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Interactive hygiene training using free open source software
  1. Michael Eisenmann1,
  2. Vera Rauschenberger1,2,
  3. Jens Maschmann3,
  4. Sarah König4,
  5. Manuel Krone1,2
  1. 1Infection Control and Antimicrobial Stewardship Unit, University Hospital Wurzburg, Wurzburg, Germany
  2. 2Institute for Hygiene and Microbiology, University of Würzburg, Wurzburg, Germany
  3. 3Medical Executive Board, University Hospital Tübingen, Tubingen, Germany
  4. 4Institute of Medical Teaching and Medical Education Research, University Hospital Wurzburg, Wurzburg, Germany
  1. Correspondence to Dr Michael Eisenmann; eisenmann_m{at}ukw.de

Abstract

Objectives Regular hygiene trainings are an important way to refresh and improve knowledge about hygiene measures and the prevention of healthcare-associated infections. We aimed to develop an e-learning course to allow healthcare workers (HCWs) to learn these contents through a self-paced online format.

Methods We developed an interactive hygiene training for HCWs of a tertiary care hospital using different content types of the HTML-5 package (H5P) plugin embedded into a Moodle-based learning management system. We evaluated the course using a short online questionnaire.

Results We present various suitable topics for online hygiene trainings as well as their implementation in an e-learning course. Examples include content on hand hygiene indications and techniques, information on multidrug-resistant organisms and other current topics in infection control. HCWs reported high overall satisfaction, perceived increase in knowledge, practical relevance as well as good usability and comprehensibility.

Discussion Currently available commercial and non-commercial hygiene trainings present a number of specific advantages but also drawbacks. The presented approach combines the advantages of both approaches. The majority of the presented content can be readily adapted to suit various hospitals and care facilities or serve as inspiration for creating similar courses while remaining cost-effective.

Conclusion H5P course presentations are a low-threshold, cost-effective way to implement digital hygiene trainings in a wide variety of clinical settings.

  • Hand Hygiene
  • Health professions education
  • Hygiene
  • Infection control
  • Medical education

Data availability statement

Data are available upon reasonable request. The hygiene training files are available upon reasonable request from the corresponding author.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • E-learning courses have gained immense popularity but compared with other medical fields deployment of courses in infection prevention and control remains limited.

WHAT THIS STUDY ADDS

  • We created and evaluated an interactive hygiene training using only license free open source software.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • The presented approach allows IPC professionals to offer customisable electronic hygiene trainings, especially in resource-limited settings.

Introduction

Digital, interactive learning formats have gained immense popularity in medical education, surpassing traditional teaching methods such as frontal-class teaching.1 Since the onset of the SARS-CoV-2 pandemic, e-learning has not only solidified its popularity but has also become an essential requirement.2 3 It is important to note that modern learning methods are not exclusive to medical students; digital learning formats can also greatly benefit mandatory hygiene trainings in various healthcare facilities. By incorporating digital learning formats, medical students and healthcare professionals can acquire knowledge about hygiene measures and infection control procedures through self-paced online courses. However, it is crucial to acknowledge that the implementation and integration of these digital formats may pose several technological and financial challenges, particularly in resource-limited settings.4 These challenges can hinder the widespread adoption and effectiveness of such learning methods.

Regular hygiene trainings are an important way to refresh and improve knowledge about hygiene measures for healthcare workers (HCWs). However, recent surveys among trainees in clinical microbiology (CM) and infectious diseases (ID) indicate limited usage of e-learning in CM/ID compared with other medical fields despite more than half of the participants expressing favourable opinions towards its use.5

Methods

We developed an interactive hygiene training using only license-free, open-source software. The hygiene training was developed using the HTML-5 package (H5P) based ‘course presentation’ content type.6 H5P content can be integrated in a variety of different learning- and content-management systems. In this case, the content has been created in a Moodle-based learning management system (LMS).7 The presentation was rolled out to HCWs of a tertiary care hospital in Germany such as nurses, physicians and technical assistants as well as medical students during the clinical phase of their studies.

