Improving children’s and their visitors’ hand hygiene compliance

Abstract

Background:

Numerous interventions have tried to improve healthcare workers’ hand hygiene compliance. However, little attention has been paid to children’s and their visitors’ compliance.

Aim:

To test whether interactive educational interventions increase children’s and visitors’ compliance with hand hygiene.

Methods:

This was a cluster randomised study of hand hygiene compliance before and after the introduction of educational interventions. Observations were compared for different moments of hygiene and times of the day. Qualitative data in the form of questionnaire-based structured interviews were obtained.

Findings:

Hand hygiene compliance increased by 24.4% (P < 0.001) following the educational interventions, with children’s compliance reaching 40.8% and visitors’ being 50.8%. Compliance varied depending on which of the five moments of hygiene was observed (P < 0.001), with the highest compliance being ‘after body fluid exposure’ (72.7%). Responses from questionnaires showed educational interventions raised awareness of the importance of hand hygiene (69%, 57%) compared to those who had not experienced the educational intervention (50%).

Conclusion:

Educational interventions may result in a significant increase in children’s and visitors’ hand hygiene (P < 0.001).

Background

Over the last few years, it has become clear that the healthcare environment is a potential source of harm for patients and the reduction of healthcare-associated infections (HCAI) is now part of the everyday delivery of healthcare treatment. To prevent and reduce HCAI transmission, it is important to determine if the main routes of exposure to infection are direct, indirect or due to repeated person-to-person contact. Hand hygiene (HH) is the single most important measure for reducing HCAI and interventions can improve compliance (Randle et al., 2010), with the most effective ones being multimodal (Gould et al., 2017; Naikoba and Hayward, 2001).

Children are especially vulnerable to infectious diseases (Willmott et al., 2016). In children, the transmission of infections is likely to correlate with their natural behaviour (e.g. regular exploration of their mouths). The resultant spread of respiratory secretions coupled with an immature immune system combine to increase children’s risk of infections (Snow et al., 2008) and they are particularly at high risk of respiratory infections and gastrointestinal diseases (Stein et al., 2007). In response to this, there have been calls for education providers and parents to do more to promote good HH practices (NICE, 2017). This is especially relevant when considering children’s vulnerability in healthcare settings where they are not only treated by a plethora of healthcare workers (HCWs) who travel in and out of different clinical settings but are typically also surrounded by other ill people.

Unsurprisingly, studies have focused on HCWs’ hand hygiene compliance (HHC). In contrast, patients’ and visitors’ health hygiene practices have been overlooked, with only limited literature being available (Buet et al., 2013; Strigley et al., 2016). The existing literature suggests that interventions that improve the HH of patients and visitors may reduce the incidence of HCAIs. The HHC of patients and visitors is especially important if they augment the care provided by the HCWs as would likely happen if the visitors are parents or carers of the patient. Patients and visitors pose a high risk because of their potential to: (1) transmit virulent pathogens from the community to the healthcare setting; and/or (2) transfer pathogens within clinical areas to the patient (directly or indirectly) (Gould et al., 2017; Munoz-Price et al., 2012; Randle et al., 2010).

The aim of the present study was to test whether two educational interventions can improve HHC of children and their visitors. To do this, we evaluated children’s and their visitors HHC before and after the introduction of the educational interventions (Suppl. Figure 1, Suppl. Table 1). With the objective of determining if all or some HH opportunities are improved, HHC was evaluated for specific moments (Sunkesula et al., 2015; World Health Organization [WHO], 2009) and at different times of the day. A questionnaire was used to evaluate whether participants improved their awareness of handwashing or increased their knowledge and understanding of germs and handwashing.

Methods

Ethical and regulatory aspects

The Research Ethical Committee (REC) Committee East Midlands Research NHS and the Research & Innovation Department, NHS, approved this study.

