Hand Hygiene

Self-Assessment in COVID-19: Know Your Baseline, Measure Your Progress

By Paul Alper

This column originally appeared in the August 2020 issue of Healthcare Hygiene magazine.

This month, we provide a facility-based self-assessment tool, informed by the latest guidance from CMS and the CDC. This is designed for infection prevention and clinical leaders to get a solid baseline of where they stand today and then conduct routine self-assessment updates to measure improvement. Accordingly, a scoring guide is provided.

A Hand Hygiene Self-Assessment Tool

Note that point values for each response are included as part of the questions, but these should be removed when using the tool with the units.

Select the response that best describes your facility and its routine practices related to hand hygiene:

1. Our facility has a comprehensive hand hygiene program that creates accountability for the following program elements 1.1 - 1.7:

1.1 Hand hygiene products and appropriate dispensers are available at all points of care with appropriate measures in place to ensure prompt replenishment when they are empty

a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)

1.2 Individual (personal carry) size hand sanitizers are provided for all staff and volunteers for use when hand hygiene is indicated but access to dispensers is not convenient

a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)

1.3 New and on-going staff are trained and educated routinely on performance expectations including the indications for hand hygiene along with proper technique and when to use soap vs. sanitizer

a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)

1.4 Staff are required demonstrate that they can do a proper 20 second hand wash + hand sanitization at training times

a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)

1.5 Patients, family members and visitors are educated on hand hygiene behavior expectations

a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)

1.6 Tools for such training are reviewed and updated at least annually

a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)

1.7 We use and update facility wide reminders of hand hygiene behavior expectations

a. Strongly Agree (10)
b. Agree (7)
c. Neither Agree nor Disagree (0)
d. Disagree (0)
e. Strongly Disagree (0)

2. Our units/departments are individually responsible for hand hygiene improvement and they are held accountable for meeting monthly/quarterly compliance growth targets.

a. Strongly Agree (10)
b. Agree (7)
c. Neither Agree nor Disagree (0)
d. Disagree (0)
e. Strongly Disagree (0)

3. Our units/departments leaders’ annual performance appraisal/bonus is tied in some way to meeting our hand hygiene improvement goals.

a. Strongly Agree (10)
b. Agree (7)
c. Neither Agree nor Disagree (0)
d. Disagree (0)
e. Strongly Disagree (0)

4. Our units/departments routinely identify obstacles and barriers to hand hygiene performance and then put in place action plans with the goal of eliminating them.

a. Strongly Agree (10)
b. Agree (7)
c. Neither Agree nor Disagree (0)
d. Disagree (0)
e. Strongly Disagree (0)

5. Our units/departments identify the obstacles and barriers to hand hygiene compliance using:

a. Direct Observation (10)
b. Group Discussion (7)
c. Other (1)

6. We measure hand hygiene compliance and give feedback on performance.

a. Daily or Weekly (10)
b. Monthly (7)
c. Quarterly (5)
d. Twice a year (1)
e. Once a year (0)

7. We celebrate when goals are achieved and identify what we will do differently when they are not.

a. Strongly Agree (10)
b. Agree (7)
c. Neither Agree nor Disagree (0)
d. Disagree (0)
e. Strongly Disagree (0)

8. When our goals are met, we then set a new, higher goal.

a. Strongly Agree (10)
b. Agree (7)
c. Neither Agree nor Disagree (0)
d. Disagree (0)
e. Strongly Disagree (0)

9. Psychological safety is the way we work in our facility – anyone can speak up when there is risk of doing harm without fear of retribution or other negative consequences.

a. Strongly Agree (10)
b. Agree (7)
c. Neither Agree nor Disagree (0)
d. Disagree (0)
e. Strongly Disagree (0)

10. Our organization’s senior leaders are responsible for modeling proper hand hygiene behavior and they are authentically engaged in our hand hygiene improvement efforts.

a. Strongly Agree (10)
b. Agree (7)
c. Neither Agree nor Disagree (0)
d. Disagree (0)
e. Strongly Disagree (0)

Add 10 points if you stop a healthcare worker as a matter of standard practice when conducting direct observation and they fail to perform hand hygiene, reminding them that they need to do so before providing care.
Scoring: Max Score including 10 Point Bonus = 170 Points
• 150-170: Outstanding. Stay diligent and focused
• 130-150: Excellent, but still room for improvement
• 100-130: Good, but should make getting over 110 a high priority for the next period
• Below 100: Poor, and in need of coaching and feedback. It’s an opportunity to take your safety culture and HH practices up a notch

We are still a long way from getting hand hygiene right; this is just one framework that requires no investment other than time and that might make sense to consider in some adapted form. Feel free to modify and adapt in any way that aligns well with your culture and organization.

Paul Alper, BA, led the launch of PURELL®, invented the first electronic hand hygiene monitoring system proven to reduce infections while improving behavior and eliminating costs and is now the VP Patient Safety Innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC.

Performance Measurement, Feedback and Teamwork: Keeping the Foot on the Gas

This column originally appeared in the July 2020 issue of Healthcare Hygiene magazine.

By Paul Alper

While chatting with a few of my infection preventionist friends over the past few weeks, it was interesting that they all observed a similar pattern of behavior -- in March and April, hand hygiene compliance rates (whether measured with direct observation OR electronic monitoring) shot up into the 90s, if not hitting 100 percent routinely, and then, as dealing with COVID-19 became the new abnormal, rates have backed off a bit, albeit still much higher than pre-COVID-19 levels. But still, a drop off.

While not surprising, it begs the question, if COVID-19 doesn’t make us get hand hygiene right, what will? Maybe this is a good time to think again about the measurement and feedback process and ensure we are including space for barrier and obstacle identification at the unit level, and using such insight to drive unit-specific (team-based) behavior change. Times like these call for constant vigilance and diligence.

Unless you are using an electronic hand hygiene monitoring system, which it is estimated that less than 5 percent of the U.S. market is doing, that means using direct observation for a dual purpose -- first, for performance measurement and second, for barrier and obstacle identification. Here is a quick checklist for each:

A. Direct Observation for Performance Measurement based on the WHO 5 Moments for Hand Hygiene
1. Observation of hand hygiene behavior is accomplished using the WHO Data Collection Tool1 or a modified version as such was used in the Steed et al “HOW2 Study”2. Johns Hopkins Medicine also has created a Hopkins Medicine Monitoring Tool3.
a. Complete the top part of the header before commencing observation (except end time and duration)
b. A session should last no more than 20 minutes.
c. Record HHOs in the appropriate column and fill in the square corresponding to the indications for hand hygiene detected.
d. Record hand hygiene events or hand hygiene actions (HHEs) observed or missed for each indication.
i. Consider immediate feedback to any healthcare workers who have “missed” in order to recover and eliminate the practice of seeing misses and allowing care to proceed with unclean hands.
e. Glove use may be recorded only when a hand hygiene event is missed while the healthcare worker is wearing gloves.
f. At the end of the session, record end time and duration.
2. Compile the Data. Data from each Observation Form should be entered into a master data base such as Excel. Total hand hygiene events for a period are aggregated and divided by the total number of HHOs to determine the Compliance Rate for specific periods of time (week, month, quarter, year) for specific units as well as aggregated for the entire organization.
3. Create Graphs and Reports. Performance graphs and appropriate reports should be created and then shared with unit and organization leadership.
4. Give Front Line Staff Feedback against unit specific goals. Front line workers should be provided with performance feedback as immediate as possible after report creation.
5. Celebrate successes when goals are met; stay the course when results fall short.
6. Persistently continue the cycle.

