Healthcare-acquired infections (HAIs) can put a significant dent in hospitals’ budgets since Centers for Medicare and Medicaid Services refused to reimburse for certain infections not present on patient admission. Adoption of electronic hand-hygiene (HH) compliance systems, which is on the rise, is one way for facilities to address it. Studies clearly demonstrate a correlation between high rates of HH compliance to reduced rates of HAIs.1
“Hand hygiene is the single most important measure one can take to prevent the spread of infection2 ; so, it is not surprising that HH compliance is an area of focus for most U.S. hospitals,” said John Lerner, GOJO SMARTLINK Solutions Business Development Vice President. Lerner added that hospitals in the lowest-performing quartile, with respect to the overall rate of certain HAIs, will see their payments reduced by one percent. “Because of intense pressure to improve quality of care and avoid financial penalties, hospitals have amplified efforts around HAI reduction, including increasing HH compliance,” he said.
Manual observation isn’t enough
The traditional method of establishing HH compliance rates is the observation method, also known as the secret-shopper method. Observation has inherent flaws, not the least of which is the Hawthorne effect, which simply means that people alter their usual behavior to perform better when being watched.
Brent Nibarger, Chief Client Officer, Biovigil Hygiene Technologies, observed, “Manual observation and audit techniques for HH behaviors cannot solve the vast HH compliance gap. If they could, we would not still be fighting the out-of-control infection-risk problems we face in every U.S. hospital. The clinical and economic benefits of closing the HH gap have been well understood and studied for many decades. There are countless reference articles to support the economic cost and associated benefits.” Nibarger believes “the so-called manual-audit gold standard results in massive numbers of patient harm, injury, and death cases every year. Why healthcare providers and consumers continue to accept these risks is disturbing.”
The World Health Organization (WHO) notes that HH monitoring is vital because it establishes a baseline, provides feedback on defective practices as well as improvements, and is useful in evaluating the impact of interventions and in investigating outbreaks. “Promising innovative electronic systems for the automatic monitoring of hand hygiene compliance are now available and can significantly facilitate data collection,” the WHO stated. “They allow continuous monitoring over time and automatic data download and analysis. Importantly, the Hawthorne effect is significantly mitigated and required human resources are minimal.”3
The advantage of electronic HH monitoring systems, according to Lerner, is that they eliminate variables and inconsistencies in measuring HH compliance, and collected data offer a basis for action. He said, “The primary reason for implementing an electronic HH monitoring system is that it allows for the 24/7 collection of robust data that is statistically significant, unbiased, and actionable.”
Joining forces to drive change
Earlier this year nine healthcare companies united to establish the Electronic Hand Hygiene Compliance Organization (EHCO). The consortium’s “purpose is to increase patient safety, reduce avoidable harm, and eliminate unnecessary costs at hospitals nationwide by driving change in HH measurement policy and guidelines at accreditation organizations, government agencies, health insurers, third party payors, and hospitals,” explained Paul Alper, Chairman. EHCO member companies “all produce SMART [systems that measure accurately and in real time] HAND HYGIENE technology that can capture 100 percent of HH events, in virtually real time, and report compliance accurately and reliably or that provide HH products that work with SMART systems,” he said.
Alper also suggested that some healthcare facilities may have been slow to adopt automated HH compliance systems because data supporting efficacy just was not there. That is clearly changing as more convincing data becomes available and hospitals begin to realize the benefits, namely improved patient care and bottom line-savings.
“The case for electronic monitoring is becoming compelling as studies flow into the literature,” Alper said. “At Riverside Medical Center in Kankakee, IL, Bouk et al demonstrated a 39 percent increase in HH compliance with a concurrent 50 percent reduction in hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) infections during the same period using data from a SMART electronic monitoring system.4 Their ACA penalty for readmissions paid in 2013 was eliminated, and no penalty was paid in 2015.”
Alper pointed to another study in which Greenville Memorial Hospital in Greenville, SC, saw fewer Clostridium difficile infections due to a significant increase in HH compliance, according to data obtained from a SMART electronic monitoring system that they had implented.5 “At the same hospital, Kelly et al proved that electronic monitoring improved true HH compliance by over 25 percent and reduced MRSA infections by over 42 percent,”6 cited Alper. “The reduction in MRSA infections resulted in avoided costs of $434,000 per year, based on their actual costs for extra care and length of stay associated with the infections that were eliminated.”6
To receive a compendium of research demonstrating positive impact on clinical, financial, and cultural outcomes, contact [email protected].