To evaluate the hygiene training we designed a digital short questionnaire for an updated version of the hygiene training in 2024. The questionnaire included questions about general satisfaction with the course, perceived increase in knowledge about the presented topics, comprehensibility, perceived practical relevance and usability of the training inside the LMS.

The short questionnaire comprised five items that used a 5-point Likert scale. The scale was labelled with ‘very satisfied’ on the left pole and ‘not at all satisfied’ on the right pole for the item asking about the overall satisfaction and ‘strongly agree’ on the left pole and ‘do not agree at all’ on the right pole for the remaining four items. HCWs were requested to fill in the short questionnaire at the end of hygiene training and were able to complete it via the online survey tool EvaSys (evasys GmbH, Lüneburg, Germany) by clicking on a link inside the course presentation.

Patient or public involvement

Patients and the public were not involved in any way in this study.

Results

The hygiene training was developed with a thematic emphasis on basic hygiene measures. It includes pre-recorded videos on personal protective equipment (PPE) handling, port handling and hand hygiene among other topics. Interactive elements such as quizzes on hand hygiene indications and multidrug-resistant organisms (MDROs) were integrated into the interactive presentation format. Direct links to documents in the in-house quality management software were added as well. Participation could be verified with Moodle reporting tools to be able to provide feedback to clinicians.

Between November 2022 and February 2023 650 HCWs including 207 physicians, 66 medical assistants, 145 healthcare technicians and 232 nurses completed the first version of the interactive hygiene training. The online training was promoted on the message board of the hospital’s internal network. Access to the LMS was possible both through the hospitals internal network and the internet.

In early 2023 the hygiene training was updated with the removal of content that has lost clinical relevance (eg, mPox) and the addition of new content (eg, handling of sterile goods, virtual ward inspection).

In 2024 the hygiene training was updated once again. The virtual ward inspection now includes pictures from recent ward inspections. The section on PPE was expanded to include information on the correct donning, doffing and usage of protective gloves. Additionally, info slides about recent changes in hospital-specific disinfection agents were added at the end of the course presentation.

Between May 2023 and December 2023, an additional 2180 HCWs including 786 physicians, 190 medical assistants, 287 healthcare technicians and 917 nurses completed an updated version of the hygiene training. In 2022 and 2023 a total of 877 medical students in the clinical phase of the study completed a slightly modified version of the hygiene course.

Between June and July of 2024 an additional 1019 HCWs completed the latest updated version of the hygiene training.

The following paragraphs show possible topics for the hygiene training and how they have been realised and edited for the course presentation content format.

General structure and branding/corporate identity

Some institutions may already have templates for presentations that are used throughout the institution. To maintain a consistent appearance with other educational content in our institution, we used an existing Microsoft PowerPoint template to create the background for the slides within the course presentation. The slides were exported as PNG images and integrated into the course presentation as image elements. While H5P also offers the option to set images as the background for the course presentation, there are differences in default aspect ratios between H5P and PowerPoint. As a result, if the exported slides are used without modifications in the PowerPoint slide master, they may appear stretched.

At the beginning of the presentation, explanatory slides were integrated to introduce participants to the navigation elements and controls within the interactive format.

Hand hygiene

WHO five moments of hand hygiene

Foundation is a widespread graphical illustration depicting the WHO five moments of hand hygiene. Participants can access additional information about each of the five moments by clicking on the blue info-buttons which open text fields (figure 1). This slide is strategically positioned early in the course presentation to facilitate the initial engagement with the digital, interactive format, particularly for participants with limited digital literacy.

Figure 1

(A) WHO five moments of hand hygiene. (B) Participants receive additional information by clicking on the blue info-buttons.

Hand disinfection technique

Hand hygiene technique is demonstrated through the use of various media. First, images of the correct technique split into the respective steps of hand hygiene with alcoholic rub are shown (figure 2). On clicking on the blue info buttons, participants receive additional information about each step. The slide is complemented by an instructional video that demonstrates the technique in real-time. Especially when integrating multiple videos, it is advised to host the videos in an external source (eg, YouTube, Vimeo or self-hosted) rather than storing them directly in the H5P file as this significantly slows downloading times.

