And when you finish with education; still more education, education and education.

Hi Clara

You asked a very challenging questions. The standard is to observe hand hygiene covertly and report "rates" of hand hygiene after all meaningful patient contacts. Ideally this should be done on all shifts and probably tied to observation of a given patient (or "bed") for a certain amount of time.

People have used innovative strategies to look at markers, such as use of liquid soap or alcohol hand rinses.

There is also promising work using engineered approaches by colleagues at U Iowa.

I know that strategies have been reviewed by Elaine Larson and colleagues a few years ago.

There is need for development of innovative strategies and tools that are unobtrusive, not as time demanding as direct observation (or so prone to bias).

We have trained staff to measure adherence for short periods of time and provide direct feedback to their colleagues. I think that is an important strategy!

There's a story out about the reason Van Halen insisted on having a bowl of M&M's without any red ones backstage before every show. Not sure if it's true but it may be relevant.

According to the story, the band had exacting technical requirements. If they got their M&M's as requested, then the auditorium staff showed they could follow instructions. If the M&M's weren't present, or they found red ones, it was a signal to check how the stage was set up.

I bring this up because I've been wondering for a while about what kind of dummy "red M&M" indicators could be set up to show lack of compliance in hospitals.

A real culture change is essential, to make it OK to confront people who do not wash their hands. Most providers just simply forget. But compliance is not just about culture: it's about habit, and habits must be reinforced. Make handwashing hard to avoid - more dispensers, more monitoring, more reminders. Direct observation only works while direct observation is performed - people will revert to their prior patterns of behavior without incentive to change. However, automated surveillance options are available, linking usage detection with RFID in provider ID badges. A novel approach would be to "gamify" the interaction, making it a positive rather than a punitive experience, but I don't think we're quite there yet.

For me, the best way is education and formation, for the physicians too.....

In my hospital (C. Poma Mantova Italy) we perform a control and monitoring of the quantity of hand hygiene products. We see an increase of this quantity.

Bye Gianni Gattuso

Enhanced infection control practices include active surveillance (non-clinical) cultures of patients, staff, and the environment of care, to detect asymptomatic carriage at a

single time or repeated at regular intervals; geographic (spatial) cohorting of patients; geographic cohorting of staff; contact precautions (donning gown and gloves at entry of

patient care area); dedicated patient equipment (i.e., glucometers and stethoscopes); un-identified unit observations of infection control practices; staff education; and regular

consultation with infectious disease specialists.

Additionally, in some centers, the use of periodic screening surveillance cultures has been recommended to better detect potentially unrecognized sources or reservoirs of resistant pathogens in the surgical setting.

Education is very important . Habits must be reinforced. In our hospital one of indirect manners to have a look about compliance is the measure of the amount of líquid soap that is used in every department for example by month. This amount can be measured for example before and after an intervention to improve washing hands or be used to test the influence of our intervention in one of the most important points to avoid nosocomial infections. I think that is important to feed back this results to the clinicians.

Approaching this with a pre and post survey method is way better or PDSA method. It's best to monitor their behavior via a person who is already part of the environment. Otherwise the primary estimates(pre) will be wrong. Then go in with the teaching and changing their behavior. Later after 3-5 months re check behavior(post) pattern. It normally takes more than 1-2 cycles to have a long lasting change.

I listened with interest the lecture of Mark JM Bonten to ECCMID 2013 entitled “other measures have more impact”and the results of MOSAR-ICU trial and I believe that my comments were born after understanding that are needed more than one intervention to reduce transmission of resistant pathogens

Sincerely

Hi Clara!

I've just had a short course on basic Healthcare Associated Infections and no Medicine Doctor was present!!! Why???. In my country the picture is that nurses and nurse aids are more compromised than doctors in handwashing, being doctors at the limit of a satisfactory level (~50%). This kind of adherence is poor and in my opinion that's not just a matter of education, it´s also matter of bad clinical behaviour and irresponsability for instances. Close audit (at least weekly) by Infection control comissions of disinfection practice should be done to raise the levels of awareness and patient safety, and who knows penalties might be introduced by administrations.

