Annually in the United States, it is estimated that 1.7 million patients acquire a health care associated infection (HAI), defined as an infection acquired in a hospital or health care facility which results in approximately one hundred thousand deaths [1] . Of 700 thousand HAI’s that took place in hospital settings in 2011, 75 thousand deaths were the result [2] . In addition, one-third to three-fourths of these infections may be preventable [3] . Approximately 90% of HAI’s are of bacterial origin with routes of transmission including contact, droplet, airborne, or through a common vehicle such as food or medical equipment [4] . Examples of common HAI’s include staph infections and illnesses such as pneumonia. Common sources include medical equipment such as catheters [5] . Most researchers including the Centers for Disease Control and Prevention [2] have compiled data primarily associated with inpatient settings despite increasing trends in treatment of patients in outpatient centers and no formal studies have assessed patient behaviors specifically within the context of preventing HAI’s though recommendations have been suggested [6] .

Schimier [7] is among researchers who argue that approximately three-fourths of HAI’s are preventable. An aggregate analysis of 30 multi-modal studies found that HAI rates could be reduced by 10% - 70% with prevention and control strategies [1] . Strategies such as frequent hand washing and provision of sanitizing equipment are well known among most health care professionals with specific recommendations for outpatient settings proposed by the CDC [8] but awareness of systematic approaches pursuant to reducing infection rates among health care providers and patients are less prevalent, especially in outpatient settings including Cardiac Rehabilitation (CR). In fact, a recent examination of HAI prevention strategies in outpatient settings did not include any CR or rehabilitation centers or facilities similar to CR in the assessment [6] .

A systematic approach includes but is not limited to optimal surveillance of HAI’s, use of trained infection control public health and/or allied health professionals, feedback mechanisms, and use of a dedicated epidemiologist. In addition, knowledge of risk factors, environmental variables, and identification of increased risk groups as well as the most common sources and types of HAI’s are required to reduce infection rates [4] . Considerations related to the present study include the applicability of these strategies to patient populations in outpatient settings such as CR.

Identified risk factors for HAI’s that are relevant to CR patients include the type or severity of diagnosis at admission and specific risk factors include advanced age, comorbid factors, and nutrition status. Chief among risk factors is advanced age with between 40% - 60% of all HAI’s occurring in patients over 65 years of age [9] . Additional variables found to increase risk particularly among CR patients include infection risk post bypass surgery or angioplasty procedures if healing from those procedures is delayed [1] . Though the most common types of infections include urinary tract infections, pneumonia, infections at the surgical site, bloodstream infections, and central nervous system infection [2] respiratory illnesses such as the flu or upper respiratory tract infections are particularly relevant to CR settings especially within the context of adherence rates for influenza and pneumonia vaccinations which varied in 2015 between 35 and 65% among the age ranges typically observed in CR [10] .

Hand hygiene practices and in particular hand washing among health care professionals was identified as a compelling factor in the promotion of health and reduction of infections as early as the 1840’s by Dr. Semmelweis in his comparison of health care setting and home setting differences in maternal fatality rates after childbirth [11] . Hand hygiene practices including hand washing and sanitizing with an alcohol-based cleanser are widely recognized methods of preventing and reducing the prevalence of HAI’s in health care settings [12] despite HAI’s remaining a top cause of death in the United States. Hand hygiene has been at the forefront of infection control strategies due to its simplicity in nature and influential outcomes^; however, the compliance rate in CR outpatient settings for both staff and patients has not been documented outside of reports at professional conferences [13] . Umscheidand colleagues [1] observed after an extensive review of infection prevention strategies that up to 75% of HAI’s, including pneumonia, flu, and upper respiratory tract infections, could be prevented via hand washing and sanitizing equipment.

The majority of HAI related research has been conducted in inpatient settings. As a result, outpatient settings including ambulatory care centers and rehabilitation settings are underrepresented relative to assessment and research. In fact, researchers conducting one of the few studies examining infection control effectiveness in outpatient ambulatory centers found that 67% of the 68 ambulatory care centers had at least one lapse in infection control during the year of assessment [12] . Additionally, no publications were found that assess infection related interventions and behaviors among patients in CR settings though research has been disseminated in other settings such as poster presentations at professional peer reviewed conferences [13] . Outpatient or ambulatory centers were included in Son and colleague’s [14] three-year intervention and assessment of 19 inpatient hospital departments and 15 outpatient centers with marked overall improvement in compliance among staff from 60% up to 97%.

