Health Care Associated Infections (HCAIs) are currently a common issue in all health care settings. According to the Center for Disease Control (CDC, 2016), about one in every 20 hospital patients will develop HCAIs and each day 270 people die from these kinds of infections. There are new hand hygiene technologies evolving with numerous benefits, stemming from the field of health informatics. These may become promising sources to encourage hand hygiene compliance by healthcare professionals. Especially in clinical settings, there is less hand hygiene compliance from staff. This paper presents a literature review intended to present a comparison of different hand hygiene technologies including badge technologies, electronic auditing tools, video technologies and other advancements in the health care industry. These technologies can be used to monitor, measure and give feedback on hand hygiene compliance among healthcare workers (HCWs). As well, within the reviewed literature, the competence of some emerging hand hygiene compliance technologies is evaluated. An evidence-based systematic approach to using hand hygiene compliance technologies helped in minimizing HCAIs to some extent. Ultimately, teamwork with support from administration, management and staff is necessary to fully implement the efficiency and effectiveness of hand hygiene technologies within healthcare.
Methicillin-resistant staphylococcus aureus (MRSA), clostridium difficile infection, central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) are the most common and serious Health Care Associated Infections (HCAIs). Ironically, one of the main reasons for transmission of HCAIs is poor hand hygiene compliance of health care workers (HCWs). This literature review showed that the effectiveness of hand hygiene technologies is evaluated by a reduction in HCAIs and increased hand hygiene compliance of HCWs. For instance, the use of the World Health Organization’s (2009) Five moments (washing hands before touching a Patient, before a procedure, after a procedure or body fluid exposure risk, after patient contact and after contact with patient surroundings) in hand hygiene practices is very helpful to fight against HCAIs. Five Moments brings into line the verification base with reference to the spread of hospital acquired infections. Furthermore, it is interconnected with the routine workflow of quality care and is designed to be easy to study, reasonable and relevant in a wide range of settings (World Health Organization, 2009)
Most of the developing countries do not have specialized technologies in healthcare settings for monitoring or measuring HCWs hand hygiene practices. The importance of technological advancements and encouragement to discover new technologies in the healthcare system is important to improve patient safety. Hand hygiene is a critical technique for avoiding HCAIs. Several surveys and studies supported that when employees knew someone was around to watch for hand hygiene, they were more aware of completing hand hygiene tasks correctly. If nobody monitored hand washing, staff often ignored hand hygiene protocol. This process is commonly called a “Hawthorne Effect” (Morgan, Pineles, Shardell, Young, Ellingson, Jernigan, & Perencevich, (2012). To overcome this effect, the use of hand hygiene compliance monitoring technologies can be used to increase staff hand hygiene compliance, which in turn, curtails HCAIs incidence.
This literature review was conducted to explore the efficiency of hand hygiene technologies in health care settings. The key question that guided the review was: Do hand hygiene technologies enhance HCWs hand hygiene compliance rates, and reduce HCAIs incidence?
Direct Observation Method versus Technologies
Unobtrusive direct observation has for many years been considered the gold standard for evaluating hand hygiene compliance. Observation by a trained observer is a hand hygiene monitoring technique which has been widely accepted. Observers can be trained and validated by the WHO hand hygiene principles through educative films and slides. However, the innovative arrival of technologies and electronic systems for the automatic monitoring of hand hygiene compliances are now widely accepted especially in developed countries. Direct observation is very time consuming and costly. Calculation of hand hygiene compliance rate requires more time and is less effective since trained observers can watch only a portion of HCWs. After the evolution of hand hygiene technologies, staff engagement led to strategic decisions, resulting in consistent, sustained improvement in HCWs hand hygiene performance, helping to reduce HCAIs.
Well Known Hand Hygiene Technologies
Some examples of the badge technologies are Zigbee technology, Proventix RFID and DebMed. Badge technologies can be utilized via infrared badges, radio frequency wireless badges, or badges that interact with real time location systems (RTLS) and wireless bracelets. These badges interact with tap/soap dispensers and RTLS. The technology encourages HCWs to perform hand hygiene correctly by issuing a warning when hand hygiene is not done properly through communication of the badge and soap or sanitizer dispensers.