Francisco

I think the answer is 'both'. There is poor compliance but also poor monitoring techniques. How to best monitor depends on exactly what you are wanting to monitor. Observation can tell you not only frequency of HH but also HH technique. However, it is beset by issues with bias, and the fact that one can usually only observe a tiny fraction of overall interactions. Even when there are quite rigorous protocols for observation in place, there is still that issue. Other techniques like solution audit, and automated monitoring systems perhaps give good info on frequency which can be adjusted for the no. of patient days, but don't provide info on how compliant the HH technique is. Triangulation through a mix of methods would probably give the most accurate picture. All very time consuming!

Dear Francisco,

Yes, I can say that physicians have to be targeted and encouraged to participate more in education activities dedicated to hand hygiene since they have a lower compliance than nurses.The observation of hand hygiene in different hospitals has shown the same paradigm.

Hello,

I think that the best way is education and formation, including physicians, visitors and also technical staff (i.e. plumber,...). The formation can be delegated and so performed by someone of the staff. I want to underline that if some of the other good practicies (physician clothes,...) are not adequate it may be very difficult to obtain good compliance with hand hygiene

Hi

In WHOs guidelines on Hand Hygiene in Health Care (http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf) the suggested gold standard is observations of compliance by trained observers. But as all measures it has advantages (e.g. detailed information of the actual performance) as well as disadvantages (e.g. subjective, laborious and thereby costly).

Another way of doing it is to measure purchase of disinfectives. This is a rough estimation and has to be compared to patient days but also such as numbers of personnel. By "new" electronic devises linked to computer for real-time measurement of alcohol-based hand rub use it has been made more precise and also easier. It can provide specific data on how frequently used the dispensers are, where dispenser mostly used are located and also the time of day and the day of the week, etc.The electronic equipment will cost but require less manpower. Direct obseravtions of the compliance could be used as a complement now and then to monitor if hand hygiene is actaully correct performed as this is also important.

Implementation of procedures is a reserach field of its one. Why does people not do as we tell them to? What is hidden behind ? And how do we do to maked them act correct ? There are so many different reasons to skip a procedures as hand hygiene, although most of us know that it can save lifes in health care. The reasons can differ between countries, regions and even between departments within a hospital. There are certainly some common reasons to non-compliance, but we have to find also the local weak spots and address these.

Ask your Microbiology dept for a supply of plates and screen staff after completing rounds, it'll either compel staff to wash more regularly or identify those who aren't.

Infection Prevention and Control is everyone's job. It would be achieved through communal efforts. In addition some of the steps towards excellent outcome include:

-Constant education on various disciplines on the subject: audience should include all staff, physicians and visitors/clients

-Education through journal club involving the organisation staff and sometimes with visitors

- Protocols should be available covering different disciplines for easier and quick grasps on techniques of hand hygiene performed before, during and after touching patients/end of procedures.

-Ensure incentives, encouragement are in place at all times

-Unannounced spots checking should be performed periodically

-Encourage patients'/clients' observation on staff and ability to challenge staff/physicians on hand washing at all times in the course of their (patients/clients) care

Auditing; and results should be shared within members of staff for encouragement and NOT for castigation.

Above all surveillance should be active.

Sr. Helen Ugbome

Good Discussion, While we are constantly chasing people to wash hands, its amazing we are struggling to address this issue. Why? is it that people do not care? I think if we offer easier ways to assess hand cleanliness people may clean their hands more- since repeated process are always prone to attrition- we will never succeed in enforcing it- Can you force kids to repeat addition and subtraction every hour or every day?

Any person working in healthcare will wash their hands if they know their hands have MRSA or VRE or C.Diff. I think we need to work on developing a technology where you scan hands and get instant results- I know this sounds like fantasy or Star Trek- but empowering people with ability to know- will allow them to take corrective action-

And developing such a technology may not be as hard as you think- Recently they have developed apps to convert iphone into oxygen sensor!!!! if you can sense oxygen you can sense other things too....

