Infectious Disease Physician Uses Technology to Drive Hand Hygiene Compliance

Infectious disease physician Andrew G. Sahud, MD, of the Division of Infectious Diseases at Allegheny General Hospital in Pittsburgh, Pa., has invented a pedometer-like device he hopes will help boost hand hygiene compliance and raise awareness among healthcare workers.

Sahud, who also serves as chairman of the infection prevention department, says he was frustrated with the observational methodology for determining hand hygiene, something he says is time-consuming but more importantly, “never gives the healthcare provider individualized feedback,” Sahud emphasizes. “I was driving my car into the garage which uses an radio frequency technology to open the gate with the car badge and thought that this sort of technology could be used to monitor hand hygiene and serve as a kind of pedometer to give feedback,” he explains. “I did some investigation on radio frequency technology and its applications. The hospital helped me to obtain patent protection and some grant money helped me to develop prototypes. I worked with an engineer to develop and test prototypes which I included in my study that we completed last fall.”

In his study, Sahud and colleagues (2010) sought to evaluate the feasibility of using an electronic hand hygiene surveillance and feedback monitoring device in a 700 bed tertiary care teaching hospital. The two-phase pilot study included initial direct observation of hand hygiene practices as part of routine hospital quality assurance (phase I) and subsequent monitoring using an electronic hand hygiene surveillance device (phase II). During phase I, healthcare workers were directly observed at patient room entry and exit from April 2008 to November 2008. During phase II, hand hygiene data were gathered through indirect observation using the electronic device in August 2009. Twenty patient rooms were fitted with electronic trigger devices that signaled a reader unit worn by participants when they entered the room, and 70 dispensers for liquid soap or hand sanitizer were fitted with triggers that signaled the reader unit when the dispenser was used. The accuracy of the devices was checked by the principal investigator, who manually recorded his room entries and exits and dispenser use while wearing a reader unit.

During phase I, hand hygiene occurred before room entry for 95 (25.1 percent) and after room exit for 149 (39.4 percent) of 378 directly observed patient room visits, for a cumulative compliance rate of 32.3 percent. Among the 378 room visits, 347 (91.8 percent) involved contact with the patient and/or environment. During phase II, electronic monitoring revealed a cumulative composite compliance rate of 25.5 percent. The electronic device captured 61 (98 percent) of 62 manually recorded room entries and 133 (95 percent) of 140 manually recorded dispensing events.

Sahud calls his device the Semmelweis Hand Hygienometer. “Semmelweis is after Ignaz Semmelweis who discovered the health benefits of hand hygiene in preventing hospital-acquired infection in 1847,” Sahud explains. “I used the term hand hygienometer to capture the sensibility of a pedometer. The device is about the size of a pager and is placed into the pocket of the healthcare provider. This device then picks up electronic triggers which are placed into the dispensing units (hand sanitizer and liquid soap) in the patient rooms. An additional room trigger is placed adjacent to the patient’s bed. Each room entry is an individual circuit constituting one room entry and two potential dispensing events. Presumably the healthcare provider is to perform hand hygiene before and after the patient encounter, so two hand hygiene events or dispensing events for each room entry would constitute 100 percent compliance. If I leave the room the device will either time out of that room entry circuit or restart another circuit when entering into a new room. The device has an LCD screen which displays data on compliance. The device can then upload the data to a computer via USB port and the data over time can be extracted and help to show changes over time. I worked with Patrick O’Keefe of O’Keefe electronics in Wellington, Ohio, who runs a small electronic lab in his basement. I worked with him to help translate the patent into electronics and to test and validate the device.”

Sahud says that the device is not yet in widespread use at his hospital but says he and his colleagues have made improvements to the battery life in the model device and in a forthcoming study will plan to follow healthcare workers for an entire year. “Participants will receive an e-mail reminder every month to log onto my Web site and connect their device,” Sahud says. “The information will then be uploaded and different metrics will be displayed such as total compliance, ranking among peers, performance before and after patient encounters, performance variation as per time of the day, etc. We plan to have a new educational module on hand hygiene at the Web site each month. We will have the flexibility to set the threshold for anonymity so that a person’s identity would be anonymous and their data would be anonymous unless their compliance dropped below our established threshold. My goal was to engage and empower the healthcare provider and give them the opportunity to improve upon their behavior as opposed to creating a strict big brother model of oversight. I try to align myself with the language in the hospital safety realm which stresses avoiding an atmosphere of blame in order to avoid creating a toxic environment for clinicians. I also think that professionals need to maintain a certain amount of autonomy and should treated with respect as opposed to the ‘ankle bracelet’ model which other technologies embrace.”