Study design

This control, before-and-after, intervention, cluster randomised study was conducted on six paediatric wards in a teaching hospital in the East Midlands. Random sampling (slips of paper in a hat) allocated two paediatric wards for each educational intervention. The educational intervention was either the Glo-yo (Suppl. Figure 2, Suppl. Table 1, demonstrated during a 30-min session by Dina Lary) or a video on a mobile phone (Suppl. Table 1, mobile learning technology [MLT], demonstrated during a 30-min session by a research student). The control group received a leaflet accompanied by a 2-min session outlining its content (see Suppl. Figure 3). In order to enable comparison with parallel observations of the HCWs (to be reported separately) and identify if HHC was linked to any particular activity; the baseline phase included rates of HHC using the WHO 5 moments of hand hygiene (2009) and the time of day. Since visitors are carers of the patients, they support the HCWs, and thus it was relevant to collect ‘after body fluid exposure risk’ data. However, moment 2 (before/after clean procedure) was omitted as it was not relevant to the population under observation (Sunkesula et al., 2015). HHC observations were undertaken by research students on the same day as the intervention. For both Baseline and Intervention Phases, the HHC audit sessions lasted 30 min and were repeated in the same ward five times per day with a period of 45 min between audits (morning audits were undertaken at 09:00 and 11:00, afternoon audits at 13:00, 15:00 and 17:00). Multiple sinks, soap and alcohol hand rubs were available for the patients and visitors as well as HCWs around the ward and next to the doors. Alcohol hand rub was situated out of reach of children. Individual hand wipes were provided at mealtimes. The dialysis ward had hand rub next to beds plus a separate sink. The intervention phase included rates of HHC and the educational interventions. During the afternoon observation in the intervention phase, a meal arrived, and thus the additional HHC opportunity before the meal was observed. After the interventions, a qualitative questionnaire was given to the parents/carers of the children (aged 3–15 years), children (⩾ 16 years) and visitors. Questions were asked about awareness of HH, knowledge and understanding of germs and HH, and views about the different approaches to HH, including the use of the Glo-yo or video. The questionnaire consisted of a Likert scale and open-ended questions that referred to the patient (Suppl. Figure 4). A 5-min interview to conclude the intervention was conducted to take account of the age range of the children and facilitate discussion with carers/visitors to discern the understanding of their child. The children taking part were aged 3–17 years. In total, 62 patients and visitors were approached; 31 agreed to participate and signed a consent form (16 visitors and 15 patients).

Statistical analysis

The data were analysed using SPSS statistic software (IBM SPSS statistic v. 21) and GraphPad Prism6. Simple frequency counts and Chi-square tests of proportions of HHC opportunities adhered to across variables were used to calculate HHC rates and indicate the degree of significance of variation. The questionnaire responses were collated in categories inherent in the questions themselves, compared using simple frequency counts and grouped into themes.

Results

With the aim of measuring HHC before (baseline) and after intervention, and with the objective to identify if HHC depended on prior activity or timing, HHC was observed after each relevant hygiene moment and at different times of the day.

Baseline observations of HHC

A total of 525 HH opportunities of the 31 patients and visitors were monitored; the overall compliance rate was 130/525 (24.8%) (Tables 1 and 2: proportion complied). HHC was low, particularly for children (9%). This rate was significantly different from that of their visitors (26%; P < 0.05). When the visitors were observed, there was also a significant difference in HHC dependent on the moment of HH (P < 0.001). The lowest level of patient compliance was observed after body fluid exposure (3.7%) and the highest was before patient contact (41.3%). Similarly, HHC of visitors depended on the ward that they were on (P = 0.35) and were significantly different dependent on the time of day (P < 0.001).

Table 1.

Rates of visitor HHC increased following educational interventions.

