hand hygiene
By Paul Alper
Direct Observation vs . Electronic Monitoring : The Essential Evidence and Facts to Consider
Studies have shown that the combination of electronic monitoring for measurement with direct observation for coaching and intervention can lead to significant improvement in hand hygiene compliance . 3
The Leapfrog Group have guidelines and recommendations for hand hygiene compliance in acute care hospitals . Among them , The Leapfrog Group has established a leadership position by developing best practices for optimizing hospital hand hygiene ( HH ) performance and incorporating them into their evolving Hand Hygiene Standard . This Standard has five domains of performance that hospitals must meet : ●Training and Education ●Infrastructure ●Monitoring ●Feedback ●Culture
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This column will address and focus on compliance monitoring , but to be clear , getting hand hygiene right to improve patient safety and drive the best possible outcomes requires meeting the performance and practice criteria for all five domains . While we will only consider in-patient units in acute-care hospitals , similar principles and approaches as described in this column would apply to emergency departments and out-patient units .
Many infection preventionists and C-suite leaders are facing the choice of the two options for measuring compliance — direct observation or a validated electronic compliance monitoring system that can capture both hand hygiene opportunities ( HHOs ) as well as hand hygiene events ( HHEs ). Regardless of how they measure compliance , the evidence suggests 1 , 2 that a hospital use direct observation for coaching and intervention , with the goal of identifying and removing barriers and obstacles to hand hygiene .
But when it comes to accurate , reliable and cost-effective measurement , which makes more sense ? Studies have shown that the combination of electronic monitoring for measurement with direct observation for coaching and intervention can lead to significant improvement in hand hygiene compliance . 3
There are five essential factors to consider .
Direct Observation , The Hawthorne Effect
1 and Data Quality : It is well established that staff behave differently when being observed leading to overstatement of hand hygiene compliance by up to 300 percent . 4 This significant lack of accuracy and reliability can easily lead to staff and leadership complacency , putting patients at risk of avoidable harm . A validated electronic monitoring system can be capable of capturing virtually all hand hygiene opportunities and events , eliminating the risk of the Hawthorne Effect and generating data truly representative of all facility wide hand hygiene behavior 24 / 7 .
Observer Bias : For hospitals using direct
2 observation , they need to have a system for initial and recurrent training and validation of hand hygiene compliance observers which is essential to achieve inter-rater reliability . However , observers have been shown to be quite biased 5 and controlling for inter-rater reliability takes time , effort and practice . A validated electronic monitoring system eliminates the risk of bias and also precludes the need for the validation of the direct observers as they will only need to be deployed for coaching and intervention .
Timeliness of Feedback . Typically , a hospital does
3 not provide feedback from direct observations for up to 30 days . To be truly actionable , feedback should be timelier . There are electronic monitoring systems that enable feedback on hand hygiene compliance rates in less than 24 hours , some with real-time alerts to prevent potentially missed events . Data from an electronic monitoring system combined with appropriate front line staff feedback has been shown to drive higher compliance , reduce infections , eliminate significant costs due to extended length of stay and additional patient care and have a positive impact on safety culture . 6
Sufficiency of Sample Size : When direct observation is the only available method for monitoring
4 hand hygiene compliance , many hospitals are setting a target of 200 direct observations or 1.7 percent of total hand hygiene opportunities per unit per month . There is , however , potentially a much larger and richer dataset to mine when one considers the estimated number of hand HHOs based on the HOW2 Study . 7