Automating measurement of hand hygiene compliance - The next big question for Australian hospitals

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Until Australia’s national rate of hand hygiene compliance reaches 100 per cent, Australian hand hygiene experts must diligently review current approaches to hand hygiene promotion, education and monitoring, writes Professor Cathryn Murphy. In this article, Cathryn reviews international experience with automated measurement of hand hygiene activity and considers opportunities and risks associated with Australia adopting similar systems.

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Since 2009, Australian hospitals have directly observed staff compliance with national hand hygiene recommendations¹.Depending on hospital size and type, each month a specially trained hand hygiene observer selects a convenient time and assumes a position where he or she can watch and record the activity and associated hand hygiene practice of their peers.Australia’s national rate of hand hygiene compliance has improved from 63.5 per cent to its current 76.4 per cent.² Less than 100 per cent compliance places patients at risk by providing opportunities for harmful microbes to contaminate the patient and their environment. Australian hand hygiene experts must diligently review our current approaches to hand hygiene promotion, education and monitoring.
Internationally, researchers have reported a variety of technologies used as alternatives to direct observation of hand hygiene.^3-7 These include systems employing non radio-frequency measurement devices, pressure-sensitive mats located at sinks, various recording devices and real time video monitoring. Hospitals employing these systems have almost all reported lower rates of hand hygiene when monitoring is done automatically compared to those rates reported when direct observation has been used in the same setting. This suggests that concerns regarding the validity, reliability and impartiality of directly observed hand hygiene compliance may be legitimate. Perhaps it also should provoke Australian health care providers and consumers to ask “is Australia’s reported hand hygiene compliance rate accurate or grossly over inflated?".
Professor Elaine Larson from New York’s Columbia University argues that “direct observation is not sustainable and should be replaced with more automated monitoring methods”. A world leader in hand hygiene, Larson recognises the importance of providing immediate feedback to individuals  and groups or are distracted. Debate continues regarding the most accurate and appropriate automated system for hand hygiene monitoring; however, most experts agree with Larson that direct observation of hand hygiene is no longer the best option.
Healthcare workers frequently resist change, especially change involving new technologies. Opponents often cite patient and staff privacy concerns as barriers to introducing technologies. This is particularly applicable to those innovations which produce recorded data. US clinicians have expressed serious privacy  concerns about the use of video observation for hand hygiene monitoring.¹⁰ Supporters argue  that careful placement of cameras can limit vision to areas such as sinks and hand hygiene product dispensers only.¹¹ The current balanced viewpoint is that clear evidence of efficacy should exist before any infection control measure that potentially jeopardises patient privacy is introduced.^{8, 10} Further issues for consideration include necessary protections to ensure access to recordings is limited, assurances that storage is secured and that reproduction or broadcasting is impossible. It appears that no researchers have addressed the question of action to be taken if a patient or family member requests access to hand hygiene footage related to their own or their loved one’s care.A patient developing a healthcare associated infection could potentially use recordings in legal proceedings against an organisation or its staff.
There are many advantages to automated hand hygiene monitoring systems. They are less resource intensive than direct observation. They eliminate bias. They rapidly provide large sets of data with the potential to further inform our understanding of healthcare worker hand hygiene behaviour. Conversely, they eliminate one opportunity for infection control and prevention staff to interact  directly with staff at grassroots level. They are often incapable of providing necessary detail about hand hygiene technique and preceding activity. They are expensive to install. Importantly, for hospitals to continue to compare their results with other like institutions it is critical that data is collected and reported consistently in all settings. Data collected through direct observation cannot be compared to data collected through automated systems. Direct comparison of data collected by automated systems is only possible if the same automated system is used.
Ideally, Australia will adopt automated systems of hand hygiene observation. Such systems will unburden infection control teams and provide accurate, reliable data.This data is essential to help better understand the complex issue of healthcare worker hand hygiene behaviour. Ideally, Australia will adopt automated systems of hand hygiene observation. Such systems will unburden infection control teams and provide accurate, reliable data. This data is essential to help better understand the complex issue of healthcare worker hand hygiene behaviour. It also has the potential to reduce transmission of infections in hospitals and will improve the safety of Australian health consumers. At 75 per cent Australia’s current hand hygiene compliance rate compels us to pursue better systems of monitoring. We must do so thoughtfully in a manner that safeguards patient and healthcare worker privacy.
Cathryn Murphy
PhD Executive
Director of Infection Control Plus Pty Ltd
As Executive Director of Infection Control Plus Pty Ltd, Cathryn Murphy PhD provides independent consulting services to a range of clinical, public policy and commercial clients throughout the world. In more than 25 years working in Infection Control and Prevention Cath’s career has covered senior positions within the clinical, government, non-government and professional associations within Australia and internationally.
For more than twenty years Cath helped shape infection control domestically as an Executive member and then President of both her state and national Infection Control Associations. She was a foundation member of the Asia Pacific Society of infection Control (APSIC) and an invited member of the World Health Organisation’s Expert Technical Infection Control Group. Since 2004 she has been a senior partner in Infection Control Plus.
References
1. Grayson ML, Russo PL, Cruickshank M, et al. Outcomes from the first 2 years of the Australian National Hand Hygiene Initiative. The Medical journal of Australia. Nov 21 011;195(10):615-619.
2. National Health Performance Authority. My hospitals. 2013; http://www.myhospitals.gov.au/. Accessed 17th March, 2013.
3. Boyce JM. Update on hand hygiene. American Journal of Infection Control 2013;41(5, Supplement):S94-S96.
4. Sahud AG, Bhanot N, Narasimhan S, Malka ES. Feasibility and effectiveness of an electronic hand hygiene feedback device targeted to improve rates of hand hygiene. Journal of  Hospital Infection. 2012;82(4):271-273.
5. Morgan DJ, Pineles L, Shardell M, et al. Automated hand hygiene count devices may better measure compliance than human observation. American Journal of Infection Control. 2012;40(10):955-959.
6. Stewardson AM, Pittet DMDMS. Commentary: Quicker, Easier, and Cheaper? The Promise of Automated Hand Hygiene Monitoring • Infection Control and Hospital Epidemiology. 2011;32(10):1029-1031.
7. Macedo Rde C, Jacob EM, Silva VP, et al. Positive deviance: using a nurse call system to evaluate hand hygiene practices. American Journal of Infection Control. Dec 2012;40(10):946-950.
8. Larson E. Monitoring hand hygiene: Meaningless, harmful, or helpful? American Journal of Infection Control. 2013;41(5, Supplement):S42-S45.
9. Armellino D, Hussain E, Schilling ME, et al. Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. Jan 1 2012;54(1):1-7.
10. Palmore TN, Henderson DK. Big brother is washing...Video surveillance for hand hygiene adherence, through the lenses of efficacy and privacy.Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. Jan 1 2012;54(1):8-9.
11. Armellino D, Trivedi M, Law I, et al. Replicating changes in hand hygiene in a surgical intensive care unit with remote video auditing and feedback.American Journal of Infection Control. (0).