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<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE development. These methods allow precise quantitative results on hand hygiene activity to be obtained, with the only costs being the installation and maintenance of the system. Changes over time can be assessed. Some studies have attempted to measure the need for hand hygiene by monitoring patient room entries and linking each entry to the use of a sink or a handrub dispenser. For the moment, no comparative studies exist to validate the appropriateness of electronic detection of hand hygiene opportunities. Wireless devices placed inside handrub or soap dispensers can provide useful information regarding patterns of hand hygiene frequency. A recent study evaluated wireless devices that were placed inside handrub dispensers on a general medical ward and in a surgical intensive care unit. 1040 During a 3-month trial period, 17 304 hand hygiene episodes using handrub were recorded on the medical ward for a rate of 9.4 hand hygiene episodes/patient-day. A total of 50 874 hand hygiene episodes using handrub were recorded in the ICU for a rate of 47.7 hand hygiene episodes/patient-day. Average usage was highest between 10:00 and 19:00; the lowest was at 05:00. By mapping the location of each device, it was observed that dispensers located in rooms with patients on contact precautions were used significantly less often than those located in other rooms on the ward (P = 0.006). Table III.1.1 Advantages and disadvantages of various hand hygiene monitoring approaches Monitoring approach Advantages Disadvantages Direct observations by expert observers Self-report by healthcare workers Direct observations by patients Consumption of hygiene products such as towels, soap, and alcohol-based handrub Automated monitoring systems • Only way to reliably capture all hand hygiene opportunities • Details can be observed • Unforeseen qualitative issues can be detected while observing hand hygiene • Inexpensive • Inexpensive • Inexpensive • Reflects overall hand hygiene activity (no selection bias) • Validity may be improved by surrogate denominators for the need for hand hygiene (patient-days, workload measures, etc.) • Absence of observer may reduce observation bias • May potentially produce valuable detailed information about hand hygiene behaviour and infectious risks • Time-consuming • Skilled and validated observers required • Prone to observation, observer, and selection bias • Overestimates true compliance • Not reliable • Potential negative impact on patient–HCW relationship • Reliability and validity required and remains to be demonstrated • Does not reliably measure the need for hand hygiene (denominator) • No information about the appropriate timing of hand hygiene actions • Prolonged stocking of products at ward level complicates and might jeopardize the validity • Validity threatened by increased patient and visitor usage • No possibility to discriminate between individuals or professional groups • Scarce real world experience so far • Potential ethical issues with tracking of individual activity • Unknown impact on staff and patient behaviour • Systems may be costly and failure-prone 162
PART III. PROCESS AND OUTCOME MEASUREMENT Table III.1.2 Potential bias in hand hygiene observation Bias Observation bias Observer bias Selection bias Description Presence of an observer induces better than usual hand hygiene behaviour Observers systematically interpret the observation method and definitions for hand hygiene opportunities and actions in their own way; consequently, their results are different from those of other observers Observers systematically select certain times, care situations, health-care sectors, HCWs or opportunities for their observations; consequently, their results do not reflect the overall hand hygiene compliance Table III.1.3 Potential scope of hand hygiene observations • Compare the evolution of compliance over time in the same institution or sector • Compare different sectors • Perform a baseline measurement of compliance in an institution • Perform formal observations with immediate feedback to the observed HCW for training purposes • Establish the impact of system changes and multimodal interventions on compliance (before/after study) • Compare the quality of care in different hospitals • Evaluate hand hygiene practices in the framework of an outbreak investigation 163
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