Approaches to hand hygiene monitoring: From low to high technology approaches

Evaluating the accuracy of an automatic counting system to detect dispensing of hand hygiene product

BACKGROUND

Hand hygiene (HH) is an essential element of infection prevention and control programs. Direct observation of adherence to the 5 moments for HH is considered the gold standard in compliance monitoring. However, as direct observation introduces potential bias, other strategies have been proposed to supplement HH compliance data in healthcare facilities. This study evaluated the accuracy of an automatic counting system (MEZRIT™) to detect when a HH product (soap or alcohol-based hand rub) was dispensed, and thus measure product usage as opposed to compliance with the 5 moments for HH.

METHODS

A quasi-experimental study was conducted in a nursing simulation lab where seven participants undertook basic nursing tasks which included performing HH. Sensors were attached to soap and alcohol-based hand rub dispensers to record the time at which a product was dispensed. HH events were video recorded (time-stamped) and validated against timestamps from the automatic counting system.

RESULTS

260 HH events were detected by the automatic counting system and confirmed by video recordings. 5182 non-HH events were calculated from analysis of the video recordings. The automatic counting system had 90 % sensitivity (95%CI 85.8-93.1 %), and 100 % specificity (95%CI 99.9-100 %). This model generated a positive predictive value of 100 % (95%Cl 98.4-100 %), and a negative predictive value of 99.5 % (95%CI 99.3-99.7 %).

CONCLUSION

The MEZRIT™ system accurately identified 90 % of HH events and excluded 100 % of non-HH events. The real-time monitoring of HH product usage may be beneficial in responding quickly to changes in product usage.

Theory-driven approach to hand hygiene promotion intervention in hospitals: a case of theory of planned behaviour

Nosocomial infections are among the major challenges faced by health systems worldwide, with hand hygiene being one of the simplest and most important preventive measures. This study aimed to assess the effectiveness of an educational intervention based on the Theory of Planned Behaviour (TPB) in improving hand hygiene behaviour among hospital nursing staff. A total of 194 nursing staff members were selected using a random sampling method and randomly assigned to intervention and control groups. Data were collected through researcher-made questionnaire based on the TPB and the World Health Organization's five moments of hand hygiene. The intervention programme was developed and implemented following a pretest, response analysis, and educational needs assessment. The results showed a significant change in the mean scores of subjective norms, perceived behavioural control, behavioural intention, and behaviour at baseline, immediately after, and 2 months after the intervention in the intervention group. Hand hygiene adherence at the moments of 'before touching a patient', 'after body fluid exposure', and 'after touching a patient' showed significant differences in the intervention group. Given the effectiveness of TPB-based intervention and the influence of factors like the environment and reinforcement, combining TPB with constructs from other behaviour change theories, particularly Social Cognitive Theory is recommended to improve hand hygiene compliance.

Workflows and locations matter - insights from electronic hand hygiene monitoring into the use of hand rub dispensers across diverse hospital wards

Background

While healthcare-associated infections (HAIs) affect approximately 3.2-6.5% of hospitalised patients in the US and Europe, improving hand hygiene (HH) could reduce HAI rates. Investigating HH is time-consuming and not always objective, and comprehensive, unbiased data is needed to develop effective strategies. Using electronic tools can provide new and detailed insights on the determinants of HH.

Aim

To evaluate location-dependent usage of wall-mounted dispensers (WMDs) and point-of-care dispensers (POCs) using an electronic HH recording system.

Methods

In this retrospective study, hand rub volumes were anonymously recorded for 931,446 disinfections from 17 wards in nine German hospitals using the electronic monitoring system NosoEx®. Number of disinfections and rub volumes of WMDs/POCs by ward and room type were analysed.

Findings

Generally, WMDs were most prevalent. With >3 dispensers per bed and >20 disinfections per patient day, availability and use were highest in intensive care (ICU) and intermediate care (IMC), but here rub volumes from WMDs were lowest (∼2.0 mL). Although most dispensers are located in patient rooms (∼42%), they are more frequently used in hallways. In surgical ICUs, dispensers are often used in patient rooms, where contact with open wounds is common. About 3.6 mL of hand rub is used per disinfection in treatment rooms, the highest volume of all room types.

Conclusion

Dispenser use was dependent on location, room type, ward specialisation and workflow. Optimising the location of hand rub dispensers (HRDs)s is not the only solution to improve HH, but can help reduce inconvenience, achieve more ergonomic workflows and better meet user needs.

