Level-2 Lab: Is it a Matter of Training?
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1 Hand Hygiene in the Biosafety Level-2 Lab: Is it a Matter of Training? Jim Johnston, Ph.D., C.I.H. Department of Health Promotion & Education University of Utah Committee Members: Glenn Richardson (Chair), Scott Collingwood, Lynne Durrant, James Reading, JoAnne Wright
2 Microbiological Containment Microbiological practices Safety equipment Facility safeguards The most important t element of containment t is strict t adherence to standard microbiological practices and techniques. BMBL, 5 th ed. (p. 22)
3 Behaviors and Injury Prevention
4 Behavior and Injury Prevention At-risk behaviors Mouth pipetting Recapping needles Hand to face contact Picking up broken glass with hands Safe behaviors Handwashing Using pipetting devices Safe sharps precautions Using a mechanical device to pick up broken glass
5 Why Hand Hygiene? Small-diameter Aerosols Inhalation hazard < 5 µm penetrate to the alveoli < 10 µm penetrate to bronchi the respirable component is relatively small and does not vary widely Large-diameter Aerosols Hand/skin contamination Surface/fomite contamination > 50 µm settle out quickly hand and surface contamination is substantial and varies widely BMBL, 5 th ed. (p. 14)
6 Primary Routes of Transmission: Inhalation vs. Direct Contact Comparison of 10 most common symptomatic laboratory-acquired infections ( ) Agent No. of cases No. of deaths Mycobacterium tuberculosis Arboviruses Coxiella burnetii Hantavirus Brucella spp. Hepatitis B virus Shigella spp. Salmonella spp. Hepatitis C virus Ni Neisseria i meningitidis itidi Adapted from Harding & Byers (2006, p. 55)
7 Why Hand Hygiene? Hand transmission most likely route of infection at BSL-2 Fingers, hands, & wrists are easily contaminated during laboratory procedures Hand-to-face contact is common in the lab Generally no barrier between hands and face CDC (2007), Collins & Kennedy (1999), Evans (1990)
8 Hand Washing & Hand Disinfection Effective for removing/inactivating microbes Effectiveness varies depending on: Agent used Contact time Surfaces covered Antiseptic handwashing hi & alcohol-based hand sanitizers are superior to traditional soap & water handwashing CDC, (2002) MMWR 51(RR-16)
9 Behavioral Studies of Lab Workers Evans et al. (1990) Observational study of 119 workers in 10 NIH labs Focus: Universal precautions for blood and body fluids Inappropriate behaviors identified in 40% (15/39) areas surveyed At-risk behaviors included: Handling specimens without gloves Mouth pipetting Spills resulting in skin contamination Oral contact with contaminated items Open bench sonicating Hand braking of centrifuge rotors
10 Behavioral Studies of Lab Workers Alp, Haverkate, & Voss (2006) Observational study of clinical lab workers Focus: Hand hygiene behaviors and compliance with a no-jewelry policy (rings, wrist watches, bracelets) Findings: No-jewelry policy: 36.7% compliance rate (n=49) Potential pathogens were cultured exclusively from skin underneath the offending accessories End of shift hand hygiene compliance was 100% (n=37)
11 Behavioral Studies of Lab Workers Gaps in existing literature Very few studies measure actual behavior Limited to beliefs, perceptions, knowledge, attitudes Intervention studies Focus is primarily on training Studies show change in knowledge over time, but the knowledge-behavior gap is not bridged d Studies are short-term (weeks/months vs. years) Limited use/application of behavioral theory Why do people do what they do?
