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Infection Control Programme and World Health Organization Collaborating Centre on Patient Safety—Infection Control & Improving Practices, University of Geneva Hospitals and Faculty of Medicine, Geneva, SwitzerlandDepartment of Infectious Diseases, Centro Hospitalar Lisboa Norte and Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
Address correspondence to Didier Pittet MD, MS, Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, 4 Rue Gabrielle-Perret-Gentil, 1211 Geneva, Switzerland. (D. Pittet).
Infection Control Programme and World Health Organization Collaborating Centre on Patient Safety—Infection Control & Improving Practices, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
Monitoring practices is a crucial element of hand hygiene promotion. It is part of the widely used World Health Organization (WHO) multimodal implementation strategy to improve hand hygiene (Fig 1), proven to be successful in low-/middle- and high-income countries.
A recent meta-analysis showed that the increase in hand hygiene compliance and reduction in health care–associated infection (HAI) are significantly higher when all elements of the multimodal strategy are applied together.
The use of multimodal strategies to implement IPC activities, improve practices, and reduce HAI is endorsed as one of the 8 core components of IPC programs. Importantly, the evidence for this recommendation comes in great extent from the experience of successful hand hygiene promotion all over the world in the last 2 decades.
In the current issue of the American Journal of Infection Control, Boyce provides a clear and very detailed review of the advantages and disadvantages of the currently available methods to monitor hand hygiene.
However, despite substantial technical progress, it still has not revolutionized hand hygiene. This comes as no surprise because, as it has been highlighted, hand hygiene improvement requires behavioral change, facilitated by a multimodal strategy, of which monitoring is only one of the different components.
Automated systems might certainly bring a valuable contribution to monitoring. To optimize it, let us recall the role of direct observation within the multimodal strategy. First, direct observation yields performance data that permits to adapt and improve the hand hygiene implementation action plan. Second, the method developed at the University Hospitals of Geneva also strongly contributes to education and training of frontline health care workers (HCWs). Importantly, immediate and individual feedback provided during auditing is an inestimable moment to improve HCWs' understanding of the My 5 Moments for Hand Hygiene (Fig 1) in practice, and contributes to its promotion. Third, it underwrites institutional safety climate through regular feedback of data, target setting, and the regular presence of trained observers in the wards, reinforcing the institutional commitment to hand hygiene.
; data should be interpreted with caution, but they fulfill the necessary requirements of an improvement action plan. In the current, very careful, extensive, complete, and captivating literature review, Boyce concludes that new methods are needed and would be welcomed to complement the WHO direct observation method, and further contribute to HCWs' hand hygiene compliance improvement.
Nowadays, one can monitor hand hygiene compliance (number of hand hygiene actions performed when an opportunity exists divided by the number of hand hygiene opportunities), consumption of alcohol-based handrub (ABHR), and the quality of the observed hand hygiene action. The WHO direct observation method is able to monitor hand hygiene compliance and the quality of action.
Automated monitoring systems can accurately monitor frequency and volume of ABHR use. Interestingly, some systems are further optimizing this by estimating the expected number of hand hygiene actions in a scenario of 100% compliance with the My 5 Moments for Hand Hygiene, thus providing a denominator for the number of actions systematically collected in the wards by automated ABHR dispensers.
In spite of these and other exciting advances, one should keep in mind that none of the systems available today are able to provide hand hygiene compliance data, simply because it is nearly impossible for an automated system to accurately detect opportunities for hand hygiene. An opportunity occurs when a hand hygiene action potentially interrupts cross-transmission of microorganisms via HCWs' hands.
Cross-transmission is potentially avoided by a hand hygiene action when HCWs sequentially touch a health care zone and the patient, or vice versa (moments 1, 4, and 5), when HCWs' hands access a sterile site (moment 2), or after HCWs' hands move from a contaminated body site (moment 3) (Fig 1). Thus, all the 5 moments are important to avoid cross-transmission between patients, inoculation of microorganisms in critical sites, and to protect HCWs.
A word of caution is required. As seen, automated systems available today use surrogate markers of hand hygiene opportunities that are, for the most part, quite distant from the meaningful 5 moments proposed by WHO.
In addition, if there are fewer attempts to monitor moments 2 and 3, we might depart from the initial objective of hand hygiene monitoring. The risk is to accumulate large amounts of data of questionable relevance. Even if, as mentioned by Boyce,
monitoring moments 1, 4, and 5 provides reasonable estimates of compliance with all the 5 moments, this does not mean that we may safely stop monitoring moments 2 and 3. Monitoring, training, and education go hand-in-hand. Discontinuing the monitoring of moments 2 and 3 could result in a dangerous decrease in compliance, especially with moment 2. In addition, this would go unnoticed because of the very fact that they would no longer be monitored. We respectfully disagree with the idea that monitoring moments 1, 4, and 5 is enough for a successful hand hygiene improvement strategy. Monitoring systems should aim to reflect the 5 moments, which implies taking into account concepts such as patient zone and health care zone and detecting aseptic procedures, potentially contaminated sites, and use of gloves (Fig 1).
Electronic monitoring systems have other great potential as providing constant reminders and immediate feedback to HCWs at the point of care. These can be of great added value in promoting and maintaining behavior change.
Some questions remain unanswered. Although a few single-center, uncontrolled studies show a trend toward hand hygiene improvement, no robust study has definitively demonstrated the added value of electronic monitoring systems in improving hand hygiene and reducing HAI.
In addition, the costs —and thus the cost-effectiveness—of these systems remain to be determined. Further research is needed to demonstrate the possible benefit of the use of direct observation combined with electronic monitoring to change HCWs' behavior and reduce HAI.
To conclude, electronic monitoring devices could provide continuous monitoring, real-time reminders and feedback, and automatic analysis of data and may ultimately save human resources. However, hand hygiene monitoring is not an end in itself, but one element of a multimodal strategy. It provides an outcome indicator that reflects HCWs' behavior and improves the understanding and practices of hand hygiene. To fulfill these criteria, the My 5 Moments for Hand Hygiene concept needs to be reflected by the monitoring systems. Electronic systems are no magic bullet, but constitute a promising tool to further improve hand hygiene and patient safety when integrated in a wider multimodal approach.
We thank Mohamed Abbas for the editing contribution to the manuscript.
World Health Organization
Guide to the Implementation. A guide to the implementation of the WHO multimodal hand hygiene improvement strategy.
Funding/support: D.P. is supported by the Swiss National Science Foundation ( 32003B_163262 ) for hand hygiene research activities and by the Fundação para a Ciência e a Tecnologia ( SFRH/SINT/95317/2013 ).
Monitoring hand hygiene compliance among health care personnel (HCP) is an essential element of hand hygiene promotion programs. Observation by trained auditors is considered the gold standard method for establishing hand hygiene compliance rates. Advantages of observational surveys include the unique ability to establish compliance with all of the World Health Organization “My 5 Moments for Hand Hygiene” initiative Moments and to provide just-in-time coaching. Disadvantages include the resources required for observational surveys, insufficient sample sizes, and nonstandardized methods of conducting observations.