B. Direct Observation for Barrier and Obstacle Identification (consider using or adapting the Joint Commission’s Hand Hygiene Targeted Solutions Tool [TST]4 for data capture and overall approach)
1. Deploy direct observers to collect a total of 30 missed hand hygiene opportunities per unit.
2. After missed opportunities are noted, the direct observers should approach staff, provide verbal feedback and ask what was the reason for the miss?
i. Capture and cluster the reasons to see which are the major obstacles for that particular unit.
3. Conduct mini focus groups with each unit to review the data, highlight primary obstacles and barriers observed on that unit and agree on unit-based changes (= action plan) to eliminate the obstacles and thus increase compliance. Keep it positive and opportunity embracing - not negative or punitive sounding.
a. It is important to set unit specific (again, team based) improvement goals.
4. Measure performance post the mini focus groups and Action Plan implementation using A above, or your electronic system if you have one in place, to track progress against goals and give feedback to the units.
5. Celebrate successes when goals are met; stay the course when results fall short.
6. Persistently continue the cycle.

This approach has been shown to drive statistically significant improvement. Kelly et al, 20165 achieved aggregate performance increase on four test units of 23.5 percent within six months. A three- to four-unit, four- to six-month pilot will help you see if it works for your organization.

While data from direct observation may be overstated, if collected consistently, it should provide a sound tool for measuring baseline plus real improvement along with the impact of initiatives designed to drive sustainable growth in hand hygiene behavior. Let’s be sure we keep our foot firmly on the gas to retain early COVID-driven gains in all aspects of infection prevention and patient safety.

Paul Alper, BA, led the launch of PURELL®, invented the first electronic hand hygiene monitoring system proven to reduce infections while improving behavior and eliminating costs and is now the VP Patient Safety Innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC.

References:
1. WHO Data Collection Tool
2. Steed C, et al. (2011). Hospital hand hygiene opportunities: Where and when (HOW2)? The HOW2 Benchmark Study. Am J Infect Control. 39(1), 19–26. doi:10.1016/j.ajic.2010.10.007
3. Hopkins Medicine Monitoring Tool
4. Joint Commission TST for Hand Hygiene
5. Kelly W, et al. (2016) Use of the Targeted Solutions Tool and Electronic Monitoring to Improve Hand
Hygiene Compliance. Paper presented at the 2016 SHEA meeting.

Hand Hygiene During the Covid-19 Pandemic: A Practical Guide for Long-Term Care Facilities

By Paul Alper

This column originally appeared in the June 2020 issue of Healthcare Hygiene magazine.

The pandemic has been disproportionately hard on the nation’s long-term care facilities (LTCFs.
Here are some big numbers; according to a recent New York Times1 article, while 11 percent of all coronavirus cases in the U.S. have occurred in long term care facilities, a staggering 35 percent of all U.S. coronavirus deaths are nursing home residents or workers.

Populations in LTCFs are at a high risk of being infected by, and dying from, the coronavirus, according to the Centers for Disease Control and Prevention.2 COVID-19 is known to be particularly lethal to older adults with underlying health conditions, and can spread more easily through congregate facilities, where workers move from room to room in a confined environment, according to the same New York Times article.

At least 28,100 residents and workers have died from the coronavirus at LTCFs in the U.S., according to the May 11 New York Times database. The virus so far has infected more than 153,000 individuals at 7,700 facilities.

While reducing the risk of infection requires a multi-modal approach, hand hygiene remains one the most important elements of an infection control program. This month’s column is devoted providing a framework for a best practice hand hygiene framework for LTCFs. Prior columns offered quite a bit of advice, and I recommend you refer to the November 2019 column that provided a checklist to drive higher hand hygiene compliance, as well as:
• December 2019 for a self-assessment tool (change the word “unit” to “facility” to make it work at the facility, versus Unit level)
• February 2020 for information on the importance of gloves as part of a total hand hygiene program
• March 2020 for a robust approach to the WHO 5 Moments of hand hygiene
• April 2020 for information on the importance of moisturizers
• May 2020 for advice for hand hygiene at home for healthcare professionals

Following is a simple checklist to use as a framework for a best-practice program that incorporates the CMS, CDC, JC and WHO guidance on hand hygiene.
1. Make hand hygiene a corporate priority. C-suite engagement, psychological safety (anyone-workers, volunteers and patients- can and do speak up when HH is missed) and role modeling by leaders organizational norms become integral to the facility’s safety culture.

2. Identify barriers and obstacles to hand hygiene with front line staff as well as leadership and establish action plans to remove them.

3. Train staff and volunteers on the WHO 5 moments for hand hygiene. How to properly sanitize hands with an alcohol based hand sanitizer and how to wash hands with soap and water.

a. Include training on resident and family engagement along with your C. difficile hand hygiene protocol.

b. Train residents and families on hand hygiene basics and explain your program and commitment to excellence to them.

4. Measure (audit) hand hygiene performance against goals, give feedback routinely and celebrate successes. See my March 2020 column for more on this.

5. Product Access - Dispensers etc.:

a. Place automatic (touch-free) dispensers with alcohol based hand sanitizer on stands at all entrances with appropriate instructional signage.

b. Place wall mounted dispensers with alcohol based hand sanitizer outside and inside (as close to bedside as is reasonable) all resident rooms, in elevator lobbies (can also use stands here if more convenient) and any other area where care is going to take place or hand hygiene is indicated.

i. Optional - provide alcohol-based hand sanitizing wipes at bedside for resident and family use as appropriate while considering the self-care and cognitive capabilities of each individual resident.

c. Place wall mounted soap dispensers adjacent to all sinks throughout the facility. Use pump bottles if wall space is not available.

d. Place wall mounted dispensers with alcohol based sanitizer at all nurses’ stations. If wall space is not convenient, consider table top pump bottles (at least 12 ounces or larger).

e. Provide 2-4 ounce size personal carry size bottles of alcohol based hand sanitizer (or small packets, such as 20 count, of hand sanitizer wipes) to all caregivers with the training that hand hygiene should take place using wall mounted dispensers when convenient, but when not, to use the personal carry size.

Hand hygiene consistency, diligence and vigilance are “musts” in today’s pandemic environment and adherence to the above Check List should provide an effective road map to achieving them.

