With hand hygiene compliance, there's no such thing as 'good enough'

As healthcare costs continue to pile up and superbugs raise new concerns, hospital leaders should look to button up their organization's approach to a seemingly simple task that continues to be stumbling block for too many hospitals — hand hygiene.

                                                   This content is sponsored by Ecolab.

Hospital-acquired infections are a lingering and troublesome problem for healthcare facilities. Every year, Medicare cuts payments by 1 percent for hospitals that fall in the worst-performing quartile on hospital-acquired conditions, which includes patient infections with potentially deadly pathogens like methicillin-resistant Staphylococcus aureus (MRSA). In 2017, CMS penalized 751 hospitals for poor performance on these measures, reducing Medicare reimbursements for fiscal year 2018.

The burden MRSA places on hospitals extends beyond CMS penalties. The drug-resistant bacteria was associated with 80,000 infections and 11,285 deaths in 2011, according to the CDC. Estimates cited by PEW Charitable Trust suggest the annual cost of treating hospitalized MRSA patients falls between $3.2 billion and $4.2 billion. Hospitals can better protect their patients and their bottom lines from potentially deadly infections with effective, technology-supported solutions designed to improve hand hygiene compliance.

Hand hygiene can reduce infection rates — when staff comply

A CDC-backed 2016 study of an 835-bed hospital identified a link between improved hand hygiene compliance and lower rates of hospital-acquired infections. When the hospital improved hand hygiene compliance by 10 percent, the facility saw 197 fewer infections and 22 fewer deaths over a 17-month period. The improvements correlated to an estimated $5 million in savings.

While the benefits of strong hand hygiene are significant and demonstrable, achieving high rates of compliance among providers remains an obstinate challenge for many hospitals and health systems. The CDC estimates some healthcare workers initiate hand hygiene less than 50 percent of the time they should.

To boost compliance, many hospitals rely on direct observation, which involves individuals monitoring hand hygiene practices of providers. While shown to have some positive influence over compliance, direct observation has several shortcomings that make it a relatively unreliable method by which to achieve excellent and sustainable hand hygiene adherence in the long-term.

For one, employing individuals to manually observe handwashing practices is labor-intensive and costly, especially for small or mid-sized organizations with limited resources. Another notable challenge is the Hawthorne effect, or the occurrence of altered behavior when an individual is aware he or she is being observed.

When hand hygiene auditors monitor compliance, researchers suspect the Hawthorne effect may artificially inflate compliance rates. A 2014 study in BMJ Quality & Safety found providers were significantly more likely to use hand sanitizer dispensers visible to direct observers versus dispensers that were not visible to observers. This suggests that for hospitals to permanently improve hand hygiene compliance across the board, they'd have to employ a small army of direct observers to patrol the facility at all times.

"Hand hygiene event rates were approximately threefold higher in hallways within eyesight of an auditor compared with when no auditor was visible, and the increase occurred after the auditors' arrival," concluded the study's authors. "This is consistent with the existence of a Hawthorne effect localized to areas where the auditor is visible and calls into question the accuracy of publicly reported hospital hand hygiene compliance rates."

The good news is hospitals no longer have to rely on direct observation alone to achieve top-tier hand hygiene compliance rates. Healthcare leaders can leverage the latest in advanced electronic compliance monitoring technology designed to capture every hand hygiene event and deliver real-time feedback to providers in order to help keep harmful pathogens out of the patient zone.

Protect the patient zone

As part of its comprehensive hand hygiene program, Ecolab — a global provider of water, hygiene and energy technologies — offers a highly accurate compliance monitoring system. The system electronically monitors hand hygiene engagement through an electronic badge worn by providers. Importantly, the patient bed is also monitored, creating a patient zone that interacts with provider badges to ensure hygiene compliance. This element is unique to the Ecolab system. When a provider enters a patient room and engages in hand hygiene, a light on the badge will turn green indicating it's safe to interact with the patient. If the provider does not appropriately initiate hand hygiene, the badge light will turn red upon entering the patient zone. The badge can also be programmed to emit an audible chirp or beep to remind the provider to wash or sanitize his or her hands.

"It's like the reminder when you get in your car to put on your seatbelt," says Kathleen Burzycki, senior marketing manager with Ecolab. "That reminder lets you know when you're being unsafe in a car, and this reminder lets providers know when they're being unsafe around a patient. We're changing behaviors right at the point of contact."

Beyond protecting the patient zone, the Ecolab compliance monitoring system generates robust data on provider hand hygiene performance. This information is transmitted to a dashboard, which generates reports on hand hygiene adherence that can be accessed directly or disseminated via email. These reports can encompass data from the whole system or drill-down to specific locations, dates, departments and even specific providers. These reports can also provide assessments of seven-day and 90- day compliance trends, as well as detailed information about the specific nature of missed hand hygiene opportunities, such as when they occurred in the care episode.

