Handwashing Compliance: Performance Improvement Through Monitoring

Handwashing monitoring is an important aspect of healthcare and public health, as it helps prevent the spread of healthcare-associated infections (HAIs) and reduces their transmission. HAIs are a significant challenge to patient safety and can increase patients' length of stay, costs, mortality, and morbidity.

Direct observation by trained auditors is considered the gold standard for monitoring hand hygiene compliance in healthcare settings. However, this method has limitations, including time and resource consumption, insufficient sample size, lack of standardized practices, and the Hawthorne effect, which refers to changes in behaviour being aware of being observed.

To overcome these limitations, there has been a growing interest in developing and implementing electronic hand hygiene monitoring systems as an alternative or supplementary approach. These systems can provide continuous and objective monitoring, regular feedback to staff, and real-time reminders to improve hand hygiene compliance. They can also help address issues such as social desirability bias and reactivity associated with self-reported data.

While electronic monitoring systems offer several advantages, they also have limitations and challenges. These include accuracy, data integration, privacy and confidentiality concerns, potential risks, usability issues, and associated costs. Additionally, standardized metrics to measure system performance across different electronic hand hygiene monitoring systems are currently lacking.

Overall, handwashing monitoring, whether through direct observation or electronic systems, plays a crucial role in improving hand hygiene compliance and reducing the incidence of HAIs, ultimately contributing to improved patient safety and health outcomes.

Hand hygiene monitoring can be done via direct or indirect methods. Direct methods include direct observation, patient assessment or self-reporting by healthcare workers (HCWs). Indirect methods include monitoring consumption of products, such as soap or hand sanitiser, and automated monitoring of the use of sinks and hand sanitiser dispensers

Hand hygiene monitoring is an important indicator of performance improvement in healthcare settings. It serves multiple functions, including system monitoring, incentive for performance improvement, outbreak investigation, staffing management, and infrastructure design.

Hand hygiene monitoring can be done via direct or indirect methods. Direct methods include direct observation, patient assessment, or self-reporting by healthcare workers (HCWs). Indirect methods include monitoring the consumption of products, such as soap or hand sanitiser, and automated monitoring of the use of sinks and hand sanitiser dispensers.

Direct observation by trained auditors is considered the gold standard for monitoring hand hygiene compliance. It involves the detection of hand hygiene compliance by a validated observer and is currently the most effective method available. Direct observation allows for the detection of all hand hygiene opportunities and actions and the assessment of the number of times and appropriate timing of hand hygiene actions. However, it can be time-consuming and resource-intensive, and may be subject to observer bias.

Indirect methods, on the other hand, provide a more cost-effective and unobtrusive approach to hand hygiene monitoring. For example, the consumption of hand hygiene products, such as soap or hand sanitiser, can be monitored to estimate the number of hand hygiene actions. Automated monitoring systems, such as electronic hand hygiene monitoring systems, can also be used to track hand hygiene compliance and quality. These systems use technologies such as radio-frequency identification (RFID), infrared, ultrasound, or Bluetooth to sense dispenser actuation and HCWs' movements.

While indirect methods offer advantages in terms of cost and unobtrusiveness, they may not capture all hand hygiene opportunities and actions. Additionally, they may not assess the appropriateness of HCWs' hand hygiene timing and quality. Therefore, a combination of direct and indirect methods may be most effective in improving hand hygiene compliance and reducing healthcare-associated infections (HAIs).

Electronic hand hygiene monitoring systems face issues of accuracy, data integration, privacy and confidentiality, usability, associated costs, and infrastructure improvements

Electronic hand hygiene monitoring systems face several issues, including:

• Accuracy: Systems come with different metrics without standardised measurement tools, and are affected by technical issues and geometric constraints.
• Data integration: Integrating data from multiple sensors and systems is challenging and can lead to issues such as sensor registration and calibration, data format inconsistencies, and difficulties in storing and retrieving compliance rate and quality records.
• Privacy and confidentiality: Privacy concerns may influence HCWs' attitudes towards these systems, and constant surveillance may violate patient privacy and raise legal issues. The continuous collection of personal data also raises data security concerns.
• Usability: Electronic hand hygiene monitoring systems may interrupt HCWs' daily workflow and require them to change their behaviour to ensure proper functioning. Issues include heavy and bulky wearable tags, limited sensing range, and the need to frequently replace batteries.
• Associated costs and infrastructure improvements: Implementing these systems can be costly, requiring equipment, installation, maintenance, and personnel expenses. Infrastructure improvements, such as dispenser replacement and network updates, may also be necessary.

