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Hand hygiene compliance: are we kidding ourselves?
Journal of Hospital Infection 92 (2016) 307e308 Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Editorial
Hand hygiene compliance: are we kidding ourselves?
Introduction Hand hygiene is one of the main strategies for reducing the incidence of healthcare-associated infections (HCAIs) and it is included in a number of national and international guidelines.1,2 The weight of evidence for hand hygiene in preventing HCAIs has steadily increased from Semmelweis’s clinical experience in the nineteenth century to numerous studies to date.1e4 One would therefore expect, in an age of evidencebased medicine, that compliance with hand hygiene could be taken for granted. Instead, the opposite is true, with studies showing hand hygiene compliance among healthcare workers (HCWs) remaining at low levels.5 What are the reasons for this? Some possible explanations are outlined below.
Monitoring hand hygiene The systematic review by Kingston et al. and the German national reference data analysis by Wetzker et al. remind us that a decade or more after the current focus on hand hygiene began we are still nowhere near achieving the aspiration of excellence in hand hygiene in healthcare facilities, at least when independent, objective assessment of compliance is used.5,6 It is clear that hand hygiene targets in healthcare institutions are often set extremely high (e.g. 90e100%); however, results from self-performed audits presented at infection prevention and control (IPC) meetings or in written reports usually meet or even exceed these targets (my own observation). It is therefore interesting to note that the systematic review by Kingston et al. demonstrates a mean hand hygiene compliance of 34%, rising only to 57% following interventions.5 What are the reasons for the discrepancies between the results of independent and non-independent hand hygiene audits, which are also evidenced in other studies?4,7 One important reason may be that unachievably high local or national targets, and especially those where underperformance attracts penalties, might provide a perverse incentive to demonstrate high hand hygiene compliance. Therefore, accurately recording hand hygiene is very important in determining compliance rates. In modern healthcare systems where tablet and mobile phone devices are readily used for routine patient care, an app such as that
described by Viswanath et al. can facilitate better recording of hand hygiene compliance.8 It offers the potential for rapid collation of data and timely feedback to HCWs in order to facilitate improvement. Apps may also assist in reducing interobserver variation, which is an important source of bias.9 However, use of apps still depends on direct observation of practice, meaning that the risk of a Hawthorne effect remains.9 Against this background, the study by Møller-Sørensen et al. provides an important reminder that any method of observation of hand hygiene performance is subject to bias.10 Whereas the authors demonstrated an improvement in the rate of hand hygiene compliance in those using the toilet facility, this apparently favourable outcome may have been negated by the fact that there was a large fall in the usage of the monitored toilets during the intervention period. It is not clear whether the apparent avoidance of monitored toilets was because the intervention was perceived as intrusive or embarrassing, or because HCWs actually took positive action to avoid having to undertake hand hygiene. Despite the elegance, and potential usefulness, of the intervention described by Møller-Sørensen et al., it is not immediately clear how a similar intervention could be applied to all of the World Health Organization (WHO) moments of hand hygiene.1,10
Improving hand hygiene compliance To improve hand hygiene compliance, one must first consider the question: what is satisfactory hand hygiene compliance? Is 100%, 75%, or perhaps even a 50% compliance rate adequate? At what point does hand hygiene compliance fall to a level below which there is a risk of HCAI? These questions remain unanswered despite a large amount of research into hand hygiene compliance. Without addressing this question, however, it is difficult to know which hand hygiene compliance target HCWs and institutions should aspire to. It is worth noting that in many other high-throughput industries, such as catering, where personal hygiene is vital, compliance rates are similar to those found in healthcare.11 In this context, are 90e100% hand hygiene compliance targets realistic? Alternatively, would it be better to target hand hygiene education and monitoring on the highest-risk practices? Various devices and electronic systems have been employed to improve hand hygiene practice.12e14 Anderson et al. describe a novel device, designed to improve patient safety and hand hygiene compliance which includes alcohol-based hand rubs (ABHs).15 The device is appealing because the findings demonstrate a significant rise in compliance with WHO moments of hand hygiene in both simulated and real-life clinical evaluation. ABHs are provided at the bedside in many
http://dx.doi.org/10.1016/j.jhin.2016.02.004 0195-6701/ª 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
308
Editorial / Journal of Hospital Infection 92 (2016) 307e308
hospitals, including the majority of those in the UK, hence the rises in hand hygiene compliance demonstrated in this study seem somewhat surprising. The improvement might reflect availability of ABHs, which may not have been previously available at the bedside, or perhaps a novelty factor in relation to the new device. In addition, it is important to note that the rates of hand hygiene compliance demonstrated in this study, even after the intervention (79% and 65%) are nowhere near the standards set and apparently adhered to in many hospitals, through self-performed observational auditing.
