After a South Carolina health system introduced an electronic system for monitoring handwashing compliance among clinical staff, it saw MRSA rates plummet.
Discussions about handwashing irk me because there is no excuse for healthcare professionals to not wash their hands. It's simple, only takes 20 seconds, and we've all been educated about the dangers viruses and bacteria—especially the drug-resistant kinds—pose to our patients.
So can't we just wash our hands already?
But after talking with Connie Steed, MSN, RN, CIC, FAPIC, director of infection prevention at Greenville (SC) Health System, I realize applying Nike's concept of "Just Do It" to hand hygiene is too simplistic.
There's more to hand hygiene than just washing your hands. Duration and frequency of handwashing is also extremely important.
Hand Washing: Six Steps Are Better Than Three
"It really shouldn't be rub in, rub out, or zap the dispenser when you go in and out," Steed says. At GHS, the hand hygiene policy is based on World Health Organization's Five Moments for Handwashing and it's monitored through both direct observation and an electronic, algorithm-based monitoring system.
WHO's Five Moments
Launched in 2009, WHO's Five Moments calls for healthcare workers to wash their hands:
1. Before patient contact
2. Before an aseptic task
3. After body fluid exposure risk
4. After patient contact
5. After contact with patient surroundings
"We chose [the] Five Moments [protocol] because we think it's more protective for the patient," Steed says.
But in order for it to be effective, healthcare workers need to correctly follow the protocol.
Traditionally, hand hygiene compliance has been monitored via direct observation where trained nurses visit nursing units and observe whether healthcare workers are washing their hands or not.
Steed points out that this misses a large portion of hand hygiene opportunities—those that take place in the patients' rooms. In addition, direct observation may not get the most accurate data because people often change their usual behavior when they know they are being observed, which skews compliance rates to appear higher than they actually are.
To verify that the algorithm for the electronic surveillance system was accurate, Steed and her counterparts got IRB approval to put video cameras some consenting patient's rooms to video tape their care. They then compared direct observation rates to the electronic compliance index which was verified through the video monitoring.
"The electronic monitoring system data was clearly statistically within appropriate confidence intervals of being more accurate than direct observations," Steed explains.
Electronic Monitoring Improves Compliance Rates
How does the electronic monitoring system work? On every nursing unit there is a chip inside each soap and gel dispenser. The chip communicates each dispenser activation to a web-based program which logs the activation.
To determine compliance rates, activation numbers are run through an algorithm that calculates the estimated number of activations that should occur if healthcare workers are following the 5 Moments protocol. The algorithm also takes into account the hourly patient census on every unit and the nurse-to-patient ratios for that census.
Unit managers have access to the data and can address compliance issues on their individual units.
"It's not Connie Steed didn't clean her hands five times today. It's all about what their team compliance rate is," she says.
"It's [nursing staff] influencing their fellow team members, the physicians, and the other professionals that come to their unit to increase their hand hygiene."
Use of this data for unit-based improvement seems to be working.
Results
A recent study co-authored by Steed, found a direct correlation between using data from the electronic hand hygiene compliance system to improved compliance with the WHO 5 moments and a reduction in hospital onset MRSA infections.
The study found that hand hygiene compliance rates increased by more than 25%, hospital onset MRSA rates decreased by 42%, and total costs of care avoided were about $434,000.
"Hand hygiene compliance is a cornerstone of infection prevention," Steed says. "Our goal was to find a more accurate picture of what the compliance [rate] was so that we could legitimately improve it so that we would reduce [infection] rates, improve patient safety, and, for that matter healthcare worker safety."
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.