Baseline						Intervention
Variable	Proportion of HH opportunities (n (%))		Proportion complied		P value*	Proportion of HH opportunities (n (%))		Proportion complied		P value*
Visitors (n = 492)						Visitors (n = 1209)
Visitors	492	(93.7)	127/492	(25.8)		1209	(100)	614/1209		(50.8)
Ward
General paediatric	119	(24.2)	25/119	(21)	0.349	295	(24.4)	137/295	(46.4)	0.007†
Surgical ward	93	(18.9)	25/93	(26.9)		271	(22.4)	161/271	(59.4)
Dialysis and urology	33	(6.7)	5/33	(15.2)		130	(10.8)	74/130	(56.9)
Oncology	91	(18.5)	29/91	(31.9)		167	(13.8)	84/167	(50.3)
Neuroscience	109	(22.2)	31/109	(28.4)		191	(15.8)	87/191	(45.5)
Children’s assessment	47	(9.6)	12/47	(25.5)		155	(12.8)	71/155	(45.8)
Time
Morning	254	(51.6)	48/254	(18.9)	< 0.001†	610	(50.5)	321/610	(52.6)	0.1
Afternoon	238	(48.4)	79/238	(33.2)		599	(49.5)	293/599	(48.9)
Type of opportunity
Before patient contact	184	(37.4)	76/184	(41.3)	< 0.001†	658	(54.4)	377/658	(57.3)	< 0.001†
After body fluid exposure risk	27	(5.5)	1/27	(3.7)		11	(0.9)	8/11	(72.7)
After patient contact	120	(24.4)	28/120	(23.3)		324	(26.8)	134/324	(41.5)
After contact with patient surroundings	161	(32.7)	22/161	(13.7)		132	(10.9)	53/132	(40.2)
Before meal						84	(6.9)	42/84	(50)
Intervention on ward
Control (n = 7 leaflets)	94	(19.1)	28/94	(29.7)	< 0.001†	346	(28.6)	158/346	(45.7)	< 0.001†
Glo-yo (n = 7 Glo-yos)	233	(47.3)	57/233	(24.4)		401	(33.2)	235/401	(58.6)
MLT (n = 2 MLTs)	165	(33.5)	42/165	(25.4)		462	(38.2)	221/462	(47.8)

The left column shows the baseline data and the right column shows the intervention (intermediate phase data). As part of usual practice, everyone on the ward was observed for HHC for each of the WHO 5 moments of hand hygiene (2009) in the morning and in the afternoon. The data for the visitors (adults and children) are shown analysed using a Chi-squared test.

^*Significant (P < 0.05).

^†Highly significant (P < 0.001).

HH, hand hygiene; HHC, hand hygiene compliance; MLT, mobile learning technology.

Table 2.

Patient HHC increased following educational interventions.

Baseline						Intervention
Variable	Proportion of HH opportunities (n (%))		Proportion complied		P value*	Proportion of HH opportunities (n (%))		Proportion complied		P value*
Patients (n = 33)						Patients (n = 228)
Patients	33	(6.3)	3/33	(9.1)	< 0.05*	228	(15.9)	93/228	(40.8)
Ward
General paediatric	10	(30.3)	0/10	(0)	0.007	45	(19.7)	19/45	(42.2)	< 0.05*
Surgical ward	0	(0)	0/0	(0)		48	(21.1)	29/48	(60.4)
Dialysis and urology	3	(9.1)	2/3	(67)		17	(7.5)	11/17	(64.7)
Oncology	6	(18.2)	0/6	(0)		31	(13.6)	11/31	(35.4)
Neuroscience	10	(30.3)	1/10	(10)		40	(17.5)	9/40	(22.5)
Children’s assessment	4	(12.1)	0/4	(0)		47	(20.6)	14/47	(29.8)
Time
Morning	16	(48.5)	1/16	(6.3)	0.523	79	(34.6)	28/79	(35.4)	0.25
Afternoon	17	(51.5)	2/17	(11.8)		149	(65.3)	65/149	(43.6)
Type of opportunity
Before patient contact	4	(12.1)	0/4	(0)	0.183	6	(2.6)	3/6	(50)	< 0.001†
After body fluid exposure risk	4	(12.1)	0/4	(0)		0	(0)	0/0	(0)
After patient contact	2	(6.1)	1/2	(50)		4	(1.8)	1/4	(25)
After contact with patient surroundings	23	(69.7)	2/23	(8.7)		214	(93.9)	85/214	(39.7)
Before meal						4	(1.8)	4/4	(100)
Intervention on ward
Control (n = 1 leaflets)	7	(21.2)	0/7	(0)	0.006	87	(38.2)	23/87	(26.4)	< 0.001†
Glo-yo (n = 9 Glo-yos)	18	(54.5)	0/18	(0)		65	(28.5)	40/65	(61.5)
MLT (n = 5 MLTs)	8	(24.2)	3/8	(37.5)		76	(33.3)	30/76	(39.5)

The left column shows the baseline data and the right column shows the intervention (intermediate phase data). As part of usual practice, everyone on the ward was observed for HHC for each of the WHO 5 moments of hand hygiene (2009) in the morning and in the afternoon. The data for the patients are shown analysed using a Chi-squared test.

^*Significant (P < 0.05).

^†Highly significant (P < 0.001).

HH, hand hygiene; HHC, hand hygiene compliance; MLT, mobile learning technology.