12 Why do laboratory workers take risks? Martyr-to-science complex? Wedum (1961), Phillips (1969) Perception of risk is low? Blayney & Eijnde (2005) Inadequate training? Laboratory directors or principal investigators should train and retrain new staff to the point where aseptic techniques and safety precautions become second nature. BMBL, 5 th ed. (p. 15)
13 Stimulus-Response Theory (20 th century) B.F. Skinner ( ) Stimulus (Antecedent Cue) Response (Operant Behavior) Stimulus (Contingent Reinforcement or Punishment) Theoretical foundation for Behavior-based Safety
14 Theoretical Framework Social Cognitive Theory (SCT) Bandura 1986 Behavior Person Behavioral Capacity Self Efficacy Beliefs Expectancy-value beliefs Perceptions Genetics Physical Health Environment 1. Physical (resources, equipment, facilities) 2. Social (enforcement practices, social norms, modeling, behavioral reinforcement)
15 Purpose 1. What is the observed frequency of handwashing (HW) among BSL-2 lab personnel before exiting the lab and before entering clean areas? 2. Is there a difference between the observed and self-reported frequency of HW among BSL-2 lab workers? 3. What is the relationship between SCT variables and BSL-2 lab workers HW practices, and which h of these variables most strongly predict HW? 4. What is the quality of HW among BSL-2 lab 4 q y g workers?
16 Study Design 2-phase, cross-sectional study Phase 1 (May December 2009) Informed consent Behaviors measured by direct observation Frequency of HW Quality of HW Rate of HFC Situational lfactors measured Phase 2 (December 2009 January 2010) Survey of participants beliefs, perceptions, & attitudes related to HH
17 Subjects & Setting Subjects 93 participants (56% male, 44% female) Research professors Post-doctoral students Research associates Graduate students Laboratory technicians i Medical doctors
18 Subjects & Setting Participating Labs (n = 21) BSL-2 (17) BSL-2+ (4) Staffing Range 1 9 workers (mean = 4.4/lab) Approved Agents Viral only (14) Bacterial and viral (4) Bacterial only (2) Bacterial and parasitic (1)
19 Measurement Instrumentation Laboratory behavior observation tool (LBOT) Developed from 2 existing tools Handwashing assessment tool (HAT; Brock, 2002) WHO HH assessment tool (Haas, 2007) Standardized measurement tool Amount of observation time Procedure being performed Agent in use HH behaviors Situational factors within labs
20 Measurement Biosafety level 2 behavior survey (BBS) Demographic characteristics Self-reported rate of HW SCT constructs Scale Expectancy Belief scale 1 Expectancy Belief scale 2 Outcome Values Modeling Self Efficacy Behavioral Reinforcement Policy Enforcement Cronbach s alpha
21 Measurement Situational Factors Measured at lab level Time since last training Training specifically on HW Exit traffic from lab Soap in lab Paper towels in lab Type of lab HW policies written in SOPs
22 Measurement Dependent Variables HW Compliance # times washed/# opportunities Attempted to observe 5 opportunities/subject HW Opportunities included: Before exiting i BSL-2 lab (96%) Before entering clean area within BSL-2 lab (4%) HW Quality Duration of scrubbing Use of soap Surfaces covered (dorsal, wrist, palm, interdigital) Rinse Drying (did subject use paper towel to turn off faucet?) Hand sanitizer used
23 Analysis SPSS (version 15.0) Univariate statistics Correlations Significance tests Microsoft Excel Linear regression g HLM 6.08 Hierarchical linear modeling of HW predictors
24 Results Overall HW Compliance 118 hours of observation 604 HW opportunities 62 HW Events (1 w/hand sanitizer) Overall compliance rate = 10.3% Compliance by lab 336 opportunities in 12 labs with zero compliance 268 opportunities in 9 labs: 3 85% compliance
25 Overall % Compliance by Lab 90 Hand Hy ygiene Com mpliance (%) * * Laboratory
26 Observed vs. Self-reported Compliance Mean observed HW rate Upon exit = 8.8% 8% Before entering clean areas (n=6) = 45.8% Mean self-reported HW rate Upon exit = 39.5% Before entering clean areas = 82% Correlation: r =.47, P <.01
