The results of this study support the hypothesis that improving communication of infection control requirements may lead to better compliance with precautions during inpatient transfers. Introduction of a pre-transfer checklist promoted communication between porters and ward nurses, and therefore the porters were better informed of a patient’s infectious status. Using a coloured sticker to flag an infectious case was an effective means for cueing the porters to the importance of written information. In both interventions, the adherence rate to infection control precautions was significantly improved.
In this study, the researcher was actively involved in applying the interventions. In practice, both the checklist and coloured cue can be easily incorporated into existing workflow, without imposing additional workload. For example, simple software can be implemented so that the coloured cue is automatically inserted into the printed transfer form. The existing transfer form can also be extended to include a checklist for infection control precaution.
Effectiveness of the pre-transfer checklist
Adherence to the checklist was lower than expected (40%). Observations showed that subjects mostly completed the checklist by inspecting visual cues around the ward. Thus, while the frequency of verbal checks remained low, the checklist was an effective memory tool that reminded the porters to check for infection control requirements prior to transferring a patient.
Many studies have reported low adherence rate to checklists by medical workers. Healthcare professionals have largely resisted using checklists, dismissing them as “tick-box medicine” , or an insult to their intelligence . An attempt to introduce a WHO surgical checklist in one UK institution reported a compliance rate of only 42% . In spite of this, the study reported a noticeable improvement in safety processes such as timely use of prophylactic antibiotics, which rose from 57% to 77% of operations. Similar results were reported in the introduction of preventive care checklist  and anaesthesia checklist .
Our results are consistent with these previous studies of checklists. Negative attitudes towards the use of checklists are a major barrier to the implementation. Regulation of checklist use in healthcare is likely to be difficult to achieve. A fundamental change in culture and attitudes toward checklists is necessary . The support of local champions, particularly among senior consultants, is critical to their success .
Effectiveness of the coloured cue
The observed improvement in compliance with infection control precautions when a coloured cue was present is consistent with existing evidence on the importance of colour in the communication of information . When a red sticker was attached to the transfer form, the information was noticed by the subjects immediately. The appropriate use of colour in safety signs is addressed under a series of standards published by the American National Standards Institute (ANSI) [34, 35]. The choice of colour red to signify infectious cases was consistent with colour stereotypes used for communicating hazard. Informal interviews with the porters revealed general consensus on the effectiveness of the intervention. Some porters commented on their struggle to read information in the transfer form, due to diminished vision caused by presbyopia. Redundantly coding critical information with colours increased its detectability.
Checklist versus coloured cue: which intervention is better?
Implementation of a pre-transfer checklist and coloured cue resulted in comparable improvement in compliance. The improvement gained from applying both interventions concurrently was only marginal, indicating that there were little additive benefits in implementing both interventions. Based on the reactions of the participants towards the intervention, however, it would appear that the coloured cue will be more effective in the longer term. As with any patient safety improvement strategies, acceptance by care providers is crucial to their success.
Barriers to compliance with infection control precautions
While improved communication can enhance adherence to infection control precautions, however this alone is not sufficient in tackling this complex problem. Behavioural change remains a challenging obstacle. Infection control protocols were sometimes knowingly violated by the porters. Non-adherence to infection control precautions was also prevalent among nurses and physicians. Poor examples shown by superiors, and normalization of deviance can cultivate a culture of non-compliance in all parts of the hospital [36, 37].
Another significant barrier to compliance was understaffing on the ward. When resources were stretched, the need to assist porters with transfer was a source of unwelcomed distraction. Transfer activities were often rushed, and infection control precautions were overlooked as a result. The role of understaffing in the spread of hospital acquired infection has been documented in several studies [38, 39]. It might be conjectured that implementing the pre-transfer checklist further competed for the nurses’ attention, and this may have contributed to the low acceptability of the intervention.
Our observations further showed that there was variability in the performance of the required precautions. The guidelines for the use of gloves and gowns (as outlined in Table 1) were rarely adhered to. In particular, gloves worn when handling patients requiring contact precautions were not discarded or changed before touching environmental item and surfaces; gowns worn were not removed before leaving the patient’s room. The practice of hand antisepsis was particularly poor. The porters, in general, preferred using gloves as a protective barrier. There appeared to be a misconception that glove use eliminates the need for additional hand antisepsis. Hand antisepsis was almost never practised whenever gloves were used. This observation is consistent with existing evidence that the use of gloves represents a major barrier for compliance with hand antisepsis . There is therefore a need to educate the porters on the importance of hand antisepsis, as the use of gloves cannot be guaranteed to provide complete protection against contamination of the hands.
Informal interviews with the porters and ward nurses also revealed that guidelines on infection control appeared to vary across different departments. In particular, there was confusion regarding whether a gown should be worn. Whilst standard protocol mandated the use of a gown when transporting patients requiring contact precautions , some staff members believed that wearing of gowns increased the risk of infection. Such conflicts in protocols led to confusion and frustration amongst ward nurses and porters. Clear and consistent guidelines need to be in place across the hospital.
Our observations confirm existing evidence that isolation precaution signage and promotional materials are ineffective in encouraging compliance. In the study site, posters were used to signal isolation precaution, and educational materials were displayed on the ward notice boards. However, compliance remained low. A review of the literature specifically exploring the impact of posters and promotional materials found little evidence that the messages they convey increase lasting compliance . In most cases, compliance improved initially, but returned to baseline levels within several months.
Limitations and future research
Our study had several limitations. Firstly, we evaluated the interventions at one hospital and the number of participants involved in the study was relatively small. Thus, our results may not be generalisable across settings. Secondly, there is the possibility of carry-over effects, where earlier exposure to one intervention affects a subject’s response when a different intervention is applied. To minimise carry-over effects, the interventions were randomised. Our observations showed that the rate of compliance for each study arm remained relatively stable throughout the experimental period, indicating that any carry-over effects were minimal. Finally, there is the possibility of Hawthorne effects, where subjects improve their compliance when being observed. Since the interventions were presented to the subjects by the researcher, and the researcher was present during the transfer, the subjects may have modified their compliance behaviour. To prevent this, the design of the interventions included the escort requirement so as to blind the subjects to the true intent of the study. To further minimise Hawthorne effects, the researcher shadowed transfers of both infectious and non-infectious patients.
In this study, we evaluated our interventions by measuring compliance with infection control precautions. Future studies should assess the effects of improved communication on actual infection rates. Further, the interventions were evaluated on a small number of healthcare personnel, over a short period of time. Follow-up studies should be carried out to examine if the effects of the interventions can be sustained over time on a larger sample size. The effectiveness of the interventions should also be evaluated in the absence of an observer. And finally, in this study, no specific efforts were made to encourage the use of the checklist. It is not clear whether active promotion would lead to improved compliance, but the hypothesis is certainly worthy of further investigation.