Observation of HCP involves directly watching hand hygiene behavior and allows prospective recording of the number of hand hygiene indications, opportunities, and actions. When choosing a tool to measure hand hygiene compliance, it is important to know which indications will be captured. Hand hygiene compliance is calculated by dividing the number of hand hygiene actions performed when an opportunity exists by the total number of hand hygiene opportunities.^7,31

Opportunities represent the points in time within the care process when hand hygiene should be performed, as specified by indications. An opportunity exists whenever at least one of the indications for hand hygiene is present and observed.^7,31 Since the WHO published its guidelines, the definition of hand hygiene opportunities has focused on the My 5 Moments (M5M) for hand hygiene: before patient contact, before aseptic task, after body fluid exposure risk, after patient contact, and after contact with patient surroundings.^7,32 Another method that is routinely applied is room entry and exit monitoring (entry/exit method). Because most U.S. facilities have wall-mounted alcohol hand rub stations outside patient rooms due to fire code regulations, it is significantly easier to observe entry/exit compliance with hand hygiene practices compared with M5M.³³ In a U.S.-based study, researchers were able to observe many more entries and exits than opportunities before and after patient contact. In addition, opportunities to perform hand
hygiene after touching patient surroundings (Moment 5) was observable the same number of times as before patient contact, whereas opportunities after patient contact were less frequently observable.³³ A European study performed by Stewardson et al. found that the moments observed in the entry/exit method were very comparable to Moments 1 and 4 in the M5M method, whereas Moments 2, 3, and 5 rarely occur.³⁴

A U.S. Veterans Health Administration (VHA) survey²⁸ revealed considerable variation in how hand hygiene measurement was implemented. The study demonstrated that 12 hand hygiene opportunities were used system-wide and were derived from CDC and WHO guidelines along with the existing VHA Hand Hygiene Directive.^2,7 Data from this VHA study showed that the three most frequently reported opportunities were room exit (71.9%), room entry (69.1%), and after removing gloves (60.4%). The proportion who follow the M5M of hand hygiene guidelines were 56.1% before touching a patient, 48.2% before clean/aseptic procedure, 47.5% after body fluid exposure, 57.6% after touching a patient, and 48.9% after touching patient surroundings. None endorsed only the M5M as recommended by guidelines, but 41.1% reported monitoring all five Moments in addition to other opportunities.²⁹ Importantly, the authors of the M5M themselves acknowledge the difficulty of observing all 5 Moments.³²

Direct Observation Direct observation is considered the gold standard method for evaluating hand hygiene compliance.^2,13,35 The WHO recommends observing a minimum of 200 opportunities during each measurement period in a specific setting (eg, hospital or ward) to allow for meaningful comparison before and after hand hygiene improvement interventions.⁷ Using observational data collected in a multicenter, prospective cohort study, Yin et al. estimated how many hand hygiene opportunities must be observed to statistically compare changes in hand hygiene compliance from period to period using standard sample size calculation methods (Table 4-1).³⁶ In this way, it is possible to predetermine the number of hand hygiene opportunities needed on the basis of an improvement goal or target compliance rate.

Others have advocated measuring the volume of hand hygiene products consumed in liters per 1000 patient days and using electronic hand wash counters as options for evaluating hand hygiene compliance.^13,37 There are limitations for this approach because product measurement can be difficult to tie directly to opportunities for hand hygiene and measuring product use does not reveal whether HCP perform hand hygiene when indicated and can be inaccurate and produce misleading results.^13,31

One study found that episodes observed represented only 1.3% of the estimated number of hand hygiene opportunities.²⁴ The same study found a strong correlation between the number of product dispensing episodes per patient days and ABHR consumption per patient days, but there was no correlation between the rate of hand hygiene adherence and ABHR consumption per patient days. However, studies employing direct observation are likely biased by the “Hawthorne effect”.³⁰ This may explain why in 2009 The Joint Commission led a quality improvement study targeting hand hygiene compliance, in which facilities reported compliance as high as 85%, rather than the 48% measured using more accurate methods.³⁸

The Hawthorne effect is a prevalent observer effect that causes behavioral changes among participants of epidemiological studies or infection control interventions.³⁹ Reducing the observation duration, frequency, or intensity can reduce the impact of the Hawthorne effect.^36,39 The longer the observers remained on the unit, the higher the measured hand hygiene compliance, which has been attributed to the Hawthorne effect.³⁶ The Hawthorne effect has been demonstrated to have a “performance ceiling”.³⁹ In one study, the influence of the Hawthorne effect on hand hygiene performance increased over time until this performance ceiling was reached.⁴⁰ The compliance rate increased in the first 10 minutes of observations but started to flatten out at 95% as auditors stayed more than 15 minutes on the ward.⁴⁰ Limiting direct observation periods to ˜15 minutes to minimize the Hawthorne effect and determining the required number of hand hygiene opportunities observed per period on the basis of statistical power calculations are expected to improve the validity of hand hygiene surveillance program.³⁶

