Leading the Change: The Advent of Technology for Improved Patient Safety

A lack of hand hygiene compliance is a major contributor to the high rates of health care-acquired infections in hospitals.

Any health care administrator would agree that hospitals should make every effort to reduce complications and increase patient safety. Hand hygiene tops the list of simple behaviors that can make a big impact on patient safety. High levels of hand hygiene compliance can have a tremendously positive affect on the number of complications experienced by patients in the hospital setting, but the ramifications of poor hand hygiene range far and wide.

According to the World Health Organization (WHO), the typical rate of hand hygiene compliance among health care workers is estimated to average only 38.7 percent (WHO, 2009). While the Joint Commission requires hospitals to monitor hand hygiene as a condition of accreditation, it has not established a standard process for doing so. Hospital officials are then left to determine their own monitoring methods, and most turn to direct observation as their method of choice.

Because direct observation is not a high-tech method for monitoring hand hygiene compliance, it has many limitations. Observers cannot monitor every interaction between clinicians and patients in a hospital 24 hours a day, seven days a week. As a result, it is estimated that direct observation monitors only 1.2 percent to 3.5 percent of all hand hygiene events, according to a study done at the University of Iowa (Fries et al., 2011). This makes the statistical reliability of direct observation very low.

Direct observation also involves observer bias. The individual who is conducting a study may not be properly trained in standard observational techniques, and he or she may be biased -– either negatively or positively -– toward the person he or she is observing. In addition, direct observation methods are extremely time consuming, costly, and resource intensive.

Perhaps the most significant flaw of direct observation is the Hawthorne Effect, which states that individuals will exhibit different behavior when they know they are being watched by others simply because they are aware of the observation being conducted in their presence. This effect often results in artificially high rates of compliance.

One recent study, published by Infection Control and Hospital Epidemiology, found "direct observation cannot be considered the gold standard for assessing hand hygiene, because there [is] no relationship between the observed adherence and the number of dispensing episodes or the volume of product used" (Marra et al., 2010).

The Impact of Low Compliance
A lack of hand hygiene compliance is a major contributor to the high rates of health care-acquired infections (HAIs) in hospitals. HAIs are almost completely preventable, yet they are responsible for an estimated 1.7 million infections and almost 100,000 deaths each year in the United States alone (Centers for Disease Control and Prevention, 2011).

In addition, nearly one-fifth of all Medicare beneficiaries who are discharged from a hospital -– roughly 2 million individuals per year –- will return within 30 days, according to the Medicare Payment Advisory Commission. Many of these patients return because of an infection they acquired while in the hospital. According to Dr. Donald Berwick, former chief executive officer of the Institute for Healthcare Improvement, "even something as simple as uniform hand washing requirements would cut hospital infections in half."

In addition to the patient safety factor, there are also financial implications. A study conducted at Duke University Medical Center concluded that just a 1 percent increase in hand hygiene compliance would result in annual savings of $39,650 for the 200-bed facility. It was also estimated that the cost per non-compliant hand hygiene event was as high as $52.53 (Infection Control and Hospital Epidemiology, April 2010).

Five Critical Moments
While most hospitals only perform hand hygiene before and after patient care, WHO has identified five critical moments for hand hygiene in the health care setting. The "Five Moments" are before patient contact, before an aseptic task, after body fluid exposure, after patient contact, and after contact with patient surroundings. Clearly, performing and monitoring hand hygiene only when entering or exiting a patient's room is putting patients at risk –- yet direct observation often fails to capture all five of these critical moments.

Electronic monitoring systems have been designed to eliminate the problems associated with direct observation. Because electronic monitoring systems are impartial and unbiased, they eliminate the human factor and, with it, the Hawthorne Effect. These systems are more accurate than direct observation and capture 100 percent of hand hygiene events, which are reported in real time. Some electronic monitoring systems provide statistically developed algorithms that calculate compliance rates and provide supporting educational tools to help enable behavior change and improve compliance.

Electronic monitoring systems typically measure compliance one of two ways: by "tagging and tracking" individuals through a badge system or by providing performance data at the group or unit level. While systems using individual badges can identify who specifically is or is not in compliance, they also can be seen by staff as punitive or as an invasion of privacy. Monitoring hand hygiene compliance at the hospital unit level is thought to encourage collaboration among staff to improve compliance.

"It is essential that we create a unit-wide culture for patient safety, including hand hygiene, where it is acceptable to talk to each other about hand hygiene and to support each other in improving behavior," said Dr. Elaine Larson, associate dean for research and professor of pharmaceutical and therapeutic research, Columbia University School of Nursing, and editor of the American Journal of Infection Control. "It is important then to have a way to both monitor and provide feedback to individual units so that hand hygiene becomes the culture for the entire unit, not just for individual professionals. It is very clear from research that the culture on the unit affects hand hygiene behavior for the whole group."

ACA Penalizes Excessive Readmissions
In study after study, electronic monitoring systems have been proven to be superior to direct observation. In one such study at the Johns Hopkins School of Medicine, hand hygiene compliance increased by 37 percent in phase two of a three-phase electronic monitoring and feedback program, with a 41 percent increase in phase three. In addition, nosocomial infections decreased by 22 percent in phase two and by 48 percent in phase three of the program (Critical Care Medicine, February 2004).

"While hospital officials are aware of the importance of increasing hand hygiene compliance and preventing HAIs, until now, it has simply been a matter of doing the right thing," said Dr. Thomas Diller, MD, MMM, CPE, vice president of quality and patient safety at Greenville Hospital System University Medical Center in South Carolina. "But recent legislation has brought this problem to the forefront of every health care administrator's agenda."

Under the Affordable Care Act, the Hospital Readmissions Reduction Program reduces reimbursements to hospitals with excessive readmissions. Hospitals to which patients return within 30 days of discharge will face up to a 1 percent penalty, which could average $125,000 per facility in 2013, according to government estimates. The penalties will increase over time, up to 3 percent in 2015. Therefore, it makes sense for hospital officials to focus on easily preventable readmissions, such as those caused by HAIs.

If hospital officials wish to avoid the penalties associated with readmissions, particularly those caused by HAIs, they clearly need more advanced methods of measuring hand hygiene compliance. New technology now offers a superior alternative to direct observation. Hospitals can implement technology that will support best practices and recognized guidelines for patient safety, and that same technology can deliver quantitative and qualitative results.

"With legislation threatening hospital reimbursements as a result of patient readmissions, it is imperative that patient quality and safety are top of mind," Diller added. "Hospitals need to adopt best practices in patient safety by implementing evidence-based technology to monitor hand hygiene compliance in order to limit readmission penalties."

In addition to the tragic toll that HAIs take on human life, these infections also have tremendous financial repercussions -– and now, hospitals face ever-increasing government penalties associated with preventable readmissions.

Proper hand hygiene, as dictated by WHO's Five Moments, is the number one way to increase patient safety, but direct observation can no longer be counted on to assist hospitals with monitoring hand hygiene behaviors in order to prevent HAIs. The time has come for health care organizations to adopt new technologies to assist them in the war against HAIs and financial penalties, and the electronic monitoring systems here now are clearly the wave of the future.

This article originally appeared in the January 2013 issue of Occupational Health & Safety.

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