July / August 2012
Compliance Improvement through Technology
According to The World Health Organization (WHO; 2010), at least 7 of every 100 hospitalized patients in developed countries—and 10 out of 100 in developing countries—will experience a hospital-acquired infection (HAI). To reduce the risk, WHO recommends specific hand hygiene methods involving soap and water or an alcohol-based sanitizer.
WHO published its "Five Moments for Hand Hygiene" several years ago, which have been accepted as a standard in most facilities. It states simply that healthcare workers should clean their hands:
1. before touching a patient,
2. before clean/aseptic procedures,
3. after body fluid exposure/risk,
4. after touching a patient, and
5. after touching patient surroundings.
Major companies and entrepreneurs in the healthcare segment have been taking WHO's suggestions and trying to find ways to help hospitals and other facilities to implement them using technology as well as training, policy changes, and improvements.
As part of WHO's Private Organizations for Patient Safety (POPS) program, for example, Sealed Air's Diversey division, Elmwood Park, New Jersey, is working with leading healthcare professionals to develop and promote best practices in hand hygiene using an online platform to implement WHO recommendations.
The online platform aims to improve the implementation of the recommendations and reduce HAIs by allowing WHO participating companies to share information. Diversey will collaborate in aligning its promotional messages for hand hygiene products with WHO recommendations, continue to enhance the quality of its hand hygiene products, and encourage product availability and accessibility in all parts of the world.
That's the type of thing that needs to be done; the devil resides, as usual, in the details of how.
In his book, Better: A Surgeon's Notes on Performance (2007), surgeon Atul Gawande, wrote:
Plain soaps do, at best, a middling job of disinfecting. Their detergents remove loose dirt and grime, but fifteen seconds of washing reduces bacterial counts by only about an order of magnitude. Today's antibacterial soaps contain chemicals such as chlorhexidine to disrupt microbial membranes and proteins. Even with the right soap, however, proper hand washing requires a strict procedure. First, you must remove your watch, rings, and other jewelry (which are notorious for trapping bacteria). Next, you wet your hands in warm tap water. Dispense the soap and lather all surfaces, including the lower one-third of the arms, for the full duration recommended by the manufacturer (usually fifteen to thirty seconds). Rinse off for thirty full seconds. Dry completely with a clean, disposable towel. Then use the towel to turn the tap of. Repeat after any new contact with a patient.
He then adds,
Almost no one adheres to this procedure. It seems impossible. On morning rounds, our residents check in on twenty patients in an hour. The nurses in our intensive care units typically have a similar number of contacts with patients requiring hand washing in between. Even if you get the whole cleansing process down to a minute per patient, that's still a third of staff time spent just washing hands. Such frequent hand washing can also irritate the skin, which can produce dermatitis, which itself increases bacterial counts.
Mirroring Gawande's concerns, Brent Nibarger, chief client officer at BioVigil Systems, Ann Arbor, Michigan, says, "Healthcare workers are not deliberately choosing not to wash their hands. When we look at the data, when we're monitoring users with electronic tools, we find that the average healthcare worker is doing between 80 to 110 hand-hygiene events per day, per shift. Whenever a human is asked to do something 110 times a day in a very busy, high-tech, high-touch, multitasking, stressful environment, it's understandable how it can often get overlooked."
There has been a lot of work done examining various strategies for improving hand hygiene compliance in acute care facilities. Jane Kirk, MSN, RN, CIC, clinical manager at Gojo, a company that produces hand sanitizers, explains that a recent comprehensive report issued by the Center for Transforming Healthcare, a not-for profit affiliate of The Joint Commission, studied the issue as part of their Hand Hygiene Project. "In the project, hand hygiene compliance was raised from 48% to 82% and then sustained for 8 months by using system process improvement methods to identify problem areas, create solutions to address the issues, and provide for the effectiveness of the solutions."
By interacting with caregivers, solutions that could apply to any healthcare setting were identified. The study validated that providing easy access to hand hygiene products in the correct delivery system can make a difference in hand hygiene compliance—and staff and patient satisfaction.
"The first thing is sanitizing facilities have to be absolutely available, at the point of use and point of care," agrees Dr. Hudson Garrett, senior director, clinical affairs at Professional Disposables International (PDI) in Orangeburg, New York. "For example, if you come out of a patient's room and you need to practice hand hygiene but you have to go down the hall to find alcohol-based hand sanitizers, then obviously that's not going to be very effective."
In a similar vein, if you don't have a product that the staff is willing to use, hand hygiene becomes more of a task to avoid. According to Kirk, "Both the Centers for Disease Control and Prevention and the World Health Organization identified products that cause irritation and dryness as deterrents to hand hygiene adherence. For healthcare facilities, when choosing hand hygiene products it is recommended that they seek information from manufacturers regarding the irritancy potential of both soap and alcohol-based hand sanitizers. Additionally, the CDC makes a strong recommendation for soliciting input from healthcare workers regarding the feel, fragrance, and skin tolerance of any products under consideration."
