Introduction of an electronic monitoring system for monitoring compliance with Moments 1 and 4 of the WHO "My 5 Moments for Hand Hygiene" methodology

Healthcare-associated infection (HCAI) poses a great threat to patient safety in a modern healthcare system. At any point in time, up to 8% of patients in acute care hospital have HCAI, while 19% of patients may have the manifestation of infection after hospital discharge as shown in a cohort study of 4000 patients in UK [1]. In the USA, HCAI is amongst the top ten causes of death [2, 3]. The US Institute of Medicine estimated that preventable adverse patient events, including HCAIs, were responsible for 44,000-98,000 deaths annually in the US at a cost of $17-$29 billion [4].

For these reasons, the World Health Organization (WHO) in 2005 initiated the 'First Global Patient Safety Challenge' aiming to improve patient safety by promoting hand hygiene in healthcare facilities with a multimodal strategy that included the use of alcohol-based handrub at the point of care [5]. Hand hygiene is always considered the cornerstone practice to reduce HCAIs as most pathogen transmission is mediated by the hands of healthcare workers (HCWs) [6]. Numerous studies have demonstrated the benefit of alcohol-based handrub in terms of reducing incidence of endemic infection such as MRSA and outbreak controls [7‐11]. However, the main hurdle remains the poor hand hygiene compliance of our HCWs, especially in clinical settings with high intensity of patient care such as intensive care units. There have been different strategies in enhancing hand hygiene such as our recent introduction of directly observed hand hygiene practice [8, 9]. Another commonly adopted strategy has been regular hand hygiene observation with performance feedback, which is rather labor intensive.

Introduction of an electronic device for monitoring hand hygiene practice can be a simple but innovative idea in solving our limitation in manpower. In fact, previous works have described the use of electronic monitoring systems to record entry and exit from patient rooms as well as frequency of alcohol or soap dispenser use [12‐18]. However, the detail of patient care practice cannot be captured by these systems. To our understanding, this is the first study to introduce an electronic system to monitor the compliance of hand hygiene based on the WHO recommended guidelines among HCWs in open cubicles with multiple beds.

We have successfully implemented an electronic monitoring system (MedSense) for compliance of hand hygiene based on the WHO "My 5 moments for hand hygiene" methodology in a neurosurgical intensive care unit with 6 beds of which 5 are in one cubicle. In contrast to the previously described electronic monitoring devices, which were mainly focused on recording the entries and exits of the HCWs and visitors to or from a single room or the measure of frequency of the alcohol or soap dispenser used; our current system can precisely calculate the hand hygiene opportunities in an open cubicle with multiple beds, which is strategically important in promoting infection control practice. The compliance of hand hygiene tends to be higher with patient care in single rooms with a door, which serves as a reminder to the attending HCWs to perform all necessary infection control measures [23]. Therefore, an electronic monitoring system targeted at patient care in open cubicles is urgently needed. The compliance measured by the system was closely correlated with the finding by manual observation. However, it is interesting to note that the system's compliance data showed that during the periods when the observer conducted the audit, the compliance was 2.8 times higher than the overall compliance for the same days. Similarly, hand hygiene compliance was significantly higher in the HCWs wearing designated badges than shared badges because their performance can be recognized. Intuitively, this makes sense as the HCWs may alter their behavior on knowing the presence of an observer [24]. Both of these observations may be explained by the Hawthorne effect which was also found in another study on the compliance with antiseptic handrub use in intensive care units [25]. Therefore, the overall hand hygiene compliance was only 35.1% for the study unit, which was lower than our previous reports of compliance to hand hygiene by direct observation [10, 11, 23]. Thus, the Hawthorne effect associated with the MedSense was less pronounced than that associated with the infection control nurses. The use of MedSense carries the advantages of reduced manpower requirement and provides an unobtrusive scientific tool for monitoring.

