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. Health care 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 electronic 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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