Actions of badge technologies. These technologies consist of small wearable electronic monitors or badges and protected zones installed to define individual patient environments, and include personal wearable alcohol gel dispensers. By using infrared communication with controllers installed in patient zones, the technologies measured the number of times healthcare professionals cleaned their hands by examining soap and hand sanitizer dispenser use. Every time a dispenser is triggered, it sends a cellular signal to indicate hand hygiene action. Each monitor records in real-time the events of the user entering and leaving patient areas and their hand hygiene actions. The actual number of hand hygiene actions recorded by the the soap and sanitizer units is divided by the expected number of hand hygiene actions and is recorded in a compliance file.
Using automated count technology, Morgan et al. (2012) evaluated the utility of estimating hand hygiene compliance, in a 12-bed Neuro-Intensive care unit (NICU) and a 15-bed cardiac intensive care unit (CCU) in a university tertiary care hospital. A study conducted by Klee & Onofre (2014) also focused on automated hand hygiene technology and showed a significant reduction in HCAIs. The combined effort of information technology, leadership, accountability and education helped to achieve hand hygiene compliance greater than 90%. Using a permanent, real-time technology solution helped to generate meaningful data and encourage long-term change in caregiver hand-hygiene habits.
Brazell (2014) conducted a study where clinical leaders used radio frequency identification technology to monitor hand hygiene compliance in an organization after installation of a hand hygiene monitoring system. HCWs earned no-cost incentives from this measure: caregivers with the highest compliance scores were given first priority in selecting preferred shifts for the upcoming pay period using an existing self-scheduling program. This cost-free and highly beneficial incentive system achieved significant improvements across a variety of care areas. These efforts resulted in greater employee compliance to hand hygiene protocol, helped in reduction of HCAIs and promoted a safer patient care environment.
Zigbee technology. Marra et al. (2014) conducted a detailed study after the implementation of a wireless Zigbee technology in a tertiary care hospital in São Paulo, Brazil, where a significant increase in hand hygiene compliance was noted. This system was activated through a wireless identification device (badge) and recorded when a HCW performed hand hygiene using alcohol electronic dispensers inside the patient room. Marra and colleagues found there was a reduction in HCAIs that led to an improvement in infection control through the use of this technology.
Proventix’s RFID. Meyer (2014) assessed the Proventix’s RFID technology to assess caregiver movement and correlate it with their hand hygiene activity at existing sanitizer and soap dispensers. This technology productively induced staff to follow proper hand hygiene patterns, and appealed to HCWs individually and resourcefully via dynamic communication. The first unit tested increased hand hygiene compliance by 160.6%. This specific technology performs monitoring, reporting and analytics of the hand hygiene moments.
DebMed technology. Kelly, Blackhurst, McAtee & Steed (2016) evaluated electronic hand hygiene monitoring as a tool. There was a 25.5% increase in hand hygiene compliance over the entire analysis period. They installed an automated networker dispenser ( DebMed GMS/ DebMed USA/Charlotte, NC) and recorded usage counts by direct observation with feedback. During this time, the rate of health care–associated MRSA decreased by 0.114 per 1,000 patient days (42% from baseline), preventing an estimated 24 MRSA infections during the observation period. This electronic dispenser improved hand hygiene compliance, improving patient safety and resulted in reduced HCAIs.
Hand Hygiene Auditing Tools
Handy audit. Boscart, Lee, Márquez-Chin, Tsang, & Fernie (2011) compared the HandyAudit, a novel hand hygiene compliance measurement system, with the standardized observation tool that was being used by the Ministry of Health in Long-Term Care in Ontario, Canada. This system permitted auditors to record actions of HCWs using a hand held personal digital assistant (PDA). The system analyzed recorded actions and automatically calculated hand hygiene opportunities and compliance. Hand cleanliness data and compliance rates of the unit staff were collected using both the paper tool and the HandyAudit. Systemm which removed the potential for biased analysis when recording activities. Auditors recorded what they observed, and the system robotically verified the results. Additionally, the Handy Audit system eradicated the need for observer dictation, which eliminated allied transcription miscalculation as well as saving time. This new hand hygiene compliance measurement method could therefore advance the accuracy and competency of computing hand hygiene compliance among HCWs.