Sahud says his study was intended to be a pilot study to demonstrate that patient room entries and dispensing events could serve as a surrogate marker for hand hygiene compliance. “In our subsequent study I’m hoping that we will be able to show improvement over time. Our rates of hand hygiene compliance are around 41 percent, which is disappointing, but I think we have a great opportunity to engage people and change behavior with this technology,” he adds.

For the purposes of establishing rates of hand hygiene compliance, Sahud says that electronic methods are more accurate, operate 24 hours a day, and provide individualized data as opposed to composite data extracted from 20-minute observation periods done at random times. Sahud emphasizes that his device is less of a surveillance tool and more of a feedback tool. “With this device, the user owns his/her data,” Sahud says. “The information is stored in the device as opposed to on a central server managed by an administrator. The data is anonymous and can be set to be unencrypted if compliance drops below a certain threshold. For the testing purposes we choose to make the data anonymous, otherwise no one would participate in the study.”

There is debate in the infection prevention community currently about whether some high-tech hand hygiene monitoring systems in the market are punitive or personally invasive; Sahud says physicians and other healthcare providers must be engaged on this issue in order to achieve change in compliance rates and improvement in healthcare professionals’ attitudes toward hand hygiene. “The best way to give them some insight is to give them the data and let them own it and act on it,” Sahud says. “As far as I am concerned it would be better to place incentives out there to have people wear the device rather than use a strictly punitive model. A punitive model creates a very negative environment for healthcare providers. I think that it’s too easy to create a system which acts like a GPS and keeps track of your every move so that an administrator can follow your whereabouts. I don’t think that any worker in any environment would want to feel as though they were being tracked all day long. We are at a critical place with regard to hand hygiene technology because the other products out their all use a punitive model and essentially overlook the mindset of the clinician. I think that using a real-time locating system to track equipment makes sense but I think it tracking people is much more complicated. The culture of blame in hospitals has been shown to create a toxic atmosphere and doesn’t allow for deeper understanding of why mistakes occur in the hospital. We need to inculcate a model of hand hygiene in the context of achieving the highest of standards for patient safety and the best way to not only change behavior but to gain buy in and earn the respect of clinicians is to engage them as opposed to confronting them. I think that having the vantage point of being a physician who specializes in infectious diseases and infection prevention and working at a teaching hospital has given me a different insight into the nuances of behavioral change in the hospital environment. This invention would take a very different form if it were invented by an engineer.”

Sahud says that electronic monitoring supplements good hand hygiene practices because it “teaches one to gain a better understanding of the typical discordance between their perceived hand hygiene compliance rates and their true rates of compliance.” Sahud adds that it also provides individualized feedback, gives the person a sense of their standing amongst their peers, and affords them the opportunity to regularly educate themselves on the matter. “I believe that our study, albeit a small pilot study, is the first time that any group of healthcare providers has ever been given feedback on their hand hygiene, had the ability to assess their behavior over time, and gave them the opportunity to compare themselves with their peers.”

As for the future of the Semmelweis Hand Hygienometer, Sahud says he hopes to perform additional studies of longer duration as well as “delve into the realm of behavioral modification to try to effectively impact hand hygiene behavior with the use of the device.” Sahud adds, “I think there’s a real opportunity for using the device outside the hospital setting. It would be easy to implement such technology in the restaurant industry to ensure that employees wash their hands after leaving the restroom. We would love to be able to collaborate with a business partner to help shepherd the idea along and potentially market or license the device. At this point it’s still sort of a mom-and-pop operation, but we do have our patent and have filed for international patents which I think gives us an edge.”

Reference: Sahud AG, Bhanot N, Radhakrishnan A, Bajwa R, Manyam H and Post JC. An electronic hand hygiene surveillance device: A pilot study exploring surrogate markers for hand hygiene compliance. Infect Control Hosp Epidemiol. 2010;31:634-639.