Perspectives on Safety
Innovations in Promoting Hand Hygiene Compliance
One hundred sixty-five years after the publication of Ignaz Semmelwiess's seminal study demonstrating the impact of hand hygiene in the inpatient setting, hospitals continue to struggle with suboptimal rates of compliance with this basic infection prevention activity. This is all the more remarkable given widespread agreement that hand hygiene is the most important intervention for infection prevention.(1) The most common reasons given by health care workers (HCWs) for noncompliance include insufficient time, work overload, inadequate knowledge, skepticism about hand hygiene as a prevention method, inconvenient locations for sinks and soap dispensers, and lack of incentives for hand hygiene compliance.(2) Studies have confirmed that hand hygiene compliance can be affected by the accessibility of products and by the formulations of these alcohol-based hand rub products (liquids, gels, and foams).(1,3) We also know that using alcohol-based hand rubs requires less time than washing with soap (plain or medicated) and water, yet is as effective for most pathogens.(1,3)
Implementation science is a relatively new field (in health care, at least) that focuses on the development of strategies and tools that promote the adoption of effective interventions to improve the quality of care. There is often a considerable gap between experimental results for an intervention and its transformation into practice, and implementation science aims to fill this gap.(4) The World Health Organization's "My Five Moments for Hand Hygiene" is a very nice example of the use of implementation science. We have used the Five Moments during discussions with HCWs about how many opportunities there are in our hospital activities to remind them what is necessary to do and what is important to enhance hand hygiene compliance. Although the Five Moments can add value to any hand hygiene improvement program (3,5), in many medical centers where alcohol gel has been made available, hand hygiene compliance rates continue to be only approximately 50%.(2,6)
Complicating the problem of suboptimal compliance with hand hygiene are the challenges we face in measuring compliance (Table). Direct observation is considered the gold standard for evaluating hand hygiene compliance.(2) However, it generally captures only a very small fraction of hand hygiene opportunities.(7) Observers can be workers who are primarily assigned to this function and are roving throughout the hospital, HCWs embedded in their own units, or workers from other units (i.e., "secret shoppers"). It has been also demonstrated that directly observed rates of adherence may not be accurate because they did not correlate with other hand hygiene metrics (such as by electronic handwash counters or volumes of product used). While traditional secret shopper methods have involved observers recording their observations with pen and paper, technology can now be used to assist direct observation. In one study, intensive care unit (ICU) nurses surreptitiously recorded opportunities for hand hygiene and compliance on a handheld personal digital assistant (i.e., iPod, Apple) using a free application (i.e., iScrub).(8) This may contribute to a reduction in the Hawthorne effect and save time during data collection.
Another option for compliance measurement is electronic handwash counters built into alcohol-based hand rub dispensers.(7,9) These systems have several advantages. For example, studies using observers have generally employed relatively short observation periods (2,7); however, electronic counters record 24 hours per day. The electronic handwash counter should supplement, and not supplant, direct observation, since it is not able to evaluate the quality of hand hygiene performed by HCWs when using alcohol-based hand rub.(7,10) The use of these electronic handwash counters is not yet widespread, in part due to the cost and the need for installation of the necessary infrastructure. Even those institutions that have the ability to implement electronic systems for hand hygiene need to work closely with their engineering department in order to examine whether there may be interference with existing equipment or if an existing wireless network may be overloaded.(10,11) Recently, the number of nurse visits to patient rooms was measured by a nurse call system, which was installed in two step-down units.(9) This allowed for calculation of the ratio of alcohol rub aliquots dispensed and nurse visits to patient rooms (9), and ultimately improved compliance.
Another system for monitoring hand hygiene is to assess handwash product utilization, which can be used as a proxy for direct observation for determining hand hygiene compliance.(7) Typically, the total volume of product used (alcohol gel and chlorhexidine) is expressed in liters per 1000 patient days. This hand hygiene metric can be used in an overall hospital-wide or in a specific hospital-unit assessment. One disadvantage, however, it that the method does not allow one to distinguish hand hygiene practice among HCWs. While data collection is relatively simple and trends may be useful over time, this method provides less detail about hand hygiene compliance than direct observation. Moreover, we have found that results from electronic handwash counters may not correlate with the consumption of alcohol gel.(12) Since patients are taught about the importance of using alcohol gel to prevent infections, but generally not educated about the quality of hand hygiene or the manner of using the electronic handwash dispensers, it is possible that patients and family members pushed the dispenser multiple times in a short time period, accounting for the discrepancy. Although the product will be dispensed on demand, only one episode of hand hygiene is recorded for every two-second period.
Compliance assessment methods have historically focused on observation only. More recently, electronic hand hygiene systems have emerged to not only record compliance but also to promote it among HCWs. These monitoring methods can vary; some use sensors that detect alcohol vapors on the HCW's hands (13) or radiofrequency identification to determine when hand hygiene has occurred.(10,14) Another system involves the placement of cameras focused on gel dispensers to monitor compliance (15) and still another employs ultrasound transmitters to measure hand hygiene compliance.(16) Whatever the assessment method, each of these systems is able to transmit data on compliance wirelessly to a centralized tracking station, which can display personal compliance rates for every HCW, either in real time on the floor or to unit leaders.
