Hand Hygiene Compliance Monitoring Provides Benefits, Challenges

By Elizabeth Srejic

Hand hygiene is the most important factor in preventing the spread of healthcare associated infections (HAIs), a major threat to patient safety and cause of morbidity and mortality worldwide.(1-5) Beyond their human costs, HAIs are fiscally costly, accounting for billions of dollars’ worth of expenditure in the U.S. healthcare system annually. Studies substantiate the connection between hand hygiene and HAIs; however, hand hygiene compliance among healthcare workers (HCWs) remains alarmingly low, with average rates of only 40 percent to 50 percent,(6-7) in spite of widespread education and awareness.(8)  

Reported factors behind poor hand hygiene compliance among HCW, including skin irritation from handwashing agents, lack of materials, understaffing, cultural factors and high intensity of patient care(9-11) are numerous and therefore challenging to target without extensive multidisciplinary interventional programs.(12) Although education, training, leadership, and behavioral incentives are important potential components of such programs, the Joint Commission, the World Health Organization, (WHO) and the Centers for Disease Control and Prevention (CDC) further advise healthcare institutions to implement monitoring systems to enforce hand hygiene practices and provide feedback to HCWs.(13-15) Studies suggest these monitoring systems can produce measurable improvements in hand hygiene compliance among HCWs which is associated with lower HAI incidence in a variety of settings.(16-18)

Unfortunately, the diversity of hand hygiene compliance systems can make choosing a system unduly challenging. As yet, none of the systems is equipped to address all of the issues in hand hygiene monitoring and each system has its limitations. Furthermore, the systems differ in which aspects of hand hygiene they measure and none of them is universally applicable to the individual needs of different healthcare institutions. 

In choosing a system for monitoring hand hygiene compliance, the Joint Commission advises healthcare facilities to first investigate the reasons for non-adherence as well as the organizational context of healthcare delivery which may facilitate or inhibit adherence.(19) It further recommends that healthcare facilities determine which aspects of hand hygiene they wish to monitor, such as moments in time when hand hygiene should occur and hand hygiene technique. The Joint Commission also advises that monitoring systems must conduct observation in a standardized and consistent manner in order to be useful.(20)

Choosing a system requires healthcare institutions to predict which of the many pros, cons and emerging technologies of these systems best match their specific needs and fit within the constraints of their budget, infrastructure and organizational culture. Furthermore, the lack of high-quality research establishing and comparing the efficacy of the available systems – and newer systems in particular – may push decision makers uncomfortably far into the realm of guesswork, where they are compelled to turn to marketing materials rather than science for guidance. The authors of a Cochrane Database Systemic Review (Gould et al., 2010) assessing the quality of various hand hygiene intervention strategies including monitoring systems, wrote: “The quality of intervention studies intended to increase hand hygiene compliance remains disappointing. Although multifaceted campaigns with social marketing or staff involvement appear to have an effect, there is insufficient evidence to draw a firm conclusion. There remains an urgent need to undertake methodologically robust research to explore the effectiveness of soundly designed and implemented interventions to increase hand hygiene compliance.”(21)

The limitations of some systems immediately render them incapable of meeting some institutions’ goals. For example, certain systems are not equipped to collect a complete set of data for assessment purposes, as with those unable to monitor all of WHO’s five moments, the most commonly recognized set of guidelines for hand hygiene (before patient contact, before an aseptic task, after body fluid exposure risk, after patient contact, and after contact with patient surroundings).(22-23) Such systems tend to monitor entry and exit moments only, which are the easier to measure than the other moments and respect patient privacy but do not represent a complete picture of hand hygiene compliance.(24-25) Similarly, some systems are unable to collect all of data necessary to measure compliance as it is typically assessed: as a percentage where the numerator is the total number of times an HCW was observed to have appropriately washed his or her hands before and after a patient encounter and the denominator is the total number of observations made.(26) And while certain systems may provide the desired data, unsuitability in just one other area, such as cost, personnel requirements, equipment level, or any other area may render them inappropriate.

Although emerging technology continues to expand the available choices, widely recognized hand hygiene compliance systems currently include direct observation, electronic or automated systems, and systems based upon advanced technologies.(27)

Direct observation is currently considered the gold standard in hand hygiene compliance technology. Direct observation involves in-person evaluation of hand hygiene habits of HCW within the healthcare environment by highly trained personnel.(28-29) Direct observation allows for real-time feedback and evaluation of all five of WHO’s five moments for hand hygiene, and allows observation of which hand hygiene products are used, the thoroughness of cleansing, the tools and technique used for drying, and the use of gloves.(30) Direct observation can also be combined with newer innovations like ultraviolet light testing after scrubbing with fluorescent solution, which helps to assess the efficacy of surgical hand technique and allows real-time feedback.(31)