Scherer et al.⁴¹ demonstrated that the Hawthorne effect introduces a significant amount of bias when hand hygiene compliance is measured via overt observation, the method almost universally utilized by hospitals.^{35,39,42,43,44} In this recent study, the absolute difference in hand hygiene compliance estimated between the standard and new audit (secret shopper) 15-minute method was ˜30%.⁴¹

Much work remains in standardizing direct observation practices, particularly training and validating observers, if more than one observer will be collecting data.⁴⁵ Reliability among observers is often referred to as observer interrater reliability or observer interrater agreement. After two or more observers observe and document the same event, observer interrater agreement is determined by comparing the amount of agreement or disagreement in their measurements.^45,46

Automated Hand Hygiene Methods Electronic hand wash counters on ABHR dispensers are an important tool for obtaining data about hand hygiene, offering a novel and automated way to capture hand hygiene adherence in the hospital setting,^37,47,48,49 principally in the intensive care unit (ICU).²⁴ Current evidence supports electronic hand wash counters as a method to supplement but as yet do not supplant direct observation, since current systems are not able to evaluate the hand hygiene quality that HCP perform during ABHR use nor do they typically allow for immediate peer-to-peer correction at point of care.^24,48,50

Interestingly, it has been reported that directly observed adherence rates could be inaccurate because they did not correlate with volumes of product used, assuming that the number of opportunities for hand hygiene was relatively stable. In one such study, ICU nurses surreptitiously recorded opportunities for hand hygiene and compliance on a handheld personal digital assistant (iPod, Apple) using an application (iScrub).^51,52 In another study, the number of nurse visits to patient rooms was measured by a nurse call system, which was installed in two step-down units.⁵³ The additional metric of compliance with the use of ABHRs by the nursing staff allowed calculation of the number of alcohol rub aliquots dispensed/number of nurse visits to patient rooms.⁵³

Generally, hand hygiene studies using observers have 60-minute hand hygiene observation periods^13,24,30,36; however, electronic counters record 24 hours per day. A 12-week study measured hand hygiene compliance with direct observation, electronic counting devices on dispensers, and measurement of the volume of hand hygiene products used.²⁴ Direct observation yielded a compliance rate of 62%, but there was no correlation with observed compliance and daily product use per patient day. Another study assessed hand hygiene compliance through a 30-week quasiexperimental method using automated count technology and direct observation by a secret shopper with a feedback intervention.⁵⁴ Electronic hand hygiene dispenser counts increased significantly in the postintervention period relative to the preintervention period, with an average count per patient day increasing by 22.7 in the neurology ICU and 7.3 in the cardiac care ICU. However, direct observation of compliance did not change significantly (percent compliance increased by 2.9% in the neurology ICU and decreased by 6.7% in the cardiac care ICU). The investigators concluded that passive, electronic monitoring of hand hygiene dispenser count does not correlate with direct human observation of hand hygiene, and this electronic device was more responsive than direct observation to a feedback intervention.⁵⁴

Electronic hand hygiene systems are designed to ensure that HCP perform hand hygiene prior to patient care and issue an automated notice to do so.⁵⁵ One study placed electronic monitoring devices on AHBR dispensers, which also had motion detectors, outside 12 patient room entrances on one unit.⁵⁶ The investigators defined a hand hygiene opportunity as an entry to or an exit from one of the 12 rooms. If hand hygiene was not performed on entry or exit, the device produced a flashing light and a series of three simultaneous beeps, along with a prerecorded voice prompt that said, “Please wash your hands.” The system recorded each hand hygiene opportunity and each time an HCP dispensed hand rub in conjunction with the opportunity. The authors concluded that the electronic devices not only effectively monitored hand hygiene adherence but also facilitated improvement in compliance from a baseline of about 36% to about 70% after the electronic monitoring devices were in use. Another group conducted a two-phase intervention study that included 4 weeks of direct observation of hand hygiene compliance (phase 1), followed by a 2-week evaluation of a hand hygiene alerting system in which nurses wore alcohol-sensing badges.⁵⁷ Room sensors detected room entry and exit by HCP wearing badges. The badge alerted HCP for the need to perform hand hygiene using a light and an audible reminder embedded in the badge. The light on the badge turned green if the sensor embedded in the badge detected alcohol on the
healthcare provider’s hands within a set number of seconds after entering the room but turned red if alcohol was not detected by the badge. All of the data from the badges were transmitted via wireless telemetry to a software application where individual HCP compliance rates could be monitored. Using this system, investigators demonstrated a significant 23% improvement in hand hygiene compliance.

