Electronic Monitoring for Hand Hygiene: Impact on Hospital-Acquired Infection Prevention

1. Introduction

WHO guidelines for hand hygiene state that monitoring methods should be simple, reproducible, and reflective of real practice, and that they should provide meaningful and actionable feedback to healthcare workers. The guidelines state that direct observation should be the reference standard for validation of other monitoring methods, but this method is labor-intensive, intrusive, and subject to bias. Compliance with hand hygiene is generally overestimated when healthcare workers are aware that they are being observed. Whether this is due to increased hand hygiene at these times, or due to a Hawthorne effect altering the behavior of healthcare workers throughout the entire observation period, is unclear. Observation also requires an adequate sample size to provide a reliable estimate of true compliance, making it impractical for routine monitoring. High false negative and false positive rates have also been reported for observation of hand hygiene. This is thought to be due to poor observer technique in some cases, and in other cases because healthcare workers may alter their behavior if they are aware of observer presence, leading to overestimation of compliance in the absence of observation. Due to these limitations, WHO guidelines state the need for research into alternative monitoring methods.

Monitoring hand hygiene compliance is an essential element of any hand hygiene promotion program. It provides healthcare workers with feedback on their performance, allows identification of local problems, helps to identify targets for improvement, and provides data for research. Despite its importance, the World Health Organization recognizes that the promotion and improvement of hand hygiene compliance is hampered by a lack of a standardized, effective, and efficient method of assessing it.

Hand hygiene is considered to be the most important measure in preventing healthcare-associated infections. Numerous studies have demonstrated the association between increased hand hygiene compliance and reduced infection rates. For example, as little as a 20% increase in hand hygiene compliance was associated with a 40% reduction in infection rates in an intensive care unit. The impact of hand hygiene in infection prevention spans across various healthcare settings and is considered to be cost-effective. Despite the overwhelming evidence regarding its importance, healthcare worker hand hygiene compliance remains universally low.

1.1 Importance of hand hygiene in infection prevention

With signs pointing to hand hygiene as the Achilles heel of infection prevention and patient safety, there is significant evidence indicating hand hygiene non-compliance among healthcare providers. Hand hygiene practices are known to be the most effective way for a practitioner to prevent the spreading of infection to a patient while providing direct care. Compliance by healthcare providers with hand hygiene guidelines is critically low according to various evidence-based studies. These studies show that, on average, healthcare providers only comply with hand hygiene protocol 40% of the time. This low percentage can be attributed to many reasons. In a study by Pittet, he identifies the three important reasons to understand why hand hygiene compliance is low: it is due to a lack of recognition of the importance of hand hygiene, a lack of resources, and behavioral attitudes to accept practice change.

Healthcare is a critically necessary facet of society. While the major goal for the success of patient care and recovery is primarily focused on the attentiveness of healthcare providers, it can also lead to negative effects. Errors caused by healthcare providers can have extreme effects on patient complications and recovery. Healthcare-associated infections (HAIs) are a major issue resulting from the patient’s condition worsening after being admitted to the hospital due to an entirely different cause. With the possibilities of these scenarios occurring, studies have shown that proper hand hygiene compliance, which can be defined as cleaning one’s hands when needed to prevent the spread of pathogens, bacteria, and viruses, can lead to the prevention of infections vital to the patient’s recovery and to the added cost of treatment and procedures for the patient. Hand hygiene is an important aspect of preventing the transmission of infection among patients and provides a safer environment and quality of care. As proven by the World Health Organization’s publication “Save Lives Clean Your Hands,” this statement supports guidelines recommended by the Centers for Disease Control and Prevention (CDC), and various healthcare medical boards and directors.

