The University of EdinburghPrincipal’s Teaching Award Scheme

Project Final Report

'In Their Hands: Students outcomes and experiences with Gesture Recognition System for handwashing' Team members: CarolineMosley,CatrionaBell,JohnMosley,KayAitchison,JillMacKay,SusanRhindThisreportoutlinestheoutcomesofourPTAS-fundedstudytoevaluatetheSurewash®systemasanaccessibleeducationaltrainingtoolforveterinarystudents.

Handhygieneisanimportantstepinthepreventionofinfectionsacrosspatients,studentsandstaffwithinbothhumanandveterinaryhospitals.Despiteregulartraining,compliancewiththehandwashingprotocolhasbeenshowntobeanissueacrossstudentsinallyearsoftheundergraduateRoyal(Dick)SchoolofVeterinaryStudies(RDSVS)programme.TheRDSVSadoptstheNationalHealthService(NHS)clinicalhandhygieneprotocolwhichisanadaptedversionoftheWorldHealthOrganisationguidanceandincludesthecleaningofwristsforclinicalwork(SeeAppendixAforacopyofthecurrenthandrubprotocol).

TheSurewash®machineisastandaloneeducationalaidthatusesgesturerecognitionsoftwaretoallowuserstolearnandpracticetheNHSHandHygienesteps.Themachinerecordseachstepoftheprocess,includingstepsthatwerefoundtobedifficult(timetakenisusedtoassessthis)andprovidesadownloadablereporttoallowhospitalstomonitorcompliance.ResearchQuestionsWillthestudentsusetheSurewash®machinetopracticehandhygiene?Whatstepsofthehandhygieneprocessdotheyfinddifficult?UsingSurewashTheSurewash®Machineinvolvesplacinghandsontoatemplate,thencompletingthesevenstepsoftheNHShandhygieneprotocol.Themachinemonitoredthemovementofhandstoassessforcorrectrotationandplacementofthehandsforeachstep.Duringeachsteptherewasaprogressbaronthescreen,studentscouldobserveiftheywereperformingitcorrectlyandthenmakesmalladjustmentstomaketheirrotationsmoreeffective.Eachstepwastimed,includingbothleftandrighthands,andanaveragetimewasprovidedat

theend.Shouldastudentstrugglewithoneparticularstepthiswashighlightedtothemattheend.Theycouldalsoskipthestepiftheywereunabletocompleteit,howeverthiscountedasafail.Shouldasteptaketoolong,themachinewouldmoveontothenextstepandthisresultedinafailoftheprocedure.Studentshadapproximately20secondsperstepbeforetheSurewash®machinewouldmoveon.MethodologyThisprojectwassplitintotwostudies:StudyAinvitedtheYear1students(viae-mailandverbalendorsementinclass)tousethemachineintheweekpriortosittingtheirhandwashingexams.StudyBintroducedInfectionControlAmbassadorsineachyeartopromotetheSurewash®trainingtoolandintroduceacompetitiveelementtoencourageallyearstotakepart.StudyADuringStudyA,theSurewash®machinewasstationedinahighthroughputareaoftheR(D)SVSteachingbuilding,andYear1studentswereemailedinvitingthemtousethemachinetopracticefortheirexams.TheacademicmemberoftheteamwhoteachesHandHygieneduringaformaltaughtclassalsointroducedtheyeartothemachineviaverbalendorsement.DetailswerethenrecordedbytheSurewash®machineeachtimeitwasused.StudyBAttheRDSVStheundergraduatestudentsoncampusrangefromYearOnetoYearFiveand‘theGraduateEntryProgramme(GEP)’year.TheRDSVSrunstwoprogrammesofstudy–UndergraduateandGEP.TheUndergraduateprogrammelastsfiveyears,withtheirfirsttwoyearsofstudyseparatetothefirstyearGEP.Thetwoprogrammesmergeandstudentscompletetheirlastthreeyearstogether.Studentswereinvited(viaemailandatthestartoflectures)tobecomeInfectionControlAmbassadors(ICA)fortheiryear.WiththeexceptionofYearTwo,whereonestudentwasrandomlyselectedfrommultipleapplicants,onlyonestudentperyearvolunteeredtobecomeanICA.ICAswereprovidedwithaprojectt-shirtandthechancetowinanipadtointroduceacompetitiveelement.Duetothenatureoffinalyear,itwasagreedthatthestudywouldnotincludeYear5students,asmanywerenotoncampusforthedurationofthestudy.TheSurewashmachineoffers3levelsof‘gaming’,witheachlevelincreasingindifficulty(leveloneshowsanimageofthehandhygienesteptodemonstrateit,andtheinformationisreducedaseachlevelisprogressed).One–to–onetrainingwasgiventotheICA’sbyCarolineMosleyandtheprojectwasrunoverafourweekperiod.ICA’swereencouragedtogetasmanystudentsintheiryear