Should automated electronic hand-hygiene monitoring systems be implemented in routine patient care? Systematic review and appraisal with Medical Research Council Framework for Complex Interventions

Manual hand-hygiene audit is time-consuming, labour-intensive and inaccurate. Automated hand-hygiene monitoring systems (AHHMSs) offer advantages (generation of standardized data, avoidance of the Hawthorne effect). World Health Organization Guidelines for Hand Hygiene published in 2009 suggest that AHHMSs are a possible alternative. The objective of this review was to assess the current state of the literature for AHHMSs and offer recommendations for use in real-world settings. This was a systematic literature review, and publications included were from the time that PubMed commenced until 19th November 2023. Forty-three publications met the criteria. Using the Medical Research Council's Framework for Developing and Evaluating Complex Interventions, two were categorized as intervention development studies. Thirty-nine were evaluations. Two described implementation in real-world settings. Most were small scale and short duration. AHHMSs in conjunction with additional intervention (visual or auditory cue, performance feedback) could increase hand hygiene compliance in the short term. Impact on infection rates was difficult to determine. In the few publications where costs and resources were considered, time devoted to improving hand hygiene compliance increased when an AHHMS was in use. Health workers' opinions about AHHMSs were mixed. In conclusion, at present too little is known about the longer-term advantages of AHHMSs to recommend uptake in routine patient care. Until more longer-term accounts of implementation (over 12 months) become available, efforts should be made to improve direct observation of hand hygiene compliance to improve its accuracy and credibility. The Medical Research Council Framework could be used to categorize other complex interventions involving use of technology to prevent infection to help establish readiness for implementation.

Hand hygiene monitoring: Comparison between app and paper forms for direct observation

Healthcare-associated infections (HAIs) are a global public health threat. Italy is one of the countries with the highest prevalence of HAI. Hand hygiene (HH) is a pillar of infection prevention and control. Monitoring HH is necessary to improve HH compliance, and direct observation is considered the gold standard. Transcription and analysis of data collected during direct observation of HH compliance with the WHO paper form are time-consuming. We collected, during a 9-day observation period, HH opportunities and compliance both with a smartphone application (SpeedyAudit) and with the WHO paper form. Then, we investigated the difference in the required time for data transcription and analysis between the WHO paper form and the use of the app. The difference in the required time for data transcription and analysis was significant with a mean time of 2 s using the app and about 14-54 min/day using paper form (p = .004) while no significant difference was found in measured compliance rates between the two data collecting methods. HH monitoring with an app is time-saving, and the app we used was easy to use.

Health care workers' experiences of video-based monitoring of hand hygiene behaviors: a qualitative study

BACKGROUND

Hand hygiene is key to preventing health care-associated infections. Human observation is the gold standard for measuring compliance, but its utility is increasingly being questioned with calls for the use of video monitoring approaches. The utility of video-based systems to measure compliance according to the WHO 5 moments is largely unexamined, as is its acceptability amongst health care workers (HCW) and patients. This study examined HCW acceptability of video monitoring for hand hygiene auditing.

METHODS

Following trial of a video monitoring system (reported elsewhere), 5 participating HCW attended 2 in-depth group interviews where they reviewed the footage and explored responses to the approach. Transcripts were analyzed using thematic analysis.

RESULTS

Four themes were identified: 1) Fears; 2) Concerns for patients; 3) Changes to feedback; and 4) Behavioral responses to the cameras. HCWs expressed fears of punitive consequences, data security, and confidentiality. For patients, HCWs raised issues regarding invasion of privacy, ethics, and consent. HCWs suggested that video systems may result in less immediate feedback but also identified potential to use the footage for feedback. They also suggested that the Hawthorne Effect was less potent with video systems than human observation.

CONCLUSIONS

The acceptability of video monitoring systems for hand hygiene compliance is complex and has the potential to complicate practical implementation. Additionally, exploration of the acceptability to patients is warranted.

CHECKLIST

COREQ.

Learning to interact with new technology: Health care workers' experiences of using a monitoring system for assessing hand hygiene - a grounded theory study

BACKGROUND

Recently, innovative technologies for hand hygiene (HH) monitoring have been developed to improve HH adherence in health care. This study explored health care workers' experiences of using an electronic monitoring system to assess HH adherence.

METHODS

An electronic monitoring system with digital feedback was installed on a surgical ward and interviews with health care workers using the system (n = 17) were conducted.  The data were analyzed according to grounded theory by Strauss and Corbin.

