What Is Needed to Improve Hand Hygiene Compliance—Electronic Surveillance or a Traditional Approach?


Kari Simonsen, MD, and Matthew Linam, MD debate the best way to measure and improve hand hygiene compliance.

One of the most simple and effective ways to prevent the spread of infections in health care facilities is by practicing hand hygiene. The problem, according to the US Centers for Disease Control and Prevention, is that health care providers are cleaning their hands less than half of the times that they should be.

As such, health officials are constantly trying to figure out ways to measure and improve hand hygiene compliance. Always a hot topic, in a session at this year’s annual SHEA Spring 2018 Conference, Kari Simonsen, MD, division chief of Pediatric Infectious Diseases at the University of Nebraska Medical Center, and Matthew Linam, MD, associate professor of Pediatric Infectious Diseases at Emory University School of Medicine, went head-to-head in a friendly debate over what is truly needed to improve hand hygiene compliance in facilities. Electronic surveillance or a traditional approach?

Dr. Simonsen kicked off the session by providing conference attendees with a rundown on different automated hand hygiene monitoring systems that are available for organizations to try if they are looking to stray from more traditional approaches, and their potential benefits.

She admitted that traditional practices for measuring hand hygiene compliance do have some benefits. For example, one of the most common methods, direct observation, is easy to do and inexpensive. Observers can provide feedback, and monitor all 5 moments of hand hygiene as described by the World Health Organization that all facilities are trying to capture. However, there are also disadvantages to this approach: it’s time consuming, resource intensive, and it can be biased.

According to Dr. Simonsen, there are newer options available to measure compliance that may be more advantageous than traditional approaches. These include electronically-assisted direct observation, video-monitored direct observation, electronic dispenser counters, and automated hand hygiene monitoring networks.

With electronically-assisted direct observation, what Dr. Simonsen referred to as “yes, there’s an app for that,” the use of pen and paper to observe compliance is replaced with an app. Although a recent pilot study found that the app did not provide any particular advantages over the pen and paper method, they did find that the process of collecting the data was much easier.

In another study, investigators at Duke University found that using an electronic recording tool for some directly observed automated data resulted in a significant increase in hand hygiene compliance (from 50% to 86%). Furthermore, they noted a significant increase in the number of observations they were able to record, increasing their total number of observations to 90,000 a year.

Dr. Simonsen also touched on video-monitored direct hand hygiene observation tools, “where your hospital room is actually on camera and someone off-site can see what’s going on and record hand hygiene opportunities.” She cited a study that found that hand hygiene compliance increased from 6.5% in the pre-intervention period to a whopping 81% after performing the video monitoring and compliance feedback.

Electronic dispenser counters are another new way to track hand hygiene compliance in facilities. These counters are activated after health care workers put their hands under the soap/alcohol-based hand gel dispenser and the machine counts that soap has been dispensed. Although a recent study by Marra et al did not see a correlation between observations, product use, or the dispenser counter, they did record “significantly greater numbers of opportunities,” according to Dr. Simonsen.

Lastly, she discussed an automated hand hygiene monitoring network “where the health care worker is wearing a badge that has a sensor and the room also has sensors within it.” In a Marra et al study, “the sensor was by the bed, and as the health care worker near the bed it sensed they were there and then they were either alerted to perform hand hygiene or some systems detected whether or not hand hygiene had been performed through dispenser monitoring or through sniffing or sensing alcohol-based hand rub through a sensor in the badge.” These systems allow for accurate tracking of individual users and their compliance history. Citing another study using this method, Dr. Simonsen explained that the method not only showed an increase in observation but also an increase in hand hygiene compliance.

In her own facility in Nebraska, their team switched over from using the unknown observer method for hand hygiene compliance to investing in an automated hand hygiene monitoring system where personnel donned the sensor-embedded badges.