Post-intervention phase HHC

A total of 1437 HH opportunities were observed for the 31 patients and visitors. The control leaflet group consisted of eight participants, the MLT intervention of seven participants and the Glo-yo intervention group of 16 participants. There was an increase of 24.4% in HHC compared to the baseline phase, which was significantly different (P < 0.001) between: (1) the moments of contact providing the opportunity; (2) the type of paediatric ward observed; and (3) the intervention used (Tables 1 and 2). The higher HHC was not significantly different between: (1) the morning and afternoon shifts (P = 0.29); or (2) visitors and children (P < 0.5). The HHC of patients and visitors in all groups was higher than the baseline phase HHC. Interestingly, improvement in HHC was greatest after the intervention session using the Glo-yo; this statistically significant difference (P < 0.001) was particularly marked for the children where HHC rose from 0% to 61.5% (Table 2). In contrast, the HHC for the wards receiving the MLT intervention remained similar to that of the baseline phase for the children (39.5% and 37.5%, respectively). With the control leaflet, the children’s HHC rose from the baseline 0% to 26.4% following the intervention phase (Table 2). For the visitors, HHC for the control leaflet and MLT rose by 16% and 22.4%, respectively, while for the Glo-yo there was a rise in HHC by 34.2% (Table 1).

Post-intervention evaluation

The Glo-yo group included 16 (51.6%) out of the 31 participants. The video group included 7 (22.5%) of the 31 participants. The control group included 8 (25.8%) of the 31 participants (who only had access to HHC leaflets; Suppl. Figure 3).

Children and their visitors/carers in all groups reported that the awareness of HH had been raised, with the Glo-yo intervention prompting the highest proportion of the participants to indicate that they ‘strongly agreed’ with this (Table 3, Q1). The answers to the questions asking if knowledge and understanding of germs and handwashing had been increased varied between intervention and subcategory of question. The Glo-yo intervention group ‘agreed strongly’ with respect to all question subcategories except question 2b where most of the participants ‘agreed’ and the remainder ‘strongly agreed’ (Table 3). Almost two-thirds of participants in the Glo-yo and video MLT intervention groups ‘strongly agreed’ that the session and both training aids focused on why we wash our hands (62.5% and 71.4%), but 100% of the control group ‘agreed’ rather than ‘strongly agreed’ with this (Table 3, Q2a). When asked about whether the intervention increased knowledge about bacteria and germs, 31.3% of the participants in the Glo-yo group ‘strongly agreed’ and 100% of the video group ‘agreed’, which contrasted with the control group, who were 100% ‘neutral’ on this point (Table 3, Q2b). When the participants considered whether the intervention sessions dealt with when to wash hands, 88% of the Glo-yo group ‘strongly agreed’, whereas 71% of the video group and 88% of control group were ‘neutral’ (Table 3, Q2c). Finally, when asked whether the intervention session increased the knowledge and understanding of the parts of hands that are difficult to wash, 69% of the Glo-yo group, 43% of the video group and only 13% of the control group ‘strongly agreed’. Indeed, a small proportion of the participants of the video and control groups ‘disagreed’ with this (Table 3, Q2d).

Table 3.

Participant feedback indicated that interactive sessions raised their awareness, increased knowledge and understanding, and would be effective in improving children’s handwashing, with the strongest positive response being for the Glo-yo intervention.

