Hand hygiene.pdf

PART III. OUTCOME MEASUREMENTS
1. MONITORING HAND HYGIENE COMPLIANCE
Monitoring hand hygiene practices is an activity of crucial importance to assess baseline
compliance by HCWs, to evaluate the impact of promotion interventions and to provide
feedback to HCWs. Monitoring can also be helpful in investigating infection outbreaks, in
assessing the potential role of ongoing hand hygiene practices, and also in determining the
extent to which infection can be decreased depending on the different rates of compliance
(see Part I, Section 20.1).
Compliance with hand hygiene can be evaluated directly or indirectly. Direct methods
include observation, patient assessment or self-reports. Indirect methods include monitoring
consumption of products, such as soap or handrub, and electronic monitoring of
the use of handwash basins. Direct methods are necessary to determine precisely hand
hygiene compliance rates. A direct method, according to the definitions for hand hygiene
indications, consists of a count of the number of hand hygiene episodes performed by
HCWs divided by the number of hand hygiene opportunities. Performance feedback
on hand hygiene behaviour is critical to improve compliance with hand hygiene among
HCWs 262,504,507,511,518,526,528,530,531,535,536 .
1.1 DIRECT OBSERVATION
Direct observational survey is currently the “gold standard” and the most reliable method
for assessing adherence rates 7 . Data can be collected on the types of patient procedures,
moment (time, day), and practices before and after the use of gloves. HCWs are not usually
identified personally on the data collection forms. Awareness of being observed may
improve HCW compliance because of a “Hawthorne effect” 261,571,692 . If observational
surveys are conducted periodically, this bias would be equally distributed among all observations
583 . A major drawback of direct observation is the cost as it requires a trained person
(either HCW or non-HCW). This can be time-consuming and expensive. Furthermore,
defining the ideal methodology for direct observation may be very difficult, especially
because the interpretation of the recommended indications for hand hygiene in practical
daily care may be very complicated. An accurate evaluation of hand hygiene compliance is
valuable for performance feedback purposes. Such audits are best performed by staff who
routinely come to the unit for other reasons, such as quality improvement professionals,
as this tends to reduce the Hawthorne effect. However, HCWs will generally pay less and
less attention to auditors over time if they are seen as a routine part of system monitoring.
Direct observation for routine surveillance needs to be kept simple. It is best to focus on
a few major types of hand hygiene opportunities rather than trying to be comprehensive.
For example, hand hygiene before and after contact with the patient, before performing
an aseptic procedure such as intravenous catheter site care, and after glove removal
would be suitable targets. Observation for research purposes may be more complicated,
depending on the research objectives. Compliance with proper precaution procedures
could also be monitored. Whichever parameters of care are monitored, the definition of
non-compliance should be clear so that trained observers will have high inter-rater reli-