Video technologies are used to provide responses on regularity and quality of hand hygiene techniques. There are Sealed Air ‘Smart Video’ technology that supply images/films when individuals do not use correct personal protective apparatuses when expected. Armellino et al. (2013) and Srejic (2015) conducted studies using video auditing technologies. Cameras were mounted in hand washing units which had viewpoints restricted to hand washing areas and sanitizer dispensers to protect patient privacy. Motion antennas were installed in the doorway of each patient room, enabling recognition of all doorways and exits. When activated, the doorway motion sensor sent a signal with a time stamp to the digital video recorder. Arrowsight, Inc (Mount Kisco, NY), the third party technology company used, remotely uploaded the video from the digital video recorder to analyze hand hygiene measurements. These independent auditors reviewed 20 seconds of video data surrounding each sensor-detected event to document compliance. The examiner rated actions as a pass, fail, or not able to be scored. The data were regularly uploaded into an electronic record and results supported increased hand hygiene compliance from 30% to 90%.
Technologies like ‘Smart Patient Room’ enable hand hygiene auditing by positioning monitors and lights with RFID for recording and giving feedback on hand hygiene. Some technologies are monitored through tap use and quality is judged by length of wash. Some dispensers’ usage helps to compare expected hand hygiene rates asked for on the validated context-specific WHO 5 Moments benchmark. Dispenser systems using RTLS help to record hand washing usage in specific units. Thermal detection sensors monitor activity within defined zones and compare it with expected activity within health care settings (Dawson & Mackrill, 2016).
Measuring the Effectiveness
Outcomes can be seen in the literature through the measurement of HCW hand hygiene moments data, dispenser count data, the collection of pre and post hand hygiene technologies implementation data, as well as healthcare associated infection rates. Another way to measure outcomes is to collect data of hand hygiene compliance before the HCWs awareness before and after auditing technology implementation. Limper, Garcia-Houchins, Slawsky, Hershow, & Landon (2016) proposed a rigorous method for validation of hand hygiene monitoring technologies (HHMT) through a designed protocol that calculated the accuracy of the technologies. For instance, sensitivity of HHMT can be measured using direct observation to identify true-positive events (those captured through both direct observation and counted by HHMT), false-positive events (events that are not observed but are counted by HHMT), and false-negative events (those which are observed but are not captured by HHMT).
According to Dawson and Mackrill (2015) and Cheng et al (2011), integration of WHO’s (2009) five moments of hand hygiene can be analyzed to validate efficiency of HHMT. If the technology shows a positive approach towards any of these moments or all of these moments, their competence can be measured to validate their usefulness to monitor hand hygiene compliance.
Advantages & Disadvantages
Hand hygiene technologies can help researchers and administration to know the ‘who, when and where’ details of HCWs hand washing behaviors since they automatically monitor compliance rates and trends in a real time system. These technologies help to support work flow and increase patient safety and contribute to improved HCW situational awareness to promote a good safety culture within healthcare. They help to monitor and document improvements in hand hygiene compliance across institutions which in turn should help to reduce serious HCAIs.
There are also some disadvantages in using hand hygiene technologies. First, it is somewhat unclear how HHMT correlates with directly observed hand hygiene compliance, primarily due to cost of the HHMT equipment. Their actual cost effectiveness remains uncertain. Also, the five moments for hand hygiene concept are not fully integrated in all HHMT at present. Different algorithms are needed to characterize methods of hand hygiene occurrences as an alternative of compliance, thus stronger evidence is needed to prove the efficiency of HHMT overall. Future studies and research are needed to measure the impact and present a complete assessment of these technologies.
As a nurse, it is important to know about the evolving technologies in hand hygiene and the critical importance of following hand hygiene guidelines consistently in practice. Proper infection control measures are absolutely critical for quality patient care. Proper hand hygiene is also a key factor to promote patient safety. Every nurse must be cognizant of basic hand hygiene practices as well as the auditing system used in their employing institution (whether direct observation or through the use of HHMT) to both reduce the incidence of hospital acquired infections and improve both HCW and patient hand hygiene compliance. Measurement of HCWs hand hygiene compliance is a common approach adopted by many hospitals to support infection control and patient safety. An evidence-based systematic approach for using hand hygiene technologies can ensure that the expense and training needed to use these technologies well result in actual reduced HCAI rates and improved patient outcomes.
