Hand Hygiene Compliance Monitoring

- Strategies and techniques

PTY Ching
Principle Nurse
WHO CC
School of Public Health
The University of Hong Kong

Most common mode of transmission

of pathogens is via hands!
Infections acquired in healthcare
Spread of antimicrobial resistance (MDROs)

Possible cross
contamination
between Patient
A and Patient B

Proper Hand Hygiene

is the single most effective mean
to prevent
health care-associated infection
and to reduce
the spread of
multi-resistant microorganisms!
WHO Hand Hygiene Guideline 2009

GUIDE TO IMPLEMENTATION & TOOLS TO

TRANSLATE GUIDELINES INTO PRACTICE.

Available at http://www.who.int/gpsc/5may/tools/en/index.html

HAND HYGIENE IMPLEMENTATION STRATEGY

Evidence-based
approach, made
up of 5 core
components, to
improve hand
hygiene

SYSTEM CHANGE: ABHR at point-ofcare

+
Training and Education of Staff

+
Hand Hygiene Observation and
Feedback

+
Reminders in the Workplace

(WHO 2009)

Establishment of a Safety Climate

Individual active participation & site
support

EXAMPLES OF HAND HYGIENE PRODUCTS

EASILY ACCESSIBLE AT THE POINT-OF-CARE

HAND HYGIENE IMPLEMENTATION STRATEGY

Evidence-based
approach, made
up of 5 core
components, to
improve hand
hygiene

SYSTEM CHANGE: ABHR at point-ofcare

+
Training and Education of Staff

+
Hand Hygiene Observation and
Feedback

+
Reminders in the Workplace

(WHO 2009)

Establishment of a Safety Climate

Individual active participation & site
support

HAND HYGIENE IMPLEMENTATION STRATEGY

Evidence-based
approach, made
up of 5 core
components, to
improve hand
hygiene

SYSTEM CHANGE: ABHR at point-ofcare

+
Training and Education of Staff

+
Hand Hygiene Observation and
Feedback

+
Reminders in the Workplace

(WHO 2009)

Establishment of a Safety Climate

Individual active participation & site
support

Patient safety climate

Change in hand hygiene practice

Behavioral change among HCW

Hand Hygiene Observation and Feedback is Key

15

IMPROVING HAND HYGIENE COMPLIANCE

MEASUREMENT
Why

Measure Hand Hygiene Compliance?

To

understand performance

To

use data to change behaviors

To

assess impact of interventions

How to Measure Hand Hygiene Compliance

Direct observation of practice

Alcohol hand rub utilization
Technology monitoring
Healthcare-associated infection (HAI) rates

HOW IS HAND HYGIENE MONITORED TODAY?

1. Direct observation
2. Consumption modeling
3. Patient Surveys

C O N F I D E N T I AL

MEASURING HAND HYGIENE COMPLIANCE

Auditing compliance by healthcare providers

provides benchmark for improvement
Results of observational audits help identify
most appropriate interventions for education,
training and promotion

METHOD OF OBSERVATION

Direct observation of hand hygiene practices

done by trained observers using standardized
audit tool (WHO)
Observation based on Patient Routine
Practices
Observer conducts observations openly

Identification of HCW kept confidential, no names

attached to the information

Each observation session is ~20 minutes

WHO IS 0BSERVED?

All healthcare providers working with

patients or in the patient care area may
be observed

NOT visitors and patients

Observers ONLY record what they see

HOW TO OBSERVE HAND HYGIENE

Direct observation using consistent approach

and tool is most important
Observer must familiarize him/herself with
methods and tools and be trained to identify
and distinguish opportunities for hand hygiene
occurring during healthcare practices

HOW TO OBSERVE HAND HYGIENE

Observer must conduct observations openly

without interfering with ongoing work, and keep
HCW identity confidential

Compliance should be detected according to

opportunities for hand hygiene as
recommended

CRUCIAL CONCEPTS AND DEFINITIONS

Healthcare activity: succession of tasks during
which HCWs' hands touch different surfaces:
patient, his/her body fluids, objects or surfaces
located in patient environment