Questionnaire item	Intervention group	Strongly agree (n (%))	Agree (n (%))	Neutral (n (%))	Disagree (n (%))	Strongly disagree (n (%))
Q1. The session was successful at raising awareness of the importance of handwashing
	Glo-yo (n = 16)	11 (68.8)	5 (31.3)	0 (0)	0 (0)	0 (0)
	MLT (n = 8)	4 (57.1)	3 (42.9)	0 (0)	0 (0)	0 (0)
	Control (n = 7)	4 (50)	4 (50)	0 (0)	0 (0)	0 (0)
Q2. The session helped increase your child’s knowledge/ understanding of the following:
a. Why we wash hands
	Glo-yo (n = 16)	10 (62.5)	6 (37.5)	0 (0)	0 (0)	0 (0)
	MLT (n = 8)	5 (71.4)	2 (28.6)	0 (0)	0 (0)	0 (0)
	Control (n = 7)	0 (0)	8 (100)	0 (0)	0 (0)	0 (0)
b. Germs and bacteria
	Glo-yo (n = 16)	5 (31.3)	11 (68.8)	0 (0)	0 (0)	0 (0)
	MLT (n = 8)	0 (0)	7 (100)	0 (0)	0 (0)	0 (0)
	Control (n = 7)	0 (0)	0 (0)	8 (100)	0 (0)	0 (0)
c. When to wash hands
	Glo-yo (n = 16)	14 (87.5)	2 (12.5)	0 (0)	0 (0)	0 (0)
	MLT (n = 8)	0 (0)	2 (28.6)	5 (71.4)	0 (0)	0 (0)
	Control (n = 7)	0 (0)	1 (12.5)	7 (87.5)	0 (0)	0 (0)
d. Parts of hands that are difficult to wash
	Glo-yo (n = 16)	11 (68.8)	3 (18.8)	2 (12.5)	0 (0)	0 (0)
	MLT (n = 8)	3 (42.9)	1 (14.3)	2 (28.6)	1 (14.3)	0 (0)
	Control (n = 7)	1 (12.5)	3 (37.5)	3 (37.5)	1 (12.5)	0 (0)
Q3. Do you think the session will improve children’s handwashing, even if for one day?
	Glo-yo (n = 16)	9 (56.2)	5 (31.3)	2 (12.5)	0 (0)	0 (0)
	MLT (n = 8)	0 (0)	1 (14.3)	5 (71.4)	1 (14.3)	0 (0)
	Control (n = 7)	1 (12.5)	1 (12.5)	3 (37.5)	3 (37.5)	0 (0)

Due to the limited time that patients spend in hospital, and because the session was only performed once with each participant, the final part of the questionnaire aimed to determine whether a single intervention session could improve handwashing. More than half of the Glo-yo group ‘strongly agreed’ (56%) with the question ‘Do you think the session will improve children’s handwashing, even if only for one day?’, while the participants of the video intervention group were mainly ‘neutral’ and the control group were primarily either ‘neutral’ or ‘disagreed’. It should be noted that a small proportion of the control group ‘agreed’/’strongly agreed’ (Table 3, Q3).

Free comments (Table 4) indicated that the control group thought the session would help children understand how to wash hands in a school setting. The MLT group felt the video was more appropriate for adults than children, although in general the session was encouraging. The Glo-yo group found their session very effective, interesting, encouraging and helpful, and would recommend it to be used in a school setting.

Table 4.

Participant comments in response to two of the questions on the questionnaire.

Intervention group	Comments on the question ‘How would they describe the session and the activities carried out by the facilitator?’	Comments on the question ‘Would you recommend the sessions to children in schools’
Glo-yo	‘The session is very effective though the time is not enough to explore the new toy (Glo-yo)’	‘Strongly agree, schools will be much better to learn about handwashing’
	‘I found the session very interesting and very encouraging and very easy task to do’	‘Very interesting would like to have same session in schools’
	‘Very helpful, the toy was interesting to use and good way to teach kids handwashing’	‘Mum found it interesting and very worthwhile. I would recommend it to school children. My daughter found it interesting’
		‘I would recommend the hand wash in schools it will encourage children more to wash hands and be germ-free than hospital’
MLT	‘The session in general is encouraging for children to learn about handwashing and germs. The use of phone is not easy for my child to understand’	‘For my child was too much information, I enjoyed the video as a parent’
	‘The video is too long and not easy to follow by a child’	‘The session was encouraging!’
	‘The video is very complicated for a child to understand. I enjoyed the video as it’s easier to follow and understand’	‘The session with the facilitator was fun handwashing session was useful. However, the phone video is not easy for child to understand’
Control		‘Session was helpful in understanding when to wash hands, and how, will recommend for school children’
		‘Helpful session should be more practical to apply in schools’

All participants (n = 31) completed the questionnaire, but not all elaborated in the free-text comment boxes, so all the comments (n = 15) obtained are shown.