Whether the use of electronic monitoring and alert systems can make an improvement in hand hygiene practice remains controversial in the literature (Table 3). One prospective 1-month study conducted in a 30-bed hematopoietic stem cell transplantation & hematology unit demonstrated an improved compliance of hand hygiene from 36.3% to 70.1% after the provision of audible alert system to prompt HCWs to perform hand hygiene on 12 electronically monitored rooms upon entry and exit [14]. Another study conducted in a 14-bed intermediate care unit showed improved hand hygiene compliance by 37% when a voice-prompt system giving prerecorded messages reminded the individual to wash hands in one of the sinks and dispensers if they had not done so before exiting the room or within 10 seconds [12]. However, the use of electronic monitoring and feedback intervention did not reveal any significant change in hand hygiene compliance in two 20-bed step-down units [15]. In fact, the most recent study on the electronic monitoring device being installed in 20 patient rooms' entrance and 70 dispensers for soap or hand sanitizer in 5 patient care units of a territory hospital in US reported the hand hygiene compliance was as low as 25% without any feedback intervention [18]. Therefore, further investigation has to be performed to understand if a sustained improvement in hand hygiene practice can be achieved by the use electronic monitoring system.

Since the electronic monitoring system is non-intrusive for HCWs and allows information to be continuously collected throughout the day, it can provide concrete data on the performance of individual staff or clinical units at any given time. For instance, the compliance of each HCW can be assessed and compared with the aggregated compliance of all the team members. Positive reinforcement with award can be accorded to HCW who has sustained achievement in hand hygiene, whereas further reinforcement by infection control team can be provided for those who have not complied with the hand hygiene recommendations. As the confidentiality of data is ensured, the system is acceptable to our HCWs, which is similar to the report from Boscart VM et al [16]. As another example, we have identified an interesting intraday pattern that the hand hygiene compliance was significantly lowered to 21.3% between the hours of 12:00 and 14:00. This might be attributable to the rush to finish off work within the period as the morning shift ended at 13:45. The system could report this information to the infection control team so that the issue can be further investigated.

There are several limitations in this study. Firstly, the electronic sensor was not installed in the pocket size alcohol-based handrub during the initial phase of this study. Hand hygiene action when using pocket size alcohol-based handrub has not been analyzed, which may underestimate the overall hand hygiene compliance among our staff. However, we advised our staff to use the bottle size alcohol-based handrub inside the area during the study period. Secondly, the compliance algorithm was configured to only match hand hygiene actions to opportunities when the action occurred at most 90 seconds before or after the opportunity. This may in some cases lead to positive opportunities being incorrectly classified, which would negatively bias the system's compliance. However, the 90-second matching span is not a technical limitation of the system but rather a configurable parameter that was selected based on intuition and the results of a sensitivity analysis of manual observations. Thirdly, while the system can detect the HCW's entry and exit to and from patient zones, it cannot definitively determine the actual sequence of hand hygiene and patient contact, especially when hand hygiene occurs during the event. This is a limitation to the method of inferring patient contact over directly observing it. However, all methods of observation are subject to uncertainty, and in most circumstances, the manual observation closely correlates with the system's findings in the correct sequence. Fourthly, doubt might exist on whether the predefined reference table (described in Table 1) used to predict the probability of patient contact having occurred during an event, which was built based on observations, might be different from the "normal setting". However, in reality, the two were actually quite similar. In order to establish the predefined reference table, observations on the duration of direct patient contact time during various patient care clinical activities were made. The staff performed routine patient care activities during the observational period which were similar to the "normal setting". Finally, we only performed four sessions of hand hygiene observation during the evaluation phase, which may not be able to fully demonstrate the discriminatory power of the electronic system. A three-month evaluation phase is a rather short period. We only obtained baseline data during the study period without making any intervention and may not be able to show any change in incidence of nosocomial infection as reported in the previous study [12]. Though at this stage of its development the cost of this system is not yet defined, this issue remains a concern for resource limited settings. Therefore, a cost-effectiveness analysis must be conducted before the system is to be installed in all clinical units of the hospital. However, priority should be given to those high-risk areas such as intensive care units, coronary care units, and blood and marrow transplantation centers.

Since MedSense can continuously monitor the activity of different professional categories without disturbing their patient care practice, the performance of the individual staff or clinical units can be reviewed from time to time by their respective supervisor, infection control team and the hospital administration. Therefore, timely feedback and intervention can be introduced to enhance the compliance of hand hygiene practice.