In 1847, Austrian physician Ignaz Semmelweiss proved

In 1847, Austrian physician Ignaz
Semmelweiss proved that washing
hands drastically reduced deaths from
sepsis on maternity wards, and he
published those findings in his book
Etiology, Concept and Prophylaxis of
Childbed Fever. Healthcare-acquired
infections (HAIs) are almost completely
preventable, yet more than 150 years
after Dr. Semmelweiss’ observations,
HAIs are responsible for an estimated
two million infections and almost
100,000 deaths (Centers for Disease
Control and Prevention, 2011) each
year in the United States alone.
In addition to the tragic toll that HAIs
take on human life, these infections
also have tremendous financial repercussions. The estimated total cost
associated with HAIs is $45 billion
(Scott, 2009), which is a huge burden
on hospitals, particularly considering
the portion not reimbursed by insurance
or the government. As a result, HAI
rates have come under intense media
focus, as they represent an easy way
to measure the quality of healthcare
facilities across the nation.
Starting with Dr. Semmelweiss and
continuing into the present day, a
lack of hand hygiene has continually
been identified as a leading cause
of HAIs. Not surprisingly, healthcare
officials are continually searching for
cost-effective ways to reduce HAIs and
increase hand hygiene in the hospital
setting.
According to Dr. Donald Berwick,
former CEO of the Institute for Healthcare Improvement, “even something
as simple as uniform hand washing
requirements would cut hospital
infections in half.” In addition, the
Joint Commission requires hospitals to
monitor hand hygiene as a condition
of accreditation. However, while the
Joint Commission requires this type
of monitoring, it has not established
a standard process for doing so. As a
result, hospitals are left to determine
their own monitoring methods, and
most turn to direct observation as
their method of choice.
Falling Short: The Limitations of
Direct Observation
Direct observation involves the use of
human observers, who simply observe
various situations and record the
actions they witness. These records
are typically conducted manually using
paper and pen, with no electronic or
computerized process involved. While
direct observation has long been the
standard methodology for measuring
behavior, there are many significant
problems associated with the practice.
Some of these problems include:
The Hawthorne Effect
Individuals will exhibit different
behavior when they know they are
being watched, simply because they
are aware of the observation being
conducted in their presence. This
results in artificially high rates of
compliance.
Small Sample Sizes
Because it is impossible for an observer
to monitor every interaction between
clinicians and patients in a hospital 24
hours a day, seven days a week, it is
estimated that direct observation only
captures 1.2 to 3.5 percent of all hand
hygiene opportunities, according to a
study done at the University of Iowa.
As a result, the statistical reliability of
direct observation is very low.
Observer Bias
The individual conducting a study may
not be properly trained in standard
observational techniques. In addition,
he or she may be biased, either negatively or positively, toward the person
he or she is observing. If the observer
considers the subject a friend, higher
marks may be given, while someone
the observer does not know well or
does not like may receive lower marks.
High Costs
Direct observation methods are
extremely expensive, time-consuming
and resource-intensive.
Timeliness
Because of the manual nature of
direct observation, the reports are
often not provided in a timely enough
manner to help change behavior.
Despite these drawbacks, hospitals
continue to employ direct observation
methods to measure hand hygiene
and other compliance issues. There
is currently no government mandate
requiring hospitals to use any other
method, so there is no motivation
to change long-established patterns.
In addition, hospital officials often
consider direct observation to be a
cost-free technique, since nurses who
are already employed at the hospital
are drafted to perform observations of
their colleagues, not taking into effect
the lost time of these nurses, who
are employed to care for patients.
Perhaps most importantly, hospital
administrators and quality officers are
often simply unaware of alternative
solutions to direct observation, such
as electronic monitoring, which has
been proven to be superior to direct
observation but is relatively new to
the market. Electronic monitoring
eliminates the need for manual, human
directed observation by incorporating
electronic technology and monitoring
100 percent of all hand hygiene
events.
The Future of Hand Hygiene Monitoring
and Compliance
Evidence highlighting the flaws and
limitations of direct observation
continues to grow, which will continue
to provide further awareness and
education to hospital staff who are
responsible for ensuring hand hygiene
compliance, encouraging them to
investigate alternative solutions. One
recent study, published by Infection
Control and Hospital Epidemiology,
found “direct observation cannot
be considered the gold standard for
assessing hand hygiene, because there
was no relationship between the observed adherence and the number of
dispensing episodes or the volume of
product used.” (Marra et al., 2010)
Researchers from Brazil and the United
States compared three different
methods of measuring hand hygiene
compliance – direct observation,
product usage and data collected from
electronic monitoring devices – over
a 12-week period in an intensive care
unit at a tertiary-care hospital. The
study’s conclusions were clear: “Other
means to monitor hand hygiene
adherence, such as electronic devices
and measurement of product usage,
should be considered.”
Elaine Larson, RN, PhD, associate
dean for research and professor
of pharmaceutical and therapeutic
research at Columbia University
School of Nursing agrees, stating “The
advantages of electronic monitoring
to measure hand hygiene behavior are
that it’s much less costly, it doesn’t
require a direct observer and it’s
available 24/7”.
By moving away from direct observation
as the standard way of measuring hand
hygiene compliance and embracing
superior methods such as electronic
monitoring, hospital administrators
can focus on the ultimate goal of
protecting the lives of the patients
they serve while reducing HAIs and
HAI-associated deaths.
Increasing hand hygiene compliance is
directly related to decreasing infections
and therefore improving patient safety.
By providing staff with real-time feedback and tools, behavioral changes
can occur, thus increasing hand
hygiene compliance.
Furthermore, while various methods
of electronic monitoring exist, the
ideal system should provide both a
numerator (the number of times staff
cleaned their hands), and a denominator
(the number of times staff should
have cleaned their hands). The World
Health Organization (WHO) recommends
that electonic monitoring systems be
based on the WHO Five Moments for
Hand Hygiene rather than just before
and after patient care, as it is a higher
clinical standard that encompasses
more hand hygiene opportunities.
The bottom line is that electronic
monitoring is more reliable than direct
observation, capturing 100 percent of
hand hygiene events and providing a
greater ability to increase compliance.
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