References:
1. New York Times
2. Centers for Disease Control and Prevention
3. Based on CDC Guidance
4. CDC CoVID-19 Guidance
5. CDC CoVID-19 Nursing Home Checklist
6. WHO Guidance
7. WHO CoVID-19 Guidance

Let me know what you think and please send me your specific hand hygiene challenges, frustrations and nagging problems – I’ll share ideas that might be of interest in this monthly column paul@next-levelstrategies.com. Connect with me on LinkedIn.

Paul Alper, BA, led the launch of PURELL®, invented the first electronic hand hygiene monitoring system proven to reduce infections while improving behavior and eliminating costs and is now the VP Patient Safety Innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC.

Hand Hygiene at Home During the Covid-19 Pandemic: A Practical Guide for Healthcare Professionals

By Paul Alper

Editor's note: This column originally appeared in the May 2020 issue of Healthcare Hygiene magazine.

Now that we are in the middle of this pandemic suddenly thrust upon us, making hand hygiene -- both on and off the job -- a matter of utmost importance when it comes to the health and safety of ourselves and family, it seems like a practical guide to hand hygiene at home might make sense and be helpful.

What does the CDC and WHO Say About Hand Hygiene in the Context of Covid-19?

Here is the CDC Hand Hygiene Guidance: “Wash your hands often with soap and water for at least 20 seconds especially after you have been in a public place, or after blowing your nose, coughing or sneezing.
• If soap and water are not readily available, use a hand sanitizer that contains at least 60 percent alcohol.
o Cover all surfaces of your hands and rub them together until they feel dry.
• Avoid touching your eyes, nose, and mouth with unwashed hands.”
Here are the WHO Recommendations for Hand Hygiene in the Context of Covid-19:
• Wash your hands with soap and running water when hands are visibly dirty.
• If your hands are not visibly dirty, frequently clean them by using alcohol based handrub [sanitizer] or soap and water.

Protect yourself and others from getting sick. Wash your hands:
• After coughing or sneezing
• When caring for someone who is sick
• Before, during and after you prepare food
• Before eating
• After toilet use
• When hands are visibly dirty
• After handling animals or animal waste

Most public health experts would add the following to the list of “when to clean hands” in the age of this pandemic and social distancing:
• After leaving the grocery, drug store or any retail environment
• When returning home from any outing
• After handling any delivered items such as boxes, take out deliveries or groceries

Always keep in mind the importance of a full 20-second wash with brisk scrubbing or rubbing of wrists, thumbs, all sides of and in between the fingers, fingertips, palms and backs of the hands. Proper technique does matter. This applies both to soap and water washing as well as sanitizing with an alcohol-based sanitizer.

Product Selection
With “rogue” products now being offered for sale, here are some facts about how soaps and sanitizers are regulated by the FDA and what you should look for when buying them:
• Alcohol based hand sanitizers should only be used if they have a minimum of 60 percent alcohol. Many healthcare professionals are migrating to at least 70 percent or higher for both professional and home use.
o Avoid non-alcohol-based sanitizers, as they are not as effective on pathogenic microorganisms and they are not recommended by the CDC or WHO.
• While under normal circumstances sanitizers must be made in FDA registered plants and have an NDC (National Drug Code) assigned and printed on the label, the FDA is allowing a liquid sanitizer with a final concentration of 80 percent v/v ethyl alcohol or 75 percent v/v isopropyl alcohol to be made, waiving most of the normal manufacturing requirements but with a set of specific formula and manufacturing guidelines.
 That’s why you see a number of distilleries now making hand sanitizer. Note that these products are liquids as opposed to the normal gels or foams on the market so don’t be surprised when it comes out runny if you buy one of these.
• Soaps can be plain or antibacterial and the latter are also regulated by the FDA. Note that the CDC and WHO do not give a specific recommendation for using plain or antibacterial soap. The key is to clean all parts of the hands for 20 seconds and not miss any surface from the wrists to the fingertips.
o The CDC web site states: “handwashing mechanically removes pathogens.”
 Antibacterial soaps must also be made in an FDA-registered plant and contain an NDC number on the label.
• Antibacterial soaps and sanitizers must be tested for safety, efficacy against 31 microorganisms including MRSA and stability. This is also known as GRASE or Generally Regarded as Safe and Effective.
o While the CDC states on its web site that: “ABHR [alcohol-based handrubs] formulations containing 80 percent ethanol or 75 percent isopropanol, both of which are in the range of alcohol concentrations recommended by CDC, inactivate SARS-CoV-2,” the FDA does NOT allow for virucidal efficacy claims on soaps or sanitizers sold to hospitals or consumers. This is an inconsistency that often causes confusion. We would like to see alignment between CDC and WHO guidance and FDA regulatory requirements.

Are there any special considerations with regard to skin health in the light of the COVID-19 pandemic?
There has been a dramatic increase in clinician hand hygiene due to the Pandemic. It is more important than ever to protect the skin’s natural barrier by applying a moisturizer routinely during the day after soap-and-water handwashing and especially before leaving the facility.

Let me know what you think and please send me your specific hand hygiene challenges, frustrations and nagging problems – I’ll share ideas that might be of interest in this monthly column paul@next-levelstrategies.com. Connect with me on LinkedIn.

Paul Alper, BA, led the launch of PURELL®, invented the first electronic hand hygiene monitoring system proven to reduce infections while improving behavior and eliminating costs and is now the VP Patient Safety Innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC.

Moisturizers: An Essential Component of Proper Hand Hygiene and Skin Health

By Paul Alper

This column originally appeared in the April 2020 issue of Healthcare Hygiene magazine.

Just as important as proper cleaning and sanitizing of hands is proper moisturizer use. We will address when and why to use moisturizers as an essential element of your overall hand hygiene and skin health strategy and ultimately, part of your facility’s infection prevention and control approach. For purposes of simplicity, we will use the term “moisturizer” here to mean collectively lotions, creams, moisturizers and other similar names.

