Validity of Hand Hygiene Compliance Observations by Ward-Based Quality Improvement Nurse Liaisons in a Community-Teaching Hospital

Background:   Observational surveys conducted by infection preventionists (IPs) are the gold standard for establishing hand hygiene (HH) compliance rates among healthcare workers (HCWs), but are time-consuming. To reduce the demands on IPs, ward-based quality improvement (QI) nurse liaisons were educated on several occasions regarding the indications for hand hygiene, were given a simplified data collection sheet and presented with examples of how to complete the collection sheet, and were asked to report compliance rates monthly.

 Objective:   Compare HH compliance rates reported by QI nurse liaisons with compliance rates determined by a volunteer observer whose activities on wards were not known to HCWs. 

Methods:  An experienced IP responsible for HH promotion educated a volunteer regarding indications for hand hygiene, and conducted simultaneous observations with the volunteer to validate the accuracy of her observations.  The volunteer made observations of HH compliance during ward visits, each lasting 30 min or less.  The volunteer used the same data collection sheet used by QI nurse liaisons.  HH compliance was defined as using either an alcohol hand rub or washing with soap and water when indicated. For this study, failure to clean hands before donning non-sterile exam gloves was listed as noncompliance. HH compliance rates before and after patient care reported by QI nurse liaisons on 4 non-ICU wards and a SICU were compared with the volunteer’s observations on the same wards during the same month by using tests of differences in proportions. 

Results:  On non-ICU wards, QI nurse liaisons reported a HH compliance rate before patient care of 60% (29/48 observations), while the volunteer reported a compliance rate before patient care of 11% (14/128 observations) (p < 0.001).  QI nurse liaisons reported a compliance rate after patient care of 75% (45/60 observations) compared to a rate of 56% (73/131 observations) reported by the volunteer (p = 0.01).  In the SICU, the QI nurse liaison reported a HH compliance rate of before patient care of 40% (4/10 observations), compared to a compliance rate of 16% (5/32 observations) reported by the volunteer (p = 0.18).  The QI nurse liaison reported a compliance rate after patient care of 100% (10/10 observations), compared to a rate of 72% (23/32 observations) reported by the volunteer (p = 0.86).

Conclusions:   QI nurse liaisons on both non-ICU wards and in a SICU reported substantially higher HH compliance rates before and after patient care than a volunteer whose observations had been validated, and whose activities were unknown to HCWs.  Limitations of the study include the small number of observations reported.  However, the findings suggest that the higher HH compliance rates reported by QI nurse liaisons may be influenced by the Hawthorne effect, by unintentional observer bias, or by an inadequate understanding of the indications for HH.