Additionally, the system can generate individual report cards, so providers can benchmark their own performance both hospitalwide and within their own department. Ms. Burzycki says this system encourages hand hygiene compliance through positive reinforcement.

"We want this to be something that's encouraging, and that people feel competitive and proud about the fact that they do a great job of washing and sanitizing their hands before interacting with patients," says Ms. Burzycki.

The dashboard also features information on device battery life and indicates when there is little to no product in automatic dispensers.

Swift installation, robust data, substantial results

Another unique component of the Ecolab system is how easily it can be installed. The solution requires little IT involvement and no major infrastructure. When Wellington (Fla.) Regional Medical Center opted to implement the Ecolab system, installation involved new faceplates for the sanitizing stations and a few monitoring beacons placed in different parts of the facility, according to the hospital's infection prevention director Dianne Manzari.

"They didn't need anything from us from an IT perspective," says Ms. Manzari. "We just had to badge our employees, and that process went really well."

When VCU Health in Richmond, Va., opted to pilot the Ecolab solution in two 30-bed units, the entire installation process took about a week, according to Nadia Masroor, an infection prevention data analyst with VCU Health. Ms. Masroor notes this swift installation process would not have been possible if VCU had chosen a realtime locating system solution to monitor hand hygiene.

"With a RTLS solution, this process would have taken much longer because the patient would have had be taken out of the room," Ms. Masroor says. "[The Ecolab] solution is much easier because the patient can remain in the room during the installation process, because it doesn't require any sort of drilling under the bed."

Ms. Masroor also notes that immediately following installation, providers began receiving feedback. With direct observation, feedback is limited — hand hygiene observers cannot be on the floor 24 hours a day. The Ecolab compliance system, on the other hand, monitors every single hand hygiene opportunity. In the span of two months, the solution captured data on 400,000 hand hygiene interactions at VCU. Ms. Masroor says they've used the data to encourage top hand hygiene performers.

"It doesn't have to be a punitive thing," Ms. Masroor says. "We acknowledge and share this information with our staff who are doing well."

At Wellington Regional Medical Center, leaders were outspoken with staff about how the solution was meant to directly translate into improved outcomes and better patient safety. This, and the fact that the compliance system does not track the movement of providers or when they go on breaks, helped some staff members overcome any concerns regarding perceived "big brother" elements sometimes associated with electronic monitoring. The implementation of the solution at Wellington Regional has yielded noticeable results.

"This system allows us to push reports out to directors on a daily basis, and they can see down to the individual level how their staff performed and they can have real-time discussions with their staff about the data," Ms. Manzari says. "This is something direct observation never gave us the opportunity to do. … It has most definitely changed behavior."

The rate of hand hygiene compliance at the Florida hospital has doubled since the installation of the Ecolab system, according to Ms. Manzari.

The sort of success documented at Wellington Regional with the

Ecolab system is not unique. Ms. Burzycki says Ecolab has been documenting significant improvements in hand hygiene adherence with those who have implemented the compliance solution.

"In one recent trial in a single unit we saw a 200 percent increase in compliance," Ms. Burzycki says. "They went from the 20s to the low 80s within 30 days of implementing the system and continued increase."

Ms. Burzycki adds that hospitals where the Ecolab system has been in place long-term, periods ranging from two to six years, are sustaining hand hygiene compliance rates of 90 percent on average.

Why now is the time to implement an electronic hand hygiene solution

Federal scrutiny of hospitals with regards to hand hygiene performance has intensified in 2018. As of Jan. 1, The Joint Commission began citing individual failures to perform hand hygiene in the process of direct patient care as a deficiency, meaning providers' accreditation is at risk when individual staff members are seen being noncompliant. The rule applies to all accreditation programs. Before 2018, surveyors with the commission would only cite a failure to implement hand hygiene improvement programs and make progress with these programs as a deficiency, with exceptions to home and ambulatory care accreditation programs.

Ecolab supports The Joint Commission's focus on hand hygiene by working to ensure each patient interaction is safe through the monitoring of 100 percent of events for provider wash in and wash out. The company also engages in risk-sharing agreements to create strong client partnerships aimed at achieving and sustaining high rates of hand hygiene compliance. The Ecolab system will help hospitals get compliance above 80 percent and keep it there, month after month and year after year.

Hand hygiene is a basic function in any hospital or health system, and no organization has it right until it can report 100 percent adherence rates around the clock. Fortunately, hospitals, clinicians and caregivers can improve their hand hygiene and augment compliance programs through affordable, easy-to-use electronic monitoring systems that help physicians practice at their best.

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