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Hand Hygiene Monitoring Goes High-Tech


By Kelly M. Pyrek

Editor's note: A roundtable from manufacturers in this segment is included at the end of this article.

In their quest to assess the prevalence and correlates of compliance and noncompliance with hand hygiene guidelines in hospital care, Vicki Erasmus, MSc, of  the Department of Public Health at Erasmus University Medical Center in Rotterdam, The Netherlands, and colleagues determined that noncompliance with hand hygiene guidelines is a universal problem that calls for standardized measures for research and monitoring. After examining 96 empirical studies, Erasmus, et al. (2010) found an overall median compliance rate of 40 percent, with lower compliance rates in intensive care units (30 percent to 40 percent) than in other settings (50 percent to 60 percent), lower among physicians (32 percent) than among nurses (48 percent), and before (21 percent) rather than after (47 percent) patient contact.

Although hand hygiene has been the target of continuous scrutiny, study and awareness campaigns, Erasmus, et al. (2010) say that  substantial and lasting effects on compliance rates has been minimal. As healthcare institutions continue to wrestle with this issue, manufacturers have stepped in to offer high-tech solutions to this perennial problem. Automated hand hygiene monitoring systems may offer a reliable method of measuring individual hand hygiene compliance, and Erasmus, et al. note, "Apart from observation and self‐reporting, there are a number of other methods that may be employed as indicators of hand hygiene compliance, such as the amount of alcohol or soap used (i.e., 2 L/day), electronic monitoring (i.e., counter in alcohol dispenser), or the number of hospital‐acquired infections. Each of these indirect measures has some advantages over direct observation by a trained observer—because some are much cheaper and easier to use—but they do not provide valid information on compliance. One study made a new step in this direction, however, by monitoring the entrance and exit of people from a patient's room and linking this to electronic monitoring of the alcohol‐based hand rub dispenser. When someone enters without using the dispenser, this is registered as noncompliance. However, this method also has limitations, because only hand hygiene behavior when entering and exiting can be monitored, and it can only be applied to single‐patient rooms."

Stewardson and Pittet (2011) answer the rhetorical question of "are new hand hygiene monitoring options needed?" by noting that although the World Health Organization (WHO)'s “My 5 Moments for Hand Hygiene" identifies opportunities that should equate to transmission of pathogens, "commonly cited limitations provide impetus to find alternative techniques, such as indirect monitoring using surrogates and automated monitoring...  The potential advantages of automated systems include minimal consumption of resources once installed, provision of large data sets, and, potentially, less observation bias or Hawthorne effect. Conversely, major risks include the counterproductive temptation to monitor the wrong things because more convenient from a technical perspective, such as hand hygiene on entry/exit to wards or rooms, and a significant initial cost, which is particularly difficult in resource-limited settings. There is also the loss of an important opportunity for connection between the infection control team and HCWs, which provides an occasion for “bottom-up” promotion."

Stewardson and Pittet (2011) add, "Most healthcare workers (HCWs) know the risks posed by inadequate hand hygiene and want to improve. Yet we are notoriously poor at estimating our own performance, thus mandating the use of an alternate method. In our experience, HCWs want access to their own hand hygiene performance results. Although this may vary between countries and institutions, they dislike being observed without feedback. Moreover, to be effective, feedback should probably be immediate and individual, rather than only systematically reported compliance rates for an entire ward or department. For this purpose, automated monitoring systems able to identify specific categories of HCWs offer great benefits. And it is even better if the device is able to remind the healthcare worker to perform hand hygiene at the correct moment in a manner that does not become either excessively irritating or easily disregarded."

John M. Boyce, MD, of the Hospital of Saint Raphael in New Haven, Conn. and clinical professor of medicine at Yale University School of Medicine, emphasizes that monitoring hand hygiene compliance and providing healthcare workers with feedback regarding their performance is considered to be integral to a multidisciplinary hand hygiene improvement program. However, he adds that observational surveys conducted by trained personnel -- once considered to be the “gold standard” method for establishing compliance rates -- have their shortcomings. Instead, monitoring hand hygiene product consumption and electronic hand hygiene monitoring systems show some promise in increased hand hygiene compliance rates. Boyce (2011) notes that "Although there are many questions remaining about the practicality, accuracy, cost, and long-term impact of electronic monitoring systems on compliance rates, they appear to have considerable promise for improving our efforts to monitor and improve hand hygiene practices among healthcare workers."

Let's review current methods for hand hygiene monitoring.
1. Direct observation. Boyce (2011) says that "Direct observation of healthcare workers (HCWs) provides the most detailed information regarding hand hygiene and has the following advantages: It is currently the only method that can detect whether HCWs have performed hand hygiene during all types of opportunities with varying degrees of risk of contamination, including the five major indications for hand hygiene, in all clinical care settings and in facilities with varying levels of resources. It is the only strategy that can provide detailed information about hand hygiene technique, such as the amount of time spent using an alcohol hand rub or a soap product, the extent to which all surfaces of the hands are covered, and hand hygiene frequency before or after glove use. It is one of the few approaches that can provide compliance rates for HCWs of different types and levels of seniority and can identify specific situations that require further education of HCWs. However, direct observational surveys have several limitations, including the fact that they are time-consuming and costly. They provide information about a very low percentage (less than 1 percent to 3 percent) of all hand hygiene opportunities occurring in healthcare settings, which raises the question of the statistical validity of compliance rates generated. Direct observation of HCWs may affect their behavior and result in spuriously high compliance rates due to the Hawthorne effect ... Observational surveys are not performed in a standardized way, making realistic comparison of rates between facilities impossible. Observational surveys vary considerably among institutions with respect to the type of observers used, the level and type of training of the observers, the level of inter-rater reliability achieved (if assessed), the criteria for compliance versus noncompliance, the duration of observation periods, the level to which observations are covert or overt, and whether observations are made on all shifts or only during weekdays."

2. Self-reporting. Boyce (2011) notes that "Self-reporting of hand hygiene compliance by HCWs has been shown to be unreliable, because HCWs often tend to overestimate their level of compliance. As a result, this approach to determining hand hygiene compliance is not recommended as the sole or major method for establishing compliance rates."

3. Measuring product consumption. Boyce (2011) points to at least 13 studies that have evaluated the relationship between product consumption and observed compliance rates; 10 of these studies found that observed compliance rates increased in conjunction with increased use of alcohol handrub, while three studies did not find an association between product consumption and compliance rates. Boyce (2011) adds that monitoring product consumption has been used as a surrogate for hand hygiene compliance in a number of hand hygiene campaigns, and points to the system from McGuckin et al. who developed a system wherein the volume (mL) of alcohol hand rub and soap products used per patient-day on each nursing unit is calculated. This number is divided by 1.7 (the proposed average mL of product used per hand hygiene episode) to arrive at the estimated number of hand hygiene episodes/patient-day for the nursing unit. The resulting estimated hand hygiene rate is compared to benchmarks for ICUs and non-ICU wards. Facilities that forward their results to a dedicated website ( are provided with graphs of their hand hygiene rates over time versus proposed benchmarks. Product consumption can also be monitored by using electronic counting devices placed inside hand hygiene product dispensers that record each time a product dispenser is accessed (hand hygiene event)."

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