The most reliable way to monitor compliance with hand hygiene practices remains direct monitoring by expert, validated, infection control professionals

Didier, while its most reliable to directly monitor, it is cost prohibitive- can you imagine to monitor 1000 personnel how many people you need.

Hi Clara, there is so many excellent resources available. Look at the WHO new drive to promote hand hygiene and also the Journal of Infection Prevention. Make use of a audit tool to measure compliance and have a framework ready for improvements.

Dear Murlikrishna,

I like the idea of scanning hands and get instant results. If people would see the bugs on their hands, surely they will clean them. And why not,this can be a futuristic idea embraced by smartphone technology.

Hi All,

In addition to my previous update, I strongly feel it is imperative Infection Prevention & Control training is made mandatory and if possible forms a compulsory module in the Physicians' education. This would to a great extent form a foundation in their curriculum. So later on their clinical postings, the Infection Prevention Society personel would build on the previously created awareness!

Sr. Helen Ugbome

Yes Clara, the key is empowering- knowledge is power- lets see if we can get a project started.

Compliance is a big problem, sustainable hand hygiene programs are a challenge but it's probably the only way to keep compliance high. Patient empowerment is also a key factor and most of our hospitals need to work harder on that.

My own opinion and experience when we did the survey few months ago, we used hand print method to access the microorganism burden on hands, when we were in the wards doing direct observation, all HCP alerted and washed their hands according to WHO 5 moments and I bet, their total hand wash in a month will never more than the day we were there!

Yes, when we do observation, HCP do hand hygiene properly, but it's because they afraid of punishment due to the present of infection control team, than their wills.

Great and usefull answers, thank you all

The WHO audit tool is an excellent tool. But then it requires dedicated observation. Hidden cameras in wards will be good to monitor compliance rather than direct observation. We can then reward compliant staff and select the non-compliant cohort to deal with. scanning their hands sound good for the future. But for now culturing their hands may force a change like we found with some staff in our hospital

Well I would take a idea from the nuclear industry, go for a entrance / exit from high risk areas and places where you must clean your hands. At INE in Germany at the old FZK site you had to be scanned and found to be free of radioactivity for the exit door of the controlled area to open.

Have a short plastic tunnel like thing with a hand wahing station in it.

At these places work out a design of sink which must be used in a particlar way to wash your hands before either of the doors of the exit / entrace station will open.

At key times you would have to press your hand on some sensor which would use electrical conductivity of the skin to work out if you have wet / dry hands. Also use a dye in the soap which can be seen by the system. You would have to set your hands and touch the first wet hand detector, then apply soap and stick you hands in the next sensor.

Then wash the soap off and put your hands in the next sensor, then dry your hands with a paper towel and then touch the last sensor which would then after each person disinfect its self.

On the floor you would have pads which sense where you are, you would have to take a step forwards between each stage. If the user tried to deviate from the SOP then both doors lock and then they needs to start again.

The floor would light up and give orders to the people to explain what to do at each stage. You could use a RFID card in the persons security badge so it would know what langauge to speak in and to be able to record details of who passed through the clean hands tunnel.

Mark, what you say is amazing! However,it is difficult to be applied in healthcare settings due to very frequent need for handwashing-remember the 5 moments for hand hygiene-

but it can be a futuristic approach.

Well when you enter / leave places which have clear potential for radioactive contamination you normally have a change room. This is room where you have hand washing, normally a contamination meter for hands / feet and often a shoe limit barrier at which you do a footwear change.

I think that in the most advanced sites a engineering control exists which requires you to use the contamination meter in the correct way (and to test clean). Maybe the first place to do something would be the entrance to a hospital ward. I have some ideas for a gadget which would check that you wash your hands, and also make your shoes sterile.

