Supporting improvement in hand hygiene

A new quality standard was issued in April outlining six statements designed to reduce infection
rates, including a statement recommending that patients should be looked after by healthcare workers who
always clean their hands thoroughly, both immediately before and immediately after contact or care.
Hand hygiene tops the list of simple behaviours that can make a big impact on patient safety, yet the typical rate of hand hygiene compliance among healthcare workers is estimated to average only 38.7% (WHO, 2009). Obtaining accurate figures is notoriously difficult, however, Healthcare providers are left to determine
their own monitoring methods with regards to hand hygiene compliance, and most turn to direct observation as their method of choice. Because direct observation is not a high-tech method for monitoring hand
hygiene compliance, it has many limitations. Observers cannot monitor every interaction between clinicians andpatients in a hospital 24 hours a day,seven days a week. As a result, it isestimated that direct observation monitorsonly 1.2%-3.5% of all hand hygieneevents, according to a study undertaken at
the University of Iowa (Fries et al, 2011). This makes the statistical reliability of direct observation very low. Direct observation also involves observer bias. The individual who is conducting a study may not be
properly trained in standard observational techniques and he or she may be biased – either negatively
or positively – toward the person he or she is observing. In addition, direct observation methods are extremely time-consuming, costly and resource intensive. Perhaps the most significant flaw of direct observation is the Hawthorne Effect, which states that individuals will exhibit different behaviour when they know they are being watched by others, simply because they are aware of the observation beingconducted in their presence. This effect often results in artificially high rates of compliance.One study, published by Infection Control and Hospital Epidemiology,found “direct observation cannot be considered the gold standard for assessing hand hygiene, because there [is] no relationship between the observed adherence and the number of dispensingepisodes or the volume of product used.”(Marra et al, 2010).

Impact of non-compliant hand hygiene A lack of hand hygiene compliance is a major contributor to the high rates of healthcare-associated infections (HCAIs) in hospitals. Many HCAIs are preventable, yet studies suggest that prevalence in high income countries is around 7.6%. In fact, the European Centre for Disease Prevention and Control (ECDC) estimates that 4,131,000 patients are affected by approximately 4,544,100 episodes of HCAI every year in Europe (figures cited by WHO, Report on the Burden of Endemic Health Care - Associated Infection Worldwide, 2011). In Europe, HCAIs cause 16 million extradays of hospital stay, 37,000 attributable
deaths, and contribute to an additional 110,000 deaths every year. In addition, annual financial losses are estimated at approximately 7 billion Euros (including direct costs only). (WHO, 2011). The UK Prime Minister’s new patient safety ‘tsar’, Donald Berwick, the former chief executive officer of the Institute for
Healthcare Improvement, in the US, commented: “Even something as simple as uniform hand washing requirements
would cut hospital infections in half.” While most hospitals only perform hand hygiene before and after patient
care, the WHO has identified five critical moments for hand hygiene in the healthcare setting. The ‘Five Moments’ are before patient contact, before an aseptic task, after body fluid exposure, after patient contact and after contact with patient surroundings. Clearly, performing and monitoring hand hygiene only when entering or exiting a patient’s room is putting patients at risk – yet direct observation often fails to capture all five of these critical moments.“Around the world, compliance of 95% and even 100% is reported. However, we know from WHO figures that around 50% of infections could be prevented with better hand hygiene. As soon as we are able to recognise the real numbers (probably around 35%-50% for hand hygiene compliance), we will be able to identify where improvements can be made,” commented Dr John Hines, research and development director for Deb Group. Speaking at the Reducing HCAIs conference, in London, Dr Hines said there should at least be a move towards using trained, objective observers. However, this can be very expensive – the human resources involved in direct observation would be better used for implementing behaviour change and
improvement initiatives, in units where there is a problem. “Just providing audit data is a wasteful use of talented people,” he commented. “Effective hand hygiene comes down to three things: hand hygiene must be performed at the right time (as outlined in the WHO Five Moments), the right product must be used and the right technique must be adhered to. This combination will ensure the best possible patient outcomes.” Dr Hines believes that electronic monitoring could provide a solution, if it is reliable and designed to drive behaviour
change. The DebMed GMS (Group Monitoring System) system automatically tracks staff hand hygiene activity, based
on the WHO Five Moments for Hand Hygiene guidelines, and provides hospitals with real time data to help create
and sustain quality and safety initiatives. It includes a suite of tools to support effective use and deployment of compliance information, at the ward or group level, and is more accurate than direct observation, without being punitive, as it provides feedback at the unit level, as a whole, rather than singling out
individuals. It has already been introduced in the US and is now being developed for other countries, including the UK. Dr Hines explained that compliance rates are calculated based on the HOW Benchmarks. These benchmarks are the expected number of hand hygiene occurrences by unit and hospital type for specific times of day and days of week. They have been developed based on amulti-hospital direct observation study by
Connie Steed and Elaine Larson et al (2011). The statistical algorithms have enabled Deb to accurately predict the number of hand hygiene opportunities per patient per day, for a wide variety of scenarios, including factors such as nurse to patient ratios and the case mix index on a unit. The accuracy of the system has been
validated in a large study in the US, usingvideo monitoring. Over four quarters, the compliance indices produced by the electronic system were virtually indistinguishable from the compliance indices calculated from the video monitoring. “At the time of the study, the hospital was using direct observation as their audit
tool. Although we had installed the electronic monitoring system for the purposes of evaluation of the technology, it was not being used as part of the hospital’s overall hand hygiene intervention. They thought that their compliance was getting better, increasing to around 98%. In fact, our data showed that their compliance was getting worse,”said Dr Hines. The system was designed to provide feedback at the hospital, ward or unit level, as individual monitoring was considered to be too intrusive. “It is important to create a positive change culture and studies have suggested that peer pressure and reinforcement are more powerful and long-lasting,” he explained.

