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Hand Hygiene: Monitoring to Improve Hand Hygiene

If you can’t measure something, you can’t manage it—Peter Drucker

By Tom Inglesby

Management guru H. James Harrington wrote, “Measurement is the first step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.” 

In the hospital setting, one of the critical quality issues is hand hygiene. Equipment, materials, chemicals, and various delivery systems are implemented to provide the staff with the tools to achieve complete hygiene compliance. But if there are no procedures in place to monitor the compliance to the requirements, the system has failed.

St. Joseph Mercy Oakland is a 443-bed comprehensive community teaching hospital in Pontiac, Michigan. Dr. Fabian Fregoli, vice president of quality and patient safety at St. Joseph Mercy Oakland, acknowledges that there have been some weak spots in this measurement. “What traditionally has been used for hand hygiene compliance is an audit tool that uses observation as a means of capturing information about compliance. Any time you sample a set of data, there is always the risk for bias, and you never have the true picture. With our commitment to quality and safety, we wanted to make certain that we were capturing proper and sufficient data and making certain that our staff was engaged in the hand hygiene compliance program at St. Joe’s.”

Dr. Fregoli continues, “Implementing a solution from Hill-Rom was a commitment we made to be certain that our patients were safe. It provides feedback about hand hygiene compliance, not only to management but more specifically, to the employees, the associates, the caregivers that deliver care to our patients. They have access to that real-time information, so there’s an opportunity for self-improvement and recognition of opportunities at the caregiver level. That’s something that you would never have without the proper technology in place.”

Adam McMullin, vice president and general manager, Hill-Rom IT Solutions, explains the system: “We had hundreds of sites that already had a technology, our nurse call, for locating people by the badges they wore. We then developed, in concert with our partner Centrak, the technology that goes with a soap or sanitization product dispenser and identifies when those people interact with dispensers, and what products they are using for hand hygiene.”

Hill-Rom was able to take the infrastructure that is already in place at many hospitals—their badges—and leverage it. The system allows a supervisor or other staff member to know when a staff member has gone into a zone where there is a hand hygiene rule—typically wash in and wash out of a patient room. It knows who went into that room, and it knows that there is a certain, predetermined amount of time to do hand hygiene, generally about 30 seconds. If that person doesn’t wash, the system has the potential to notify the supervisor to remind the caregiver of the error. It can also work with dietary, environmental services, transport, or other staff members, to remind them that they are about to miss a hand hygiene event.

Dr. Fregoli recalls their search for a solution, “We spent a significant amount of time looking at all the vendors that were in the market at the time, not only from a real-time location perspective, but looking at a variety of different infrastructures, and the analytical and reporting tools that are available. We found that Hill-Rom was most closely aligned with what we were looking for.”

He adds, “Initially we used our existing foam dispensers and attached their device to them as part of the hand hygiene system. It provided us with a good start. We’ve moved to the next level, which is an integrated system that puts a module in the actual device itself. It provides more accurate information. We’re still in the process of gathering data, but we have noticed a significant improvement in our hand hygiene compliance, compared to baseline. That has been a very powerful tool, having that data to share with our associates and to see the tangible improvements in their compliance has been quite validating. It’s been generally well received, and although it’s a brand new system, we were able to work out the details and any issues pretty quickly because Hill-Rom has been a great partner with us. They’ve been very engaged in helping us to be successful.”

Dr. Hudson Garrett, vice president of clinical affairs, PDI, adds, “The most important aspect of ensuring sustained hand hygiene compliance is a culture of accountability and peer monitoring. This approach must start at the very top of the healthcare organization with the executive suite not only setting the tone for the importance of this goal, but also ensuring adequate resources are allocated, and each leader within the organization is held accountable towards the target. All too often in healthcare we focus on the ‘science’ of the infection prevention problem, but rarely do we truly address the barriers to practice, which are most notably communication and culture driven.”

Anecdotal evidence shows that many nurses use a variation of the Five Second Rule: “I was only in the room for a short time so I didn’t have to wash my hands before or after….” Garrett replies, “Hand hygiene is as much about protecting the healthcare workers themselves as it is protecting the patients that they serve. Many systems in healthcare are not properly designed, and therefore fail routinely, and hand hygiene sadly is no exception. For a process to be hardwired, healthcare facilities must make hand hygiene for both the healthcare provider and patient themselves a requirement and treat it as such in their process of patient care. The average intervention in healthcare from the time of demonstrating its validity to true implementation at the bedside can sometimes be up to 17 years. Hand hygiene saves lives, and patients cannot afford to wait.”

While there are many materials used for hand hygiene, not all of them work equally well, especially among employees with sensitive skin. Garrett agrees, saying, “It is natural to have a fallout rate of approximately 10% of users with any hand hygiene agent, as one product does not meet the needs and preferences of 100% of the user population. To minimize risk for skin irritation and dermal sensitivity with repeated use, clinicians should use only hospital-approved, FDA-regulated hand hygiene agents that are alcohol based in accordance with the guidelines set forth by the U.S. Centers for Disease Control and Prevention. In addition, consumer products such as lotions and other agents that are not approved for use in healthcare settings should not be brought into the facility by staff members as they can adversely react with healthcare grade hand hygiene agents and cause sensitivities and reactions on the user’s skin. They also could trigger an allergic reaction.”

What does Garrett recommend for non-medical visitors to the patient? “Visitors and family members carry bacteria and viruses on their hands and skin just as all human beings do, and they can easily serve as vectors for infection transmission when hand hygiene is not performed when clinically indicated. The healthcare facility should make a concerted effort to require all visitors to practice hand hygiene. This process should be repeated upon entering and leaving the patient’s room and also when assisting with their care. For this approach to be effective, the facility must provide patient- and visitor-centric hand hygiene solutions that are readily accessible for use and not just mounted on the wall where they are virtually inaccessible.”

PDI has a robust system of clinical tools and resources in place to assist clinicians with identifying gaps to hand hygiene compliance and also to aid implementation of a sustainable approach to hand hygiene for both healthcare providers and patients. “It is critical to not forget the patient, around which all care should be centered,” Garrett says. “While there are many technologies out there to monitor hand hygiene, the most important component of any successful strategy for this intervention is staff accountability, training, and support, which is accomplished through a solid culture of leadership and innovation.”

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Tom Inglesby is an author based in southern California who writes frequently about medical technologies and improvement strategies.