Figure 2

Hand hygiene technique: step-by-step instructions (A) and video (B). Blue info buttons in (A) reveal further information for the user.

Frequent disinfection mistakes

Frequent mistakes of hand hygiene are illustrated using an image of (deliberately) poorly applied fluorescent alcoholic hand rub under UV light. Clicking on the blue info buttons reveals the mistakes that were made (figure 3).

Figure 3

Hand hygiene slides: (A) frequent mistakes when applying alcoholic hand rub. The blue info dots reveal the mistakes when clicking on them. (B) Five moments of hand hygiene quiz: participants need to drop the grey boxes that contain the moments in the right location.

Quiz WHO five moments of hand hygiene

The quiz was created using the ‘drag and drop’ content type inside the course presentation (figure 3). The same graphical illustration for the WHO five moments of hand hygiene as before has been used. Drop areas for each of the indications are placed inside the arrows for the respective indications. Grey boxes with the five indications can be dragged to the right positions. Participants can check their results immediately.

Correct handling of PPE

The handling of PPE is demonstrated through instructional videos. These videos showcase techniques for correctly donning and doffing PPE such as gloves, gowns and eye protection. We used educational videos that were created in-house. The videos are directly integrated into the course presentation format but have common navigation elements that allow participants to pause, replay or jump to specific sections as needed. As before, hosting outside the course presentation is advised to shorten loading times by minimising the .h5p file sizes. If there are limitations on locally hosting videos an alternative approach is to upload the videos (unlisted) to video streaming services like YouTube or Vimeo instead and integrate them into the course presentation afterwards. Most national and international (WHO, ECDC, etc) health organisations offer free educational content that can be integrated into the presentation if self-produced videos are not available.

Links or summaries of pre-existing quality management documents

In some institutions procedure instructions and other internal documents are provided by the infection control unit or other relevant departments. To ensure HCWs are aware of these documents, a brief introduction can be provided in the course. Direct links to the documents can then be integrated into the course presentation. In our presentation, we have included direct links to local guidelines that are stored in a document management system for quality management documents. The documents cover instructions on isolation, protective equipment, garbage management and further information about different pathogens such as SARS-CoV-2, influenza, MDROs and others.

Recent topics in infection control

As part of the course, current topics in infection control were covered through short info-sheets. Specifically, brief overviews about Mpox and MDROs were integrated. When clicking on the blue info boxes, additional images such as epidemiological illustrations and electron microscopic images of the pathogen appear. Links to the ECDC infection atlas for ID were integrated into the course presentation as well. On another slide, related topics such as sample logistics of swabs for Mpox-PCR were illustrated including step-by-step instructing images.

Finding high-touch areas

The ‘Finding high touch areas’-quiz was created to educate participants about surfaces that are frequently touched in the patient environment requiring special attention during disinfection. This was accomplished using the ‘Find multiple hotspots’-H5P content type. At the time of its creation, ‘Find multiple hotspots’ was not available in the course presentation. An image of a typical patient room in one of the hospital’s wards was used as a base (figure 4). When participants click on different areas in the picture, participants receive feedback indicating whether they have guessed correctly.

Figure 4

Finding high touch areas quiz. Participants must click on areas that are often touched in clinical routine. Red cross indicates wrong clicks, green check mark shows correctly identified frequently touched areas.

Additional topics in updated versions

Virtual ward inspection

A virtual ward inspection was created using the ‘dialogue cards’ content type to sensitise participants for frequent deficits. Participants can browse through different ‘cards’ that contain photographs of observations from recent ward inspections. By ‘flipping’ the card, the participants can read the queries made during the inspection.

Handling of sterile equipment

Basic principles of the handling and storage of sterile equipment (storage conditions, storage duration, good documentation practices) were also illustrated using the ‘dialogue cards’ content type. This was followed by a multiple choice quiz where participants could check their knowledge.

Evaluation

The short evaluation questionnaire was fully completed by 63% (645 out of 1019) of the HCWs who also completed the 2024 version of the training.

