DUKE INFECTION CONTROL OUTREACH NETWORK (DICON)
Infection Prevention News
Volume 10, Number 4, April 2015
The Struggle to Improve Hand Hygiene: Don’t Wash Your
Hands of It.
Background:
Effective hand hygiene programs reduce the rates of healthcare-associated infections,1
including central line-associated bloodstream infections (CLABSIs),2 ventilator associated
pneumonia,3 and surgical site infections.4 Thus, improving hand hygiene adherence at your
hospital will improve patient care and save money.
Opportunities for improvement:
The Society for Hospital Epidemiology of America (SHEA) recently estimated that overall
average rates of compliance with hand hygiene in American hospitals were less than 50% .5
Reasons for these poor rates of compliance are numerous and include understaffing, employee
complaints about skin irritation, lack of role models, and inconvenient location of sinks.
Current Hand Hygiene Surveillance Strategies:
Five different hand hygiene surveillance methods exist: 1) technology-assisted direct
observation, 2) event count measurement or measurement of disinfectant product consumed,
3) advanced technologies for automated monitoring, 4) self-reporting, and 5) direct
observation. We will discuss each method briefly. The advantages and disadvantages of each
surveillance method are discussed in further detail in existing SHEA guidelines.5
Technology-assisted direct observation such as the use of electronic devices to either videotape
or record hand hygiene observations. Such methods, although less labor intensive, have huge
up-front costs, are less reliable than direct observation, and may they frequently cause thorny
problems related to patient privacy.5,6
Product volume or event count measurement systems measure the volume of hand sanitizer
usage or the number of hand hygiene events that occur over a specific time period. These
methods avoid the “Hawthorne Effect” (discussed in the next section) and observation biases,
but they are indirect, expensive and are unable to provide feedback to healthcare workers.5
Advanced technologies for automated monitoring utilize radiofrequency identification (RFID)
badges to monitor provider-patient encounters. RFID badges indirectly measure hand hygiene
adherence based employee proximity to hand hygiene stations before and after patient
contacts. This method eliminates biases associated with direct observation methods. However,
accuracy of these methods is poor. For example, RFID badges accurately capture approximately
50% of actual episodes of hand hygiene.6
Self-reporting of hand hygiene compliance, although the least labor intensive method is
universally recognized as unreliable and thus, this method is not recommended by The Joint
Commission, SHEA, or DICON.5
Direct observation is the current “gold standard” for hand hygiene adherence and is endorsed
by SHEA and DICON.5 We believe that direct observation by trained observers is the best of
the five preceding methods for numerous reasons. It is the most accurate and reliable and it
provides opportunities for immediate feedback if non-compliance is observed.
Limitations in Methods to Measure Compliance with Hand Hygiene:
Since direct observation is the most practical and best method of measuring compliance with
hand hygiene, we will focus our discussion to the two limitations of this surveillance method:
the “Hawthorne Effect” and observer and selection biases.
The Hawthorne Effect7 was first described by investigators working for the Western Electrical
Company’s Hawthorne Works in Chicago. These investigators undertook a series of experiments
designed to improve employee productivity. A progressive improvement in worker productivity
occurred regardless of the intervention they utilized. In the end these investigators concluded
that improved worker productivity occurred simply because the employees were under
observation. Subsequent studies showed that the Hawthorne Effect is common and even
predictable when individual behavior is directly observed. The impact of the Hawthorne Effect
in measuring hand hygiene compliance is difficult to accurately measure, but one study
estimated that hand-hygiene compliance increase by up to 250% when healthcare workers are
under direct observation.8
Selection bias occurs when hand hygiene auditors preferentially undertake audits in hospital
units where hand hygiene is known or expected to excellent.8 Such practices, although giving
the appearance of excellent hand hygiene practices throughout the hospital, provide inaccurate
data to hospital leadership.
Observer bias occurs when a hand hygiene monitor preferentially audits healthcare workers
who are observed using hand hygiene but fails to record observations when healthcare workers
fail to wash or clean their hand with alcohol gels or foams.8 This phenomenon is particularly
and characteristically likely to occur when hand hygiene compliance monitors perform audits in
the unit in which they work.5,8
Covert observers or “secret shoppers” are utilized at some facilities to reduce these biases, but
the usefulness of such methods is predictably limited and unsustainable.5,9,10 In our experience,
“secret shopper” auditors routinely and even characteristically collect an inadequate number
of observations, have no formal training in monitoring hand hygiene compliance, and fail to
adequately record the type of healthcare worker they are observing.
Hand Hygiene Improvement Strategies:
The SHEA guidelines include multiple strategies to improve hand hygiene in hospitals. These
guidelines are well known to auditors for The Joint Commission and are commonly used during
inspections.