RESULTS

Health care workers' experiences were expressed in terms of having trust in the monitoring system, requesting system functionality and ease of use and becoming aware of one's own performance. This resulted in the core category of learning to interact with new technology, summarized as the main strategy when using an electronic monitoring system in clinical settings. The system with digital feedback improved the awareness of HH and individual feedback was preferable to group feedback.

CONCLUSIONS

Being involved in using and managing a technical innovation for assessing HH adherence in health care is a process of formulating a strategy for learning to interact with new technology. The importance of inviting health care workers to participate in the co-design of technical innovations is crucial, as it creates both trust in the innovation per se and trust in the process of learning how to use it.

Electronic hand hygiene monitoring systems can be well-tolerated by health workers: Findings of a qualitative study

Background:

Electronic hand hygiene monitoring overcomes limitations associated with manual audit but acceptability to health workers varies and may depend on culture of the ward and the nature of the system.

Objectives:

Evaluate the acceptability of a new fifth type electronic monitoring system to frontline health workers in a National Health Service trust in the UK.

Methods:

Qualitative interviews with 11 informants following 12 months experience using an electronic monitoring system.

Results:

Informants recognised the importance of hand hygiene and embraced technology to improve adherence. Barriers to hand hygiene adherence included heavy workload, dealing with emergencies and ergonomic factors related to placement of alcohol dispensers. Opinions about the validity of the automated readings were conflicting. Some health workers thought they were accurate. Others reported problems associated with differences in the intelligence of the system and their own clinical decisions. Opinions about feedback were diverse. Some health workers thought the system increased personal accountability for hand hygiene. Others ignored feedback on suboptimal performance or ignored the data altogether. It was hard for health workers to understand why the system registered some instances of poor performance because feedback did not allow omissions in hand hygiene to be related to the context of care.

Conclusion:

Electronic monitoring can be very well tolerated despite some limitations. Further research needs to explore different reactions to feedback and how often clinical emergencies arise. Electronic and manual audit have complementary strengths.

Sticky apps, not sticky hands: A systematic review and content synthesis of hand hygiene mobile apps

OBJECTIVE

The study sought to identify smartphone apps that support hand hygiene practice and to assess their content, technical and functional features, and quality. A secondary objective was to make design and research recommendations for future apps.

MATERIALS AND METHODS

We searched the UK Google Play and Apple App stores for hand hygiene smartphone apps aimed at adults. Information regarding content, technical and functional features was extracted and summarized. Two raters evaluated each app, using the IMS Institute for Healthcare Informatics functionality score and the Mobile App Rating Scale (MARS).

RESULTS

A total of 668 apps were identified, with 90 meeting the inclusion criteria. Most (96%) were free to download. The majority (78%) intended to educate or inform or remind users to hand wash (69%), using behavior change techniques such as personalization and prompting practice. Only 20% and 4% named a best practice guideline or had expert involvement in development, respectively. Innovative means of engagement were used in 42% (eg, virtual or augmented reality or geolocation-based reminders). Apps included an average of 2.4 out of 10 of the IMS functionality criteria (range, 0-8). The mean MARS score was 3.2 ± 0.5 out of 5, and 68% had a minimum acceptability score of 3. Two had been tested or trialed.

CONCLUSIONS

Although many hand hygiene apps exist, few provide content on best practice. Many did not meet the minimum acceptability criterion for quality or were formally trialed or tested. Research should assess the feasibility and effectiveness of hand hygiene apps (especially within healthcare settings), including when and how they "work." We recommend that future apps to support hand hygiene practice are developed with infection prevention and control experts and align with best practice. Robust research is needed to determine which innovative methods of engagement create "sticky" apps.

Hand Hygiene Compliance Rate During the COVID-19 Pandemic

This quality improvement study assesses hand hygiene compliance rates in a hospital with an automated hand hygiene monitoring system during the COVID-19 pandemic.

Hand hygiene during facility-based childbirth in Cambodia: a theory-driven, mixed-methods observational study

Background

Despite current efforts to improve hand hygiene in health care facilities, compliance among birth attendants remains low. Current improvement strategies are inadequate, largely focusing on a limited set of known behavioural determinants or addressing hand hygiene as part of a generalized set of hygiene behaviours. To inform the design of a facility –based hand hygiene behaviour change intervention in Kampong Chhnang, Cambodia, a theory-driven formative research study was conducted to investigate the context specific behaviours and determinants of handwashing during labour and delivery among birth attendants.

