Hand Hygiene Compliance Monitoring Methodology

Hand Hygiene Compliance Monitoring Methodology

Background: Medical experts agree hand hygiene (HH) is the single most important intervention to prevent the spread of infection, but compliance remains low.  A major component of a program to improve compliance is the collection and dissemination of accurate HH data.  There are many indications when healthcare workers (HCW) must perform HH to prevent the spread of pathogens but there is little consensus on which opportunities should be measured. 

 Objective: Develop a simple system for HH monitoring which measures compliance upon entry and exit to patient environment and assess whether there is a correlation between entry and exit compliance and other HH opportunities.

Methods: HH policy was revised to include expectations for HH upon entry and exit to patient environment, in addition to before aseptic/invasive procedures, after body fluid exposure, and before/ after removing gloves.  An observational study to assess correlation between HCW HH behaviors upon entry and exit to the patient environment and their behaviors during other opportunities for HH was conducted.  Observers logged detailed HCW activities during an encounter, defined as from the time the HCW entered the patient environment to their exit from it. In a private or semi-private room, the patient environment was defined by its walls. In a multi-patient room the boundaries were defined by the adjacent walls and the curtain line. Observations were conducted in an ICU setting where rooms have glass doors allowing for observation of activities.

Results: A total of 538 encounters were observed.  Opportunities for HH before an aseptic procedure and after exposure to bodily fluids were found in 24% and 22% of encounters, respectively. HCWs performed HH on both entry and exit to a patient environment in 51% of the encounters. HCWs who performed HH upon both entry and exit were more likely to clean their hands before aseptic procedures and after exposure to bodily fluids compared to those who did not. Odds ratio for cleaning hands before an aseptic procedure was 5.3 ( 95% CI 2.1 - 13.6 ), and after exposure to bodily fluids was 8.6 ( 95% CI 2.9- 25.1 ) .

Conclusions: Collecting data on HH is difficult, time consuming, and resource intensive. For effective feedback to HCWs, an adequate number of observations that is representative of HH practices need to be collected.  Challenges to collecting valid HH data include the Hawthorne effect and the physical environment where in many occasions, patient care is performed behind closed doors or curtains making it impossible to observe practice without an observer or cameras in the room.  A simplified method to conducting HH observations may improve feasibility of developing ongoing feedback systems, reduce inter observer variability, and reduce training time and costs for data collection. Additional study is needed to assess impact of implementing such methods on HH practices and healthcare- associated infection rates.