WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

PART III. PROCESS AND OUTCOME MEASUREMENT
number of opportunities more quickly. Observers have to be
aware that changing the method of selecting time and location
for observations between observation periods can lead to
bias because there is usually an association between density
of opportunities and compliance. Therefore, we suggest to
establish a rough location plan and timetable ahead of planned
observations that will be remain stable over observation periods.
1.2.6.2 Selection of HCWs
Once location and time are determined, observers have to
choose the HCWs to be observed during a session. Selection
bias should be minimized by choosing at random. In the case of
repeated observation periods in particular, observers may know
the intrinsic performance of individual HCWs and this could
easily influence the overall observation result by always selecting
HCWs with extreme behaviour.
1.2.6.3 Starting, continuing, and concluding an observation
session
Once a health-care situation is identified, the observer may
introduce himself/herself by indicating unobtrusively the scope
of his/her presence. The way in which this introduction is
handled depends on local social and medical culture. A balance
should be sought between increased observation bias through
a too overt presence and inducing the feeling of being cheated
in the observed by pretending to be there for another scope.
This includes also a discreet positioning of the observer.
After completing the form header, each observed opportunity
is noted on the form (see above). Only opportunities for which
the entire time between the two delimiting hand-to-surface
exposures can be observed are noted.
During the observation session, the observer must not interfere
with observed staff. The session should be concluded after 20
minutes ± 10 minutes according the duration of care activity.
The observer may want to give feedback to the observed
HCW(s) about the observed hand hygiene performance. This
depends on the scope of the observation, but it was found to be
very efficient and appreciated by HCWs.
1.2.7 Analysis
Following data entry (Epi Info databases for entering data
collected according to the <strong>WHO</strong>-recommended method for
direct observation are available), the simplest form of results
is the overall compliance. This is calculated by dividing the
number of observed hand hygiene actions performed when an
opportunity occurs, by the total number of opportunities. It has
been found useful to stratify compliance by institutional sector,
professional category, and indication (moment) for hand hygiene
using the ‘My five moments for hand hygiene’ as strata. 1
1.2.8 Reporting of results
Feedback of results to those concerned is a very powerful
promotional tool and should firstly address groups with a
strong internal identity. A short delay between observation
activity and reporting of results might increase the effect of
feedback. Continual feedback of unchangingly bad results
without any intervention should be avoided, as it may lead to
“desensibilization” and demotivation.
Special attention should be given to the potentially low number
of observed opportunities when using percentages to report
compliance. Low numbers occur especially with stratified
results. It is good practice to calculate 95% confidence intervals
and include these in graphics. For instance, for 30 opportunities
with a compliance of 50%, the confidence interval would
stretch from 31% to 69% compliance. With 100 opportunities
and 50% compliance, the confidence interval would shrink to
40–60%, and for 200 and 50% compliance opportunities to
43–57%. Finally, observations can be reported to HCWs directly
after each session, which produces an immediate impact. For
statistical methods to measure hand hygiene compliance over
time see also Appendix 4.
1.3 Indirect monitoring of hand hygiene performance
In the quest for less expensive monitoring approaches, experts
have used the consumption of hand hygiene products such as
paper towels, 1038 alcohol-based handrub or liquid soap 60,334,
429,486,489,713,803,852
to estimate the number of hand hygiene actions.
To make these monitoring techniques more meaningful, the
quantity of handrub was translated into a number of hand
hygiene actions by using the average amount per action as a
divider. The missing denominator of the need for hand hygiene
actions was either ignored by only following the evolution over
time, or substituted by a surrogate measure such as patient
days or workload indicators drawn from a computerized
database of nursing activities. 851
Some studies 60,334,486 have shown that the consumption of
products used for hand hygiene correlated with observed
hand hygiene compliance, whereas others have not. 1039 Thus,
the use of this measure as a surrogate for monitoring hand
hygiene practices deserves further validation. Other studies
found that feedback based on measured soap and paper towel
consumption did not have an impact on hand hygiene. 802,1038
Methods based on product consumption cannot determine if
hand hygiene actions are performed at the right moment during
care or if the technique is correct. The advantages, however, are
that they are simple, can be continuous, and provide a global
picture that remains unaffected by selection or observer bias
and, most likely, observation bias. The amount of alcohol-based
handrub used by health-care settings has been selected as
one of the indicators. Nevertheless, it has to be considered that
this measure may not exactly reflect the product consumption
by HCWs, but could include the amount used by visitors or
patients, especially if the dispensers are located also in public
areas of the health-care setting and they are wall-mounted.
1.4 Automated monitoring of hand hygiene
The use of sinks and handrub dispensers can be monitored
electronically. 699,710,852,986 Systems that are even able to identify
HCWs when using a sink or a handrub dispenser are under
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