Methods

This formative mixed-methods research followed a sequential explanatory design and was conducted across eight healthcare facilities. The hand hygiene practices of all birth attendants present during the labour and delivery of 45 women were directly observed and compliance with hand hygiene protocols assessed in analysis. Semi-structured, interactive interviews were subsequently conducted with 20 key healthcare workers to explore the corresponding cognitive, emotional, and environmental drivers of hand hygiene behaviours.

Results

Birth attendants’ compliance with hand hygiene protocol was 18% prior to performing labour, delivery and newborn aftercare procedures. Hand hygiene compliance did not differ by facility type or attendants’ qualification, but differed by shift with adequate hand hygiene less likely to be observed during the night shift (p = 0.03). The midwives’ hand hygiene practices were influenced by cognitive, psychological, environmental and contextual factors including habits, gloving norms, time, workload, inadequate knowledge and infection risk perception.

Conclusion

The resulting insights from formative research suggest a multi-component improvement intervention that addresses the different key behaviour determinants to be designed for the labour and delivery room. A combination of disruption of the physical environment via nudges and cues, participatory education to the midwives and the promotion of new norms using social influence and affiliation may increase the birth attendants’ hand hygiene compliance in our study settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03901-7.

A Commonly Used Biocide 2-N-octyl-4-isothiazolin-3-oneInduces Blood-Brain Barrier Dysfunction via Cellular Thiol Modification and Mitochondrial Damage

Isothiazolinone (IT) biocides are potent antibacterial substances commonly used as preservatives or disinfectants, and 2-n-Octyl-4-isothiazolin-3-one (OIT; octhilinone) is a common IT biocide that is present in leather products, glue, paints, and cleaning products. Although humans are exposed to OIT through personal and industrial use, the potentially deleterious effects of OIT on human health are still unknown. To investigate the effects of OIT on the vascular system, which is continuously exposed to xenobiotics through systemic circulation, we treated brain endothelial cells with OIT. OIT treatment significantly activated caspase-3-mediated apoptosis and reduced the bioenergetic function of mitochondria in a bEnd.3 cell-based in vitro blood-brain barrier (BBB) model. Interestingly, OIT significantly altered the thiol redox status, as evidenced by reduced glutathione levels and protein S-nitrosylation. The endothelial barrier function of bEnd.3 cells was significantly impaired by OIT treatment. OIT affected mitochondrial dynamics through mitophagy and altered mitochondrial morphology in bEnd.3 cells. N-acetyl cysteine significantly reversed the effects of OIT on the metabolic capacity and endothelial function of bEnd.3 cells. Taken together, we demonstrated that the alteration of the thiol redox status and mitochondrial damage contributed to OIT-induced BBB dysfunction, and we hope that our findings will improve our understanding of the potential hazardous health effects of IT biocides.

Association of environmental surface contamination with hand hygiene and infections in nursing homes: a prospective cohort study

Background

Little is known about the presence of infections in nursing home residents, the causative micro-organisms, how hand hygiene (HH) influences the presence of infections in residents, and the extent to which environmental contamination is associated with the incidence of infection among residents.

Aims

To establish if environmental contamination can be used as an indicator for HH compliance, and if environmental contamination is associated with the incidence of infection.

Methods

Environmental surface samples (ESS) were collected in an exploratory study as part of a HH intervention in 60 nursing homes. ESS results from three distinct surfaces (nurses' station, communal toilet and residents' shared living area) were compared with nurses' HH compliance and the incidence of infection among residents. Real-time polymerase chain reaction assays were used to detect norovirus genogroup I and II, rhinovirus and Escherichia coli. HH compliance was measured by direct observation. The incidence of infection was registered weekly.

Findings

Rhinovirus (nurses' station: 41%; toilet: 14%; living area: 29%), norovirus (nurses' station: 18%; toilet: 12%; living area: 16%) and E. coli (nurses' station: 14%; toilet: 58%; living area: 54%) were detected. No significant (P<0.05) associations were found between HH compliance and the presence of micro-organisms. An association was found between E. coli contamination and the incidence of disease in general (P=0.04). No other associations were found between micro-organisms and the incidence of disease.

Conclusion

Rhinovirus, norovirus and E. coli were detected on surfaces in nursing homes. No convincing associations were found between environmental contamination and HH compliance or the incidence of disease. This study provides reference data about surface contamination.

The holy grail of hand hygiene compliance: Just-in-time peer coaching that leads to behavior change

We describe the delivery of real-time feedback on hand hygiene compliance between healthcare personnel over a 3-year time period via a crowdsourcing web-based application. Feedback delivery as a metric can be used to examine and improve a culture of safety within a healthcare setting.