aspossibletousethemachinerepeatedly,althoughprogressionthroughthelevelswasnotnecessary.ResultsStudyAThemachinewasusedatotalof98timesovera7dayperiodpriortotheyearonehandhygieneexamination.Theresultsidentifiedthatlessthanhalfofattempts(43%)passedthehandhygienestepsandthatstudentsoptedtousethe‘Visitor’access(n=60)ratherthantypetheirnameintothemachineAkeylogisticalfindingofthisstudywastheidentificationthatmanystudentsselectedthe‘visitor’optionwhenloggingintothemachineasthesigninoptionwastootimeconsuming,andasthevisitoraccesswasavailableforanyone,itisimpossibletodeterminehowmanyuserswerestudentsorhowmanystudentusedthemachineonmorethanoneoccasion,.Thisstudythereforeallowedustoidentifyakeyconstraintintermsofidentifyingindividualusers,andenabletheprojectteamtoalterthelog-inprocedurepriortothelaunchofthelargerStudyB.Aswipeaccesswasinstalledontothemachine,tologindividualstudentcardnumbers.StudyBThemachinewasusedatotalnumberof304times,with94uniqueusers.Acrosstheyeargroups,theGEPstudentsengagedthemostwithanaverageof5.9attemptsperstudentand67%oftheGEPyear(n=52)loggingintothemachineatleastoncetouseit(Fig1).Acrossallyears,33studentswhoattemptedtousethemachinedidnotcontinueuntiltheypassedallstepssatisfactorily,ofthesestudents9werefromY1.TheY1studentshadrecentlysattheirhandhygieneexamsandhadbeenintroducedtothemachineearlierintheSemester,yetoutof15Y1studentswhousedthemachineonly6weresuccessfulinpassingalloftherequiredstepsintheprocedure.

050100150200250

Year1 Year2 GEP Year3 Year4

Num

berofstudents

YearGroup

Surewashusers

Totalinyear Uniqueusers Totalattempts

Fig1:SummaryofSurewash®usersbyyear.Thexaxisshowsthetotalnumberofstudentswithineachyearcohort,totalnumberofuniqueusers,andtotalnumberofindividualattemptbrokendownbyyearofstudy.Theyaxisshowsthetotalnumberswithinthestudentyear,thetotalattemptsatthesurewashmachineandthenumberofuniqueusersperyearAnalysisofdatausingaoneway-ANOVAtestdemonstratedasigificantdifferenceinoverallperformanceacrossyeargroups(F3,566=4.08,P=0.007),andaTukey’spost-hoctestshowedthatY2performedsignificantlybetterthanY3(T=-2.87,P=0.022).HoweverthedifferenceinoverallperformancebetweenY1andGEPfromY2andY3wasnotsignificantandexploringwhatcausesthesedifferencesbetweenyearswillbeaninterestingavenueofexplorationfortheplannedfuturestudy.TheSurewashprocessreliedonsevenstepsbeingconductedandacrossallyeargroupstherewasasignificantdifferenceinperformanceacrossthesestepswhendatawasanalysedusingaone-wayANOVAtest(F6,566=7.96,P<0.001).Step5,‘RotationofThumb’wasthestepwhichshowedthelowestscores,whereasSteps1and2‘PalmtoPalm’and‘BackofHand’wererelativelyhighscoringacrossallyeargroups(Figure2).Notethat‘giveup’attemptswerenotcountedinthisanalysis,andsothismaybeindicativeofalackofunderstandingofthemechanicsofthesesteps,orasensitivityissueofthegesturerecognitioncapabilityoftheSurewashmachineinstead.