The CDC states that to maintain skin health:1
• “Lotions and creams [aka moisturizers] can prevent and decrease skin dryness that happens from cleaning your hands
• “Use only hand lotions approved by your healthcare facility because they won’t interfere with hand sanitizing products”

Why is overall skin health vital to a successful hand hygiene program? Contact dermatitis is extremely common among nurses, ranging in prevalence surveys from 25 percent to 55 percent. Actually, as many as 85 percent relate a history of having skin problems.2,3 High-frequency hand hygiene, especially in today’s pandemic environment, can lead to chronic contact dermatitis among healthcare workers, no matter how mild the soaps and sanitizers they use are.
Hand hygiene products, along with household detergents and cleaners, can damage the skin by causing denaturation of stratum corneum proteins, changes in intercellular lipids, decreased corneocyte cohesion and decreased stratum corneum water-binding capacity.4

Among these, the main concern is the depletion of the lipid barrier that may result from contact with lipid-emulsifying detergents and lipid-dissolving alcohols.4 Frequent handwashing can lead to depletion of surface lipids with resulting deeper action of detergents into the superficial skin layers. During dry seasons and in individuals whose skin is typically dry, this lipid depletion occurs more quickly.4

When the natural barrier of the skin breaks down drying and even cracks in the skin can occur which may allow bacteria an entry point and increases risk of infection. Applying a moisturizer can prevent those effects along with the itching, redness, flaking, and pain that can accompany skin breakdown. It also helps to avoid chronic damage and changes in the normal skin flora.5

Using a moisturizer will help promote and maintain healthy skin, reduce transepidermal water loss (TEWL), increase skin hydration, and improve overall skin tolerance. Moisturizing hands with the right product reduces microbial shedding from the skin and will protect people from picking up viruses and reduce the likelihood of transmission.6

Selecting a product that is non-sensitizing, non-irritating, and compatible with gloves, sanitizers and CHG based products if they are used in the facility (for example for skin decolonization) is essential. It should be an emollient rich product that is free of alcohol, artificial fragrances, and dyes. Staff should use only the moisturizers provided by the facility to ensure glove and CHG compatibility. Personal products should only be used after a shift ends and at home -- never during the work day.

Healthcare workers should use a moisturizer:
• At the start of a shift after washing hands with soap and water and drying them thoroughly
• After washing and drying hands throughout the day to keep the skin well hydrated
• At the end of the shift, again after washing and drying hands

There has been a dramatic increase in clinician hand hygiene due to the COVID-19 pandemic. It is more important than ever to protect the skin’s natural barrier. Cracks and fissures can allow easy access to microorganisms. Clinicians should be applying a moisturizer routinely during the day after soap-and-water handwashing to protect from the risk of infection, discomfort, and potentially chronic skin issues.7

Paul Alper, BA, led the launch of PURELL®, invented the first electronic hand hygiene monitoring system proven to reduce infections while improving behavior and eliminating costs and is now the VP Patient Safety Innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC.

References:
1. https://www.cdc.gov/handhygiene/providers/index.html
2. Larson E, et al. Prevalence and correlates of skin damage on the hands of nurses. Heart & Lung. 1997;26:404-412.
3. Lampel HP, et al. Prevalence of hand dermatitis in inpatient nurses at a U.S. hospital. Dermatitis. 2007;18:140-142.
4. Skin Reactions Related to Hand Hygiene. WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care., U.S. National Library of Medicine, Jan. 1,1970, www.ncbi.nlm.nih.gov/books/NBK144008/.
5. Diamond F and Popescu S. Hand Hygiene and Infection Control: Skin Care Supports Patient Care. Infection Control Today. May 19, 2008. www.infectioncontroltoday.com/hand-hygiene/hand-hygiene-and-infection-control-skin-care-supports-patient-care.
6. Gale R. Don't Just Wash Your Hands to Prevent Coronavirus. Moisturize Them, Too. The Washington Post. March 6, 2020, www.washingtonpost.com/lifestyle/wellness/hand-washing-coronavirus-moisturizer-dry/2020/03/06/ede43874-5fcb-11ea-b014-4fafa866bb81_story.html.
7. Gajanan M. COVID-19: How to Avoid Dry Skin After Washing Your Hands. Time. March 11, 2020, time.com/5800275/covid-19-wash-hands-dry-skin-tips/.

Direct Observation: A Robust Approach for the WHO 5 Moments

By Paul Alper

Editor's note: This column originally appeared in the March 2020 issue of Healthcare Hygiene magazine.

I was recently asked by the head of infection prevention at a community hospital how to design a robust hand hygiene direct observation program. Their objective was to get the most accurate compliance data possible, as they got ready for an upcoming Joint Commission visit.

I thought there might be others who would like to know how to accomplish this given that direct observation is still the most widespread method used for hand hygiene performance measurement. This is in spite of the fact that direct observation has been shown to have many shortcomings, including lack of accuracy due to the Hawthorne Effect,1 lack of inter-rate reliability and bias on the part of the observers.

An Evidence-Based Approach
Drawing on the methodology of a landmark study2 by Steed, et al. that, for the first time, scientifically determined the number of hand hygiene opportunities (HHOs) in various settings using a disciplined approach to direct observation-based on the WHO 5 Moments, I have created a “best practices for direct observation” checklist.

Here is a summary and checklist for how facilities could implement the approach used in the study and acquire compliance data that is as accurate and reliable as we likely can expect data from direct observation to be.

Checklist for a Robust Direct Observation Program
Note that apps to capture and compile direct observation data for smart phones and tablets are available from your App Store or provider. We will address the manual process in Steps 3, 4 and 5 below but simply follow app instructions if you are using one of them instead.

1. Train observers. This should consist of the following three steps:
a. Total familiarization with The WHO 5 Moments Poster.
b. Complete familiarization with the WHO Hand Hygiene Training Films and Slides Accompanying the Training Films.
c. Practice doing observations with feedback from a lead observer or infection prevention manager.

2. Assess inter-rater reliability. Conduct this routinely to ensure consistency of data collection.
a. In its simplest form, observers could conduct direct observations together and compare results. A lead observer could also accompany observers to reinforce consistent results.

3. Conduct Direct Observation. Observation of hand hygiene behavior is accomplished using the WHO Data Collection Tool or a modified version as such was the case in the HOW2 Study. Johns Hopkins Medicine also has created a Hopkins Medicine Monitoring Tool.
a. Complete the top part of the header before commencing observation (except end time and duration)
b. A session should last no more than 20 minutes.
c. Record HHOs in the appropriate column and fill in the square corresponding to the indications for hand hygiene detected.
d. Record hand hygiene events or HHEs (or hand hygiene actions) observed or missed for each indication.
e. Glove use may be recorded only when a hand hygiene event is missed while the healthcare worker is wearing gloves.
f. At the end of the session, record end time and duration.

4. Compile the data. Data from each Observation Form should be entered into a master data base such as Excel. Total hand hygiene events for a period are aggregated and divided by the total number of HHOs to determine the Compliance Rate for specific periods of time (week, month, quarter, year) for specific units as well as aggregated for the entire organization.

5. Create graphs and reports. Performance graphs and appropriate reports should be created and then shared with unit and organization leadership.

6. Give front-line staff feedback. Front line workers should be provided with performance feedback as immediate as possible after report creation.

7. Create performance improvement action plans. Units and departments should be responsible and accountable for action plans to remove unit specific barriers and obstacles to proper hand hygiene behavior.
While data from direct observation may be overstated, if collected consistently, it should provide a sound tool for measuring real improvement and the impact of initiatives designed to drive sustainable growth in hand hygiene behavior.
Thanks to the HOW2 authors for the creative research that inspired this column.