Conclusion Measures such as ongoing education, ABHs, and patient empowerment have facilitated some improvements in hand hygiene but challenges persist. First, and most important, the question remains regarding the level of hand hygiene compliance to be expected from HCWs. Clearly 90e100% compliance is not achievable as demonstrated in independent studies, but there is little evidence for any specific values below which patients are put at risk of HCAI. In addition, the quality of hand hygiene performed is very rarely assessed and hence compliance alone is not an adequate measure. Another issue is that the WHO moments of hand hygiene concept (which itself has a limited evidence base) gives equal weight to each moment, whereas some moments may have a greater bearing on HCAI compared with others.1 Second, there is the issue of influencing HCWs to adopt and adhere to best hand hygiene practices. A widely used strategy involves setting high targets (e.g. 90e100% compliance) with failures to meet these thresholds resulting in scrutiny from IPC practitioners and sometimes significant penalties. In order to avoid these negative consequences and through observer biases, self-performed audits usually meet or even exceed the set thresholds. However, they are rarely accurate, reproducible, or validated. A better approach may be to use realistic targets that slowly migrate upwards and to reward HCWs when validated monitoring methods demonstrate improved compliance. It is clear that monitoring hand hygiene compliance using direct observation is flawed and that electronic devices/methods in combination with smaller observational audits using appropriately trained staff would enable a better assessment.12e14 These changes will undoubtedly demonstrate lower levels of hand hygiene compliance but it seems unlikely that leaders of healthcare institutions and patients would accept or comprehend this ostensible deterioration. Hence, in an era of multi-resistant Gram-negative bacteria, it is now time to take stock and consider that we have spent a number of years performing research on hand hygiene with little evidence that any particular strategy works. Perhaps future research should be focused not on campaigns to improve hand hygiene at all costs, but on understanding when hand hygiene is most beneficial, setting reasonable, achievable targets, and then monitoring using validated, reproducible methods.
