Hand Hygiene Measurement and Education
May/June 2011
Hand Hygiene Measurement and Education
Compliance improvement can be successful, sustained, and cost effective.
Hand hygiene (HH) is one of the most effective practices that all individuals in a healthcare facility who deliver healthcare services and have direct contact with the patient (healthcare worker, or HCW) can perform to help prevent the spread of infection among patients. Measurement and feedback of HH performance encourages improvement. In the United States, HCWs are performing at or below 50% compliance (BioMedReports.com, 2011) even after monitoring has been implemented over a period of time (McGuckin, Waterman & Govednik, 2009).
Better results are attainable but challenging. How can the infection prevention community improve compliance when many budgets are hovering in cost control mode? Rely on the resources you already have: patients and products.
The Centers for Disease Control and Prevention (CDC), the Joint Commission (JC), and the World Health Organization (WHO) each promote the use of multimodal HH compliance programs within a healthcare facility. Recommended components typically are: HCW training, patient education, practice measurement, and feedback for the healthcare team. When designing your approaches to education and measurement, consider opportunities that cost you less but give you more. That’s less time and money, and more clinically proven reliability.
Patient Empowerment
When developing your educational component, consider how many different HCWs see a patient over the course of their stay. Your program will impact every HCW type on every shift. As various HCWs enter the patient care area day and night, the only consistent factor in that room is the patient. Patients can be effective participants in your HH education efforts if they are given permission to participate. In a 2006 study of 1,000 consumers in the United States, we found 4 out of 5 consumers said they would be willing to ask their HCW about HH if they were invited to do so (McGuckin, Waterman & Shubin, 2006).
Patient empowerment is growing in acceptance as an educational foundation. When patients are given background information on the risk of hospital acquired infections, they are made aware. Couple that knowledge with basic questions and reminder tasks presented to them by HCWs (sometimes referred to as explicit permission), and patients will have a fresh set of skills to act on their knowledge.
Implementation
In our HH compliance program (see sidebar), when patients are admitted to the hospital, a HCW (usually the nurse at initial assessment) discusses infection risks. The nurse can explicitly tell the new patient that he or she is invited to remind anyone coming into their care area to wash or sanitize their hands. It can be as simple as saying, “thank you for washing,” when approached.
Some hospitals will give patients what we call visual reminders—buttons, stickers, etc.,—that patients can place around their care area. These remind the HCW to perform HH. Just as important, they also assure the patient that asking is the norm at your facility.
The World Health Organization’s First Global Patient Safety Task Force produced the WHO Guidelines for Hand Hygiene in Health Care (2009) and included patient empowerment as one of the tactics for your patient safety and quality strategy. In the January 2011 issue of the Journal of Infection Control and Hospital Epidemiology, the task force also published a strategy for incorporating patient empowerment.
The total cost of reminding a healthcare worker for performing hand hygiene = $0.00. How you implement the program with visual reminders is up to your creative team. When HCWs are empowered to invite and patients are empowered to ask, everyone benefits.
Product Usage Monitoring
Guidelines and peer-reviewed research offer direction when developing the measurement component of your plan. Experts suggest there is no single method to measure hand hygiene compliance without human bias (direct observation) or without behavior detail (product usage measurement) (Haas & Larson, 2008; Boyce, 2008). However, nobody has concluded you need major capital investments or binding long-term service program contracts to achieve higher results.
Allocate Your Resources
Observation is an investment in personnel hours for data collection and reporting. Researchers at Virginia Commonwealth University Medical Center calculated that it cost $21,252 for hired data recorders to conduct observations in a 24% time sample (Stevens et al., 2009). We calculated annual costs for hospitals can be between $12,000 (depending on number of units) using nonprofessional observers and $36,000 for professionals to monitor one hour per unit per week (McGuckin, Waterman & Govednik, 2009). As you see, your program design impacts cost. Observation is the standard, and both WHO and JC suggest at least minimum criteria for observation monitoring.
Given that observation is the standard, you can invest those dollars and hours in observing the units where HH performance needs the most improvement. Product usage measurement has been recognized as a surrogate for observation, because data gathered on where product is used (or not used) provides insight on HH activity without requiring someone to monitor. Supporting product usage measurement methodology, the JC monograph Measuring Hand Hygiene Adherence: Overcoming the Challenges (The Joint Commission, 2009) includes 10 different product usage programs in their review (out of a total of 37 programs in the publication).
Measuring product usage includes the following factors: 1) product used, 2) patient bed days, and 3) dosage of individual HH event. Results will indicate the number of HH events performed on the unit per patient per day. A facility-wide report will show which units are performing HH more, or less, per patient. Focus observation on units where HH frequency is low. Observation will tell you why the lower HH frequency and provide insight for improvement strategy. The resulting program is a more targeted use of your personnel and dollars, while still getting a facility-wide picture of compliance with little investment needed.
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The authors offer a program called “All for One: One Patient, One Healthcare Worker, One Question: Did You Wash Your Hands?” plus other resources, research, and compliance measurement tools at www.hhreports.com. |
In our program, the four most common methods that infection preventionists use for measuring product usage are 1) housekeeping collects empty product containers in a central location; housekeeping or an infection prevention representative counts the product containers as they are accumulated; 2) housekeeping tallies the products as they are replaced in each room or common area; 3) materials management provides the orderings per unit to infection prevention for calculating; or 4) any combination of the above. Each hospital has a method that works best for their team. You don’t need additional equipment, software, or personnel to monitor your entire facility, unit by unit. Your staff is already replacing and ordering product; simply introduce the program to them and ask for tallies.