References:
1. Srigley JA, Furness CD, Baker GR and Gardam M. (2014). Quantification of the Hawthorne Effect in Hand Hygiene Compliance Monitoring Using an Electronic Monitoring System: A Retrospective Cohort Study. BMJ Qual Saf. 23, 974–80.
2. Steed C, Kelly JW, Blackhurst D, Boeker S, Diller T, Alper P and Larson E. (2011). Hospital hand hygiene opportunities: Where and when (HOW2)?
The HOW2 Benchmark Study. Am J Infect Control. 39(1), 19–26. doi:10.1016/j.ajic.2010.10.007

Paul Alper, BA, led the launch of PURELL®, invented the first electronic hand hygiene monitoring system proven to reduce infections while improving behavior and eliminating costs and is now the VP Patient Safety Innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC. He can be reached for questions or comments at paul@next-levelstrategies.com.

Gloves: An Essential Component of Proper Hand Hygiene

By Paul Alper

This column originally appeared in the February 2020 issue of Healthcare Hygiene magazine.

Just as important as proper cleaning and sanitizing of hands, is proper glove use. While there are a variety of gloves used in healthcare, we will address the proper use of non-sterile, single use (disposable) exam gloves and their role in protection of the patient as well as the healthcare provider.

Complete Hand Hygiene Education
Hand hygiene education must include instruction on proper glove use, not just when and how to perform hand washing or sanitizing. Wearing gloves does not replace proper hand hygiene practices but should be used as indicated according to accepted guidelines.
Using an alcohol based hand sanitizer before donning gloves is essential to ensure no contamination of other gloves in the box as they are removed from the original box or storage container.

Guidelines and Recommendations – When to Wear/When to Remove or Change
The WHO (World Health Organization), CDC (Centers for Disease Control) and OSHA (Occupational Safety & Health Administration) all recommend glove use during a procedure or task when contact is likely:
• With blood or bodily fluids
• With mucous membranes
• With non-intact skin
• With other potentially infectious materials
• When handling or touching contaminated equipment or surfaces

Knowing when to remove or change gloves is just as important as when to wear them. Gloves protect the healthcare worker as well as the patient but they also pose a risk if not removed when contaminated. Timing of and technique for donning and doffing of gloves is essential to eliminating the risk of HAI transmission.

he CDC, WHO and OSHA all have recommendations regarding removing and changing of gloves:

The CDC recommendations include:
• Remove gloves after caring for a patient
• Do not wear the same pair of gloves for the care of more than one patient (this also means never washing them between patients)
• Change gloves when moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs
• Carefully remove gloves to prevent hand contamination

The WHO recommends that gloves should be removed:
• As soon as gloves are damaged or suspected of being damaged
• When contact with blood, other body fluids, non-intact skin and mucous membranes has occurred and ended
• When there is an indication for handwashing or sanitizing

OSHA’s recommendations for when to change gloves include:
• As soon as practical when contaminated, torn or punctured
• Changing gloves between patients regardless of condition

Common Usage Errors
Common errors with proper glove use include prolonged use, using when not indicated and the presence of jewelry.
Prolonged use and over use of gloves also poses a risk. Using gloves for an extended period of time can result in the transmission of disease causing microorganisms due to a possible failure to identify an indication for hand hygiene and then performing it.
When there is no potential for exposure to blood or body fluids, mucous membranes, non-intact skin or contaminated environmental surfaces, gloves should not be worn.

Jewelry should never be worn during patient care, even if wearing gloves. Nor should it be worn during proper hand hygiene.

Skin Health and Gloving
Occupational dermatitis is a common issue among healthcare workers. High frequency hand hygiene can potentially remove protective lipids from the skin, making it more prone to drying and irritation. This increases the risk of colonization with bacteria and can potentially result in the spread of disease causing microorganisms.

Proper and frequent use of a latex and nitrile compatible lotion, especially at the start and end of the shift, along with the use of gloves manufactured with therapeutic additives such as oatmeal and aloe are two ways to reduce the risk as well as help soothe and recover hands that have become dry, chapped and irritated.

Importance of Glove Size
Selecting proper sized gloves is essential to achieving proper protection. In general, gloves should cover the entire hand and wrist and feel snug without being too tight and allow full movement of the hand and fingers.

Like most things in life, one size does not fit all. Common disposable gloves range in size from extra small to extra-large. Be sure to follow the manufacturer’s guidance on how to properly fit each healthcare worker on your staff.

Steps to Take Now
• Review your facility’s hand hygiene training and education and be sure that proper use of gloves is adequately covered including demonstrations for proper donning and doffing technique
• Use direct observation not only for measuring hand hygiene compliance but proper glove use adherence, taking the time for interventional feedback when errors occur.
o Make the unit leadership responsible for proper glove use by all front line workers
• Foster a psychologically safe patient safety culture so that healthcare workers feel safe talking to anyone at any level about their proper use of gloves as well as hand hygiene

Proper glove use is often taken for granted, but attention to all of the details surrounding proper use – when, why and how to use them is essential for the prevention of HAIs and the overall safety of everyone one in your facility’s community.

Paul Alper, BA, led the launch of PURELL®, invented the first electronic hand hygiene monitoring system proven to reduce infections while improving behavior and eliminating costs and is now the VP Patient Safety Innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC.

Electronic Monitoring Systems: Essential Considerations

By Paul Alper

This column originally appeared in the January 2020 issue of Healthcare Hygiene magazine.

In my October column I said the following about electronic monitoring: “While a nascent category that is still in the early adopter phase, the migration from human direct observation or secret shoppers, to validated, automated, systems that constantly measure healthcare worker performance is here to stay. The scientific evidence is becoming clear that the future “gold standard” will be the combination of direct observation (DO) as a “coaching and obstacle identification tool” with electronic monitoring as the “measurement tool.”

I thought it might make sense to follow that column up with a checklist of essential consideration” should you and your organization decide to consider potential adoption in the near future and need a framework to create an RFP.

While there are systems with many more features to consider, these are the ones that are most important to think about.

For some, you will have to choose between options based on what would best suit your organization’s culture and your budget. Of course, whatever system you consider, there should be published outcomes evidence in support of adoption:

1. Numerator capture (how many HH events actually occurred). The system must aggregate BOTH soap and sanitizer hand hygiene events into an accurate numerator with a minimum 98 percent validated capture.

2. Denominator calculation (how many HH events should have occurred). You must choose: does the system base its HH rate on a) IN and OUT HH or b) Or the WHO 5 Moments for HH? In either case, you will want to see evidence on how the denominator is calculated and how it has been validated.

3. Reporting level. You will have to choose – does the system base its reporting on a) group/unit/department level hand hygiene rates or b) Individual healthcare worker HH rates?

4. Report/dashboard access. The system should provide intuitive, unambiguous reports and dashboards both via direct system access (such as by logging on to the system) and also via “push” or automatically generated reports via email.

5. C. diff room reporting. The system should provide the ability to see both soap- and sanitizer-event trending so that real time feedback can be given to staff as to whether or not they are complying with the typical C. diff protocol - the switch to soap and water hand hygiene from alcohol-based hand sanitizer which does not kill C. diff spores.

