Characterizing Hand Hygiene Opportunities in the Emergency Department

Moore, et al. (2017) assert that hand hygiene is critical for prevention of healthcare-associated infections and explain, "Adherence measurement by direct observation is resource intensive and biased by the Hawthorne effect. Group e-monitoring systems require knowing the expected rate of hand hygiene opportunities (HHOs) per patient care hour in each ward/department. This measurement is a challenge in emergency departments (EDs) because of wide variety of care provided."

The researchers sought to characterize the type and frequency of HHOs in the ambulatory care (AC) zones of our ED by following patients throughout their ED visit.

During June and July 2016, patients who triaged to AC were enrolled in the ED waiting room. A hand hygiene observer stayed with consenting patients during their ED visit, and recorded the number of HHOs as defined by Ontario’s 4 Moments for Hand Hygiene (1). Patient type, age, chief complaint and Canadian Triage and Acuity Scale score (CTAS) were recorded. Twenty-seven of 28 patients consented to be observed; 13 patients were at risk of deterioration (CTAS score 2/3) and 14 were less/ non-urgent (CTAS 4/5). Median ED visit duration was 1.3 hr (0.3-6.1). 201 HHOs occurred in 51 hours of observation; 179 in the ED and 22 in medical imaging. Moments 1 and 4 (before/after contact with patient/environment) comprised 39% and 31% of HHOs respectively; moments 2 and 3 comprised 14% and 16%. 41% of the HHOs involved nurses, 52% physicians/nurse practitioners, 6% medical imaging technologists, and 1% others. The mean HHO/pt hour was 4.3 (95% CI 3.4-5.1); the mean HHO/visit was 6.6 (95% CI 5.2-8.1). Interactions with HHOs occurred at a relatively constant rate over each ED visit, and there was a strong correlation between visit length and number of HHOs (R2 = 0.65,P < .001).

The researchers concluded that HHO rates in AC in their ED are somewhat lower than those in major care areas (2). Physicians contribute a relatively high proportion of HHOs. They say these data will assist in defining expected rates of HHOs for the ED to enable e-monitoring of adherence.

1. Public Health Ontario. Best Practices for Hand Hygiene. Available from:
2. Goodliffe L et al. Infect Control Hosp Epidemiol 2014; 35:225

Reference: Moore TC, Xu E, McCreight L, Wilde-Friel G, So J and McGeer A. Characterizing hand hygiene opportunities in the emergency department. Antimicrobial Resistance and Infection Control 2017, 6(Suppl 3):O25