Tackling hand hygiene compliance

The World Health Organization points out that adherence to recommended hand hygiene procedures varies – with mean baseline rates ranging from 5% to 89% and an overall average of 38.7%.1 The WHO guidance on hand hygiene outlines ‘Five Moments’ when hand hygiene should be performed, which include: 1 Before touching a patient, 2 Before clean/ aseptic procedure, 3 After body fluid exposure risk, 4 After touching a patient and 5 After touching patient surroundings.2 Although achieving compliance with best practice remains a challenge, there have been significant efforts to drive improvement and compliance, in recent years. Some of the many tools being used to drive improvement include: hand hygiene monitoring systems; initiatives involving audit and observation; reporting and feedback to staff; lean or Kaizen strategies, adopted from the Japanese car manufacturing industry; use of behaviour change theory/ psychology (including ‘human factors engineering’); along with the implementation of teaching aids such as culture testing, UV technologies and gaming systems, used to evaluate hand hygiene technique. In this article, The Clinical Services Journal provides an insight into some of the latest innovation and approaches being taken to drive improvement.

Compliance monitoring

Compliance with hand hygiene within healthcare settings is traditionally assessed by observational audit. However, this may be prone to both subject and observer bias. At the Infection Prevention Society’s annual conference (2012), Tim Boswell, consultant microbiologist, Nottingham University Hospitals NHS Trust, discussed a novel approach to verifying observational hand hygiene audits. “The problem with hand hygiene is that you cannot see microorganisms on the hand, so people do not believe they are there,” commented Tim Boswell. He pointed out that finger-tip cultures are a good educational tool – providing a visual demonstration of poor hand hygiene compliance, as well as the effectiveness of proper technique in reducing cultured microorganisms. Tim Boswell and his colleagues at Nottingham considered whether quantitative finger-tip cultures could also be used as a marker for hand hygiene compliance. An initial study was carried out to establish whether it was possible to quantify the number of microorganisms that indicated ‘clean hands’. Volunteers were divided into two groups – one group used alcohol gel every 15 minutes for one hour. The other group refrained from using any bactericidal hand product for the same duration. After one hour, fingertip impressions were made on blood agar plates. Plates were incubated aerobically overnight and the mean cfu per digit calculated for each subject. “Unsurprisingly, we found that those who had used alcohol gel four times, in group one, had a mean cfu of 14. For group 2 (who went about their normal business), the mean cfu was 55. We calculated that if we applied a mean cutoff of 24 cfu (i.e. under 24 cfu the subject was deemed to have ‘clean hands’), this had a reasonable sensitivity and specificity at differentiating individuals from group one. We could identify most of the people who had been using the hand hygiene gel by measuring the mean count.” The second part of the study took place in the clinical area and involved the sampling of 94 healthcare workers – a mix of nurses, nursing assistants and junior medical staff. Sampling was conducted anonymously, then staff were asked to complete a short questionnaire asking them how many times they thought they had used alcohol gel in the past hour and how long ago the last use had taken place. Photos were taken of the agar plates so staff were able to view their own finger-tip culture results. Only 45 of the 94 healthcare workers sampled had ‘clean’ hands. However, there was a strong correlation between having less than 24 cfu per digit and the number of self-reported uses of gel – with an odds ratio of 7.6 for healthcare workers who had used hand gel four or more times in the last hour compared to those who had not used it all. Feedback on the results was provided to all of the participants, indicating their performance. “Quantitative finger-tip cultures can be used potentially as an indicator of recent alcohol gel use – the greater the frequency of self-reported alcohol gel use, the greater the likelihood of passing this simple ‘clean hands test’,” commented Tim Boswell. “It avoids some of the bias associated with observational audit, but it is also a powerful teaching aid. In addition, it highlights the importance of technique – people may use alcohol gel but not apply it to the finger-tips and this simple test highlights this clearly.” Arrowsight, a developer of a remote video auditing (RVA) platform, has also announced plans to roll out its technology in the UK, following the results of a study undertaken at North Shore University Hospital, in the US. Remote video auditing was used at the hospital as part of a pilot programme to increase hand hygiene among healthcare professionals in the medical intensive care unit (MICU). Over an initial 16-week period, the hospital staff were monitored to establish a base rate of hand hygiene compliance without any feedback to the staff. Using a very strict definition of hand hygiene (requiring healthcare workers to perform hand hygiene before and after patient care within 10 seconds of entering and exiting the room, regardless if gloves were used), their rates were in line with previously documented findings at around 10%. The next 16-week period, staff received real-time feedback on their performance via LED screens mounted on the walls of the MICU and from management. Within weeks of providing feedback, the hand hygiene rate during the second period increased to over 80%. During a subsequent 17 month maintenance period, a sustained rate of well above 80% was achieved. There were over 430,000 hand hygiene data points collected during the 25 month study period, making this one of the most comprehensive studies conducted on hand hygiene performance. “Hand washing has been shown to be the backbone of infection control for the last 150 years. It is one of the most important aspects of preventing the spread of infectious diseases from patient to patient by the hands of healthcare professionals. This is the first time we have used third-party remote video auditing technology, combined with continuous real-time feedback. The results were not only very significant but also showed a sustained improvement in hand hygiene compliance in our facility over a two-year period,” said Dr Bruce Farber, chief of infectious diseases at North Shore University Hospital, who oversaw the study. “In addition, our staff reacted very positively to the programme. The staff did not feel their privacy was being violated or unfairly observed. It has engendered a sense of teamwork in keeping compliance rates high. Quality patient care is critical and North Shore remains committed to the study of, and prevention of, hospital-acquired infections and other infectious diseases.” The results of the study were published in Clinical Infectious Diseases.3-4