6. Type of Infrastructure. You must choose: a) is the system exclusively dedicated to hand hygiene compliance measurement (aka a stand-alone infrastructure) or b) one that works like an application (APP) with a new or previously installed real-time locating system (RTLS) infrastructure. RTLS systems will typically support multiple APPs such as nurse call, workflow assessment, people and equipment tracking etc. If you do go with option b, you will want to explore the level of hand HH expertise on the part of the RTLS/APP provider to be sure you’re comfortable that they have the requisite capability needed to support your organization’s enterprise wide adoption.

7. Behavior change support. Successful outcomes (for example sustainable compliance improvement, culture change and reduced infections) are going to be very much dependent on how you approach changing your culture from one that relies on Direct Observation for measurement (with its typical overstatement of real compliance rates by up to 300 percent) to one that relies on virtually real time data that will likely reveal a 30 percent to 40 percent compliance range when you first implement it.

You will want to verify that the system under consideration a) provides an evidence based behavior change framework, b) supports “psychological safety” – the ability for anyone to speak up in a professional and appropriate manner to colleagues (peers, superiors and subordinates) when hand hygiene does not occur when it should have and c) uses a positive and pro-active approach to dealing with data denial – this is the attitude by some on staff who will take the position that “my behavior is fine, it’s the data/system that’s inaccurate.”

8. Reminders to do HH at the point of care. You will have to decide if this a “must have,” “nice to have,” or “doesn’t matter to us” feature. This is accomplished, for example and depending on the system, by lights on the badge or dispenser, badge vibrations or by a voice reminder at the dispenser.

While I think there will be some exciting next-generation technologies introduced over the next couple of years that will leapfrog the current generation in terms of new and important features, accuracy, reliability, evidence in support of adoption and lower cost, I hope this proves helpful. Happy New Year!

Let me know what you think and please send me your specific hand hygiene challenges, frustrations and nagging problems – I’ll share ideas that might be of interest in this monthly column paul@next-levelstrategies.com. Connect with me on LinkedIn.

Paul Alper, BA, led the launch of PURELL®, invented the first electronic hand hygiene monitoring system proven to reduce infections while improving behavior and eliminating costs and is now the vice president of patient safety Innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC.

A Self-Assessment Tool: How Do Your Units Compare?

By Paul Alper

This column originally appeared in the December 2019 issue of Healthcare Hygiene magazine.

In last month’s column, (see page 34 in the November 2019 issue), I presented an evidence-based checklist for how to drive improvement with what you have; that is, regardless of how you are training, educating, measuring and giving feedback, the checklist provides a framework for driving improvement that has been shown to work when implemented with solid discipline.

This month, we will take that a step forward and provide a self-assessment tool for unit managers to use for the purpose of getting a solid baseline of where they stand today and then conducting routine self-assessment updates to measure improvement. Also included is a scoring guide so that infection preventionists (IPs) can compare their units and use the scoring to identify those units that need the most immediate coaching and feedback.

A Hand Hygiene Self-Assessment Tool

Note that point values for each response are included as part of the questions, but these should be removed when using as the tool with the units. Select the response that best describes your unit and its routine practices. Be honest and frank:

  1. Our unit is responsible for hand hygiene improvement and we are held accountable for meeting monthly/quarterly compliance growth targets.
  2. Strongly agree (10)
  3. Agree (7)
  4. Neither agree nor disagree (0)
  5. Disagree (0)
  6. Strongly disagree (0)

 

  1. Our unit leadership’s annual performance appraisal/bonus is tied in some way to meeting our hand hygiene improvement goals.
  2. Strongly A\agree (10)
  3. Agree (7)
  4. Neither agree nor disagree (0)
  5. Disagree (0)
  6. Strongly disagree (0)

 

  1. Our unit routinely identifies obstacles and barriers to hand hygiene performance and then puts in place action plans with the goal of eliminating them.
  2. Strongly agree (10)
  3. Agree (7)
  4. Neither agree nor disagree (0)
  5. Disagree (0)
  6. Strongly disagree (0)

 

  1. Our unit identifies the obstacles and barriers to hand hygiene compliance using:
  2. Direct observation (10)
  3. Group discussion (7)
  4. Other (1)

 

  1. We measure hand hygiene compliance and give feedback on performance:
  2. Daily or weekly (10)
  3. Monthly (7)
  4. Quarterly (5)
  5. Twice a year (1)
  6. Once a year (0)

 

  1. We celebrate when goals are achieved and identify what we will do differently when they are not.
  2. Strongly agree (10)
  3. Agree (7)
  4. Neither agree nor disagree (0)
  5. Disagree (0)
  6. Strongly disagree (0)

 

  1. When our goals are met, we then set new, higher goal.
  2. Strongly agree (10)
  3. Agree (7)
  4. Neither agree nor disagree (0)
  5. Disagree (0)
  6. Strongly disagree (0)

 

  1. Psychological safety is the way we work; anyone can speak up when there is risk of doing harm (such as not doing proper hand hygiene when it is indicated) without fear of retribution or other negative consequences.
  2. Strongly agree (10)
  3. Agree (7)
  4. Neither agree nor disagree (0)
  5. Disagree (0)
  6. Strongly disagree (0)

 

  1. Our organization’s senior leaders are responsible for modeling proper hand hygiene behavior and they are authentically engaged in our hand hygiene improvement efforts.
  2. Strongly agree (10)
  3. Agree (7)
  4. Neither agree nor disagree (0)
  5. Disagree (0)
  6. Strongly disagree (0)

Add 10 points if you stop a healthcare worker as a matter of standard practice when doing Direct Observation and they fail to perform hand hygiene, reminding them that they need to do so before providing care.

Scoring:

  • 100: Outstanding. Stay diligent and focused!
  • 80-99: Excellent, but still room for improvement.
  • 60-79: Good, but should make getting more than 80 a high priority for the next period.
  • Below 60: Poor. An opportunity to take your safety culture and hand hygiene practices up a notch. In need of coaching and feedback.

We are a long way from “getting hand hygiene right,” and this is just one framework that requires no investment other than time and that might make sense to consider in some adapted form. Feel free to modify and adapt in any way that aligns well with your culture and organization. A three- to four-unit pilot will help you see if it works for you.

Let me know what you think and please send me your specific hand hygiene challenges, frustrations and nagging problems – I’ll share any ideas that might be of interest and help in this monthly column paul@next-levelstrategies.com. Connect with me on LinkedIn.

Paul Alper, BA, led the launch of PURELL®, invented the first electronic hand hygiene monitoring system proven to reduce infections while improving behavior and eliminating costs and is now the vice president of patient safety innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC.

A Checklist to Drive Higher Compliance: Using Actionable Feedback to Drive Meaningful Change

By Paul Alper

This column originally appeared in the November 2019 issue of Healthcare Hygiene magazine.

