the importance of good hand hygiene, lack of compliance is more often than not unintentional. Hand hygiene should be a habit HCWs do subconsciously like putting on a seatbelt after getting in a car. Unfortunately, it is easy to miss a moment of hand hygiene while prioritizing the individual needs of several patients.
Moreover, if hospital administration is not keeping up with monitoring and enforcing hand hygiene protocols, then HCWs do not become hardwired to clean their hands when they should. HCWs must remember that the effects of noncompliance with hand hygiene are cumulative, and patients suffer the most from cumulative episodes of noncompliance. Thus, hospitals need to ingrain hand hygiene protocols in HCWs until they become second nature.
Developing good habits through scenario-based training
Developing hand hygiene habits in HCWs can be done with simulation-based training. Hospitals already use simulation during prescheduled training of new staff on hospital-specific guidelines and as part of routine skill maintenance for current staff. Therefore, it would be easy to incorporate infection prevention and hand hygiene into medical education they already receive.
Indeed, in 2019 the simulation center at Johns Hopkins Hospital designed and ran a large-scale, multidisciplinary scenario to test the biocontainment unit’s (BCU) infection control protocols. In the scenario, the HCWs in the unit attempted to deliver a baby whose mother had contracted a contagious respiratory illness. The sim center team used fluorescent ink to simulate biohazardous fluids, which allowed them to assess the spread of contamination after the scenario was completed.
At the end of the scenario, the baby was delivered successfully, and all of the BCU team members avoided contamination. Even team members who learned the BCU’s infection control protocols the day of the scenario successfully avoided contamination because the scenario helped them practice multidisciplinary teamwork, communication, and effective adherence to the unit’s protocols.
Even small-scale training sessions can make a difference
Thus, simulation can be a useful tool to improve HCW’s familiarity with infection control protocols. However, hospitals do not need biocontainment units to see the benefits of scenario-based training. Even small-scale scenarios can improve staff compliance with infection control protocols.
For example, scenarios can emphasize hand hygiene at the five instancesoutlined by the WHO: before patient contact, before an aseptic task, after bodily fluid exposure, after patient contact, and after contact with patient surroundings.
Therefore, the participants can practice routine assessment skills and incorporate hand hygiene before and after contact with the patient. Likewise, the participant can be evaluated on seemingly innocuous breaches of protocol like not performing hand hygiene after touching an item in the patient’s room like an IV line or monitor during the assessment.
The point of these scenarios is to develop behaviors in the participants that become instinctual. As a result, moments for proper hand hygiene are not missed during patient care, especially when dealing with a highly contagious pathogen.
Adding realism to the scenarios uncovers trouble areas
Additionally, an earlier blog post illustrated why real equipment should be used during simulated scenarios. This is important in the context of infection prevention because improper use and removal of personal protective equipment (PPE) have been linked to poor health outcomes for HCWs and patients. A 2019 study by the Society for Healthcare Epidemiology of America found that 39% of HCWs do not remove PPE correctly, increasing the incidences of contamination for themselves and patients.
As such, simulated scenarios could incorporate the use of PPE so participants can practice how to properly use, wear, and remove the PPE and ensure maximum protection. Furthermore, a simple education-based intervention like a simulation-based training can help hospitals reevaluate their guidelines for removing PPE so new rules and strategies can be tested and developed.
Using PPE during the simulated scenarios also helps keep staff trained adequately on those methods. During the scenario, HCWs can practice the proper order in which to put on and remove the PPE. Thus, using PPE correctly becomes second nature, even during high-stress events wherein proper PPE use might not be an immediate priority in the HCWs’ mind.
Considering the limited amount of PPE available to HCWs during the COVID-19 pandemic, participants can forgo using real equipment until supplies increase. Nonetheless, incorporating PPE into scenarios can help develop the skills needed to fight future infectious illnesses.
Compliance is the key to success
In conclusion, simulation-based training is a helpful tool to help monitor the knowledge base of HCWs and the bedside application of that knowledge. The Joint Commission already requires some type of monitoring or quality assessment protocols for hand hygiene in hospitals. Thus, simulation-based training can help hospitals and other healthcare institutions keep in line with those requirements.
Moreover, ongoing staff training is vital to keep infection control and patient safety guidelines fresh in the minds of HCWs and address any gaps in knowledge. Even experienced clinicians can be confused by hand hygiene or PPE protocols. Simulation-based training provides the perfect opportunity to help close those gaps and ultimately help protect patients, HCWs, and save lives.
 Larson, Elaine, et al. “A multifaceted approach to changing handwashing behavior.” American Journal of Infection Control, vol. 25, no. 1, 1997, pp. 3-10.
 Barzilay, Julie. “Doctors’ Hand Hygiene Plummets Unless They Know They’re Being Watched, Study Finds.” ABC News, https://abcnews.go.com/Health/doctors-hand-hygiene-plummets-watched-study-finds/story?id=39737505. Accessed 19 March 2020.
 Anderson, Deverick. “Infection prevention in hospitals: The importance of hand hygiene.” Infectious Disease News, https://www.healio.com/infectious-disease/nosocomial-infections/news/print/infectious-disease-news/%7Bdd1e115b-8a00-4889-9e85-8566391f2541%7D/infection-prevention-in-hospitals-the-importance-of-hand-hygiene. Accessed 19 March 2020.