Implementing hand hygiene technology and improving compliance in the ED

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Implementing hand hygiene technology and improving compliance in the ED

Two studies take on relevant hand hygiene issues: the Big Brother effect of surveillance technology and overcrowding in the ED

After reading this article, you will be able to:

  • Identify reasons why healthcare workers are apprehensive about hand hygiene technology
  • List the predictors of worsened hand hygiene compliance in the ED

Hand hygiene is the simplest way to prevent infections, and in nearly every hospital, someone is watching for compliance. Now that "someone" is ­gradually turning into "something" as more hospitals turn to automated surveillance technology in order to capture a larger sample size and improve or maintain compliance.

But as healthcare technology rapidly improves, so does the need to implement that technology appropriately. Failure to do so will only alienate healthcare workers and establish a "Big Brother" feeling throughout the hospital.

A recent study published in the November issue of Infection Control and Hospital Epidemiology addressed this issue, conducting focus groups with frontline staff members, mid-level management, and leadership at healthcare facilities that had not yet used the technology. Almost universally, frontline staff showed reluctance to the technology and concern over the possible effects of the data that was collected, says Kate Ellingson, PhD, epidemiologist for the CDC's Division of Healthcare Quality Improvement and lead author of the study.

"Healthcare workers and the frontline weren't necessarily wary about the technology itself, but they were wary about not knowing enough about it," Ellingson says. "Many of them expressed that they would feel more confident and accepting of the technology if they knew exactly how that worked and how the data was going to be used."

The study highlighted that while technology may have positive effects on behavior, appropriate implementation will lead to a more willing workforce.


Communication and transparency

The key to this technology is open and honest communication. Of the members in the focus group, leadership was typically the most familiar with hand hygiene surveillance technology, but they were also the most willing to share the data, going so far as to release it to the public.

Healthcare workers, on the other hand, were very concerned with how the data would be used.

"There is a concern that with the oversight technology an individual healthcare worker could be fired or called out for having poor adherence," ­Ellingson says. "So when you're thinking about it from that perspective as the individual healthcare worker, there are a lot of concerns with accuracy."

There are also some areas where technology falters. For example, there may be instances in which a physician enters the room but does not touch the patient. Surveillance technology would track that as noncompliance, but given the context of the situation the physician would not be at fault.

"If you are talking about one hand hygiene opportunity, a single healthcare worker and a single opportunity, the direct observation is probably better because it's an observer who can see exactly what is going on and he's aware of the context of the situation," Ellingson says.

Moving past direct observation

Although direct observation does provide better context to individual instances of hand hygiene behavior, it is limited in the amount of observations that are possible.

Direct observers are also intended to be clandestine, but they are often easily recognized by healthcare workers, thus influencing compliance.

"I think where the technology brings us forward is in getting a complete sample and a better statistical proxy of hand hygiene overall, rather than that little sliver that a direct observer can give you," Ellingson says.


Improving compliance in the ED

Another study also published in the November issue of Infection Control and Hospital Epidemiology focused on hand hygiene in the emergency department (ED), a particularly challenging sector of the hospital given its high patient load and hectic environment.

The study determined that hallway or high visibility location, worker type, and glove use were all predictors of decreased hand hygiene compliance, with hallway location being the strongest indicator for noncompliance. For the first time, the study defined some of the unique issues present in the ED.

"Nobody has really looked at things that are unique in the emergency department that may not even be factors in other parts of the hospital or clinic," says Arjun Venkatesh, MD, MBA, an emergency medicine resident at Brigham and Women's Hospital in Boston and lead author of the study.


Hallway location

According to Venkatesh, when ED workers were forced to take care of a patient in a bed placed in the hallway, it elicited a couple of key points:

  • Hand hygiene in the hallway is much more difficult because of environmental characteristics. A hand sanitizer may not be nearby or the work flow might not easily allow access to a sink compared to a private room.
  • When patients are in the hallway it means that the ED is overcrowded, making it more difficult for healthcare workers to wash their hands.


Traditionally, overcrowding has been linked to other bad outcomes such as delays in antibiotics or painkillers. As a result, EDs have to take into account overcrowding and its effect on healthcare worker behaviors when planning hand hygiene campaigns.

"We're starting to show a clinical impact of crowding, especially a patient safety effect, and that will hopefully drive hospitals to new policies and delivery models," Venkatesh says.


Worker type

Most hand hygiene campaigns focus on nurses and physicians, but the dynamics of the ED should force IC departments to consider a much more comprehensive campaign that includes physician assistants, nurse practitioners, and even transport workers.

"Transport workers had very low hand hygiene compliance, almost 60%," Venkatesh says. "The reason that matters is because it only takes one missed hand hygiene opportunity to transmit an infection. If you spend all your educational efforts and resources on just physicians and nurses, you miss a whole swath of healthcare workers out there that can contribute to horizontal transmission."


Glove use

Similar to other healthcare environments, glove use contributed to worse hand hygiene.

"We've always kind of hypothesized that it's because either the time of doing both is too much of a burden or people think that because they wore gloves they don't need to wash their hands," Venkatesh says.

Thus, it's important to not only educate ED workers, but also provide immediate audits and feedback to ensure they understand the risks of cross-contamination. Given the diversity of critical patients entering the ED, and the number of deadly bugs, reminding all healthcare workers about proper hand hygiene before and after glove use is imperative to achieving higher compliance rates.