Hand hygiene: how can you be sure your workplace is getting it right?

Compliance is critical to patient safety, but monitoring it is far from straightforward

Monitoring nurses’ compliance is critical for prevention of healthcare-associated infections, but it’s far from straightforward

  • Read about the advantages and disadvantages of different observation methods in healthcare settings
  • Find out how digital technology is being harnessed to monitor nurses’ hand hygiene compliance
  • How the COVID-19 pandemic could change attitudes to infection prevention and control in the long-term
A person washing their hands
Picture: iStock

Healthcare-associated infections are the most common untoward incidents in healthcare.

Such infections – known as HCAIs – include respiratory, urinary, surgical site, gastrointestinal and bloodstream infections, as well as clinical sepsis and many others.

Morbidity, mortality risk and patient experience

HCAIs can pose a major patient-safety risk. All have a detrimental toll on patient morbidity, mortality, satisfaction with healthcare and act as a drain on NHS resources.

Meanwhile, the overuse of antimicrobial drugs, such as antibiotics, to treat such infections is aiding the development of ‘antimicrobial resistance’ (AMR) – a term that refers to bacterial, viral, fungal and parasitic drug resistance.

Antimicrobials used to treat infections become ineffective, and infections persist in the body, increasing the risk of them spreading to others.

Why hand hygiene matters and striving for best practice in healthcare

Regular, timely, hand hygiene to break the infection chain is crucial, not to mention inexpensive compared to many other precautions.

Healthcare premises are heavily contaminated with pathogens, which are easily transmitted to vulnerable patients through hand contact if not been removed with alcohol-based hand hygiene products, or by thorough hand-washing and drying.

So, what is the best way to ensure best hand hygiene practice is being carried out among nurses and other healthcare staff?

Hand hygiene audits have become an accepted part of quality assurance in healthcare but ensuring the results genuinely reflect healthcare workers’ adherence to hand hygiene is challenging.

Prevalence of healthcare-acquired infections

Sign on the floor in a hospital reminding people to use alcohol hand gel
Picture: Charles Milligan

Infection is a major safety risk in hospital.

Between 5-10% patients on general wards develop healthcare-associated infections (HCAIs), with rates as high as 30% in some intensive care units.

Respiratory infections are the most common, accounting for 23% of all those reported.

Next come urinary infections (17%), surgical site infections (16%), clinical sepsis (11%), gastrointestinal (9%) and bloodstream infections (7%).

HCAIs are estimated to cost the NHS £1 billion annually, representing 1% of all healthcare expenditure.

Sources: NICE 2016, Review on antimicrobial resistance, 2016

Pros and cons of direct observation

Direct observation of healthcare staff is considered the gold standard for hand hygiene monitoring.

This method can detect hand hygiene opportunities as they arise in the sequence of care and see how often they are acted on, giving an assessment of performance.

Observers can identify problems with adherence to hand hygiene protocols, intervene to improve practice in ‘real time’, and identify individuals’ training needs.

But direct observation has limitations, delivering only a snapshot of hand hygiene practice by staff at a moment in time and unable to capture events obscured by bedside curtains or in treatment rooms.

The need for rapid documentation means that, inevitably, some hand hygiene opportunities and episodes are missed by observers.

Observer bias and lack of standardisation

An additional shortcoming is the likelihood of observer bias. In an ideal world, staff observers would receive standardised training with regular updates and checks to ensure quality control. In reality, training may be a one-off, hasty event, and data collection may drift over time.

The lack of standardisation renders the comparison of data generated by different people meaningless and makes it impossible to identify trends over time.

‘Covert observation may cause mistrust and resentment among staff’

Furthermore, correction of sub-optimal practice carried out in real-time may be unwelcome, as staff may resent negative feedback delivered in front of patients and colleagues.

How overt observation changes behaviour of healthcare staff

In a bid for transparency, the World Health Organization recommends discreet but overt observation methods, with staff informed when the observation is about to begin.

Awareness of scrutiny prompts behaviour change, a phenomenon known as the Hawthorne effect.

Hand hygiene frequency increases by anything from 7% to 65% when the observation is overt, according to a recent literature review by UK researchers. In this review, the increase in hand hygiene was most marked in critical care units but varied between wards in the same organisation.

However, the Hawthorne effect can reduce the validity of audit, misleading managers and service users.