Discussion

Our data support previous studies that reported an increase in HHC after educational intervention (Chen and Chiang, 2007; Fishbein et al., 2011; McGuckin et al., 1999) with HHC increasing for both children and their visitors in this study, even though the activities primarily engaged the patients. The educational intervention tested here that raised awareness of the importance of handwashing most strongly, in addition to increasing the child’s knowledge and understanding of germs and handwashing, was the Glo-yo. The qualitative comments indicate that it is possible that this effectiveness derives from the interesting and encouraging nature of the Glo-yo intervention session, which participants felt would be appropriate for use in schools. The design of the Glo-yo with children in mind may have contributed to the particularly marked increase in the HHC changes for the children (0% rose to 61.5%) compared to the visitors (24.4% rose to 59%).

Visitors had the highest level of compliance ‘after exposure to body fluids’ in the intervention phase, which has previously been identified (Randle et al., 2010). This may be as a result of self-protection or due to emotional sensations including feelings of unpleasantness, discomfort and/or disgust (Whitby et al., 2007). Surprisingly, this was very low in the baseline phase (3.7%). The lowest compliance after intervention for the visitors was found for the moment ‘after contact with patient surroundings’ (40.2%). Although this is considered a low compliance rate, it is higher than recent data (Randle et al., 2013) and the baseline phase. It is important as near touch sites pose the highest risk to patients, especially those in close and direct contact with patients (Dancer, 2009). A high increase in HHC was observed ‘after contact with patients’. This was mainly observed in visitors, increasing from 23.3% to 41.5%, but is considerably lower (> 35%) than previous observational studies (Randle et al., 2010). Limited literature is available looking at HHC of patients before a meal (Sunkesula et al., 2015). In this study it was observed that compliance at this opportunity at the intervention phase was 50% for visitors and 100% for patients, which may reflect the provision of wipes with the meal. Interestingly, a higher HHC was observed in the afternoon than the morning (31.7% compared to 18.1%) during the baseline phase, and this increased after the intervention such that morning and afternoon HHC was similar (50.6% in the morning and 47.9% in the afternoon).

This study indicates that HHC is better than previously reported and provides evidence of a significant increase in HHC after intervention (P < 0.001). Both interventions (Glo-yo and video) and the control leaflet improved HHC and raised awareness of the importance of HH. The Glo-yo session proved the most successful intervention (particularly with children), raising HHC of patients and visitors by 36.3%, with 68.8% of participants strongly agreeing it would increase awareness of the importance of HH and 56.2% parents strongly agreeing that the Glo-yo session will improve their child’s handwashing. This aligns with previous research indicating educational and psychological programmes which integrate tangible materials and images of the subject to be learnt can improve motivation and learning with the added benefit of long-term behavioural change (Bairaktarova et al., 2011; Ho et al., 2009; Worthington et al., 2001).

The responses to the questionnaire (Table 3) indicate that both of the interventions (the Glo-yo and the MLT) as well as the leaflet could be improved by providing more information about germs. The MLT and leaflet could also be improved by conveying more information on when to wash hands and which parts of the hands are more difficult to wash. The leaflet would also be improved by explaining the reasons why it is important to wash hands. From the comments in Table 4, the MLT video and leaflet might be more effective if redesigned with children specifically in mind. This suggestion is supported by the finding that the MLT and leaflet raised visitor HHC to similar levels (41.8% and 46.7%, respectively), both of which are higher than the HHC of the children with either (26.4% control leaflet and 39.5% MLT) This small study therefore demonstrates that providing resources that integrate these changes may improve HHC.

The leaflet is readily available from this publication and the video can be obtained from the NHS cleanyourhands campaign. The Glo-yo requires funding under a license agreement for a manufacturer before it is available for widescale use and is subject to design rights owned by the University of Nottingham. Although it was not possible to follow up the participants to explore long-term change, the effects of the Glo-yo were evident within the school setting for more than a year (Randle et al., 2013) and it would be interesting to see if this could be emulated in a healthcare setting.

The limitations of this study include the impracticality of blinding the participants, but to minimise the potential of cross-over contamination, distantly located wards were chosen for this study. Attrition was avoided by including the questionnaire structured interview to conclude the session. The demographics of the intervention/control groups were similar, however the study was limited by sample size and we cannot exclude the possibility that factors other than the interventions contributed to the improvement in HHC or whether the length of time used to deliver the different interventions had an impact on the data.

In summary, the Glo-yo interactive educational intervention was able to improve HHC of children and their visitors most effectively, but the control leaflet also improved HHC and has the advantage of being both readily available and cost effective. Future studies are required to determine whether this improvement in HHC is sustained and if it can reduce HCAIs.