To Do No Harm, Rethink How to Measure Hand Hygiene
Outcomes achieved by early adopters
Electronic monitoring has only become widely available over the past four to five years. Now, evidence is beginning to emerge that it is accurate and reliable and can help reduce the incidence of infections.
A number of hospital systems have conducted early research and pilots to help develop and validate these systems. One of them is Greenville Health System (GHS) in Greenville, South Carolina. Connie Steed, director of infection prevention at GHS, has been working with one electronic hand hygiene company for the past seven years to help develop and perfect its system.
“We are excited to have electronic hand hygiene compliance measurement throughout our seven hospitals,” says Steed. “We now have a better understanding of the compliance rate for all of our hand hygiene behavior 24/7. We switched away from direct observation, the most common monitoring methodology, because it only gave us data for a small snapshot in time and healthcare workers behave differently when being observed. Thus, our rates with direct observation were much higher than our 24/7 reality.
“We have seen consistent double-digit increases in hand hygiene compliance and reductions in healthcare-associated infections,” continues Steed. “These benefits have come with cost savings that can justify the cost of the system.”
In an early study at GHS, hand hygiene compliance was measured on the same patient population for 15 months in three ways: direct observation, video monitoring (with patient consent), and electronic monitoring. Rates of compliance measured by video and electronic monitoring were statistically equivalent for the final 12 months of the study, while direct observation overstated compliance by an average of 33%. This study proved the accuracy and reliability of an electronic monitoring system and showed that the Hawthorne effect produces overstated and unreliable hand hygiene compliance rates (Diller et al., 2013).
In another study, staff feedback on soap versus sanitizer usage enabled by data from an electronic monitoring system significantly increased hand hygiene compliance with the hospital’s Clostridium difficile (C. diff) protocol. The protocol says to shift from sanitizer to soap-and-water hand washing when C. diff is identified because sanitizer does not kill C. diff spores; they need to be washed off with soap and water. During the study, the C. diff infection rate decreased from 7.03 cases per 10,000 patient days to 2.38 per 10,000 (Robinson, Boeker, Steed, & Kelly, 2014).
A third study, pending publication, will show MRSA rates decreased significantly when an electronic system was implemented and staff were properly trained on how to use and engage with the data to drive improvement.
Other hospitals are beginning to achieve similar results. Following implementation of an electronic monitoring system at a suburban Chicago hospital, overall hand hygiene compliance increased from 57% in December 2013 to 79% in September 2015—a 39% increase. Additionally, the rate of hospital-acquired MRSA dropped from 3.94 to 1.98 cases per 10,000 patient days—a 50% reduction. The facility paid no readmissions penalties in 2015 and was one of only seven hospitals in Illinois that paid no ACA-related penalties in 2015. In comparison, the facility had paid a 0.24% CMS readmissions penalty in 2013 (Bouk, Mutterer, Schore, & Alper, 2016).
Conclusion
Now, for the first time since Ignaz Semmelweis first proved the linkage between hand hygiene and deadly infections, there is a way to really know how well staff members are doing. Just as alcohol emerged as the new way to clean hands in the 1980s and 1990s and changed the way we think about and perform hand hygiene, electronic monitoring will likely change the paradigm for measuring compliance.
Direct observation still has an important role to play in hand hygiene, as an interventional tool for discovering and overcoming barriers and obstacles, as well as for giving feedback on technique and evaluating performance of specific groups, such as units or disciplines. However, the evidence is clear that its use as a measurement tool needs to be eliminated in the interest of patient safety and healthcare quality.
Just as we look down a hospital corridor today and see alcohol-based hand sanitizer dispensers as the standard of care, we will likely see unit managers looking at compliance rates for their unit on a monitor in real time, with pens and clipboards—along with many avoidable HAIs—a thing of the past.
Paul Alper is chairman of EHCO, the Electronic Hand Hygiene Compliance Organization (www.ehcohealth.org). He may be contacted at ehcohealth@gmail.com.
References
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