Trading Spaces - Differences in Health Care Workers (HCWs) Hand Hygiene (HH) Compliance (C) Hospital Based (HB) Observers (Os) vs. External (E) Os

Background: HH is generally considered the most important way to prevent HAIs. Previous studies have found that healthcare workers (HCWs) perform HH about half the time. Our Health System (HS) requires that all HS hospitals measure HHC. However, standardized methods were not utilized. Initially HHC across the HS was low (~40%) but after a HH educational campaign rates significantly improved. In 2005 Hospital A did an audit and found that reported HHC was significantly higher than actual C and so employed dedicated independent (DI) Os (Voth J, et al. #292, 15^th Annual SHEA Mtg, 2005). Over the past 5 years, Hospital A has reported the lowest HHC with maximum achieved C at ~60%. All other hospitals (AOH) utilized a variety of Os and the identity of the O was often not concealed. AOHs reported HHC averaging 94%. Because of concern of falsely elevated C in AOH group, trained Os traded spaces and recorded HHC at a hospital where they did not work.

Objective: To determine if HBOs and DIOs report HHC as accurately as EOs.

Methods:   Standardized HCW HH observations were conducted by trained Os and compared to results reported by HBOs. A minimum of 10 observations was required in small hospitals and 30 for large. HCWs were monitored on room entry and exit. The HCW must have had contact with the patient and/or environment to meet criteria for a HH opportunity. 25% of observations were from an ICU and if the O was recognized or questioned, they were asked to move to another location. Observing a HCW on entering and exiting was recorded as 2 separate opportunities. EO HHC rates were calculated and compared to the previous month’s HBO HHC data.

Results:   

Hand Hygiene Compliance
	HBOs			EOs			Analysis
Hospital	Numerator	Denominator	Rate (%)	Numerator	Denominator	Rate (%)	p value	OR	CI
A	680	1050	65	16	30	53	0.27	0.62	0.28-1.36
B	81	81	100	8	10	80	0.01	1.25	0.92-1.7
C	NA	NA	NA	39	60	65	NA	NA	NA
D	47	48	98	7	22	32	<1X10-7	100.7	10.6-239.3
E	94	110	85	17	30	57	0.001	4.49	1.68-12.0
F	241	251	96	32	60	53	<1X10-7	21.1	8.8-52.0
G	237	258	92	12	30	40	<1X10-7	16.9	6.7-43.7
H	87	87	100	11	22	50	<1X10-7	2	1.32 – 3.04
I	214	219	98	13	20	65	5.9X10-6	23.1	5.5-100.0
J	452	470	96	21	31	68	1.1X10-6	12	4.5-31.6
K	1987	2124	94	22	30	73	5.7x10-4	5.3	21.-12.7
Total w A	4120	4698	88	205	355	58	<1X10-7	5.2	4.1-6.6
Total wo A	3440	3648	94	189	325	58	<1X10-7	11.9	9.1-15.6

 

 

 

 

 

 

 

 

Conclusions:

1)  The best practice for observing and recording HHC has not yet been determined.

2)  Hospital A was the only hospital that HHC did not significantly differ (p=0.27) during the 2 evaluations.

3)  HBOs may not accurately report HHC either because as clinicians’ knowledge regarding HH opportunities varies significantly or because HCWs will perform better when the identity of the O is not concealed.

4)  Standardizing HH observation methodology such as “trading spaces” may more accurately reflect true HHC; however this methodology will likely be associated with greater resources/increased observation time.