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Hand Hygiene Improvement Strategies
Develop a multidisciplinary team that includes representatives from administrative
leadership as well as local (unit-level) champions
Implement a multimodal strategy for improving hand hygiene adherence to directly
address the organization’s most significant barriers
Provide feedback to healthcare providers in multiple formats and on more than one
occasion
Consider rewards or recognition for wards modeling good hand hygiene behavior
Provide meaningful data with clear targets and an action plan in place for improving
adherence
Collect hand hygiene data on all hospital units
Trend hand hygiene performance over time to monitor for improvement and retention
of predetermined compliance goals
Educate, motivate, and ensure competency of healthcare personnel about proper hand
hygiene
Only use designated and properly trained hand-hygiene observers
Use of hand held electronic data collection devices that can wirelessly transmit audit
results to a central server for “real time” monitoring of compliance data
Hospitals are not expected to perform every intervention or strategy in the guidelines. But
hospitals should include at least some of these strategies in their program.
Numerous success stories can also be found in the literature. For example, Duke University
Hospital dramatically achieved and then sustained marked improvement in rates of compliance
with hand hygiene. Duke utilized trained hand hygiene observers with portable electronic
devices that wirelessly transmitted data from each audit to a central data server. The server
provided continuously updated unit-specific hand hygiene compliance scores.11 These scores
were available in a convenient and easy to understand “dashboard” that was used to assess
performance of individual care units and their leadership. Key reasons for the success of this
program (which achieved sustained hospital-wide compliance rates >90%), was the use of
dedicated auditors who performed thousands of audits each month and the direct involvement
in the senior hospital leadership in the assessment of performance.
Currently, vendors exist who can provide wireless transmission of hand hygiene audit data
collected by a variety of hand held-devices such as smart phones, ipods, and/or tablets without
reliance on existing hospitals IT resources. These data are in turn used to provide time-trended
highly specific data reports with “real time” feedback for costs as low at $3000/year for a
typical 200-bed community hospital. Some community hospitals currently utilize hospital
employees who are on light duty because of injuries or other disabilities or hospital volunteers
to collect audit data; thus saving costs.
DICON can provide materials and criteria for training hand hygiene auditors to ensure
consistency in data collection methods. In the near future, we anticipate providing
benchmarked data reports on hand hygiene compliance analyzed and reported by type of
healthcare worker, and unit location for all hospitals that choose to use DICON endorsed
commercial vendors.
References:
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Kirkland KB, Homa KA, Lasky RA, Ptak JA, Taylor EA, Splaine ME. Impact of a hospital-wide hand
hygiene initiative on healthcare-associated infections: results of an interrupted time series. BMJ
Qual Saf. 2012;21(12):1019-1026.
Johnson L, Grueber S, Schlotzhauer C, et al. A multifactorial action plan improves hand hygiene
adherence and significantly reduces central line-associated bloodstream infections. Am. J. Infect.
Control. 2014;42(11):1146-1151.
Koff MD, Corwin HL, Beach ML, Surgenor SD, Loftus RW. Reduction in ventilator associated
pneumonia in a mixed intensive care unit after initiation of a novel hand hygiene program. J.
Crit. Care. 2011;26(5):489-495.
Le TA, Dibley MJ, Vo VN, Archibald L, Jarvis WR, Sohn AH. Reduction in surgical site infections in
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Control Hosp. Epidemiol. 2007;28(5):583-588.
Ellingson K, Haas JP, Aiello AE, et al. Strategies to prevent healthcare-associated infections
through hand hygiene. Infect. Control Hosp. Epidemiol. 2014;35 Suppl 2:S155-178.
Pineles LL, Morgan DJ, Limper HM, et al. Accuracy of a radiofrequency identification (RFID)
badge system to monitor hand hygiene behavior during routine clinical activities. Am. J. Infect.
Control. 2014;42(2):144-147.
McCarney R, Warner J, Iliffe S, van Haselen R, Griffin M, Fisher P. The Hawthorne Effect: a
randomised, controlled trial. BMC Med. Res. Methodol. 2007;7:30.
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Srigley JA, Furness CD, Baker GR, Gardam M. Quantification of the Hawthorne effect in hand
hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort
study. BMJ Qual Saf. 2014;23(12):974-980.
Gould DJ, Chudleigh J, Drey NS, Moralejo D. Measuring handwashing performance in health
service audits and research studies. J. Hosp. Infect. 2007;66(2):109-115.
Larson EL, Aiello AE, Cimiotti JP. Assessing nurses' hand hygiene practices by direct observation
or self-report. J. Nurs. Meas. 2004;12(1):77-85.
Chen LF, Carriker C, Staheli R, et al. Observing and improving hand hygiene compliance:
implementation and refinement of an electronic-assisted direct-observer hand hygiene audit
program. Infect. Control Hosp. Epidemiol. 2013;34(2):207-210.