CR characterizes outpatient programs that treat patients after a variety of acute and chronic conditions including myocardial infarction, coronary bypass graft procedure, angioplasty, and congestive heart failure [15] . CR includes supervised exercise and also nutrition education, stress management, and other services that address holistic health variables [16] . Though only between 14% - 35% of eligible patients are referred to CR programs, this patient population ranges between 100,000 and 275,000 in number [17] . Though the average age of CR patients is above 60, age ranges vary between children and adults older than 100 years of age [18] . Recently published consensus statements continue to promote the cost effectiveness of CR programs relative to other tests and procedures [16] . Given the prevalence of HAI’s, the increased number of HAI risk factors among CR patients, and the outpatient often hospital based setting of many CR programs, it is relevant to examine this topic and the outcomes of infection prevention strategies in CR. Implications of these findings could be applied to numerous outpatient settings including respiratory therapy, physical therapy, and occupational therapy among others.

CR programs are relevant venues for infection prevention strategies given the relative immunodeficiency among patients with chronic disease [3] , and increased infection risk associated with invasive cardiac procedures [19] . Any hospital based outpatient setting potentially exposes patients to hospital based as well as community based infections. Additionally, all previously described studies assess staff hand hygiene behaviors, and this study assessed behaviors among patients.

A hospital in Connecticut USA promoting HAI prevention strategies and policies in outpatient settings among hospital staff was the site for the study given that prevention strategies in place for staff were applied to and assessed among patients for the first time. A total of 69 patients were observed during the study; Forty-three patients during an initial data collection period in 2012 and 26 during a second observation in 2013. Sixty-two percent of the patients were male with an average age of 61. The remaining patients were female with an average age of 64. IRB approval for retrospective analysis of aggregate de-identified data was obtained at the target hospital as well as from the collaborating university. All attending patients during the data collection period were observed; however, attendance varied for patients. The data collection period was directed by the duration of a clinical placement of a student in allied health and associated clinical instructor who were the individuals collecting observations for the department.

The CR staff and interns were charged with providing education, interventions, and were routinely collecting data relative to HAI prevention behaviors among staff and patients for the purpose of outcomes analysis. Specifically, the CR staff consisted of nurses, exercise physiologists, nutritionists, and student interns who were previously trained in HAI prevention strategies by the hospital. These identical strategies were incorporated into existing CR educational programming for patient education. The educational programming occurred in between exercise sessions and included a video detailing hygiene behavior related to HAI’s, and orientation to signs and hand washing stations added to the CR gym/room specifically for patient use. Baseline data was collected for 4 weeks prior to all interventions. Intervention 1 took place during week 5 and 6. Intervention 2 took place during week 7 and 8. Intervention 3 took place during week 9 and 10 and intervention 4 took place during week 11 and 12 of the 2012 data collection period. Data was collected 12 weeks from May to August 2012 with a follow up data collection period one year later in August 2013 for two weeks to determine the effectiveness of four infection prevention strategies on washing in (WI) and/or washing out (WO) behaviors among patients.

The specific interventions provided during CR sessions included:

1) Signs to promote hand washing and accessible cleaning stations.

2) “Bioderm” demonstration of hand washing techniques.

3) Educational video.

4) Provision of sanitizer samples.

Table 1 provides additional details including the timing of all interventions. All interventions were provided during the 2012 data collection period. Interventions 1 and 3 were provided during the 2013 data collection period. Figure 1 displays the provision of hand sanitizer in the CR center.

Quantitative data was analyzed pre and during the initial 12-week intervention period and included the mean number and % of patients WI and WO of the CR room. Follow up data was collected one year later to assess longer term effectiveness of the program. At that time intervention strategies 1 and 3 were assessed among a new patient cohort. Specifically, the percentage of patients observed WI or WO for six days within two weeks was reported in August 2013 and compared to data collected in August 2012. Descriptive statistical analysis was applied to assess the percent of patients adopting hand washing behaviors pre and post interventions and for the one year follow up period. Descriptive and inferential statistical analysis using PASW Statistics 18 was used to assess the observed changes in hand washing behaviors among patients. Specifically, unpaired t tests were used to assess mean changes during the initial 12-week intervention period.