5 Moments for Hand Hygiene meets electronic monitoring
The WHO defines five key moments when caregivers should perform hand hygiene: before patient care, before aseptic task, after body-fluid—exposure risk, after patient contact, and after contact with patient surroundings. The WHO strongly encourages manufacturers of electronic HH monitoring “to integrate the 5 moments for hand hygiene concept into the design of these tools. These new technologies present numerous advantages and may become the future approach to hand hygiene compliance monitoring when available resources permit, and provided that they can reflect the 5 moments for hand hygiene . . .”3
Ron Chappuis, Vice President, DebMed USA LLC said the company has incorporated the WHO 5 Moments for Hand Hygiene into their HH compliance system and described how it takes HH compliance monitoring to the next level. “When discussing HH compliance, the highest standard has to be the only standard,” he said. “Doing HH properly is pretty straightforward and easy to achieve, with the right system, such as one that monitors around the WHO 5 Moments for Hand Hygiene.”
The DebMed Electronic Hand Hygiene Compliance System provides feedback on 100 percent of HH behaviors 24/7/365 by signals sent from soap and sanitizer dispensers to a dedicated server that converts data into real-time, customized, HH-compliance performance reports. “As a badge-free system, the individual does not need to wear or do anything differently,” noted Chappuis, “simply adhere to the standard. The reports document unit-level compliance rates based on real-time comparisons of HH performance versus HH opportunities, based around total adherence to the WHO 5 Moments of Hand Hygiene.”
Referring to the Greenville Memorial Hospital study noted earlier, Chappuis said the facility used the DebMed system to achieve those notable results. “The DebMed System conserves resources by reducing the financial risk inherent in health-acquired conditions, readmission penalties, and minimizing costly capital investments.”
However, using compliance systems to achieve high standards of care must be cost-effective, easy to use by healthcare and information technology staff and not disruptive to workflow. In other words, systems should improve, rather than hinder, their ability to perform effectively and efficiently.
With those factors in place, “accurate, personalized feedback leads to accountability around WHO guidelines; this is critical to ensure the highest standards of care for every patient,” said Mert Hilmi Iseri, CEO, SwipeSense. “The SwipeSense System offers an automated audit of all HH activity from across the organization anytime, anywhere. Individual Compliance Reports are accessible on-demand from any desktop or mobile device. Healthcare workers wear intelligent badges to collect room entry and HH data, which then goes to a centralized dashboard for the entire hospital. The system can report data by individual, role, or a specific location for long-term improvement in HH scores. The system captures all HH events before, during, and after a patient interaction. The key is attributing this data to the individual healthcare worker; this leads to trends and insights for effective behavior change.”
Chris Hermann, PhD, Chief Executive Officer, Clean Hands Safe Hands (CHSH), said the three components of the HH compliance system—Badge Reel, Sensor, and Network Hub—are based on wireless technology. “The CHSH Bluetooth system uniquely identifies individual or group employee compliance and records HH events throughout the hospital,” he explained.
The CHSH Sensors mount to all dispensers of alcohol and soap, and their Natural Language Voice Reminder provides a real-time reminder to staff only when needed, so as not to interfere with work-flow. This audio message is customizable and can be changed as needed. “This unique verbal reminder is an effective way to encourage HH and improve patient awareness and satisfaction,” said Hermann. A cloud application stores and manages CHSH HH data, and reports can be generated to gauge organization effectiveness and compliance and determine where problem areas are or to promote and reward high compliance.
“The Sensors record what action was taken and send that information to our cloud application via a secure Ethernet connection. The wireless network used to transmit the data is created by the Sensors and requires no additional network hardware. The CHSH System is adaptable to varying patient conditions, flexible to differing alcohol or soap dispensers, requires no facility changes, and provides robust reporting dashboards at the individual and/or group level.”
Hermann continued, “Our technology can improve hospitals’ ability to improve HH compliance through verbal reminders and individual dashboards; improve data collection through the implementation of a non-disruptive monitoring system; raise awareness on individual and collective best practices; shift clinician focus from data collection and analysis to infection prevention and control; and reduce direct costs associated with HAIs.”