If the right products are made available, the hygiene stations are conveniently located, and the training reinforces the need for hand hygiene, all should go right, right? Apparently not.
Hand Hygiene for All
Dr. Garrett explains, "We know that essentially infections come from three common sources. One of them is from contaminated hands, and that's not just the healthcare professional but it's also the patient and the family. The second is contaminated environmental surfaces, and the third is contaminated skin of the patient."
The nursing staff, for example, may rationalize they are only going into the patient's room for a minute, "just going to say hello, how are you," or to silence an alarm or check something on a monitor. "Even so, she's still touching an environmental surface, and the danger is that most likely she's not wearing gloves because she's just running in/running out," says Garrett. "The concern is then she's taking those contaminated hands and she's going back to either the nurse's station—or worse, to another patient—and is running the risk of cross transmission amongst patients."
The answer at some facilities has been to try hand hygiene surveillance methods. These range from actual cameras above the wash station to wall-mounted "sniffer" stations or badges that require the wearer to submit their cleansed hands to the equipment for approval.
Where it gets sticky is how does the badge or the system implementation get done, at what cost, with what complexity, requiring what kind of internal infrastructure to enable it and, more importantly, how does the badge support or not support all of the myriad of clinical-use cases, and there are a lot of them.
Representing one approach is to monitor the amount and frequency of dispensed sanitizer. Paul Alper, vice president of Deb Worldwide Healthcare (DebMed) explains their system: "The DebMed system utilizes hardware and software components to capture and calculate hand hygiene compliance rates in virtually real-time. It utilizes wireless communications technology built into product dispensers to automatically track soap and sanitizer utilization by staff in patient care areas. This information is sent to a server via cellular network, for clients to access their unit, hospital, and multi-hospital dashboards and reports via the web. The DebMed GMS does not individually tag and or track healthcare workers."
He goes on to say, "If you're only monitoring based on in and out, you're missing 50% of the potential events and you're not hardwiring behavior that's necessary for patient safety. A technological solution that monitors and provides feedback in real time based on the Five Moments for Hand Hygiene is the only clinically relevant solution. Technology will improve solutions, because it'll provide feedback in real time and it will allow healthcare workers to know exactly how they're doing, to know the real data, and to know the real score in real time."
Another approach is to monitor the caregiver's movements and related hand hygiene activities. Using RTLS (real-time location services), personnel movement in the patient care areas can be determined and hand hygiene activities related to that movement.
Charlotte Miller, director of nursing informatics at AeroScout, Redwood City, California, explains their system this way: "In many hospitals, staff members are wearing our RTLS tags to help with process improvement. Once they have those we are able to embed a device inside a sanitizer dispenser that, when the dispenser is activated, when you're actually using it, it triggers a note that the badge wearer is at the dispenser and did a hand-hygiene event. And because we're location based, we know if that person entered or left a patient room within an acceptable timeframe. Then we can automatically calculate compliance rates—we know how many hand-hygiene events staff members do, and we know if they were compliant, based on the rules that the hospital has."
Addressing the issue of staff members who "just pop in for a chat," Miller notes, "We know when staff enters a patient room, we know how long they were in the patient room, and we know when they left. Our rules setup is that when a staff member enters or leaves a patient room, there has to be a hand-hygiene event within a particular time—it's generally one minute at the most—before you enter a patient room or upon entry, and the same with exit. But you have to have been in a patient's room usually longer than 30 seconds before we even look for a hand-hygiene event in our database. We don't ding a staff member because they just popped in and did not do a hand-hygiene event when it's not needed."
Since all staff in hospitals wear some sort of badge—and many wear multiple part badges—using them to monitor hand hygiene is a growing trend. BioVigil has developed a "sniffer" badge that can sense and acknowledge a hand hygiene event using alcohol-based sanitizer. According to Nibarger, "We found that many solutions get in the way of clinical workflow. As example, when the sensor goes with you wherever you go, you have the ability to do a hand-hygiene-compliant event, whether in a room, out of a room, down the hall, or around the corner. You don't have to place monitored dispensers or wall-mounted sensors all over."
Whether badges that react to hand sanitizers, dispensers that report on their usage, or improved hand hygiene gels and soaps, technology can increase the likelihood of compliance, but it can't enforce it. As Garrett says, "When you look at the data, your average compliance nationally is about 40%. I think it's not necessarily the technical aspects of the issue, it's really more of the cultural, performance, and behavior-based components that are more of an issue. It's not just getting people to buy into the fact that hand hygiene is absolutely necessary, that it's the most important intervention to perform, but it is holding them accountable, and that is where a lot of facilities fall flat. There's no penalty if you're not actually practicing hand hygiene."
Tom Inglesby is an author based in southern California who writes frequently about medical technologies and improvement strategies.