Armellino, D., Trivedi, M., Law, I., Singh, N., Schilling, M. E., Hussain, E., & Farber, B. (2013). Replicating changes in hand hygiene in a surgical intensive care unit with remote video auditing and feedback. American Journal Of Infection Control, 41(10), 925-927. doi:10.1016/j.ajic.2012.12.0
Bailey, C. (2014). Success and expansion of hand hygiene technology through executive involvement, goal Setting, competition and caregiver recognition. American Journal Of Infection Control, 42S103-4. doi:10.1016/j.ajic.2014.03.231
Booth, K. A. (2016). Preventing Healthcare-Associated Infections (HAIs). Journal Of Continuing Education Topics & Issues, 18(1), 18-23.
Boscart, V. M., Lee, J. H., Márquez-Chin, C., Tsang, M., & Fernie, G. R. (2011). Validation of a novel electronic auditing tool for hand hygiene activity. Canadian Journal Of Infection Control, 26(2), 119-125.
Brazzell, B. D. (2014). No cost reward for improving and sustaining high hand-hygiene compliance. American Journal Of Infection Control, 42S24. doi:10.1016/j.ajic.2014.03.074
Center for Disease Control (CDC). (2016). Healthcare-associated Infections. Retrieved from https://www.cdc.gov/hai/index.html
Cheng, V. C., Tai, J. M., Ho, S. Y., Chan, J. W., Hung, K. N., Ho, P. L., & Yuen, K. Y. (2011). Introduction of an electronic monitoring system for monitoring compliance with Moments 1 and 4 of the WHO 'My 5 Moments for Hand Hygiene' methodology. BMC Infectious Diseases, 11(1), 151.
Dawson, C. H., & Mackrill, J. B. (2014). Review of technologies available to improve hand hygiene compliance – are they fit for purpose? Journal Of Infection Prevention, 15(6), 222-228. doi:10.1177/1757177414548695
Kelly, J., Blackhurst, D., McAtee, W. & Steed, C. (2016). Electronic hand hygiene monitoring as a tool for reducing health care-associated methicillin-resistant Staphylococcus aureus infection. American Journal of Infection Control, 44(8), 956-7. doi: 10.1016/j.ajic.2016.04.215
Klee, A. K., & Onofre, B. (2014). Setting a high bar: increasing hygiene compliance rate using an automated hand-hygiene monitoring technology. American Journal Of Infection Control, 42S73. doi:10.1016/j.ajic.2014.03.175
Limper, H. M., Garcia-Houchins, S., Slawsky, L., Hershow, R. C., & Landon, E. (2016). A validation protocol: assessing the accuracy of hand hygiene monitoring technology. Infection Control & Hospital Epidemiology, 37(8), 1002-1004. doi:10.1017/ice.2016.133
Marra, A. R., Sampaio Camargo, T. Z., Magnus, T. P., Blaya, R. P., dos Santos, G. B., Guastelli, L. R., & ... Edmond, M. B. (2014). The use of real-time feedback via wireless technology to improve hand hygiene compliance. American Journal Of Infection Control, 42(6), 608-611. doi:10.1016/j.ajic.2014.02.006
Meyer, B. (2014). Technology enhanced hand hygiene and increased patient satisfaction. American Journal Of Infection Control, 42S104-5. doi:10.1016/j.ajic.2014.03.233
Morgan, D. J., Pineles, L., Shardell, M., Young, A., Ellingson, K., Jernigan, J. A., & ... Perencevich, E. N. (2012). Automated hand hygiene count devices may better measure compliance than human observation. American Journal Of Infection Control, 40(10), 955-959. doi:10.1016/j.ajic.2012.01.026
Srejic, E. (2015). Remote Video Auditing with Feedback Boosts Compliance, Infection Prevention. Infection Control Today, 19(2), 8-12.
World Health Organization (WHO). (2009). WHO Guidelines on Hand Hygiene in Health Care. First Global Patient Safety Challenge Clean Care is Safer Care. Retrieved from http://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng…
Sneha Divakaran Samuel, originally from India, is pursuing a Masters in Nursing Administration at Indiana University of Pennsylvania. She is a registered nurse and midwife in India, and graduated with a BSN from Rajiv Gandhi University of Health Sciences in Bangalore, Karnataka, India in 2011. She has worked as an Occupational Health Nurse for two years and also worked as a Healthcare Administrator for another two years in India. In 2017, she presented this paper at an international healthcare conference in Chicago.