Direct observation is far from a perfect system, however. It is time-consuming, costly and personnel intensive and raises concerns over patient privacy.(32) More importantly, its validity is greatly limited by the Hawthorne effect, or altered behavior of HCWs in response to being observed; one study found that Healthcare workers performed eight HHEs per hour when not under observation compared with 21 HHEs per hour during observation(33) while a similar study found that hand hygiene event rates were approximately threefold higher in hallways within eyesight of an auditor compared with when no auditor was visible and the increase occurred after the auditors' arrival; the authors of the second study added that the results called into question the accuracy of publicly reported hospital hand hygiene compliance rates.(34)

To minimize the Hawthorne effect, some facilities conduct direct observation through covert observers, or “secret shoppers.”(35-36) However, using secret shoppers has raised ethical concerns over people being observed without their knowledge and their efficacy ends when their identity is eventually discovered.(37-38)

Technology-assisted direct observation includes use of mobile devices or video monitoring to document hand hygiene adherence; these devices may use commercially available programs like iScrub for iOS mobile devices(39-40) or a proprietary application for a mobile device(41-42) to help standardize data collection. These devices can eliminate the time involved in data entry and standardize measurement but can impact patient privacy, often require substantial investment, need routine maintenance and are subject to loss.

Another variety of technology-assisted direct observation is remote video monitoring of areas in which hand hygiene is performed.(43-44) The video is reviewed in real time or later by trained auditors to assess hand hygiene in the same manner as in-person direct observation. Some systems provide real-time feedback by showing group compliance rates on LED screens mounted in work areas.(45) As with the other forms of direct observation, remote video monitoring can impact patient privacy.(46)

A newer type of hand hygiene compliance system is automated or electronic monitoring. These indirect monitoring systems offer superior data collection by allowing continuous 24/7 monitoring leading to a larger sample size with thousands of data points, as well as automatic data download from the Web via Wi-Fi, and data analysis, and can be used to monitor trends in consumption over time, daily patterns, and use by type of care unit.(47-49) In addition, these systems are unobtrusive, the Hawthorne effect is significantly mitigated, and required human resources are minimal.

One type of automated or electronic data measurement is automated count dispensers on hand hygiene product dispensers, which allow collection of data such as frequency, date and time of use.(50-52) A simpler form of assessment using product dispensers is simple measurement of liquid soap, alcohol-based handrub, paper towels, or other hand hygiene products used in these systems is obtained by simple product measurement. Unfortunately, simple product measurement can be hampered by unreliable usage data from distribution or materials management or intentional tampering with dispensers or deliberate waste of product.(53)

One drawback of automated or electronic systems is that they are not equipped to measure the denominator – or the total potential opportunities for hand hygiene -- in the hand hygiene compliance calculation; however, one study noted this number can be substituted by an alternate figure such as patient days or workload indicators drawn from a computerized database of nursing activities.(54) In addition, in most cases these systems do not monitor standard hand hygiene evaluation frameworks such as WHO’s 5 moments and can be very costly. Furthermore, these systems cannot assess hand hygiene technique and only the more sophisticated systems can detect who used the product.(55-57)

More sophisticated systems use personal badges and ceiling-mounted infrared emitters, or use Wi-Fi or radiofrequency identification (RFID) tracking. Some of these link product dispensing to healthcare workers' patient room entries or exits or to personal electronic badges, detect alcohol vapor, or correlate HCW movement around the patient with hand hygiene action.(58-60) These systems usually capture hand hygiene moments within the patient care environment. Others use battery-powered devices to communicate over unused space in the Wi-Fi spectrum to generate sensor contact logs and event time stamps for inference of hand hygiene.(61) Unfortunately, these systems may be expensive to implement, require ongoing maintenance for devices and may not assess technique.

Since each variety of hand hygiene compliance system has its share of benefits and drawbacks and studies have failed to establish the definitive superiority of one system over the others, a multi-modal approach comprising complementary systems is widely recommended in place of a single system. As the Joint Commission notes, “Using multiple measurement approaches helps to verify findings. … It is important to investigate the reasons for non-adherence to hand hygiene guidelines before deciding on one or more improvement strategies. It is also useful to examine the organizational context of health care delivery, which may facilitate or inhibit adherence.”(62)

The Joint Commission (2009) also suggests that using multiple methods to measure hand hygiene compliance is likely to yield more reliable results than using a single method and advises that healthcare facilities decide which hand hygiene indications they want to capture when choosing monitoring systems.(63) Likewise, Ellingson et al. (2014) note that “Using multiple methods to measure hand hygiene is a way to address the strengths and limitations associated with a single-measurement approach.” Using multiple methods to measure hand hygiene is a way to address the strengths and limitations associated with a single-measurement approach.(64-66) Healthcare facilities should therefore consider choosing more than one of these systems for their hand hygiene compliance programs.

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