one who has pointed that out , including the problem of the Hawthorne Effect , which can skew results two to three times higher . Some hospitals using direct observations are reporting 80 , 90 , 95 percent hand hygiene compliance . They may think that they ’ re doing pretty great , but if you conduct a study using other methods such as an automated monitoring system , you find out that they ’ re not operating at 90 percent , they ’ re often operating at 30 , 40 or 50 percent . So , some hospitals may have become complacent because they think their compliance rates are so high .”
Another challenge is the variation in following either the WHO 5 Moments for Hand Hygiene , or the CDC ’ s guidelines , or possibly a hybrid of both in some institutions .
“ The group of researchers in Iowa have looked at the difficulties of performing observations using the WHO 5 Moments for Hand Hygiene , and they pointed out that sometimes even the architecture of the wards and other things make it so it ’ s not so easy to monitor all five Moments , particularly , Moments two and three ,” Boyce says . “ For that reason , many hospitals monitor compliance by observing hand hygiene upon entering and upon exiting a patient room , because it ’ s so much easier . Going into the room is a proxy for Moment one , and coming out of the room is a proxy for Moments four and five . I don ’ t know what proportion of hospitals try to monitor all five Moments . I don ’ t know what proportion of hospitals monitor the 5 Moments vs monitoring hand hygiene on room entry and exit because I haven ’ t seen any data on this . But I don ’ t think which guideline a facility is following ( CDC or WHO ), or if they are mixing and matching guidelines , is a problem . In fact , the 2014 SHEA Compendium conducted a comparison of the WHO guideline versus the CDC guideline and found a lot of overlap . So , my current opinion is that the differences between the guidelines is not the issue here , but rather the fact that there are so many indications for hand hygiene .”
Boyce continues , “ I published a paper a couple of years ago about the frequency of hand hygiene by nurses and the number of opportunities they have . For example , if you look at the number of hand hygiene opportunities in an ICU , there can be as many as 100,000 or more per month , and so it ’ s difficult for healthcare workers to clean their hands as often as would seem to be recommended by the guidelines because they ’ re so busy performing so many different kinds of patient care . There ’ s an excellent paper out of Canada by Victoria Williams and colleagues who saw an uptick before those Canadian hospitals had admitted very many patients with COVID , and yet hand hygiene compliance started to slow back down when they were having their peak of COVID cases in the hospitals partly because healthcare personnel weren ’ t as scared then , and as Williams points out the fear factor probably partly explained the initial uptick and then as people got more used to taking care of COVID patients and they were using PPE , they became desensitized to it . That is not what you would expect to find in the middle of a pandemic , but that ’ s what researchers have been documenting .”
Boyce says he believes an important way to fight the complacency is to facilitate a major cultural and behavioral shift .
“ I endorse the need for strong institutional support from top leadership down ,” he says . “ There must be administrative support of interventions to improve the overall institutional culture related to hand hygiene , which is part of the multi-modal approach recommended by WHO .”
Boyce says he thinks some overall improvement in hand hygiene compliance has been achieved . “ I don ’ t think that hand hygiene rates in hospitals are the same as they were in 2002 , so I think we have made some progress . But it is frustrating that many hospitals are still challenged in getting their compliance rates up as high as they want them , and we don ’ t know how high they have to get in terms of infection prevention . It could be that there ’ s a point of no return , but no one knows for sure . I don ’ t know if 80 percent is as good as 100 percent ; in some institutions it ’ s taken years to get up to 60 or 65 percent compliance . So , while we have made progress , even more progress must be made .”
Boyce says he is a proponent of automated monitoring systems because of the advantages they have over use of direct observations . “ Automated systems provide orders of magnitude more data on hand hygiene events and opportunities than direct observations on a 24 / 7 basis , and are not affected by the Hawthorne Effect in the same way that direct observations are .” However , he acknowledges that there are barriers to the adoption of automated monitoring systems .
“ One of the things that ’ s keeping many hospitals from investing in the automated systems is the cost , along with concerns about how accurate they are , as some of them are more accurate than others . A hospital could spend a million dollars on an advanced system , which is a substantial investment , but they must remember that it must be considered how many healthcare-associated infections are going to be prevented by using a sophisticated system like that , because HAIs can be expensive , too . I think there is a clear need for additional cost-effectiveness studies . It may turn out -- if those studies are carefully done – that the cost savings from preventing HAIs may cover a lot of the costs , if not all , related to the purchase of an automated compliance monitoring system .”
As healthcare institutions weigh the pros and cons of direct observation versus automation , guidance can be found in numerous places , including the 2014 Compendium produced by the Society for Healthcare Epidemiology of America ( SHEA ), which details several key interventions gleaned from the medical literature to boost compliance .
The first is the important of engagement . According to the literature , this involves developing a multidisciplinary team that includes representatives from administrative leadership as well as unit-level champions . This team is tasked with identifying and defining the barriers to hand hygiene that are specific to the unit or institution , as well as ensuring that institutional leadership is aware and supportive of hand hygiene improvement strategies and supports these efforts with adequate resources . Leadership