hand hygiene, electronic monitoring

1. 20-03-19
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Andreas Voss, MD, PhD
CWZ and Radboud umc, Nijmegen, The Netherlands
Compliance with Hand Hygiene

2. 20-03-19
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Ignaz Philipp Semmelweis before and after his HH campaign
Pittet D et al, Lancet 2000; 356: 1307-1312
12/94 12/95 12/96 12/97
Alcohol-based handrubbing
Handwashing (soap + water)

3. 20-03-19
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Beware the Semmelweis’ effect of HH campaigns

4. 20-03-19
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Certainly true with regard to HCWs and Infection Control.
More MDs &
RNs
Secretary
New HCW
CEO
MD
RNs

5. 20-03-19
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Certainly true with regard to Infection Control.
Less new
HCW
Secretary
CEO
MD
RNs

6. 20-03-19
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Direct observation of HH
Goldstandard
¤ Direct observation is considered to be the reference
standard method for evaluating HH compliance, but …
² Capture only a very small fraction of HH opportunities
² Validity, including inter-rater reliability
² Hawthorne effect
² Cannot determine the quality of HH episodes
² Concerns regarding patient privacy
STILL … pivotal role of human auditors as educators (learning audits)

7. 20-03-19
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and many more ….
¤Systems include 1 or more of the following 3 components:
² dispensers for soap or ABHR
² patient zone indicators in doorways or around beds
² HCW tags (eg, badges, wrist bands, or pager cases) that communicate with
the dispensers or the patient zone indicators or both.
¤Components collect and exchange information using a combination of
technologies, including infrared, ultrasound, Wi-Fi, radio-frequency
identification (RFID), remote video monitoring, or alcohol vapor-
sensing technologies.
¤The systems differ in their capacity to issue a prompt to perform HH/
issue immediate feedback in addition to compliance reports.

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¤ Some systems require that existing dispensers be replaced
¤ Some systems or data-bases require fixed hard wiring with all
consequences (most wire-less)
¤ Dispensers are needed inside patient rooms and in patient zone
¤ Some wireless systems have the potential to interfere with
medical equipment or to overload existing wireless network – not
with RFID
¤ Monitoring tags can be heavy, bulky, not durable, battery failures,
too heavy vibrating, disturbing audio
¤ Costs (system itself and/or annual fees)
Conway et al. American Journal of Infection Control 44 (2016) e7-e12
¤ Record continuously for 24 h per day
¤ Gather rapid results without requiring the expenditure of many
hours of work to obtain a small sample of observations
¤ Electronic monitoring HH dispenser counts does not correlate
with direct human observation
¤ Promote HH compliance by direct feedback or reminders, and
“positive” Hawthorne effect
¤ Dispenser activity is not HH compliance
¤ Lack utility for determining the appropriateness of HH episodes
¤ Cannot determine the quality of HH episodes

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¤ Patient census in each unit (hour – shift - day)
¤ Patient-to-nurse ratio (consider it stable)
¤ Patient type
¤ Coverage of all “moments” (need in the room)
² just entry and exit as opportunities for HH, will include instances
when HCW do not touch the patient or his environment
Goetz T. The Mental Machine. Cover: The Feedback Loop. Wired, 19 July 2011, p. 126

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Srigley et al. Journal of Hospital Infection 89 (2015) 51e60

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Srigley et al. Journal of Hospital Infection 89 (2015) 51e60
o Insufficient evidence to recommend adoption of HHMT in general
o Limited data suggest that future research studies should prioritize use of VMS; EMSs also
merit additional testing.
o Future trials should include stronger designs, control groups, and system-independent
measures of hand hygiene.
Ward et al. Am J Infect Control 2014:42:472

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Conclusions: Limited data are currently available to recommend
adoption of specific automatic or electronically assisted hand
hygiene surveillance systems. Future studies should be
undertaken that assess the accuracy, effectiveness, and cost-
effectiveness of such systems. Given the restricted clinical and
infection prevention budgets of most facilities, cost-effectiveness
analysis of specific systems will be required before these systems
are widely adopted.
Ward et al. Am J Infect Control 2014:42:472
Hand hygiene rates were approximately threefold higher in hallways
within eyesight of an auditor

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Kwok et al. American Journal of Infection Control 44 (2016) 1475-80
Kwok et al. American Journal of Infection Control 44 (2016) 1475-80

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Conclusions:
Automation provided a unique opportunity to respond to daily
rates, but compliance will return to preintervention levels once
active intervention ceases or human auditors leave the ward,
unless clinicians are committed to change.
Still, automation is superior to human auditors for data accura-
cy, validity of daily HHOs, and prompt feedback of an aggregate
of all or some of the 5 moments.
Kwok et al. American Journal of Infection Control 44 (2016) 1475-80
Significant correlation between unit-specific improvements in electronic monitoring
compliance and reductions in MRSA infection rates

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vA substantial investment of human capital is required to fully adopt a
EMS.
vA team of champions is needed to communicate information about
the EMS, answer questions, engender confidence in the automated
data, optimize use of the data for improvement, and troubleshoot
problems.
vAdministrative and vendor support is essential to successful
implementation of a EMS.
vData reported as events per patient visit or per patient hour may be
more meaningful to HCW than the HHCI.
vFurther research is needed to validate the number of HH
opportunities (expected events) in multiple settings with different
patient populations.
E. Larson et al. Implementing An Electronic Hand Hygiene Group Monitoring System (poster)
Automated HH monitoring CWZ

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Automated HH monitoring CWZ
Weekend dip

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dirt & waste
ABHR > soap
Entrance/exit > in room
isolation rooms
POC does not change basic principles of use
but adds extra use

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¤ It is not about how accurate (it is not real compliance)
¤ We picked HH moments per patient per day
¤ HCWs picked the aim (started at 6, they picked 30 HH/pat/d)
¤ All we did is to forward the rates
¤ It is depending on team-leader (is he/she doing something
with the data)
¤ Enabled me to see if interventions led to changes
¤ Data (24/7 and heat-map) you would never see otherwise
www.ischemo.org
Thank you! Any questions?

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Automated HH monitoring CWZ