A Multifaceted Strategy to implement the NVAB-Guidline for prevention of work related skin problems among health care workers. A randomised controlled trial & cost effectiveness evaluation.

BACKGROUND Skin diseases are in the top 3 of registered work-related disorders in Europe. The individual and societal burden of skin diseases is high. In the Netherlands, annual costs of medical care, absenteeism and disability pensions due to occupational skin disease in employees are estimated at € 98,1 mln. Health care workers are the largest(>400.000 nurses/nursing aids) and second highest group at risk, with a prevalence up to 24%. Hand eczema/dermatitis is one of the major causes for low adherence to hand hygiene procedures, which is responsible for >20% of all healthcare related infections, associated costs(€ 384 mln) and mortality(2%). It is obvious that better adherence to worker-safe hand hygiene procedures has huge potential for healthcare workers, patient safety and related costs. OBJECTIVES To evaluate the cost-effectiveness of a multifaceted strategy to implement a guideline based prevention program to reduce work related skin disorders in healthcare workers. INTERVENTION The prevention program for work related skin disorders consists of an evidence based prevention program derived from the NVAB guideline for contact dermatitis based on a two way approach: 1. Elimination of relevant contact factors at work 2. Skin protection by preventive measures (gloves, skin barrier products). IMPLEMENTATION PROBLEM & STRATEGIES Based on our systematic review there is strong evidence for the effectiveness of skin care education including skin protection measures, as promoted in the NVAB-guideline. Studies on prevention of hand eczema report however difficulties towards the implementation of (organisational) preventive measures and the actual use of individual preventive measures, such as hand washing procedures and protection measures (gloves & barrier products). Although for patient safety a rigorous hand hygiene is promoted in hospitals, it is shown that dermatitis/eczema of the hands and lack of support by senior role models are the main obstacles for adherence to preventive measures among health care workers. Changes at the individual and organisational level are therefore needed. IMPLEMENTATION STRATEGY The multifaceted implementation strategy consists of an educational program, participatory working groups and role models which have shown to be effective in other settings: 1. Educational program to inform and train all nurses in actual use of individual preventive measures according to the NVAB-guideline, such as hand washing/desinfection procedures and the use of gloves/barrier creams. In addition, all the health care workers receive a leaflet with recommendations to prevent skin disorders. Key messages will be posted at sinks in the department (reminders). 2. Participatory working groups for organisational interventions and to enhance support of (in)formal and (opinion) leaders: This implementation strategy is based on a structured method with active participation of both the nurses and their management. Under guidance of a specialised occupational nurse, a two-way approach will be followed by a working group consisting of both (senior) nurses and management: 1 to detect and avoid relevant contact factors at work by implementation of organisational measures (‘source approach’) 2. to make an implementation plan to increase adherence to the use of skin protection measures. 3. Role models: the nurses/health care workers in the working group will be trained and act as senior role models for their peers/colleagues. STUDY DESIGN Cluster randomized controlled trial with two arms and one year follow-up; randomisation takes place on the level of departments to avoid contamination(n=2x613). USUAL CARE Usual care consists of distribution in the control departments of a leaflet of the evidence based recommendations derived from the NVAB-guideline. STUDY POPULATION In this study, health care workers (henceforward also referred to as 'nurses') in the VU Medical Center, the UMCG and Radboud UMC will be included in collaboration with their Occupational Health Services. Inclusion criteria are working for more than 8 hours a week and being employed at follow-up. OUTCOMES The primary outcome is the frequency of (an episode) of contact dermatitis on hand or forearms in the past 3 months, measured with the modified NOSQ every 3 months. Secondary outcome measures include the actual use of preventive measures, exposure, information uptake, and discussions on prevention of skin problems (modified NOSQ-2002), worker’s skin disease-specific quality of life, generic quality of life, sickleave and work productivity loss. The cost-effectiveness analysis is performed from the societal and company perspective. All outcome measures are assessed at baseline and after 3, 6 and 12 months. A processevaluation is part of the study. PLANNING 0-36 months: organisation of the study, inclusion of workers, interventions, measurements, datacollection, -entry; 36-48 months: Data analyses & publication