Comparison of two electronic hand hygiene monitoring systems in promoting hand hygiene of healthcare workers in the intensive care unit

Background

Hand hygiene (HH) is the cornerstone of infection control, and the promotion of HH is the focus of the world. The study aims to compare the role of two different types of electronic hand hygiene monitoring systems (EHHMSs) in promoting HH of healthcare workers (HCWs) in the intensive care unit (ICU).

Methods

In a 16-bed ICU of a general tertiary hospital in Shenzhen, the research was divided into three stages with interrupted time series (ITS) design. In the first stage, the direct observation method was used to monitor and feed back the HH compliance rate of HCWs monthly. In the second stage, the type1 EHHMS was applied to monitor and feed back the individual number of HH events monthly. In the third stage, the type2 EHHMS with a function of instant reminder and feedback was employed, and the personal HH compliance rates were fed back monthly. Meanwhile, direct observation continued in the last two stages.

Results

In the second stage, The HH compliance rate increased. However, there was no significant difference in the trajectory of the rate compared with the first stage. In the first month of the third stage, the HH compliance rate increased by 12.324% immediately and then ascended by 1.242% over time. The number of HH events per bed day and HH products’ consumption per bed day were consistent with the change of HH compliance rate observed.

Conclusion

Monitoring and feedback can improve the HH of HCWs. The EHHMS, with the function of real-time reminders and feedback, has a more noticeable effect on promoting HH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05748-3.

Influence of the Internet of Things management system on hand hygiene compliance in an emergency intensive care unit

BACKGROUND

Hand hygiene is a critical strategy for infection prevention in all healthcare settings. Automated electronic monitoring systems are expected to improve hand hygiene performance.

AIM

To investigate the impact of the Internet of Things (IoT) management system on hand hygiene compliance among medical staff in an emergency intensive care unit (EICU).

METHODS

This retrospective observational study was conducted between July 1^st, 2017 and February 28^th, 2018 in a 19-bed EICU. The changes in hand hygiene compliance among 54 members of medical staff and the incidence of hospital infections were compared, counted, and analysed before and after implementing the IoT management system in the EICU that was initiated on November 1^st, 2017.

FINDINGS

After the application of the IoT management system, the hand hygiene compliance rates among the members of the medical staff before (29.5% (3347/11,338) vs 57.9% (4690/8094), P < 0.001) and after (59.9% (9915/16,556) vs 73.8% (17,194/23 286), P < 0.001) the contact with patients and surrounding environment significantly improved. However, hand hygiene compliance among three cleaning staff did not significantly improve after the application. Moreover, there was no significant difference in healthcare-acquired infection rates (2.535% (9/355) vs 2.047% (7/342), P = 0.667) nor in the detection rates of the four major multidrug-resistant bacteria in the EICU before and after the application of the IoT management system (P > 0.05).

CONCLUSION

The IoT management system significantly improved hand hygiene compliance among medical staff, except cleaners, in the EICU of one provincial hospital; however, the rates of nosocomial infection did not significantly decrease. The quality of hand hygiene implementation needs to be improved.

The impact of coronavirus disease 2019 (COVID-19) on provider use of electronic hand hygiene monitoring technology

The use of an electronic hand hygiene monitoring system (EHHMS) decreased due to the coronavirus disease 2019 (COVID-19) pandemic. We analyzed dispenser use, hand hygiene (HH) badge use, and HH compliance to determine the effect of COVID-19 on EHHMS use and HH compliance. HH product shortages and other pandemic-induced challenges influenced EHHMS use.

Obstetric Healthcare Workers' Adherence to Hand Hygiene Recommendations during the COVID-19 Pandemic: Observations and Social-Cognitive Determinants

Background

Hand hygiene is crucial to avoid healthcare‐associated infections and the transmission of COVID‐19. Although the WHO has issued global hand hygiene recommendations for healthcare, adherence remains challenging. Considering social‐cognitive theories such as the health action process approach (HAPA) can help to improve healthcare workers’ adherence. This study aimed to observe adherence and to assess determinants in obstetric hospitals during and after the onset of the COVID‐19 pandemic.

Methods

In all, 267 observations of behaviour were conducted in two German obstetric university hospitals over three time periods (pre‐COVID‐19 pandemic, heightened awareness, and strict precautions). In addition, 115 healthcare workers answered questionnaires regarding social‐cognitive determinants of hand hygiene behaviour. Multiple regression and multiple mediation analyses were used to analyse associations.