Success at the Local, State, and National Levels
Good Samaritan Hospital in Baltimore, Maryland, highlighted how compliance improvement increased with a multimodal plan in a scientific conference abstract (Karanfil et al., 2009). Observation alone produced scores that matched management’s goals. But, once McGuckin’s product usage monitoring was introduced, compliance differences between observation and product measurement revealed lower rates on some units. Infection preventionists knew from other HH research that the high observation rates might be biased. The plan helped target specific areas for improvement not made apparent with observation. Their program was selected as part of the kickoff for the Maryland Hand Hygiene Collaborative (2009).
Hospitals are not in this alone when devising compliance plans. The Washington State Hospital Association added the product volume measurement program in a group of 55 facilities. Compliance increased after 5 months (McGuckin et al., 2007). Working together they devised a “safe table” discussion format to share improvement tactics and to support individual hospitals trying to meet desired goals from management. We congratulate Washington State Hospital Association on recently being awarded the 2010 John Eisenberg Award for Patient Safety and Quality, in which the safe table program was acknowledged.
By 2009 the resulting database from the first 300 hospitals in our program gave, to the best of our knowledge, the first nationwide study of compliance improvement in the United States (McGuckin, Waterman & Govednik, 2009). At baseline, HCWs in ICUs were performing HH 26% of the total opportunities presented for HH. After 12 months, ICUs increased to 36%. Baseline for non-ICUs was 36% and after 12 months, increased to 51%.
Have we improved since 2009? At a hand hygiene forum in March 2011, Mark R. Chassin, MD, FACP, MPP, MPH, president of The Joint Commission, shared that hospitals participating in the JC’s Center for Transforming Healthcare were performing at 48% compliance (BioMedReports.com, 2011). We still have a long way to go!
National Benchmarking and Local Performance
Our database of product usage measurement from healthcare facilities in the United States provides insight in national trends—information that individual hospitals can apply to their own data analysis. We compared soap vs. sanitizer usage and found that when HCWs were faced with an HH opportunity, they were choosing soap more frequently in 2008–2009 than in past measurement periods (Govednik, Waterman & McGuckin, 2009). Recalling the guidelines from WHO and CDC, sanitizer is the recommended method for hand hygiene if your hands are not visibly soiled. Nationally, we are trending backward from these recommendations.
On a local level, a hospital that tracks product usage can determine which units are using less sanitizer than soap and then focus observation on discovering why. This could impact local training, or could impact future placement of sanitizer products on that unit.
In another example of national and local applicability, we were able to compare product usage results for the period of heightened Novel A H1N1 activity (spring 2009 to spring 2010) to the period prior to the onset of H1N1 (spring 2008 to spring 2009). We found ICUs, non-ICUs, and ERs had greater HH frequency during H1N1 period than in the same time for the prior year. However, as the CDC reported a drop in the number cases of patients admitted with influenza-like illnesses, HH dropped back to pre-pandemic compliance levels before the winter flu season was over (Govednik, Waterman, & McGuckin, 2010).
As one infection preventionist explained to us, complacency set in with HH practices once HCWs felt we all dodged a bullet (recalling the unknown with H1N1 and some speculation in various media that many people would get infected and require hospitalization). Individual hospitals can track their HH usage trends against local or global health concerns as well, noting which units have increased or relaxed their HH practices as HCW’s perception of danger has passed.
With product usage measurement, your team gets more than just instant compliance feedback. The returns on your minimal investment of tallying product provide great insight into your hospital’s usage trends as applied to greater HH and infection prevention matters
Plan for Now and the Future
Which brings us to fiscal planning for 2012 and beyond. In the long term, we are monitoring the growing number of compliance-monitoring electronic devices to see how, or if, technology is proven in peer-reviewed research or healthcare scientific conferences. We emphasize the focus on scientific research to distinguish from what we’ve noticed to be pre-clinical-trial press releases flooding our news feeds. Will applications of electronic surveillance simply introduce another method with strengths and weakness to consider just as we’ve seen in comparisons of observation and product usage measurement? Will new technology appeal to a cost-conscious budget? Many questions need to be answered via peer-reviewed studies and future guideline review from CDC, JC, and WHO.
For those in cost-control mode, we have outlined cost-effective education and measurement that has been proven in research, reviewed in the guidelines, and applied at hundreds of hospitals in the United States. The focus is not on glossy solutions, but rather on the simple task of getting HCWs to wash or sanitize their hands. Let’s get back to basics!
John Govednik is the program manager for McGuckin Methods International’s (MMI) hand hygiene measurement and consumer programs. He is the primary contact for infection preventionists who implement MMI’s measurement program. He is a former member of the National Directorate Board of the American College Personnel Association’s Health and Wellness Commission and has held positions in counseling, multicultural affairs, and educational assessment at several colleges and universities. He has written for several peer-reviewed journals and has presented at APIC, IDSA, SHEA, and spoken to several healthcare groups. He may be contacted at govednik@hhreports.com.
Maryanne McGuckin is founder and president of McGuckin Methods International (a Patient Safety Organization), and is a senior scholar in the health policy department at Thomas Jefferson University in Philadelphia. She has been on the faculty and staff of the University of Pennsylvania for more than 30 years, focusing on infection control and hospital epidemiology. She served on the Centers for Disease Control and Prevention task force that developed the Guideline for Hand Hygiene in Healthcare Settings and was lead author for the chapter on patient empowerment for the World Health Organization’s WHO Guidelines on Hand Hygiene in Health Care. She may be contacted at mcguckin@hhreports.com.
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