Figure2:Comparisonsofmeanscoreforallstudentsacrosshand-washsteps.Meanscoreiscalculatedperstep,with0beinganentirelyunsuccessfulstepand1

0

0.2

0.4

0.6

0.8

1

1.2

PalmtoPalm BackofHand FingersInterlaced

BackofFingers

Rota>onofThumb

Rota>onofFinger>ps

Rota>onofWrists

AverageScore

Hand-WashStep

AAB ABC ABC BCDCDD

beinganentirelysuccessfulstep.MeanvaluesthatdonotsharealetteraresignificantlydifferentaccordingtoTukeyPostHoctestsatɑlevelofp=0.05ProjectOutputsSchool Detail DateVMEDSymposium,R(D)SVS

PosterpresentationtoR(D)SVSandotherUofEdinburghcolleaguesontheSurewashproject

Edinburgh,June2016

National/InternationalConferences

VETED2016conference Shortcommunication/poster

GlasgowJuly2016

Publication JournalofVeterinaryMedicalEducation

*manuscriptinpreparation

FutureWorkFollowingthefirstprojects,athirdprojectaimedatstaffintheHospitalforSmallAnimalswascarriedout,datafromthisisexpectedtobeusedforinternaltrainingandsecondpublication.Inafuturestudyweintendtoinvestigatethedifferenceinperformanceatdifferenttimesintheyeartoexploreevidenceoflearningwithrepeateduseofthemachine,andtoestablishifthedifferencesinyeargroupscanbeattributedtopoorerperformanceincertainstages.Wearealsoconsideringtheuseoffocusgroupstoexploreuserattitudestothemachineandtheirconfidenceinhandhygieneprotocols.Asmoststudentsfoundtherotationalstepsofthehandwashprocesstobethemostdifficult,thisisperhapsduetothedesignofthemachine,ortechniqueissuesacrossstudents.Afocusgrouptoexplorethisfurtherwillbeausefulnextstep.Introducinganannualhandhygieneassessmentinthestudentsclinicalskillsportfoliohasbeenconsidered,howeverthecosttohireandpurchasethemachinelong-termisprohibitive.InthePTASaward,itwassuggestedthattheprojectcouldconsideracomparisonbetweenSurewashandotherlessexpensiveoptions.Thisisunderreview,howevernoothertrainingsystemshavebeenidentifiedthatwouldallowastudenttohaverepeatedaccesstogainfeedbackontheirpractice.

Appendix A

Apply sufficient alcohol gel to a cupped hand to cover all surfaces

Rub hands palm to palm

Rub palm to palm with fingers interlaced

Rub back of each hand with the palm of the other hand

with fingers interlaced

Rub with back of fingers to opposing palms with fingers

interlocking and vice versa

Rub each thumb clasped in opposite hand using a

rotational movement

Rub tips of fingers in opposite palm in a

circular motion

Rub each wrist with the opposite hand using a rotational movement

Allow hands to air dry

Digitial Education Unit

qrs.ly/zg4tbjg

** Steps 2 to 8 require a minimum

of 3 repetitions

1 2 3

4 5 6

7 8 9

Hand Rub Technique with Alcohol Gel

Digitial Education Unit