Between 20 June 2024 and 19 July 2024, 653 HCWs submitted a short questionnaire. Eight participants did not complete the full questionnaire and were therefore excluded. The majority stated overall high satisfaction with the course (89% were ‘very satisfied’ or ‘satisfied’). The majority of the HCWs found the contents of the course to be easily understandable (totally agreed or agreed: 91, 5%) and relevant to their clinical practice (totally agreed or agreed: 92, 6%). Most stated a self-perceived increase in knowledge about the topics (80, 9% totally agreed or agreed). The majority found the course inside the LMS easy to use (91, 6% totally agreed or agreed). Figure 5 shows an overview of the results.

Figure 5

Overview over the results of the evaluation.

Discussion

Many countries legally require HCWs to participate in annual hygiene trainings. For example in Bavaria, where the described training was implemented.8 Considering, that healthcare personnel are often occupied with their clinical responsibilities, it is becoming increasingly important to facilitate the integration of these mandatory and crucial hygiene trainings into their daily work. Recent publications already showed that even a limited time investment in an e-course teaching about HAI prevention basics showed good learning effects in healthcare professionals.9 Therefore, e-learning portals are advantageous as participants can engage in the course at their own pace, at any time and potentially between other obligations.

While there is a plethora of commercial as well as non-commercial hygiene trainings by health organisations available, each approach has its drawbacks. Commercial solutions, although customisable to specific institutional needs, can pose a financial burden, particularly for smaller facilities. On the other hand, materials provided by state institutions or the WHO10 11 may not have the same level of customisability to seamlessly integrate local peculiarities and maintain a consistent appearance.

Although the OpenWHO platform11 currently offers detailed courses about most of the topics covered in the hygiene training (eg, contact precautions, hand hygiene) the courses cannot be customised and adapted to local policies and offer fewer interactive elements.

Our approach combines the advantages of the previously mentioned commercial and non-commercial solutions. Although this course has been developed and implemented at a German tertiary care hospital, the majority of the presented content can be easily adapted to suit various other hospitals or healthcare providers and serve as inspiration for creating similar courses. Particularly, the recommendations on basic hygiene measures, such as hand hygiene, are universally applicable across different healthcare settings.

When using the H5P-content inside an LMS such as Moodle, another advantage is the ability to closely monitor participant rates at an individual level and meet legal requirements for the documentation of participation. Learning effect can be verified by using the integrated quizzes either in the course presentation or the LMS itself.

Although most participants reported a perceived increase in knowledge, future research should include a more in-depth evaluation of the participants’ learning outcomes, possibly using a pretest/post-test design for this specific e-learning format. Additionally, any changes in adherence to hygiene measures should be assessed in a future investigation.

Conclusions

H5P-interactive course presentations in Moodle LMS offer a feasible, accessible and cost-effective approach to enable both medical students and HCWs to learn or review the content of mandatory hygiene trainings. Unlike commercially or publicly available solutions, this type of content can be easily replicated by infection preventionists in various types and sizes of settings. The content can be modified to accommodate facility-specific needs and regulations.

Data availability statement

Data are available upon reasonable request. The hygiene training files are available upon reasonable request from the corresponding author.

Ethics statements

Patient consent for publication

Ethics approval

Participation in the evaluation was voluntary and completely anonymous. An ethics review was therefore deemed unnecessary.The Ethics Committee of the Julius-Maximlians-Universität Würzburg waived the need to formally apply for ethical clearance after viewing the design of the study (File Nr. 20240729 01)

Acknowledgments

We would like to acknowledge Christian Huß who supervised the implementation of the Learn-Management-System at Würzburg University Hospital.

References

Footnotes

  • Contributors ME: guarantor, visualisation, conceptualisation, data curation, methodology; project administration, writing - original draft. VR: conceptualisation, validation, writing - review and editing. JM: resources, supervision, writing - review and editing. SK: supervision, writing - review and editing. MK: conceptualisation, project administration, validation supervision, writing - review and editing. During the preparation of this work the authors used ChatGPT (OpenAI, San Francisco CA, USA) May 24 Version in order to improve language and grammar. Solely the authors mentioned by name carried out the actual writing of the manuscript. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.