One problem I think that the health care sector might suffer from is "will one doctor (a junior one) remind a senior doctor to do the right thing if he/she spots the older one doing something wrong ?".

In the nuclear / radioactivity sector it is normal if you find someone doing something odd to stop and talk to them. Years ago there was an accident (SL1) in which someone did something very different to the instructions which they were given. As a general idea if people stop and ask coworkers who are behaving in a odd or different way then it does help to prevent accidents and other adverse outcomes.

Maybe the people in charge of a hospital should get a pair of dirty shoes and some mucky clothing, stick them through a medical products irradator (10 kGy would do nicely) and then ask someone to walk around the hospital. Get them to go into a ward, and if nobody stops and questions the person then discipline the staff in the ward.

Some years ago I saw a film about airports, in the film a man with a red jacket and no visible ID was wandering around in a restricted area. The security boss knew about this man becuase he sent him there, the man was told to try to enter a building. If the occupants of the building stopped and challenged the man then they passed the test and were told that they did the right thing, if they ignored him or just let him in then they lost their security clearance / right to work airside.

Maybe the hospitals should get a man / woman with a sterile but very dirty looking nurses / doctors uniform to test the attitudes of the medical staff.

If you do use a gamma irradation machine to prepare the clean but dirty uniform then do not use PVC shoes if you are going to stick them through the machine many times. As I have a PhD student working on the radiation chemistry of plastics I can tell you which plastics / fabrics tolerate radiation and which do not.

the most reliable way is direct obervation by well trained infection control practioners. the biggest problem with this method is that the medical staff tends to practice more hand hygiene when they know they are being monitored. the advantage of this is that you improve the compliance rate. in addition patients and medical staff need to be empowered to help remind the medical staff at evry opportunity for HH.

I gave an infection control lecture to 70 4th year medical students yesterday and a section of the lecture is the 5 moments of hand hygiene. I took a poll by handraising asking which one of the five moments was the most important. The order of importance was close to the percentage complliance we see in our hospitals when we monitor hand hygiene. The moments which give most protection for themselves are seen as most important.

How do we change the view of which moments are more important to all the moments are important, if the opinion is already set before students are qualified?

A very valid question. It may not be feasible to directly monitor the compliance. However, I still feel that periodic anonymous questionnaires would serve as an effective tool

Anonymous surveys have their own limitations. The staff will mark of the 'best practice' option, no matter what they actually practice. It would be only helpful to a certain extent if we were to know their level of awareness about the issue. In reality, handing out a questionnaire will induce bias.

The main factor to capture here is what is actually being practiced by whom; for good policy making. This would result in a short list of targeted population for education and reinforcements.

Currently at my organization we are in the trial phase for Electronic  systems for HH  monitoring. Meanwhile standardized direct  observation by IC staff and trained nurses as secret observers is the most recommended methodology , we need also to think about making our collection tool computerized rather than manual for more valid data analysis.

Next step which I seek your opinions about is:effective strategies  to  improve HH  compliance rate among HCWs, could you please share your experience?

Thanks 

Hand hygiene is extremely important to contain spread of infectious diseases.

The most reliable way is to educate the medical staff about significance of hand hygiene. To monitor the compliance, a closed-loop control can be implemented with an image processing software. As surgeon enter an operating room, a microscope with an image processing software can look at his/her hand. The image captured from the microscope is processed to detect variations from clean hand of the surgeon from the database. The measure for variation can be an indicator to determine hand hygiene. 

The cameras in smartphones have already reached 13MP. With a microscopic lens attachment and an image processing app, these cameras can also be used to check skin infection/hand hygiene. Again calibration will be needed. When the lens itself is unclean, the algorithm must detect and ask the user to clean the lens before trusting the results. One smartphone scan by a medical security guard can save hours of effort in reducing the rate of infection.The smartphone scanning techniques can be very helpful for containing spread of ebola virus in West Africa.

For a good do-it-yourself idea, following hardware is the minimum:

The significance of hand hygiene to reduce the rate of infection cannot be underestimated.