27 HW Compliance by Job Title Postdoc/RA (n = 29) Lab Tech (n = 26) Prof/MD (n = 8) Grad student (n = 30) Years in Lab Compliance Rate Overall Upon Exit SR Compliance Upon Exit
28 Observed vs. Self-reported Compliance 1 n = 4 Comp pliance Rat te Upon Exi it n = 1 n = 6 n = 4 n = 5 n = 4 n = 1 n = 6 n = 5 n = 4 n = 4 Observed n = 1 Self Reported n = 4 n = 8 n = 4 n = 5 n = 4 n = 3 n = n = 9 n = Laboratory
29 Compliance by Agent in use and Type of Lab Washed Did Not Total % Compliance Wash Agent in Use on Day of Observations Infectious (n = 51) Potentially Infectious (n = 57) Non-Infectious (n = 14) Type of Lab BSL-2 (n = 17) BSL-2+ (n = 4) *X 2 (2, N=604) = 15.6, P <.001 **X 2 (1, N = 534) = 14.86, P <.001
30 Determinants of HW Correlations between HW and SCT predictors Variable Correlation Coefficient Expectancy Belief Scale 1.17 Expectancy Belief Scale 2 Modeling Outcome Values Self Efficacy Perception of Safety Policies Reinforcement ** P ** P < 0.01 * P < **.41 **.27 **.28 **.26 *.38 **
31 Determinants of HW Correlations between HW and situational factors Variable Safety Training Training i on HW Exit Traffic Soap in Lab Paper Towels in Lab Type of Lab HW Policy in SOPs * P < 0.05 Correlation Coefficient *
32 Relationship between HW compliance and exit traffic Complianc ce Rate y = x R² = Foot Traffic Through BSL-2 Lab (exits/hr.)
33 Quality of HW 61 soap and water HW performed by 23 subjects (24.7%) from 9 labs 49 HW scored, 12 not scored (n=22) Average score = 11.3 (range = 2 18 points) Scrubbing 9 seconds or less (84% of cases) Soap use (92%) Lathering not visible ibl to observer (51% of cases) Turned off faucet with bare hands (59% of cases) Foot operated (27%) Turned off with paper towel (14%)
34 Quality of HW by Gender and Job Title Gender Female (n=8) Male (n=14) Time Scrubbing Soap Surfaces Covered Rinse Dry Mean Score Job Title PostDoc/RA (n=10) Lab Tech (n=6) PI/MD (n=2) GradStudent (n=4) Duration of Scrubbing: < 5 sec. = 0; 5-9 sec. = 2; sec. = 4; 15 sec. = 6 Soap: Soap not used = 0; Soap (lather not visible) = 2; Soap (lather visible) = 4 Surfaces Covered: One surface only = 0; Two surfaces = 2; Dorsal, wrist, palm, interdigital areas = 4 Rinse: No rinsing = 0; Partial = 1; All surfaces = 2 Drying: Did not dry = 0; Dried, turned off faucet with hands = 2; Dried, used paper towel to turn off faucet or foot operated = 4 * Maximum score = 20
35 Conclusions Rate and quality of HW is suboptimal BSL-2 containment may be routinely and pervasively violated by poor HW behaviors This study supports the need for research on the behavioral aspects of biological safety
36 Conclusions Self-reported compliance is not a reliable metric for use in future studies Direct observation is the gold standard for measuring hand hygiene in the healthcare setting, and should be used in the laboratory setting
37 Conclusions Space utilization and occupancy rates in BSL-2 labs may significantly influence workers HW behaviors Risk assessments should consider the location of equipment and the number of workers in the lab Alcohol-based l hand sanitizers may be appropriate for routine hand decontamination when supported by risk assessment
38 Future Research Apply lessons learned in the healthcare setting to the laboratory Intervention studies are needed, but time should not be wasted on duplicating failed experiments Multi-faceted rather than single-shot approaches Top-down management support Performance feedback Interdisciplinary support Participation by lab workers in program development Alcohol-based l hand sanitizer i if supported by risk assessment
39 Future Research Need for studies focused on the development of valid and reliable instruments for measuring psychosocial variables Development of novel methods for measuring HH compliance Measurement of biological indicators of worker exposure
40 Equipping a laboratory with the finest safety devices does not insure against all possible laboratory infections. Equipment is no substitute for safe technique Reitman & Wedum, 1956
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