References 1. World Health Organization. WHO guidelines for hand hygiene in health care. Geneva: WHO. Available at: http://apps.who.int/ iris/bitstream/10665/44102/1/9789241597906_eng.pdf; 2009 [last accessed January 2016]. 2. Loveday HP, Wilson JA, Pratt RJ, et al. epic3: national evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2014;86:S1eS70. 3. Pittet D, Boyce J. Hand hygiene and patient care: pursuing the Semmelweis legacy. Lancet Infect Dis 2001;1:S9eS20. 4. Davis R, Parand A, Pinto A, Buetow S. Systematic review of the effectiveness of strategies to encourage patients to remind healthcare professionals about their hand hygiene. J Hosp Infect 2015;89:141e162. 5. Kingston L, O’Connell NH, Dunne CP. Hand hygiene-related clinical trials reported since 2010: a systematic review. J Hosp Infect 2016;92:309e320. 6. Wetzker W, Bunte-Scho ¨nberger K, Walter J, Pilarski G, Gastmeier P, Reichardt C. Compliance with hand hygiene: reference data from the national hand hygiene campaign in Germany. J Hosp Infect 2016;92:328e331. 7. Allegranzi B, Sax H, Pittet D. Hand hygiene and healthcare system change within multi-modal promotion: a narrative review. J Hosp Infect 2013;83:S3eS10. 8. Viswanath SK, Jie L, Meng QS, Yuen C, Tan TY. An Android app for recording hand hygiene observation data. J Hosp Infect 2016;92:344e345. 9. Jeanes A, Coen PG, Wilson AP, Drey NS, Gould DJ. Collecting the data but missing the point: validity of hand hygiene audit data. J Hosp Infect 2015;90:156e162. 10. Møller-Sørensen H, Korshin A, Mogensen T, Høiby N. New technology markedly improves hand-hygiene performance among healthcare workers after restroom visits. J Hosp Infect 2016;92:337e339. 11. Arendt S, Strohbehn C, Jun J. Motivators and barriers to safe food practices: observation and interview. Food Protection Trends 2015;35:365e376. 12. Srigley JA, Gardam M, Fernie G, Lightfoot D, Lebovic G, Muller MP. Hand hygiene monitoring technology: a systematic review of efficacy. J Hosp Infect 2015;89:51e60. 13. Storey SJ, FitzGerald G, Moore G, et al. Effect of a contact monitoring system with immediate visual feedback on hand hygiene compliance. J Hosp Infect 2014;88:84e88. 14. Sahud AG, Bhanot N, Narasimhan S, Malka ES. Feasibility and effectiveness of an electronic hand hygiene feedback device targeted to improve rates of hand hygiene. J Hosp Infect 2012;82:271e273. 15. Anderson O, Hanna GB. Effectiveness of the CareCentre at improving contact precautions: randomized simulation and clinical evaluation. J Hosp Infect 2016;92:332e336.
N. Mahida Nottingham University Hospitals NHS Trust, Nottingham, UK E-mail address: [email protected] (N. Mahida) Editor, Graham Ayliffe Fellow Available online 27 February 2016
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Editorial
Hand hygiene compliance: are we kidding ourselves?
Introduction Hand hygiene is one of the main strategies for reducing the incidence of healthcare-associated infections (HCAIs) and it is included in a number of national and international guidelines.1,2 The weight of evidence for hand hygiene in preventing HCAIs has steadily increased from Semmelweis’s clinical experience in the nineteenth century to numerous studies to date.1e4 One would therefore expect, in an age of evidencebased medicine, that compliance with hand hygiene could be taken for granted. Instead, the opposite is true, with studies showing hand hygiene compliance among healthcare workers (HCWs) remaining at low levels.5 What are the reasons for this? Some possible explanations are outlined below.
Monitoring hand hygiene The systematic review by Kingston et al. and the German national reference data analysis by Wetzker et al. remind us that a decade or more after the current focus on hand hygiene began we are still nowhere near achieving the aspiration of excellence in hand hygiene in healthcare facilities, at least when independent, objective assessment of compliance is used.5,6 It is clear that hand hygiene targets in healthcare institutions are often set extremely high (e.g. 90e100%); however, results from self-performed audits presented at infection prevention and control (IPC) meetings or in written reports usually meet or even exceed these targets (my own observation). It is therefore interesting to note that the systematic review by Kingston et al. demonstrates a mean hand hygiene compliance of 34%, rising only to 57% following interventions.5 What are the reasons for the discrepancies between the results of independent and non-independent hand hygiene audits, which are also evidenced in other studies?4,7 One important reason may be that unachievably high local or national targets, and especially those where underperformance attracts penalties, might provide a perverse incentive to demonstrate high hand hygiene compliance. Therefore, accurately recording hand hygiene is very important in determining compliance rates. In modern healthcare systems where tablet and mobile phone devices are readily used for routine patient care, an app such as that