Citing an estimated $10 billion in direct costs per year attributable to HAIs,7 Hermann added, “It has been estimated that improvements in HH compliance monitoring can reduce HAIs by 40 percent to 70 percent.”8 We estimate the direct costs relative to a 2,500-bed system to be approximately $25 million dollars annually, plus potential CMS fines.
AiRISTA Flow Inc. is another company that employs wireless technology, using BLE and RFID tags, to monitor HH compliance. Emily Nardone, Director, Product Marketing, explained that the AiRISTA Flow Hand Hygiene Solution provides customizable dashboards for executive-level reporting and insight in real-time. “Whether you want to monitor specific individuals across an entire facility or groups of individuals in select vicinities, the AiRISTA Flow platform will display custom metrics in a user-friendly interface to meet any organizational objective by leveraging BLE and RFID, all over Wi-Fi.”
Nardone highlighted the cost and time advantages of their technology. “AiRISTA Flow Hand Hygiene Solutions remove any need for physical documentation by a third-party to save costs and overhead associated with staffing additional personnel, plus AiRISTA Flow can deliver PDF reports automatically to any inbox. While HH programs that include technology monitoring systems such as AiRISTA Flow’s have been proven to reduce HAIs, the ultimate beneficiaries are the patients who get more devoted attention from caregivers free from the burden of manual HH documentation procedures.”
Nibarger said the cloud-based Biovigil Hygiene Technologies’ HH compliance system uses electronic badges with built-in ability to track, monitor, capture, and analyze dozens of highly detailed metrics related to HH opportunities and user behaviors. The system also can remind and intervene with users, if needed, to perform HH. “This is how and why our system is so effective at filling the compliance gap and in turn lowering HAI risks by 30 percent to 80 percent,” informed Nibarger. “The Biovigil badge actively communicates what is happening in real-time to patients and family members at the point-of-care with every user interaction. This unique engagement, communication, and accountability feature is critical to achieving and sustaining 98-plus percent compliance levels on a 24/7/365 basis.”
He said Biovigil’s system also captures WHO 5 Moments for Hand Hygiene activities; alerts for cross-contamination events; has a special feature for isolation rooms (e.g., Clostridium difficile) that ensures users wash their hands upon exit with special soap products and water; and requires no capital investment or installation risk.
The GOJO SMARTLINK Hand Hygiene Solution accommodates monitoring at a group, individual, role, and area level. It includes an app that complements direct observation, individual monitoring, activity monitoring, and clinician-based support.
“We manage the cost and value delivery side of the equation,” said Lerner, “so hospitals can optimize against their own unique situations to maximize their return on investment. Our SMARTLINK Solution can be customized to a healthcare facility’s HH protocols and practice, which delivers a clear picture of HH compliance rates. Our Observation System, launched last year, can be customized for specific HH protocols, including in/out compliance, the World Health Organization’s Five Moments for Hand Hygiene, and the Canadian Four Moments of Hand Hygiene.”
For healthcare facilities not quite ready to take the leap to a totally electronic system, Ecolab’s Hand Hygiene Observation Tool may be a good choice as a bridge between manual observation and more expensive high-tech options. “Ecolab’s Hand Hygiene Observation Tool provides an easy and cost-effective solution for performing HH audits by direct observation. The tool saves time by eliminating the need for manual data transcribing and report building,” explained Neil Ramchandani, Assistant Marketing Manager.
A mobile device captures HH observations, which are wirelessly uploaded to a secure portal that generates reports for managers to access at anytime. “Some of the reports available include compliance by role, by unit, by opportunity, compliance trends over time, and personal protective equipment,” noted Ramchandani. “In addition to providing feedback on HH compliance, the Hand Hygiene Observation Tool also allows the facility to capture valuable information around HH technique with the use of a timer to capture how many seconds HH was performed. A trained observer can also audit whether proper HH technique was used.”
Ecolab’s Hand Hygiene Observation Tool gives facilities the option to capture either WHO’s 5 Moments for Hand Hygiene or just the entry and exit moments. Linda Homan, Professional Clinical Services Manager, went on to add, “The WHO 5 moments are evidence-based and are designed to describe the natural workflow of care. However, it has been challenging to capture compliance events accurately for all 5 moments via visual observation. Because of this challenge, Ecolab’s Hand Hygiene Observation Tool gives facilities the option to choose between the entry/exit methodology and WHO’s 5 Moments for Hand Hygiene.”
