Cleaning your hands is recognized as one of the best ways to keep patients safe and prevent the spread of infections. But what’s the best way to actually measure hand hygiene rates?
For years, hospitals have sent auditors from unit to unit to monitor how often staff members are cleaning their hands. Now, a new study is trying to show that using technology to measure hand hygiene rates can provide more accurate results.
“In-person audits can actually overestimate hand hygiene rates by three to five times. Electronic monitoring, on the other hand, provides more accurate, real-time measurement of hand hygiene in a specific clinical area, which helps staff improve their rates more quickly,” says Dr. Jerome Leis, medical director, Infection Prevention and Control at Sunnybrook Health Sciences Centre.
Sunnybrook is leading a five-hospital improvement study that aims to detect a reduction in healthcare-associated infections by improving hand hygiene compliance (a measure of how often staff use alcohol-based hand sanitizer to clean their hands when moving between rooms or delivering patient care).
To do this, electronically monitored, or e-monitored, hand hygiene pumps have been installed on 18 inpatient units in Greater Toronto Area hospitals. That number will soon expand to 25, and depending on what the results show, e-monitored pumps could become the new standard of practice in Ontario.
How e-monitoring works
E-monitored hand hygiene pumps are equipped with a sensor that counts hand hygiene events. That number is compared to a pre-determined number of hand hygiene opportunities, giving each unit a compliance rate measured by percent.
“To come up with that number, we collaborated with the manufacturer of the pumps and sent them information about each unit’s level of acuity, model of care, patient census and type of patients,” says Dr. Leis. The presence of visitors on the unit was also taken into account when determining the number of hand hygiene opportunities.
One of the biggest surprises was realizing just how many hand hygiene opportunities actually exist. “In a two month period alone, one of our units had 170,000 hand hygiene opportunities,” says Dr. Leis. He adds that the system is accurate and has been validated in different care settings worldwide.
The limitations of observational audits
Hand hygiene compliance rates have plateaued at around the 85-90% range across most hospitals in Ontario. While those numbers seem high, multiple covert studies have shown that actual compliance is less than 50%.
The reason for such a large discrepancy? “People change their behaviour when they know they’re being watched, which is something known as the Hawthorne Effect,” says Dr. Leis.
Under the current observational, in-person auditing system, units only receive feedback on their hand hygiene rates every three months. E-monitored systems allow participating units to get weekly feedback on their performance. Units will also be able to track their improvement using technology that provides accurate measurement of hand hygiene compliance.
According to Dr. Leis, while many healthcare providers think they have good hand hygiene compliance, you actually need to clean your hands between eight and 20 times per hour (assuming a four-patient assignment) to have perfect hand hygiene compliance. Over a single eight-hour shift, this is an average of 120 hand hygiene events.
“Many staff members tell me they are cleaning their hands, and I believe them. But the question is whether they are cleaning enough – if you’re not cleaning your hands more than 1-2 times per hour while caring for multiple patients, your compliance is likely suboptimal,” says Dr. Leis.
A higher number of hand hygiene opportunities, combined with a more accurate measurement system, means hand hygiene compliance rates recorded by e-monitored pumps will be much lower than the numbers we’re used to seeing, at least initially.
The first e-monitored hand hygiene pumps were installed on an inpatient unit at Sunnybrook in July 2017. The improvement in hand hygiene rates was immediate.
“On that unit, we started with a baseline hand hygiene rate of 35%. By August, the compliance rate had already gone up to 58%, surpassing our original 3-month goal of 55%, so were very pleased to see that happen so quickly,” says Dr. Leis.
E-monitoring recently rolled out to two more units at Sunnybrook, and will be implemented in two more in January 2018. Dr. Leis is hopeful it will become the norm in the near future.
“Our study involves multiple hospitals and a large number of patients, which we expect will allow us to determine the benefit of this technology in preventing hospital-acquired infections. This data will help us determine whether to install these pumps in as many units as possible.”