It may give false security and, by constantly generating and delivering data that do not genuinely represent performance, it has ethical implications.

Covert observation avoids this Hawthorne effect but shares the same practical disadvantages as overt methods.

Staff will become aware that it is taking place without permission, which may cause mistrust and resentment.

Approaches to measuring alcohol gel use

A person using alcohol hand gel
Picture: Jim Varney

Many NHS organisations routinely document the consumption levels of alcohol hand rub, but spillage and wastage mean this is not the best guide to how much hand hygiene is taking place.

There have even been cases of hospital visitors stealing hand rub to drink.

The most straightforward approach, asking healthcare workers how often they perform hand hygiene, is the most unreliable method of all. Awareness of the premium placed on hand hygiene is likely to inflate self-reported levels.

Automated hand hygiene monitoring

A newer approach might be for organisations to deploy electronic and automated hand hygiene monitoring systems, which vary in cost and sophistication.

Basic models count the number of hand hygiene events taking place in an area.

‘Combining imaginative reconfiguration of the healthcare environment with electronic monitoring systems would reduce risks of hand contamination’

More sophisticated systems measure alcohol hand hygiene product uptake, calculate staff adherence to hand hygiene, deliver feedback and, in some cases, offer a visual or auditory cue when hand hygiene would be appropriate.

Data are generated continuously for all staff, overcoming the Hawthorne effect, and eliminating sampling and observer bias to provide a comprehensive picture of performance.

More data are gathered than with manual methods, so the system is more efficient and, because the findings are standardised, makes it possible to identify trends over time.

Electronic monitoring – the power of digital observation

Interest in continuous hand hygiene monitoring is growing.

A major NHS trust in London has recently evaluated the use of a hand hygiene compliance monitoring system made by Tork.

The system monitors hand hygiene dispenser use and movement of health staff. It can document hand hygiene frequency for individuals, entire clinical teams, wards and organisations.

Data for individual health care workers are anonymised.

Feedback appears in real time on a wall-mounted screen and is sent to the healthcare worker’s smartphone.

‘The experience of the pandemic may mean patients and the public are more likely to accept that infection prevention should be the collective responsibility of everyone’

Staff on the 31-bed medical ward hosting the evaluation welcomed the opportunity to use the system and were positive about hand hygiene and the new technology.

The electronic system was much more efficient than a corresponding manual audit.

Over a 20-hour period of simultaneous monitoring, the electronic system documented 2,623 hand hygiene opportunities on the ward.

Manual audit recorded just 294 hand hygiene opportunities because the observer could only see a single bay of eight patients at one time.

Infection and prevention and control teams

But electronic systems reinforce rather than replace the expertise of infection prevention teams.

By indicating dips in hand hygiene adherence, such systems identify the need for human investigation and action to resolve problems.

Measuring hand hygiene through direct observation is time-consuming, labour-intensive, and not scientifically robust.

Combining imaginative reconfiguration of the healthcare environment with electronic monitoring systems would reduce the risks of hand contamination.

Infection prevention teams could then spend their time more creatively in training, analysing data, exploring why changes in hand hygiene adherence have occurred and improving practice.

The impact of COVID-19 on hand hygiene monitoring

Signs at the Whittington Hospital in London designed to persuade public and staff to take responsibility for hand hygiene
Signs at the Whittington Hospital in London designed to persuade public and staff to take responsibility for hand hygiene Picture: Alamy

As an essential component of all infection-prevention programmes, hand hygiene is likely to receive renewed emphasis in light of the COVID-19 pandemic.

It could pave the way for greater investment in infection prevention.

Campaigns to promote hand hygiene can be effective but are usually targeted at healthcare workers.

However, the experience of the pandemic, may mean patients and the public are more likely to accept that infection prevention should be the collective responsibility of everyone on healthcare premises.

In future, it is likely everybody entering healthcare settings will be expected to undertake hand hygiene on entering, leaving, and moving to patient areas.

Good signage, combined with visual or auditory alerts, could promote hand hygiene at entrances to hospitals, clinics and wards, or the use of hand hygiene systems.

One-way systems and zones introduced during the pandemic in many healthcare settings could prompt hand hygiene when crossing boundaries into higher-risk locations.

Automatic door-opening devices and other non-touch surfaces could be introduced in a further effort to reduce hand contamination.