described by Viswanath et al. can facilitate better recording of hand hygiene compliance.8 It offers the potential for rapid collation of data and timely feedback to HCWs in order to facilitate improvement. Apps may also assist in reducing interobserver variation, which is an important source of bias.9 However, use of apps still depends on direct observation of practice, meaning that the risk of a Hawthorne effect remains.9 Against this background, the study by Møller-Sørensen et al. provides an important reminder that any method of observation of hand hygiene performance is subject to bias.10 Whereas the authors demonstrated an improvement in the rate of hand hygiene compliance in those using the toilet facility, this apparently favourable outcome may have been negated by the fact that there was a large fall in the usage of the monitored toilets during the intervention period. It is not clear whether the apparent avoidance of monitored toilets was because the intervention was perceived as intrusive or embarrassing, or because HCWs actually took positive action to avoid having to undertake hand hygiene. Despite the elegance, and potential usefulness, of the intervention described by Møller-Sørensen et al., it is not immediately clear how a similar intervention could be applied to all of the World Health Organization (WHO) moments of hand hygiene.1,10
Improving hand hygiene compliance To improve hand hygiene compliance, one must first consider the question: what is satisfactory hand hygiene compliance? Is 100%, 75%, or perhaps even a 50% compliance rate adequate? At what point does hand hygiene compliance fall to a level below which there is a risk of HCAI? These questions remain unanswered despite a large amount of research into hand hygiene compliance. Without addressing this question, however, it is difficult to know which hand hygiene compliance target HCWs and institutions should aspire to. It is worth noting that in many other high-throughput industries, such as catering, where personal hygiene is vital, compliance rates are similar to those found in healthcare.11 In this context, are 90e100% hand hygiene compliance targets realistic? Alternatively, would it be better to target hand hygiene education and monitoring on the highest-risk practices? Various devices and electronic systems have been employed to improve hand hygiene practice.12e14 Anderson et al. describe a novel device, designed to improve patient safety and hand hygiene compliance which includes alcohol-based hand rubs (ABHs).15 The device is appealing because the findings demonstrate a significant rise in compliance with WHO moments of hand hygiene in both simulated and real-life clinical evaluation. ABHs are provided at the bedside in many
http://dx.doi.org/10.1016/j.jhin.2016.02.004 0195-6701/ª 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
308
Editorial / Journal of Hospital Infection 92 (2016) 307e308
hospitals, including the majority of those in the UK, hence the rises in hand hygiene compliance demonstrated in this study seem somewhat surprising. The improvement might reflect availability of ABHs, which may not have been previously available at the bedside, or perhaps a novelty factor in relation to the new device. In addition, it is important to note that the rates of hand hygiene compliance demonstrated in this study, even after the intervention (79% and 65%) are nowhere near the standards set and apparently adhered to in many hospitals, through self-performed observational auditing.
Conclusion Measures such as ongoing education, ABHs, and patient empowerment have facilitated some improvements in hand hygiene but challenges persist. First, and most important, the question remains regarding the level of hand hygiene compliance to be expected from HCWs. Clearly 90e100% compliance is not achievable as demonstrated in independent studies, but there is little evidence for any specific values below which patients are put at risk of HCAI. In addition, the quality of hand hygiene performed is very rarely assessed and hence compliance alone is not an adequate measure. Another issue is that the WHO moments of hand hygiene concept (which itself has a limited evidence base) gives equal weight to each moment, whereas some moments may have a greater bearing on HCAI compared with others.1 Second, there is the issue of influencing HCWs to adopt and adhere to best hand hygiene practices. A widely used strategy involves setting high targets (e.g. 90e100% compliance) with failures to meet these thresholds resulting in scrutiny from IPC practitioners and sometimes significant penalties. In order to avoid these negative consequences and through observer biases, self-performed audits usually meet or even exceed the set thresholds. However, they are rarely accurate, reproducible, or validated. A better approach may be to use realistic targets that slowly migrate upwards and to reward HCWs when validated monitoring methods demonstrate improved compliance. It is clear that monitoring hand hygiene compliance using direct observation is flawed and that electronic devices/methods in combination with smaller observational audits using appropriately trained staff would enable a better assessment.12e14 These changes will undoubtedly demonstrate lower levels of hand hygiene compliance but it seems unlikely that leaders of healthcare institutions and patients would accept or comprehend this ostensible deterioration. Hence, in an era of multi-resistant Gram-negative bacteria, it is now time to take stock and consider that we have spent a number of years performing research on hand hygiene with little evidence that any particular strategy works. Perhaps future research should be focused not on campaigns to improve hand hygiene at all costs, but on understanding when hand hygiene is most beneficial, setting reasonable, achievable targets, and then monitoring using validated, reproducible methods.
