Driving improvement in hand hygiene

Various studies continue to show ‘disappointing adherence rates’ – generally less than 50%, ranging from the low teens to occasional reports of over 80% in very select cohorts. Given that healthcare workers’ hands remain a main source of transmission, it follows that a major aspect of preventative efforts to reduce HCAIs should be directed towards improving hand hygiene practices among healthcare workers. Hand hygiene compliance can be measured using various methods – including direct observation; remote observations involving video monitors; indirect calculations based on soap or alcohol product use; individual staff member product use; surveys and selfreporting; automated monitoring technologies, such as RFID (radio frequency identification); and technologies used to identify contamination, such as Adenosine Triphosphate (ATP). A recent report published by Frost & Sullivan (Hand Hygiene Champions the Cause of Infection Control),1 predicts that the healthcare sector will see increasing growth in demand for technology-based systems to ensure compliance. The report states: “The integration of hand hygiene compliance monitoring technologies, with the use of automated and manual dispensers in the next five to seven years, will aid market growth as the value of infection prevention is increasingly being recognised by government and hospital management authorities.”1

Electronic hand hygiene monitoring

The report follows news from Ecolab that the company has entered into a strategic alliance with Proventix Systems to use the nGage RFID system to automate hand hygiene compliance monitoring. The technology, based around an RFID tag system, worn by healthcare workers, integrates with Ecolab’s hand hygiene products and dispensers to provide realtime data about hand hygiene compliance. While manufacturers of hand hygiene dispensers are recognising potential growth opportunities for integrated hand hygiene solutions, there is also a growing body of evidence emerging from the US to suggest that the impact of compliance technologies can be dramatic – pointing the way forward for UK healthcare organisations seeking to reduce HCAIs. A pilot project using nGage, at Princeton Baptist Medical Center in Birmingham, Alabama, showed a 22% reduction in HCAIs, following the introduction of compliance technology, for example. Lennox Archibald, a hospital epidemiologist from the division of infectious diseases, at the College of Medicine, University of Florida, points out that direct observation of hand hygiene compliance can be very labour intensive, while data can be biased. He believes that a system that both monitors compliance and also gives a prompt to healthcare workers provides the most effective approach. At the Annual Society for Healthcare Epidemiology of America (SHEA) Conference, he reported on the results of a study, which showed a significant reduction in infections at a paediatric hospital, based in the US, following the introduction of an electronic hand hygiene monitoring system.2 The Miami Children’s Hospital (MCH) decided, at the executive level, to improve hand hygiene in its facility, in 2009, and the infection control department was given approval to select and implement an electronic hand hygiene monitoring system (EHHS) in a 26-bed oncology unit. After researching several systems, MCH selected the HyGreen Hand Hygiene Recording and Reminding System. The integrated system consists of electronic badges worn by healthcare workers, a hand wash sensor mounted next to each gel or soap dispenser, a bed monitor positioned over each patient bed, and a wireless database (HyMarks) – an integrated data management tool that provides a broad array of reports showing all hand hygiene events and all patient-staff interactions. Each healthcare worker in the paediatric oncology unit is assigned an electronic badge that includes an identifier unique to that healthcare worker. The badge contains an LED that lights green upon confirmation of a successful hand hygiene event. A hand wash sensor is installed next to each hand hygiene station. These sensors record each hand hygiene event, including the actual time of the event and the geographic location in the unit. The sensor sends the data to an electronic database; the LED on the badge then flashes green to signal the healthcare worker that the hand wash sensor has successfully detected the presence of alcohol in the soap or gel being used and that a successful hand hygiene event has occurred. Anyone in the vicinity of the healthcare worker who has just carried out a hand hygiene procedure will see the flashing green LED light, including other healthcare workers, patients, and visitors. When the healthcare worker enters the proximity field of a HyGreen bed monitor, a data signal for the respective patient is sent to the database with a time stamp and the unique identifier of the badge. If a healthcare worker approaches a patient bed without performing an appropriate hand hygiene procedure, the badge will vibrate to remind the healthcare worker to leave the patient area and perform hand hygiene. In order to monitor and evaluate compliance, MCH personnel reviewed the data reports generated by the database (The HyGreen system uses low-power wireless chip technology from NXP Semiconductors to capture and transmit data). To evaluate the efficacy of the HyGreen EHHS system, the infection control department conducted a study to determine the impact of the system on hand hygiene adherence rates among healthcare workers and HCAI occurrence in the paediatric inpatient oncology unit. The study was conducted from September 1, 2010 through March 28, 2011. During the study period, 79 healthcare workers participated – representing 25,554 hand wash sensor interactions and 12,789 bed monitor interactions (hand wash sensor interactions are approximately twice that of bed monitor interactions because they reflect MCH’s ‘wash-in, wash out’ policy). The results of the study showed 100% correlation between badge and monitors and 100% correlation between the badge and hand wash stations. The mean daily compliance to hand hygiene among physicians and nurses was similar at 94%, respectively, while the mean overall compliance among all healthcare workers was 92% (range: 75% to 100%). All data were accurately transmitted to the database; the system detected all attempts by healthcare workers to approach a monitor or bed without conducting prior hand hygiene and appropriately reminded the respective persons to do so. Hand hygiene observations increased from <50/month to >5,000/month and overall adherence in the unit was maintained consistently over 92% across all shifts. The MCH oncology unit has been monitoring HCAIs since 2008. Compared with the respective fourth quarters of 2008 and 2009, the overall number of infections during the fourth quarter of 2010 (i.e. the time during which the system was instituted) was significantly lower. Continuing the comparison, the number of HCAIs in the first quarter of 2011 was significantly lower than the respective quarter for 2008, 2009, and 2010. During the study period, when the only change in infection control practices in the oncology unit was the introduction of the HyGreen EHHS, there was an overall 89% reduction in the HCAI rate. Furthermore, Lennox Archibald reported that the estimated cost saving during the study period was significant. By lowering the number of infections from 4.5 per quarter to 0.5, using the average infection cost of $13,973,17 MCH saved $111,784. He concluded that electronic systems, with the ability to both monitor adherence and remind HCWs to perform hand hygiene when indicated, have an important role to play in efforts to reduce HCAIs.