These systems can also allow the use of a real-time feedback loop to improve hand hygiene compliance. Feedback loops are profoundly effective tools for changing human behavior based on a simple premise—give people information about their actions in near-real time, then show them how to engage in better behaviors.(17) One system uses a wireless identification device (badge) worn by the HCW to record when the HCW performs hand hygiene with alcohol hand rub using electronic dispensers inside the patient room. The identification devices use ZigBee technology (wireless communication protocol based on IEEE 802.15.3 standards).(14) When a HCW approaches the patient bed, if hand hygiene has not been performed a red light flashes above the patient bed, whereas a green light flashes if it has been performed. Software integrated with a database generates reports showing how many HCWs entered the rooms, how many HCWs performed hand hygiene, and how many patients were provided care by individual HCWs.(10,14)
A recent study placed video cameras with views of every sink and hand sanitizer dispenser in an ICU to record HCWs' hand hygiene. Sensors in doorways identified when an individual entered or exited. When remote video auditors observed a HCW performing hand hygiene upon entering and exiting, they assigned a pass; if not, a fail was assigned. Performance feedback was continuously displayed on electronic boards mounted in hallways (Figure), and summary reports were delivered to supervisors by email. The data were aggregated floor-wide and offered general information such as the date and the hour of the observation, the number of opportunities to perform hand hygiene during the audit interval, and the number of times hand hygiene was performed during the same audit interval; no individual HCWs were identified.(18) The remote video-monitoring of hand hygiene with real-time feedback to HCWs was associated with a significant increase in hand hygiene compliance.(18)
Despite the advantages of newer technologies, at this moment they are unable to differentiate the Five Moments. It is also important to note that these technologies have remained limited in use as they are expensive and generate high maintenance costs, though it is likely that cost will decrease over time.
An effective program to improve hand hygiene compliance will combine accurate and cost-effective methods to assess compliance (at both the unit and individual level), efforts to make hand hygiene compliance as easy as possible, educational programs to ensure that caregivers understand the significance of compliance, and new ways of using compliance data to promote improved performance. In this latter area, while traditional audit and feedback methods are important, technology is now opening the door to instantaneous feedback and alerting methods that hold great promise.
Alexandre R. Marra, MDInstituto Israelita de Ensino e Pesquisa Albert EinsteinHospital Israelita Albert Einstein, São Paulo, Brazil
Michael B. Edmond, MD, MPH, MPAVirginia Commonwealth University Medical CenterRichmond, Virginia, USA
2. Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Am J Infect Control. 2002;30:S1-S46. [go to PubMed]
3. World Alliance for Safer Health Care. Patient Safety. WHO Guidelines on Hand Hygiene in Health Care. First Global Patient Safety Challenge Clean Care Is Safer Care. Geneva, Switzerland; 2009. [Available at]
5. Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. 'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect. 2007;67:9-21. [go to PubMed]
6. Aboumatar H, Ristaino P, Davis RO, et al. Infection prevention promotion program based on the PRECEDE model: improving hand hygiene behaviors among healthcare personnel. Infect Control Hosp Epidemiol. 2012;33:144-151. [go to PubMed]
7. Marra AR, Moura DF Jr, Paes AT, dos Santos OF, Edmond MB. Measuring rates of hand hygiene adherence in the intensive care setting: a comparative study of direct observation, product usage, and electronic counting devices. Infect Control Hosp Epidemiol. 2010;31:796-801. [go to PubMed]
8. Marra AR, Noritomi DT, Westheimer Cavalcante AJ, et al; Positive Deviance for Hand Hygiene Study Group. A multicenter study using positive deviance for improving hand hygiene compliance. Am J Infect Control. 2013;41:984-988. [go to PubMed]
12. Sodré da Costa LS, Neves VM, Marra AR, et al. Measuring hand hygiene compliance in a hematology-oncology unit: a comparative study of methodologies. Am J Infect Control. 2013;41:997-1000. [go to PubMed]
13. Edmond MB, Goodell A, Zuelzer W, Sanogo K, Elam K, Bearman G. Successful use of alcohol sensor technology to monitor and report and hygiene compliance. J Hosp Infect. 2010;76:364-365. [go to PubMed]
16. Fisher DA, Seetoh T, Oh May-Lin H, et al. Automated measures of hand hygiene compliance among healthcare workers using ultrasound: validation and a randomized controlled trial. Infect Control Hosp Epidemiol. 2013;34:919-928. [go to PubMed]
18. Armellino D, Hussain E, Schilling ME, et al. Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare. Clin Infect Dis. 2012;54:1-7. [go to PubMed]
Table. Comparison among compliance hand hygiene methods.
|Compliance HH methods||Description||Advantages||Disadvantages|
|Direct observation||Considered the gold standard method for HH, because it is the only HH metric that directly measures HCW HH compliance||The only HH method that can evaluate the "Five Moments for HH" and generate an HH adherence rate||a) The Hawthorne effect; b) interobserver agreement can vary, thus it requires a great effort in training data collectors; c) time intensive for observers; d) and short observation periods|
|Measuring product use||An indirect way to measure hand hygiene compliance, measuring chlorhexidine or alcohol-based hand rub use||a) Less resource intensive; b) possible to do it manually or electronically; c) can be done in different hospital settings||a) Not possible to distinguish HH practice among HCWs|
|Electronic sensors||Several different types of electronic sensors using different RFID technologies (WiFi, Bluetooth, ZigBee, ultrasound)||a) Electronic HH systems are designed to ensure that HCWs perform HH prior to patient care and issue an automated notice to do so; b) can also promote real-time feedback to HCWs; c) when integrated with a database, allow for automated reports of HCWs entering rooms, HH adherence, and a log of patient care episodes per each HCW||a) Technologies are expensive and generate high maintenance costs; b) necessary to work closely with engineering to assess possible interference with existing equipment or whether an existing wireless network may be overloaded|
|Video surveillance||Cameras with views of every sink and hand sanitizer dispenser to record HCW HH. Sensor in doorways identifies when an individual enters/exits||Remote video can monitor HH with real-time feedback to HCWs||a) Employee privacy; b) high maintenance costs|
HH=hand hygiene; HCW=health care worker; RFID=radio frequency identification
Figure. An example of screenshot of real-time feedback for hand hygiene. Reprinted with permission of Oxford University Press from (18).