“It has a regular green color indicator on the badge, so there’s a sensor in it that sniffs the alcohol-based hand gel and it will turn green after you’ve acknowledged the system,” she explained. “If a health care worker crosses the threshold of a patient room, the color will go to yellow to indicate that you should now wash your hands and if a health care worker fails to do so within 60 seconds it will turn red.”

Why did her facility make the switch? According to Dr. Simonsen, they were finding it hard to keep up with the human element of the unknown observer and they wanted to do more at point-of-care to make patients and their families aware that they were performing hand hygiene. They ended up with significantly higher hand hygiene observations and their compliance rose to over 95% consistently month after month.

Despite some limitations—start-up cost, the need for end users that are accountable—the new hand hygiene monitoring tools “allowed for improved compliance rates, reduced human time and effort for observations, fewer biases in the data, and larger data sets for analysis. Real-time feedback is provided to users and that improves their compliance within patient care setting, it gives visual reminders for all, and it can help reduce HAIs,” she concluded.

For the most part, Dr. Linam agreed with the pros and cons of both approaches, ultimately saying that there is no perfect method for making hand hygiene observations. “All the different forms come with pros, cons, advantages, and disadvantages,” he said; however, he made it clear that rather than turning to the expensive approach of using automated electronic means for monitoring hand hygiene, the focus should be on improving the more traditional approach of direct observation, which he referred to as the “gold standard.”

As such, he shared several recommendations for improving the validity of a direct observation program, including:

  • Having clear definitions of a compliant observation. What do you consider hand hygiene compliance? Define all of those situations and make a clear process for how those hand hygiene observations are made.
  • Formal training for your observers, ensuring they are validated before they collect observations, and remembering to periodically re-validate them over time.
  • Using a “mixed bag” of unit-based observers and non-unit-based observers and working hard to maintain their anonymity.

Dr. Linam stressed that although automated hand hygiene monitoring systems allow for more data to be captured, a large sample size is not necessarily needed. The reason we measure hand hygiene is to improve compliance, he said. We collect observations to improve the process. “One of the challenges that I think we often stumble into when we’re trying to collect hand hygiene observation data is we sort of slide into making hand hygiene observation almost like we’re conducting hand hygiene research and not collecting hand hygiene data for improvement,” he said.

When it comes to quality improvement, “you’re really trying to collect just enough data to help you understand what the process has been doing historically,” he explained. Then, that data can be used to inform where the focus of improvement efforts should be. “As you’re putting interventions in place, the data will help you understand how those interventions are affecting your process for better or for worse,” he explained.

Dr. Linam also stressed that although the overall goal is to measure all 5 of the WHO hand hygiene moments, just measuring moments 1, 4, and 5—mainly when a health care worker enters and exits a patient’s room, should really be the area of focus. Compliance for areas 2 and 3 are already fairly strong.

He closed his presentation by discussing a direct observation program he was involved in at the Arkansas Children’s Hospital, a 370-bed tertiary children’s hospital that has 14 units, that started in 2012. They measured hand hygiene by covert direct observation using health care worker volunteers. They provided a clear definition of correct hand hygiene compliance, ensured that the volunteers represented all units and shifts, and collected their data electronically. “That data was transmitted real-time to electronic data analysis tool and platform that anyone could look at and play with the data,” he said.

Between 2012 and 2016, they collected over 30,500 observations averaging over 600 observations a month. “We picked up a nice variety of different health care worker types, about a third of our observations were on patients that were in some sort of transmission-based isolation and we had a good breakdown of day, night, weekend day, and weekend night shifts,” he explained. Using an electronic web-based platform, which functioned like an app, they were able to collect the data in real-time and transmit the data to a data analytics platform that allowed them to see where problems were. They were also able to generate monthly reports that were distributed to leadership so that they could see how well they were doing with compliance.

“I think that direct observation still remains the gold standard for hand hygiene observations. There is no perfect method; they all have pros and cons. But I think that direct observation still remains the most informative to the improvement process,” Dr. Linam concluded.

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