I’m often asked a simple question by healthcare organizations: “We are not ready to change products or put in an electronic monitoring system yet – but we do want to use evidence-based practices to drive improvement with what we have in place today.”

Giving that some thought, I’ve put together a checklist based on an actionable feedback model that should help you make some changes in the way your organization thinks about hand hygiene compliance, its safety culture and the social fabric of your community. The checklist is based on insights and inspiration gained from some interesting studies1-3 basic PDSA cycles thinking and my 35-plus years of working in many aspects of hand hygiene and patient safety innovation.  Here’s the list:

  1. Make hand hygiene compliance a unit/ward/department responsibility. Hand hygiene compliance improvement should be a defined responsibility at the Unit level with the manager responsible and accountable for meeting growth targets.1 A great way to help ensure results is to tie this directly to the performance appraisal process.
  2. Identify the unit-specific barriers and obstacles to hand hygiene behavior plus action plans to remove Them. Each unit becomes responsible for identifying its unique barriers and obstacles to hand hygiene compliance and putting in place specific action plans to remove them.1 This might be best accomplished using Direct Observation to capture those unit specific behaviors that need to be modified.2
  3. Establish unit-specific improvement goals. Each unit is responsible for establishing its own realistic improvement goals monthly, which should be achievable assuming the action plans are carried out as assigned.1 The end game is that the barriers and obstacles identified can be continuously reduced or eliminated.
  4. Measure performance and give routine feedback consistently. Use the most robust approach to measurement available to your organization within the resource constraints (time, people, money) and provide performance feedback on a consistent basis (weekly to start, migrating to monthly, for example). Be sure to measure the behavior standard that you train staff on – in/out, WHO 5 Moments, CDC or a variant you’ve chosen for your organization. If the approach is electronic monitoring, ensure its accuracy has been validated. If you’re using direct observation, be sure you control for inter-rater reliability.

Note: A quick thought about the Secret Shopper concept: it seems difficult to comprehend why an organization would allow the practice of seeing potential risk (not cleaning hands) and then only marking down the missed hand hygiene event without intervening to ensure care is delivered with cleaned hands. It’s a troubling concept.

  1. Celebrate successes and then set a new, higher goal. When goals are not met, have the same barrier/obstacle/action plan conversation.

 

  1. Make psychological safety a cultural norm. Anyone at any level within the organization can remind anyone else regardless of their level or status when hand hygiene is missed in a professional, “out of patient view” way, without the fear of reprisal.
  2. Make leaders responsible for modeling and authentic engagement. C-suite leaders must know about, support and model the behaviors expected across the entire staff community.

In one of the studies on which the checklist is based on, Childers, et al. used this basic framework at Memorial Sloan-Kettering Cancer Center, and a baseline rate of hand hygiene of 60-70 percent increased to 97 percent as measured with direct observation.1

Kelly, et al. also used a similar approach with electronic monitoring for measurement at the Greenville Memorial Hospital and achieved a 25 percent increase in hand hygiene compliance with a 43 percent reduction in MRSA infections.3

Steed, et al. also used a variant at the same organization combining modified use of the Joint Commission’s Targeted Solutions Tool with electronic monitoring for measurement and achieved aggregate performance increase on four test units of 23.5 percent within six months that was statistically significant.2

To be clear, we are a long way from “getting hand hygiene right” – this is just one framework that requires no investment other than time that might make sense to consider in some adapted embodiment that aligns well with your culture and organization. A three- to four-unit pilot will help you see if it works for you.

Let me know what you think and please send me your specific hand hygiene challenges, frustrations and nagging problems – I’ll share any ideas that might be of interest and help in this monthly column paul@next-levelstrategies.com.

Paul Alper, BA, led the launch of PURELL®, invented the first electronic hand hygiene monitoring system proven to reduce infections while improving behavior and eliminating costs, and is now the vice president of patient safety innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC.

References:

  1. Son C, Chuck T, et al. Practically speaking: Rethinking hand hygiene improvement programs in health care settings. Am J Infect Control. 39(9), 716–724. 2011.
  2. Kelly W, Blackhurst D, et al. Use of the Targeted Solutions Tool and Electronic Monitoring to Improve Hand Hygiene Compliance. Paper Presented at the 2016 SHEA Conference.
  3. Kelly W, Blackhurst D, McAtee W and Steed C. Electronic Hand Hygiene Monitoring as a Tool for Reducing Healthcare-Associated Methicillin-Resistant Staphylococcus aureus Infection. Am J Infect Control. 44(8), 956-957. 2016.

Hand Hygiene: The Problem We Only Think We Solved

By Paul Alper, BA

Editor's note: This column originally appeared in the October 2019 issue of Healthcare Hygiene magazine.

All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as self-evident. – Arthur Schopenhauer, philosopher

What would Ignaz Semmelweis think if he were able to observe the state of healthcare hand hygiene today? The Austrian physician who, while working at Vienna General Hospital’s first obstetrical clinic, first proved the link between hand hygiene (disinfection with a chlorinated lime solution) and the reduction of infections (child bed fever) in 1847, might wonder why so much, yet so little, progress has taken place in the 172 years since his discovery. In spite of the innovations highlighted below, global hand hygiene compliance rates remain no greater than 50 percent, and patients are still getting infections from pathogens such as methicillin-resistant Staphylococcus aureus (MRSA), methicillin-susceptible Staphylococcus aureus (MSSA), vancomycin-resistant Enterococcus (VRE), associated with transmission by unclean hands.

Semmelweis certainly experienced the first two stages of truth as Schopenhauer observed them. Many contemporary doctors were offended at the notion they should wash their hands, and not only ridiculed him, but also shunned him. Acceptance of the benefits of hand hygiene as “self-evident” took the work of Louis Pasteur and Joseph Lister and occurred years after Semmelweis’s death.

Since that seminal work more than 100 years ago, there have been only three major, disruptive changes in healthcare hand hygiene.

1. “Bag in a Box” (BIB) soap technology in the 1970s:This invention introduced sealed, sanitary soap cartridge refills with a proprietary valve that only fit compatible, proprietary dispensers. The inner workings of the dispenser were engineered to accept the BIB refill. Think “razor” (the dispenser) and “disposable razor blade” (bag in a box refill) business model. Pushing or pulling the dispensing bar activated a valve that allowed the soap to flow from the dispenser. This sanitary approach eliminated the use of gallons that could fill any bulk reservoir soap dispenser by simply pouring in the liquid.

Sani Fresh® invented the original BIB with a “pull” style dispenser, and eventually Kimberly-Clark purchased that company. GOJO accelerated this trend by entering into the market with its “push” style dispenser. Of note is that the bulk soap sold in the range of $3 to $5 per gallon, but with BIB refills costing about $2 to $3 per 800 ml refill, the price of soap went up to more than $10 to $12 per gallon. Mocked as ridiculously expensive by purchasing departments, the Sani Fresh team pushed its sanitary benefits with clinical decision makers and today, sealed soap and sanitizer refills are the standard of care in healthcare, with the use of bulk, pour and fill style dispensers virtually non-existent.