Results

Adherence to hand hygiene recommendations increased from 47 per cent pre‐COVID‐19 pandemic to 95 per cent just before lockdown while simple measures against the pandemic were taken. Self‐efficacy was associated with the intention to sanitise hands (β = .397, p < .001). Coping self‐efficacy mediated the association of intention with hand hygiene adherence.

Conclusions

Obstetric healthcare workers seem to adapt their hand hygiene behaviour to prevent infections facing the global COVID‐19 pandemic. To further improve interventions, social‐cognitive determinants should be considered, especially intention and (coping) self‐efficacy.

Antimicrobial Resistance and Molecular Epidemiology of Corynebacterium striatum Isolated in a Tertiary Hospital in Turkey

Although Corynebacterium striatum is part of the human flora, it has recently drawn attention both for its multidrug resistance and its role as an invasive infection/outbreak agent. This cross-sectional study aimed to determine the antimicrobial resistance and clonal relationships among C. striatum strains. In total, 81 C. striatum strains were identified using Phoenix-100^TM (BD, Sparks, MD, USA). The antimicrobial resistance of the strains was determined using the Kirby–Bauer disk diffusion method. Clonal relatedness among the strains was performed via arbitrarily primed polymerase chain reaction (AP-PCR). All 81 C. striatum strains were resistant to penicillin, cefotaxime, ciprofloxacin, and tetracycline, but susceptible to vancomycin and linezolid. The resistance rates to gentamicin, erythromycin, and clindamycin were 34.6%, 79%, and 87.7% respectively. AP-PCR results showed no predominant clone among the C. striatum strains. Corynebacterium striatum is reportedly the cause of an increasing number of invasive infections/outbreaks. Moreover, treatment options are limited. The study showed that vancomycin, linezolid, and gentamicin can be selected for the empirical treatment of C. striatum infections. Although no single-clone outbreak was observed in our hospital, small clonal circulations were observed within some units, indicating cross-contamination. Therefore, a comprehensive infection control program is warranted in future.

Hand hygiene compliance monitoring: Do video-based technologies offer opportunities for the future?

Hand hygiene is universally recognised as the primary measure to reduce healthcare-associated infections. Studies have convincingly demonstrated a link between increased hand hygiene compliance and reductions in rates of healthcare-associated infections. Direct observation is considered the gold standard method for monitoring hand hygiene compliance. Despite the acknowledged benefits of this approach, recent literature has highlighted a range of issues impacting on the reliability and validity of this data collection technique. The rise of technology in healthcare provides opportunity for alternative methods that promise advantages over direct human observation. There have been no published examples of systems that are able to capture data consistent with all the WHO '5 Moments for Hand Hygiene'. In this paper we explore current human-based auditing practises for monitoring hand hygiene compliance and raise for discussion and debate video-based technologies to monitor hand hygiene compliance. We raise questions regarding hybrid approaches that incorporate both direct human observation and indirect video-based surveillance, and the possible advantages and disadvantages therein for monitoring hand hygiene compliance. We suggest that such methods have the potential to ameliorate, or minimise, the inherent biases associated with direct observation, notably the Hawthorne Effect. Future research into the utility of a hybrid approach to auditing, including the technical specifications, efficacy, cost effectiveness and acceptability of such a model is warranted.

The learning hospital: From theory to practice in a hospital infection prevention program

The learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation of clinical best practices. We describe a model for the learning hospital within the framework of a hospital infection prevention program and argue that a critical assessment of safety practices is possible without significant grant funding. We reviewed 121 peer-reviewed manuscripts published by the VCU Hospital Infection Prevention Program over 16 years. Publications included quasi-experimental studies, observational studies, surveys, interrupted time series analyses, and editorials. We summarized the articles based on their infection prevention focus, and we provide a brief summary of the findings. We also summarized the involvement of nonfaculty learners in these manuscripts as well as the contributions of grant funding. Despite the absence of significant grant funding, infection prevention programs can critically assess safety strategies under the learning hospital framework by leveraging a diverse collaboration of motivated nonfaculty learners. This model is a valuable adjunct to traditional grant-funded efforts in infection prevention science and is part of a successful horizontal infection control program.

Modelling the costs and consequences of reducing healthcare-associated infections by improving hand hygiene in an average hospital in England

OBJECTIVE

To assess the potential clinical and economic impact of introducing an electronic audit and feedback system into current practice to improve hand hygiene compliance in a hypothetical general hospital in England, to reduce the incidence of healthcare-associated infections (HCAIs).