Each contact is a potential source of

contamination for HCWs' hands

CRUCIAL CONCEPTS AND DEFINITIONS

Opportunity: Need (when) to perform HH,
whether single or multiple indications
Indication = reason why HH necessary at a
given moment
Hand

hygiene must relate to each opportunity

Multiple

indications may come together to

create a single opportunity

RISK OF
TRANSMISSION

INDICATION
INDICATION

OPPORTUNITY

HAND HYGIENE

DEFINITION OF PATIENTS ENVIRONMENT

Note: the patient environment may differ in some settings

THE GEOGRAPHICAL CONCEPTUALIZATION

OF THE TRANSMISSION RISK
HEALTH-CARE AREA

PATIENT ZONE
Critical site with
infectious risk
for the patient

Critical site
with body fluid
exposure risk

THE MY 5 MOMENTS FOR HAND

HYGIENE APPROACH

RECOMMENDATIONS FOR OBSERVATION

Determine how to best identify the types of HCWs

you may be observing

Accurate HCW identification is critical to ensure

reliability of data

PERFORMANCE INDICATORS
Monitor

and record adherence to

hand hygiene by ward or service

Provide

feedback to healthcare
workers about their performance

Monitor

the volume of alcohol-based

handrub used per 1,000 patient days

Monitor

adherence to policies on
wearing artificial nails
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

METHOD OF FEEDBACK

Data collected, analyzed and reported back

to each unit
Post on notice board of tearooms
Data also publicly reported on the hospital
Internet (by site and some HCW categories)

HH Compliance over the years

HH Compliance

23

58

67

33%
77%

42%

19%

2%

21%

39%

16%

51%

HH compliance(%) among
staff groups

66

74

57

59

63

45

66
42

23

26

19

22

HH compliance(%) among Drs of

different departments

87
73
67
66
50

55
36

42

36

24

47

24

56
29
21

25 26

67

51

29
18

46

13

HH compliance (%) among Nurses & HCA

of different departments

95

91

81

80

64
59
62

36

75

65

61
86

49

46

50
39

30

18
11

20

56

15
9

CONSUMPTION PER YEAR (LITRE)

2002
Hand Hibiscrub
$35 / 500ml

Hand Detergent $6
/ 500ml

2003

8587.5 10657.5

2004

2005

2006

2007

9066

11547.5

7480

1310

4785

7215

6485

5900

4500

13028

Handrub
$18 / 500ml
$4.2 / 100ml

108.75

925

400

509.5

543.8

6808.1

Hand towel
(pkt/4x250sht)

36429

57803

57190

56810

55539

53751

Save HK$ ~ 100,000

(Liter / staff)
1st HSI case in
HK (1 May)

Officially rolled out

HA wide (Jan 2008)

4 Testing
Hospitals

WHO Pandemic
(11 Jun)

Super

Role models

Hawthorne effect

Hand hygiene monitoring technology

is a potential solution to improve HCW
hand hygiene compliance

Direct observation is labor intensive and bias

Hand Hygiene Compliance Audit

New monitoring technologies

Man vs Machines

RTLS / Individual Monitoring

Dispensers

Badges

Sensory Network

RTLS Software

COMPLIANCE MANAGEMENT APPROACHES

Video
Surveillance

Cost

Person Specific
Monitoring

Observation
Apps

Area/Group
Monitoring

Direct (manual)
Observation

Impact

THREE PRIMARY TECHNOLOGIES TO CONSIDER

1.

Area / Group Monitoring

2.

Individual / Role Monitoring

3.

Direct Observations Apps

Direct Observation System / APP

Pen / Paper
Excel / PowerPoint
Time Consuming
Prone to Errors

App for iPad / iPhone & Android

Auto-feed into Software
Increases standardization of data
Significant increased efficiencies
Statistically relevant data

ACTIVITY/GROUP MONITORING

Entry/Exit activity

Dispenser activity

Compliance by location
o Building, floor, unit, room

Not Big Brother

o Community metric / no badges
o Team based performance

Group-level reporting structure

Automated Reporting 24/7

Little IT infrastructure required

Vibration

Voice reminder

Three Hand Hygiene Monitoring Technologies

(HHMT) and feedback identified:
EMS that provide reminders without feedback
EMS / VMS that provide aggregate feedback
without reminders
EMS that provide individual feedback with
reminders

Electronic Monitoring System (EMS)

Video Monitoring System
(VMS)

Hawthorne
effect

Behavioral
intent

- Limited data showing the advantage of adoption