Hand hygiene monitoring systems can be used to solve other hand hygiene-related issues, such as validating the efficacy of newly proposed hand hygiene techniques and monitoring participants' levels of dementia, Alzheimer's disease, and obsessive-compulsive disorder

Hand hygiene monitoring systems can be used to monitor the hand hygiene of people with dementia, Alzheimer's disease, and obsessive-compulsive disorder. These systems can also be used to validate the efficacy of newly proposed hand hygiene techniques.

The Hawthorne effect can be leveraged to stimulate hand hygiene compliance in a promotional intention

Hand hygiene is one of the most effective ways to prevent healthcare-associated infections and reduce their transmission. The Hawthorne effect

Hand hygiene monitoring systems can be used to provide educational interventions to HCWs and improve their practices

Hand hygiene monitoring systems are a useful tool to provide educational interventions to healthcare workers (HCWs) and improve their practices. These systems can be used to monitor hand hygiene compliance and quality, and provide feedback to HCWs to promote behaviour change.

Types of Hand Hygiene Monitoring Systems

Hand hygiene monitoring systems can be categorised into two main types: electronic hand hygiene compliance monitoring systems and electronic hand hygiene quality monitoring systems.

Electronic Hand Hygiene Compliance Monitoring Systems

These systems focus on monitoring HCWs' compliance with hand hygiene guidelines, such as the World Health Organization's (WHO) five moments for hand hygiene. They can be further categorised into four types:

• Application-assisted direct observation: This involves using applications or smartphones to record observations, which can be more unobtrusive and reduce the Hawthorne effect compared to manual observation.
• Camera-assisted observation: Cameras are used to capture hand hygiene moments, either with human auditors or automated analysis.
• Sensor-assisted observation: Sensors are used to record hand hygiene events, such as electronic dispensers or motion sensors.
• Real-time locating systems (RTLS): These systems track HCWs' movements and hand hygiene compliance using technologies such as radio-frequency identification (RFID), infrared, or Bluetooth.

Electronic Hand Hygiene Quality Monitoring Systems

These systems focus on monitoring the quality of hand hygiene practices, such as compliance with the WHO's six-step hand hygiene technique or surface coverage of hand hygiene products. They can use fluorescent substances and computer vision algorithms to evaluate hand hygiene quality.

Benefits of Hand Hygiene Monitoring Systems

Hand hygiene monitoring systems offer several benefits for improving HCWs' practices:

• Objective measurement: These systems provide an objective and accurate measurement of hand hygiene compliance and quality, reducing the bias associated with self-reporting or direct observation.
• Real-time feedback: HCWs can receive instant prompts and periodic summaries to remind them about missed hand hygiene opportunities and improve their hand hygiene quality.
• Behaviour change: By providing regular feedback and education, these systems can create a sustained Hawthorne effect and improve HCWs' hand hygiene habits over time.
• Infection reduction: Ultimately, improving hand hygiene compliance and quality can reduce the incidence of healthcare-associated infections (HAIs) and improve patient safety.

Challenges and Limitations

However, there are also challenges and limitations to consider when using hand hygiene monitoring systems:

• Accuracy and standardisation: The accuracy of these systems can be affected by technical issues, geometric constraints, and a lack of standardised metrics for comparing different systems.
• Data integration: Integrating data from multiple sensors and systems can be complex and raise issues of privacy and confidentiality.
• Usability and cost: The systems may require changes to HCWs' workflows and infrastructure improvements, and the associated costs of equipment, installation, and maintenance can be high.
• Potential risks: There are potential risks associated with the use of certain technologies, such as UV lamps for hand hygiene quality assessment, and the disruption of existing infrastructure during installation.

Frequently asked questions