METHODS

Decision analysis estimated the impact of introducing an electronic audit and feedback system into current practice to improve hand hygiene compliance among front-line healthcare practitioners (HCPs).

RESULTS

The model assumed 4.7% of adult inpatients (ie, ≥18 years of age) and 1.72% of front-line HCPs acquire a HCAI in current practice. The model estimated that if use of the electronic audit and feedback system could lead to a reduction in the incidence of HCAIs of between 5% and 25%, then the annual number of HCAIs avoided could range between 184 and 921 infections per hospital and HCAI-related mortality could range between 6 and 31 deaths per annum per hospital. Additionally, up to 86 days of absence among front-line HCPs could be avoided and up to 7794 hospital bed days could be released for alternative use. Accordingly, the total annual hospital cost attributable to HCAIs could be reduced by between 3% and 23%, depending on the effectiveness of the electronic audit and feedback system. If introduction of the electronic audit and feedback system into current practice could lead to a reduction in the incidence of HCAIs by at least 15%, it would have a ≥0.75 probability of affording the National Health Service (NHS) a cost-effective intervention.

CONCLUSION

If the introduction of the electronic audit and feedback system into current practice in a hypothetical general hospital in England can improve hand hygiene compliance among front-line HCPs leading to a reduction in the incidence of HCAIs by ≥15%, it would potentially afford the NHS a cost-effective intervention.

A comparison of the accuracy of two electronic hand hygiene monitoring systems

Interest in electronic hand hygiene monitoring systems (EHHMSs) is now widespread throughout the infection control community. We tested 2 types of EHHMS for accuracy. The type B EHHMS captured more HH events with superior accuracy. Hospitals considering an EHHMS should assess the technology’s ability to accurately capture HH performance in the clinical workflow.

Effectiveness over time of a multimodal intervention to improve compliance with standard hygiene precautions in an intensive care unit of a large teaching hospital

Background

Standard hygiene precautions are an effective way of controlling healthcare-associated infections. Nevertheless, compliance with hand hygiene (HH) guidelines among healthcare workers (HCWs) is often poor, and evidence regarding appropriate use of gloves and gowns is limited and not encouraging. In this study, we evaluated the ability over time of a multimodal intervention to improve HCWs compliance with standard hygiene precautions.

Methods

Trend analysis of direct observations of compliance with HH guidelines and proper glove or gown use was conducted in the medical/surgical intensive care unit (ICU) of Umberto I Teaching Hospital of Sapienza University of Rome. The study consisted of two phases: a six-month baseline phase and a 12-month post-intervention phase. The multimodal intervention was based on the World Health Organization strategy and included education and training of HCWs, together with performance feedback.

Results

A total of 12,853 observations were collected from November 2016 to April 2018. Overall compliance significantly improved from 41.9% at baseline to 62.1% (p < 0.001) after the intervention and this improvement was sustained over the following trimesters. Despite variability across job categories and over the study period, a similar trend was observed for most investigations. The main determinants of compliance were job category (with nurses having the highest compliance rates), being a member of ICU staff and whether delivering routine, as opposed to emergency, care. HH compliance was modified by glove use; unnecessary gloving negatively affected HH behaviour while appropriate gloving positively influenced it.

Conclusions

The multimodal intervention resulted in a significant improvement in compliance with standard hygiene precautions. However, regular educational reinforcement and feedback is essential to maintain a high and uniform level of compliance.

Impact of an automated hand hygiene monitoring system and additional promotional activities on hand hygiene performance rates and healthcare-associated infections

OBJECTIVE

Determine the impact of an automated hand hygiene monitoring system (AHHMS) plus complementary strategies on hand hygiene performance rates and healthcare-associated infections (HAIs).

DESIGN

Retrospective, nonrandomized, observational, quasi-experimental study.

SETTING

Single, 93-bed nonprofit hospital.

METHODS

Hand hygiene compliance rates were estimated using direct observations. An AHHMS, installed on 4 nursing units in a sequential manner, determined hand hygiene performance rates, expressed as the number of hand hygiene events performed upon entering and exiting patient rooms divided by the number of room entries and exits. Additional strategies implemented to improve hand hygiene included goal setting, hospital leadership support, feeding AHHMS data back to healthcare personnel, and use of Toyota Kata performance improvement methods. HAIs were defined using National Healthcare Safety Network criteria.