Another promising technology employed a hand hygiene monitoring system that uses a wall-mounted sensor to create an infrared zone around a patient’s bed, which can detect the presence of badge-wearing HCP near the bed.⁵⁸ The only inconvenience is that HCP needed to pass their hands under another sensor that detects alcohol hand rub on their hands. When this occurs, a light on the badge turns green and the healthcare provider is given credit for being compliant. If this is not done, the badge vibrates to remind the provider to clean their hands. As with the previous technology, the hand hygiene compliance using this system was very high (94%).

RFID (Radio-Frequency Identification) It has been suggested that RFID technology may be useful in monitoring hand hygiene compliance. It is important to note that this technology is expensive and generates high maintenance costs, though these systems could be cost-effective when there are many tags and only a few receivers. Another important consideration is that this technology is not yet widespread. The great attractiveness of RFID technology is that the badges do not require batteries. The use of other wireless technologies (such as Wi-Fi or ZigBee) will require the use of buttons or buttons with batteries. However, the maintenance and replacement of the batteries may prove easier to maintain and may be cheaper than the maintenance and hardware for RFID.

Wireless Technologies Other studies have evaluated new options for identification technologies.^56,57,58 The most common currently in use are Wi-Fi (wireless system based on IEEE 802.11 standards) and ZigBee systems (wireless communication protocols based on IEEE 802.15.3 standards).^59,60,61 Both types of systems have lower-cost receivers that are relatively easy to maintain and can be portable. Many medical device manufacturers are already using this technology to exchange information.^48,49 In addition, mobile devices with Wi-Fi raise the possibility of new applications (eg, the use of mobile phones for HCP identification or communication). The major inconvenience of this technology would be the need to use batteries in a badge.⁴⁸ Other limitations of badge-based systems include their complexity and cost compared with direct observations or group monitoring systems.⁴⁹ Several systems have suffered from poor accuracy in detecting hand hygiene opportunities,^62,63 whereas others have showing reasonably good accuracy.^61,64,65 A potential disadvantage of a ZigBee system is that accurate measurement may require multiple beacons in an area or combination with another technology since some existing systems may incorrectly credit two healthcare providers with a hand hygiene event if the providers are very close in proximity.^48,66

A future concept is to develop a wireless ID device to detect and link HCP hand hygiene with a given ABHR dispenser in a patient room. This technology would be equipped with automated warning lights and warning sensors close to the patient bed. These technologies, when integrated with a database, would allow for automated reports of HCP entering rooms, hand hygiene adherence, and a log of patient care episodes per each healthcare provider. This would allow implementation of a real-time feedback loop in order to improve hand hygiene compliance. Feedback loops are profoundly effective tools for changing human behavior, which are based on a simple premise—give people information about their actions in near-real time; then show them how to change those actions to immediately improve behaviors.⁶⁷

The integration of these new technologies into medical equipment or within inpatient beds is not yet widespread, likely due to cost and difficulty of necessary infrastructure. Even those institutions with the economic capability to implement hand hygiene electronic systems need to consider an interface with engineering to examine whether there may be interference with existing equipment or overload of existing wireless networks.⁴⁸ Further data are needed to determine the proportion of hand hygiene opportunities captured by these systems to avoid any miscalculations regarding hand hygiene compliance rates (eg, when HCP entering the room do not touch the patient or the environment).^48,49

Video Surveillance Armellino et al. studied the placement of video cameras with views of every sink and hand sanitizer dispenser to record hand hygiene of HCP.⁶⁸ Sensors in doorways identified when an individual entered or exited. When video auditors in another country observed a HCP performing hand hygiene upon entering or exiting, they assigned a pass; if not, a fail was assigned. During a 4-month baseline period of remote video auditing without feedback hand hygiene, compliance <10% was noted. During the 4-month postfeedback period, compliance was 81.6%. The increase was maintained through 75 weeks at 87.9%. Performance feedback was continuously displayed on electronic boards mounted within the hallways, and summary reports were delivered to supervisors by email. The authors concluded that remote video monitoring of hand hygiene with real-time feedback to HCP was responsible for a significant increase in hand hygiene compliance with sustained rates of 80% or greater. Limitations of such systems include the cost of equipment and auditor personnel time, employee privacy, and concerns about possible liability if the confidentiality of video records was not maintained, especially with video feeds and compliance monitoring occurring in different countries.⁴⁹ Given the restricted clinical and infection prevention budgets of most facilities, cost-effectiveness analysis of specific systems will be required before these systems are widely adopted.⁶⁹