Ramchandani referred to a study conducted at Duke University Medical Center, which demonstrated that use of Ecolab’s tool increased HH compliance, saved costs, and reduced HAIs. “The study showed an increase of 1 percent in HH compliance resulted in $40,000 savings to a facility.9 If cost-effective HH compliance solutions such as the Hand Hygiene Observation Tool can drive even a 1 percent increase in compliance, the solution pays for itself many times over.”
Location, location, location
Hand-hygiene products must be conveniently located or they may not be used as prescribed, noted Tom Bergin, Health Care Marketing Director for SCA’s Away from Home Professional Hygiene business in North America.
“Studies indicate that HH behavior alone is not the only key factor for achieving higher compliance rates; the placement of soap and sanitizer dispensers can play an important role, too,”10 he said. “Optimizing dispenser placement can result in a 50 percent usage increase.11 With the WHO’s 5 Moments in mind, SCA and its global hygiene brand Tork have created principles for supporting hospitals in dispenser-placement decisions. These principles are built around four areas commonly found in hospitals: the hospital entrance, semi-private patient rooms, private patient rooms, and nurse stations.”
For example, Bergin pointed out that few visitors perform HH when entering a hospital, so it is an important place to position dispensers, along with clear and simple information to educate visitors about necessity of use. Semi-private patient rooms require more than one dispenser and they should be placed in consistent and familiar locations for convenient access. Dispensers in private patient rooms should be immediately visible upon entering and located where care is frequently performed. Nurse station entrances should also have dispensers conveniently placed on the walking route. Bergin said an SCA-sponsored study showed that dispensers placed by the nurse station were used more frequently than dispensers placed on the wall behind patient beds.12
References
1. Sickbert-Bennett EE, DiBiase LM, Willis TM, et al. Reduction in healthcare-associated infections by exceeding high compliance with hand hygiene practices. Emerg Infect Dis. 2016;22(9);1628-1630.
2. Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recomm Rep. 2002;51(RR-16):1-45.
3. World Health Organization. Clean care is safer care: hand hygiene monitoring and feedback. www.who.int/gpsc/5may/monitoring_feedback/en/. Last accessed September 1, 2016.
4. Bouk M, Mutterer M, Schore M, et al. Use of an electronic hand hygiene compliance system to improve hand hygiene, reduce MRSA, and improve financial performance. Presented at: 43rd Annual Conference of the Association for Professionals in Infection Control and Epidemiology, Inc.; June 2016; Charlotte, NC.
5. Robinson N, Boeker S, Steed, Kelly W. Innovative use of electronic hand hygiene monitoring to control a Clostridium difficile cluster on a hematopoietic stem cell transplant unit. Presented at: 41st Annual Conference of the Association for Professionals in Infection Control and Epidemiology, Inc; June 2014; Anaheim, CA.
6. Kelly JW, Blackhurst D, McAtee W, et al. Electronic hand hygiene monitoring as a tool for reducing healthcare-associated methicillin-resistant Staphylococcus aureus infection. Am J Infect Control. 2016;44(8):956-957.
7. Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039-2046.
8. Boyce JM. Hand hygiene compliance monitoring: current perspectives from the USA. J Hosp Infect. 2008;70(Suppl 1):2-7.
9. Cummings KL, Anderson DJ, Kaye KS. Hand hygiene noncompliance and the cost of hospital-acquired methicillin-resistant Staphylococcus aureus infection. Infect Control Hosp Epidemiol 2010;31(4):357-364.
10. Boog MC, Erasmus V, De Graaf JM, et al. Assessing the optimal location for alcohol-based hand rub dispensers in a patient room in an intensive care unit. BMC Infect Dis. 2013;13:510.
11. Thomas BW, Berg-Copas GM, Vasquez DG, et al. Conspicuous vs customary location of hand hygiene agent dispensers on alcohol-based hand hygiene product usage in an intensive care unit. J Am Osteopath Assoc. 2009;109(5):263-267.
12. Murray R, Chandler C, Clarkson Y, et al. Sub-optimal hand sanitiser usage in a hospital entrance during an influenza pandemic, New Zealand, August 2009. Euro Surveill. 2009:14(37). Pii 19331.
Susan Cantrell
Susan Cantrell is Infection Prevention Editor for Healthcare Purchasing News.