References 1. World Health Organization. WHO guidelines for hand hygiene in health care. Geneva: WHO. Available at: http://apps.who.int/ iris/bitstream/10665/44102/1/9789241597906_eng.pdf; 2009 [last accessed January 2016]. 2. Loveday HP, Wilson JA, Pratt RJ, et al. epic3: national evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2014;86:S1eS70. 3. Pittet D, Boyce J. Hand hygiene and patient care: pursuing the Semmelweis legacy. Lancet Infect Dis 2001;1:S9eS20. 4. Davis R, Parand A, Pinto A, Buetow S. Systematic review of the effectiveness of strategies to encourage patients to remind healthcare professionals about their hand hygiene. J Hosp Infect 2015;89:141e162. 5. Kingston L, O’Connell NH, Dunne CP. Hand hygiene-related clinical trials reported since 2010: a systematic review. J Hosp Infect 2016;92:309e320. 6. Wetzker W, Bunte-Scho ¨nberger K, Walter J, Pilarski G, Gastmeier P, Reichardt C. Compliance with hand hygiene: reference data from the national hand hygiene campaign in Germany. J Hosp Infect 2016;92:328e331. 7. Allegranzi B, Sax H, Pittet D. Hand hygiene and healthcare system change within multi-modal promotion: a narrative review. J Hosp Infect 2013;83:S3eS10. 8. Viswanath SK, Jie L, Meng QS, Yuen C, Tan TY. An Android app for recording hand hygiene observation data. J Hosp Infect 2016;92:344e345. 9. Jeanes A, Coen PG, Wilson AP, Drey NS, Gould DJ. Collecting the data but missing the point: validity of hand hygiene audit data. J Hosp Infect 2015;90:156e162. 10. Møller-Sørensen H, Korshin A, Mogensen T, Høiby N. New technology markedly improves hand-hygiene performance among healthcare workers after restroom visits. J Hosp Infect 2016;92:337e339. 11. Arendt S, Strohbehn C, Jun J. Motivators and barriers to safe food practices: observation and interview. Food Protection Trends 2015;35:365e376. 12. Srigley JA, Gardam M, Fernie G, Lightfoot D, Lebovic G, Muller MP. Hand hygiene monitoring technology: a systematic review of efficacy. J Hosp Infect 2015;89:51e60. 13. Storey SJ, FitzGerald G, Moore G, et al. Effect of a contact monitoring system with immediate visual feedback on hand hygiene compliance. J Hosp Infect 2014;88:84e88. 14. Sahud AG, Bhanot N, Narasimhan S, Malka ES. Feasibility and effectiveness of an electronic hand hygiene feedback device targeted to improve rates of hand hygiene. J Hosp Infect 2012;82:271e273. 15. Anderson O, Hanna GB. Effectiveness of the CareCentre at improving contact precautions: randomized simulation and clinical evaluation. J Hosp Infect 2016;92:332e336.
N. Mahida Nottingham University Hospitals NHS Trust, Nottingham, UK E-mail address: [email protected] (N. Mahida) Editor, Graham Ayliffe Fellow Available online 27 February 2016