1.2 Challenges in monitoring hand hygiene compliance

The nursing profession primarily focuses on the actions taken to prevent hospital-acquired infections as opposed to bacterial infections occurring in the community (Melnyk & Fineout-Overholt, 2005). Hospital-acquired infections are the second most common adverse event occurring in healthcare institutions in Australia with hand hygiene being accepted as being the most important measure in preventing transmission of infection within care. Despite the well-known understanding of the importance of hand hygiene, compliance amongst allied health staff is generally poor with an average of 40-50% adherence with hand hygiene protocols (Larson, 1995). These poor compliance rates are primarily due to the fact that contamination of hands occurs several times in the care of each patient. Hand hygiene opportunities have been measured in several studies showing that in an average 100 bed hospital, 100,000 opportunities per month for hand hygiene are missed (Pittet, 2009). Compliance in hand hygiene can be simply explained using the model of human behaviour which represents behaviour as a function of the person and their environment BH=f(P,E) (Baldwin & Ford, 1988). People tend to clean their hands if reminded at the right time and if they believe that hand hygiene will prevent negative consequences of their actions i.e. getting an infection or viruses from accidentally killing a pathogen. This however is very difficult as the environment within healthcare institutions is very fast-paced and healthcare workers are often busy and preoccupied with patient care. This means they may miss moments for hand hygiene or be deterred from washing their hands due to the fact that it may damage their skin or that products are not readily accessible. This attitude is of grave concern as there is now an increase in antimicrobial resistance worldwide and with no new antibiotics being developed, hand hygiene has never been so important (Oliveira, 2014).

1.3 Role of electronic monitoring systems

Electronic monitoring systems have been developed to overcome the limitations of direct observation. These systems collect hundreds of hand hygiene opportunities per caregiver per day. They automatically collect data on the use of soap and hand rub from dispensers, and some systems provide feedback to the healthcare workers in the event of infractions. Data from the monitoring systems can be used to describe hand hygiene behavior, to provide feedback to workers, and to identify opportunities for additional training. The basic components of an electronic monitoring system include: a detector located on or near the soap or alcohol dispenser, a badge for the healthcare worker which transmits an ID signal, a local storage device and a server for data transmission. Several systems have employed video monitoring as a means of increasing the validity of electronic monitoring and reducing the need for comparison with direct observation as a gold standard. Electronic monitoring for hand hygiene is rapidly gaining interest from infection control programs and has been implemented in a few hospitals. A study which compared the compliance rates for hand hygiene obtained simultaneously by direct observation and electronic monitoring found that the electronic monitoring system was more acceptable to healthcare workers and provided results which were relatively free of bias. These initial findings suggest that electronic monitoring might overcome some of the limitations of direct observation data collection. Although in this study electronic monitoring produced lower hand hygiene compliance rates than direct observation, feedback from healthcare workers suggested that they believed the electronic monitoring results. An important unanswered question is whether higher hand hygiene compliance as determined by monitoring systems actually results in reduced HAI rates. If electronic monitoring can successfully increase hand hygiene compliance and sustain that improvement over time, it may prove to be a valuable tool in reducing HAI.

2. Benefits of Electronic Monitoring

2.1 Real-time data collection

2.2 Increased accuracy and reliability

2.3 Identification of compliance patterns

3. Implementation of Electronic Monitoring Systems

3.1 Selection and installation of monitoring devices

3.2 Integration with existing healthcare systems

3.3 Training and education for healthcare staff

4. Impact on Hand Hygiene Compliance

4.1 Improvement in overall compliance rates

4.2 Identification of non-compliant individuals or areas

4.3 Feedback and reinforcement for healthcare workers

5. Effectiveness in Reducing Hospital-Acquired Infections

5.1 Reduction in transmission of pathogens

5.2 Comparison with traditional monitoring methods

5.3 Cost-effectiveness analysis

6. Challenges and Limitations

6.1 Privacy concerns and ethical considerations

6.2 Technical issues and system reliability

6.3 Resistance and acceptance by healthcare workers

7. Best Practices for Successful Implementation

7.1 Engaging healthcare staff and leadership

7.2 Regular monitoring and data analysis

7.3 Continuous improvement and feedback mechanisms

8. Future Directions and Research Opportunities

8.1 Advancements in technology and data analytics

8.2 Long-term impact on infection prevention strategies

8.3 Integration with other healthcare quality initiatives

FAQs

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Electronic Monitoring for Hand Hygiene: Impact on Hospital-Acquired Infection Prevention