Outcomes
At the conference, Dr Hines went on to present some early outcomes data, from an installation at Cooley-Dickinson Hospital, New York. A baseline calculation of compliance was made for various units from December 2011 to August 2012. During this period, staff were unaware of the installation. Compliance was as low as 21% (on the childbirth ward) and as high as 79.4% on the North 3 Ward. This was followed by a post-intervention period from September 2012 to February 2013. Staff were made aware of the system’sintroduction during this period and the data was used in regular unit meetings, to support the development of interventions. “Overall compliance rates showed a significant increase. The data provoked people to think about what they were doing. It also came as a shock that they had moved from a comfortable position of 98% compliance (according to direct
observation), when the reality was much lower,” Dr Hines explained. The greatest increase in compliance
was around 30%, while the lowest increase was 5.6%. In all cases, there was a statistically significant increase incompliance, however. He further highlighted the outcomes on two units at the Riverside Hospital,
Illinois, following the installation of the electronic monitoring system. The baseline compliance rates for the two units were 62.4% and 71.5%. Over a three-month period, following the intervention, hand hygiene compliance increased by 23%, on one unit, and by 32% on the other.
Dr Hines also presented outcomes data from Greenville Memorial Hospital, South Carolina, in terms of infection rates. The hospital had introduced a variety of interventions, in addition to the DebMed system. Therefore it would not be possible to claim that a reduction in multi-drug resistant organism (MDRO) rates was entirely due to the introduction of the DebMed system. However, rates of MDROs and MDRO clusters declined significantly from 2009-2012 – the MDRO rate per 1000 patient days decreased by 22% and MDRO clusters per 100 unit months decreased by 35%. During this time, the WHO Five Moments for Hand Hygiene standard was implemented and the DebMed GMS was fully installed in 2011. Dr Hines observed that the system was shown to offer an important contribution as part of an organisation’s multi-modal infection prevention strategy.“HCAIs account for 5,000 deaths and 300,000 illnesses, per year. We should remind ourselves of what these numbers mean. While there are many reasons whyit is difficult to change, we must never giveup the challenge,” he concluded.

For more information contact:
Deb Ltd
Denby Hall Way, Denby
Derbyshire DE5 8NX
Tel: 01773 855100
Email: debmed@deb.co.uk
Web: www.deb.com

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