RESULTS

Hand hygiene compliance rates generated by direct observation were substantially higher than performance rates generated by the AHHMS. Installation of the AHHMS without supplementary activities did not yield sustained improvement in hand hygiene performance rates. Implementing several supplementary strategies resulted in a statistically significant 85% increase in hand hygiene performance rates (P &lt; .0001). The incidence density of non-Clostridioies difficile HAIs decreased by 56% (P = .0841), while C. difficile infections increased by 60% (P = .0533) driven by 2 of the 4 study units.

CONCLUSION

Implementation of an AHHMS, when combined with several supplementary strategies as part of a multimodal program, resulted in significantly improved hand hygiene performance rates. Reductions in non-C. difficile HAIs occurred but were not statistically significant.

Validity of hand hygiene compliance measurement by observation: A systematic review

BACKGROUND

Hand hygiene is monitored by direct observation to improve practice, but this approach can potentially cause information, selection, and confounding bias, threatening the validity of findings. The aim of this study was to identify and describe the potential biases in hand hygiene compliance monitoring by direct observation; develop a typology of biases and propose improvements to reduce bias; and increase the validity of compliance measurements.

METHODS

This systematic review of hospital-based intervention studies used direct observation to monitor health care workers' hand hygiene compliance.

RESULTS

Seventy-one publications were eligible for review. None was free of bias. Selection bias was present in all studies through lack of data collection on the weekends (n = 61, 86%) and at night (n = 46, 65%) and observations undertaken in single-specialty settings (n = 35, 49%). We observed inconsistency of terminology, definitions of hand hygiene opportunity, criteria, tools, and descriptions of the data collection. Frequency of observation, duration, or both were not described or were unclear in 58 (82%) publications. Observers were trained in 56 (79%) studies. Inter-rater reliability was measured in 26 (37%) studies.

CONCLUSIONS

Published research of hand hygiene compliance measured by direct observation lacks validity. Hand hygiene should be measured using methods that produce a valid indication of performance and quality. Standardization of methodology would expedite comparison of hand hygiene compliance between clinical settings and organizations.

Watch out, Someone is Watching You!

How to cite this article: Mehta Y, Kulkarni AP. Watch out, Someone is Watching You! Indian J Crit Care Med 2019;23(5):205.

Evaluation of Barriers to Audit-and-Feedback Programs That Used Direct Observation of Hand Hygiene Compliance: A Qualitative Study

IMPORTANCE

Audit and feedback based on direct observation is a common strategy to improve hand hygiene compliance, but the optimal design and delivery of this intervention are poorly defined.

OBJECTIVE

To describe barriers encountered by audit-and-feedback programs for hand hygiene across acute care hospitals within the Veterans Health Administration.

DESIGN, SETTING, AND PARTICIPANTS

A qualitative study was conducted at a geographically diverse convenience sample of 10 acute care hospitals within the Veterans Health Administration. Participants included 108 infection prevention team personnel and frontline staff. All data were collected between June 30, 2014, and March 18, 2015. Data were analyzed between September 6, 2017, and January 5, 2018.

MAIN OUTCOMES AND MEASURES

Barriers to audit and feedback for hand hygiene compliance were evaluated. Semistructured interviews of key personnel were performed through site visits at 6 locations and telephone interviews with 4 sites. Focus groups were conducted with frontline staff. Interviews and focus groups were audio recorded and transcribed. All transcripts were analyzed using thematic content analysis.

RESULTS

Overall, 108 individuals participated in the study. Semistructured interviews were conducted with 38 individuals, who were predominantly infection prevention team members. Focus group interviews were conducted with 70 frontline hospital staff members. Surveillance activities at all 10 sites made use of a variety of staff members with the intention of covertly collecting direct observations on hand hygiene compliance. Monitoring programs were challenging to maintain because of constraints on time and personnel. Both auditors and frontline staff expressed skepticism about the accuracy of compliance data based on direct observations. Auditors expressed concern about the Hawthorne effect, while frontline staff were worried that their compliance was not visible to auditors. In most hospitals, approaches to monitoring hand hygiene compliance produced friction between frontline staff and infection prevention teams. The feedback process for audit results did not consistently reach frontline staff and, in many hospitals, did not seem to facilitate improvement efforts.

CONCLUSIONS AND RELEVANCE

Auditing hand hygiene compliance with direct observation was problematic across these acute care hospitals. Auditing was perceived to collect inaccurate data and created tension with frontline staff, and the feedback process did not appear to encourage positive change. Strategies are needed to collect more reliable hand hygiene data and facilitate multidisciplinary collaboration toward improved compliance.