2. Alcohol Hand Sanitizer: “We’ll never use that stuff; we wash with soap and water,” was the typical response from infection preventionists in the late 1980s and 1990s when introduced to alcohol-based hand sanitizers (or hand disinfectants and handrubs, as they were also known largely in Europe). The idea of no longer using soap and water was ridiculed by infection preventionists! It was a violation of everything they took to be self-evident when it came to soap and water handwashing.

The widespread use of alcohol for hand disinfecting began in the 1970s in Europe but didn’t come into serious use in U.S. hospitals and healthcare facilities until the late 1980s when PURELL® and other brands were first introduced into institutional use. Once healthcare workers realized how much faster and efficient it was to clean hands with an alcohol hand sanitizer, objections went away, and institutional use accelerated. Use of alcohol hand sanitizer further increased with the retail launch of PURELL and the first TV ads that ran in 1997, which led to its use becoming a societal norm and part of the popular culture. The CDC’s updated Healthcare Hand Hygiene Guideline in 2002 cemented alcohol based hand sanitizers as the absolute standard of care and the primary way healthcare workers sanitized their hands, the exception being when hands are visibly soiled or recently exposed to bodily fluids or spores at which point they need to be washed with soap and water.

3. Electronic monitoring for hand hygiene compliance. Hand hygiene compliance, whether a worker properly performs hand hygiene when indicated, has typically been measured by direct observers attempting to watch healthcare workers. This practice mimics that of “secret shoppers,” whereby the observers try to remain unknown to the workers and attempt to discreetly record whether they do hand hygiene when indicated. This system is inherently flawed however, because if a secret shopper observes the lack of hand hygiene and does not intervene, they are enabling risk of harm to the patient.

The problem is that healthcare workers—no matter how discreet the secret shopper is—know when they are being observed and behave differently. This phenomenon is known as the Hawthorne Effect: people behave differently when they know they are being watched. Further compounding the problem is that direct observation typically only captures less than 1 percent of all hand hygiene opportunities, which is not a statistically valid sample. The result is that compliance rates are dramatically overstated – typically by up to 300 percent based on studies,1 and this means that compliance measured as 90 percent with direct observation may in reality be only 30 percent.

A number of electronic systems to measure compliance were launched during the 2010s. These systems eliminated many of the shortcomings of direct observation, such as the Hawthorne Effect and small sample size, since electronics can capture nearly 100 percent of hand hygiene events at all times. Die-hard defenders of direct observation certainly ridicule and oppose the technology’s adoption, citing direct observation as the “gold standard” (which it was until this more accurate, reliable and effective technology category came along). While a nascent category that is still in the early adopter phase, the migration from human direct observation or secret shoppers to validated, automated, systems that constantly measure healthcare worker performance is here to stay. The scientific evidence is becoming clear that the future “gold standard” will be the combination of direct observation as a “coaching and obstacle identification tool” with electronic monitoring as the measurement tool. 2-3 Further, overstated rates, such as those proven by Srigley et al, enable a false sense of complacency that unacceptably puts patients at risk. Given the ability to mitigate the risk of patient harm with this new technology, it is likely that it will overcome the ridicule and opposition phases and move towards widespread acceptance.

And, the market is moving, too. For instance, a growing number of progressive health systems have gone with full commercial implementation (the Greenville Health System, now Prisma Health, in South Carolina and the Atlantic Health System in New Jersey among them). Further, most of the group purchasing organizations that have added the category of e-monitoring and studies have demonstrated its clinical and economic benefits.4

Whether e-monitoring will become the standard of care will depend on whether a system that is simple, affordable and overcomes some of the inherent implementation and cultural barriers in currently available systems is developed – and there is no reason why that shouldn’t happen.

The Future of Hand Hygiene
Despite these innovations, healthcare hand hygiene still has a lot of room for improvement, given that compliance is only about half of what it should be. For instance, healthcare workers who must clean their hands 40 to 50 times a shift should be confident that the products they use actually improve skin health, but products they find drying remain a barrier.

Additionally, healthcare hand hygiene should be multidisciplinary, drawing from fields such as human factors engineering, behavioral science, and data science to propel the next innovations.

An inventory of the prospective attributes of that best in class, next generation hand hygiene approach might look like this:
• Hand hygiene products (soaps, sanitizers and lotions) that are “skin friendly,” with the lowest possible risk of healthcare worker intolerance
• Dispensers that are not only able to measure compliance, but indicate product levels and any performance issues, ensuring product is always available and empty dispensers are a thing of the past
• Training and educational tools based on sound behavioral science that drive high levels of sustainable performance improvement with requisite culture change
• Affordable, validated methodology for measuring compliance accurately and reliably, with feedback approaches that foster psychological safety (everyone feels safe reminding anyone to do hand hygiene when an opportunity is missed) and the development of a just safety culture
• Predictive analytics that forecast hot spots (risk of low compliance and/or hospital acquired infection transmission) before they occur
• And what roles will artificial intelligence, learning systems and the Internet of Things play? Probably significant ones.

One would hope that we are about to put all the learning and capabilities to work and that by the 200th anniversary of Semmelweis’s seminal research, proper hand hygiene will be a habit for every healthcare worker around the world.

Whatever the next disruptive innovation brings, it is time to get hand hygiene right. We live in an age of value-based healthcare, and variability of performance should not and cannot be tolerated. It will take early adopter pioneers, willing to accept the ridicule, knowing that what they are doing represents the truth for themselves and those for which they care.

Paul Alper led the launch of GOJO’s PROVON® and PURELL® brands in the late 1980s and 1990s. He invented and was highly involved in the clinical research behind the first hand-hygiene electronic monitoring system. He is now the vice president of patient safety Innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC.

References:
1. Srigley JA, Furness CD, Baker GR and Gardam M. Quantification of the Hawthorne
Effect in Hand Hygiene Compliance Monitoring Using an Electronic Monitoring System: a
Retrospective Cohort Study. BMJ Qual Saf. 23, 974-80. 2014.
2. Boyce JM. Electronic Monitoring in Combination with Direct Observation as a Means
to Significantly Improve Hand Hygiene Compliance. Am J Infect Control. 45(5), 528-535. 2017.
3. Kelly JW, Blackhurst D, McAtee W and Steed C. Electronic Hand Hygiene Monitoring
as a Tool for Reducing Health Care Associated Methicillin-Resistant Staphylococcus aureus Infection. Am J Infect Control. 44(8), 956-957. 2016.
4. Kelly W, Blackhurst D, Steed C, Boeker S and McAtee W. Use of the Targeted Solutions Tool and Electronic Monitoring to Improve Hand Hygiene Compliance. Paper presented at the 2016 SHEA annual meeting.