With the participation of second and third year undergraduate medical students, we assessed if the HH was enhanced by the addition of supervised personal feedback with a fluorescent AHR and UV light inspection system (UV cabinet) during simulation scenario-based for training. Our results showed that when HH educational program include the use of a supervised personal feedback with a fluorescent AHR and UV light inspection system, the completeness with the AHR handrubbing and the compliance with WHO’s HH opportunities were sustainably improved. We hypothesize that the use of fluorescent-AHR and UV-cabinet allows a direct personal feedback for the student. This feedback could have an important impact on the memorization process for the handrubbing technique allowing the complete application of the AHR. With the UV-cabinet, there would be a playful aspect which could facilitate the learning and memorization process. Further studies are needed to investigate this hypothesis.
Kaur et al underlined a lack of a rigorous evaluation of tools and educational material for medical students [8]. In our study, the presence of a control group allowed individualization of the proper effect of the intervention group inside our multimodal educational program.
Despite this multimodal program, overall, there was a low rate of completeness of AHR handrubbing (60% in the intervention group and 30.4% in the control group). Our hypothesis was that long-term outcome evaluations revealed a progressive decline in compliant handrubbing and regularly supervised personal feedback would be needed to receive the procedure’s benefits.
Some studies previously reported using supervised personal feedback with UV light inspection systems in the medical students’ training programs [11, 12, 16]. In all these studies, the absence of a control group did not allow individualizing the proper effect of feedback with UV within the rest of the training program. Scheithauer et al. observed that third-year students receiving timely training of HH had an immediate (22%) reduction in incomplete handrubbing after monitoring with the UV cabinet [11]. The baseline rate of completeness of AHR handrubbing after the first UV training was 29%. This was similar to the baseline rate observed in the first-year intervention group (30.7%), with ongoing training yielding a positive impact on outcomes. Lehotsky et al. observed that third-year students in the basic surgical techniques class used a UV based system for assessment and auto feedback immediately after receiving HH education [16]. This study reported a completeness rate of handrubbing of 61.8%, which is also very similar to the rate observed during the second-year intervention group (60%). Vanyolos et al. observed 285 medical students who were included in an educational program on “basic surgical techniques” which included a lecture on HH and a training with groups of 5 to 7 students [12]. The completeness rate of handrubbing wasn’t recorded immediately after the first application. The authors reported a rate of complete AHR application of 51.4% at week 14 and 74.3% at week 10 after the intervention [12].
Unexpectedly, when the tutor visually assessed the quality of the WHO’s handrubbing procedure without UV cabinet, the difference in the completeness rate of handrubbing in the second-year students between the two groups was not significant (Tables 3, 61.3% versus 50.5%, p = 0.096; intervention vs. control groups, respectively). This may be due to a lack of sensibility of single visual assessment without UV light to detect the forgotten steps of the WHO’s HH procedure. It may also be explained by integrating the missed skin areas despite correct procedures and consequently, the addition of supplementary movements to reach the completeness of handrubbing. The WHO’s HH procedure was designed to ensure homogenous hand surface coverage by applied AHR. However, it is not user friendly and recent studies question its adaptability. Indeed, when monitored, HCW compliance with all six steps of the procedure, is low with the last steps (fingertips and thumbs) being the most frequently missed [16,17,18]. Alternative methods with equivalent bacterial effectiveness have been proposed [19, 20]. However, more research is needed in order to validate this conclusion.
At the beginning of the second simulation session, there was a non-significant trend towards a decrease in the rate of complete compliance of the HH procedure in both groups when no technique review had been proposed. This suggests that, as with other HCWs, regular training is obligatory to comply with HH practices [21].
Our results suggested that the intervention group had a positive influence on compliant handrubbing with the WHO’s HH opportunities during the simulation scenario-based learning. This was in accordance with the Higgins et al study, which reported a sustained improvement of HH compliant handrubbing from 20 to 58% within a year after implementation of a personal feedback tool using gaming technology with an automated auditing and training unit [22]. This was however not confirmed in the Kwok et al. study [23]. This effect may be related to the role of personal feedback in awareness of HH’s importance to prevent cross transmission.
Our study has several limitations. Firstly, since we wanted to ensure that control clusters wouldn’t benefit from any feedback with the UV cabinet, we didn’t assess the completeness of their WHO’s HH procedure with UV cabinets during the first year. Consequently, their first completeness rate for the handrubbing under a UV light was only available during their second year. This rate was not significantly different from the intervention group’s rate (before supervised personal feedback) evaluated first year (data not shown). Secondly, our UV assessment cabinet didn’t provide photo storage after fluorescent AHR use for a retrospective, exhaustive analysis of the missed locations with a planimetry system. Thus, we chose to divide the AHR application as complete or not, since we could not study the relationship between the steps forgotten during the HH procedure and the areas missed. This information could have helped us better precisely understand the change in the AHR techniques induced by the UV lamp feedback. Thirdly, the personal experiences of students between the 1st and the 2nd year impacted the study outcome and represent confounding factors. On the 2nd year, we asked the students about their personal feedback for these confounding factors. However, despite our methodological cautions and the multivariate analysis, we cannot exclude that the students forgot to specify some confounding factors (memory bias). Moreover, our study did not allow to know if the students who performed AHR complete application more often remember extra-university use of UV cabinet, or, if the students using the extra-university of UV cabinet performed AHR complete application better. Finally, whether or not our results can be extrapolated in healthcare settings is speculative because students have a higher exposure to negative role models, as a poor compliance of the WHO’s HH recommendations by some heath care workers.