The Contribution of monitoring method to Hand Hygiene Compliance in the Hospital setting

白蔷薇，谢青青

（郑州大学西亚斯国际学院，河南 郑州 451150）

The Contribution of monitoring method to Hand Hygiene Compliance in the Hospital setting

白蔷薇，谢青青

（郑州大学西亚斯国际学院，河南 郑州 451150）

A literature review of the monitoring methods to hand hygiene compliance in hospital setting. The review will cover the observation method, self-report method, and calculation on hand hygiene product usage or using monitoring devices. After analysing each approach, it is apparent that there is no simple perfect monitoring method for the hand hygiene compliance, and also this reflected the need of combination methods instead of using a single approach, as well as the urgent to further explore the root reason of the poor hand hygiene compliance.

Hand Hygiene;Monitoring method;Hospital setting

【Chinese Library Classification】R181.3 【Document code】B【Article number】ISSN.2096-2479.2016.06.183.02

Hospital acquired infections (HAIs) are one of the health care complications among patients.A study which covered estimated 320 994 adult patients that acquired infections during hospitalized, showed a cost estimated £930.62 in hospital sector.In order to lessen the costs, reduce the risks of injury and ensure health care quality, taking action using the evidence-based approaches that reduce inpatient HAIs is important[1].

Due to these findings, studies have been conducted to explore different options so as to enhance the hand hygiene compliance. This paper will evaluate the contribution of the "monitoring method", one of the components that aim to increase hand hygiene compliance An analysis was made to compare the hand washing compliance before and after an educational intervention,the improved feedback immediately produced after the education program, but then as well fallen back to the hand washing baseline rates rapidly.However, McGuckin used patients as a reminding resource after educated them, it stated a longer-term positive result in increasing hand washing compliance rate[2].

From the above findings, to successfully managing the hand hygiene compliance, there should be a continuous reminding mechanism to ensure the lone-term hand washing compliance. On the other hand, it was noted in an intervention study by El-Kafrawy that, monitoring plays a vital role on this persistent reminding method.El-Kafrawy applied an audio-visual display monitor (installed an audio-visual screen) to assess the infection control procedures displayed by the visitors of the Neonatal Intensive Care Unit. In addition to this, the adherence of hand washing presents an improvement from 79.2 percent to 100 percent. But the monitor here was used to test the hand hygiene behaviour among non-health care workers (mostly are the relatives of the new-borns), the study of applying this kind of audio-visual monitor to the clinical professionals must be further confirmed[3].

Other electronic devices like counting devices have been used to monitor product usage. By measuring the frequency or the amount of using the hand hygiene product, the method can be delivered in all clinical settings and is accessible to use. Although hand hygiene products was introduced here in a more convenient way and proved to associate with higher compliance, Erasmus discovered the use of feedback also played an essential role in increasing the compliance[4].One study with brief education accompanying disinfected gel dispensers to the health care workers finally turns out to be an ineffective tool in impacting clinicians'compliance.This perhaps coincide that reporting as part of monitoring system, ensuring follow up intervention to be done to alert the clinicians. Venkatesh expressed the immediate and effective of this non-manual method, while El-Kafrawy concerned the resources regards economics, thus to advise further method which is less expensive than this kind of electronic monitor[5].

Instead of using electronic machine, which increases financial cost unlike the previous aforementioned discussion, the measuring of hand hygiene product method handling by human labour has been explored. Bittner conducted a study in a specific clinical setting, by manually measuring the height and weight of change in paper towel, and soap weight used as independent variables at the same time, counting the episodes of hand washing used as a dependent variable[6]. The result remarked a closed correlation in between the consumption of the soap, towel and the hand washing frequency. Bittner considered this measurement easy to obtain, thus can be applied as a monitoring method for hand hygiene compliance. However, this strategy has its disadvantages as those electronic monitoring devices, just like Kinsella clarified that, It cannot well assess if the hand hygiene activity is in a real proper way, because it only provides a partial picture of overall hand hygiene episodes regardless the quality of performing[7].

The consumption of the hand hygiene product also included non-staff population, which may result to an over-estimated number of the results.

To avoid those specific disadvantages brought by the indirect measurement method, and to more accurately monitoring hand hygiene, the direct observation noted as the gold standard by the World Health Organization, has been applied to be the most reliable method in assessing hand hygiene compliance. In order to yield a positive result, the following steps should be done；observers were trained and validated, the scope of an observation period was determined, followed by selecting the location, time, and the health care workers to be observed, the observers maystart an observation session after introducing himself or herself including reasons of his or her presence, but with an awareness of avoiding interference. Same here, Sax et al. also suggested to report after the observation results, together accompanied by an intervention to those suboptimal results. At the same time, the delay between observation activity and feedback of the results should be avoided. Other researchers advocated the direct observation method report the positive result as well. However, the Hawthorne effect, warns by Sax et al. would be a powerful bias for any direct observational strategies, though the observers had been trained not to be too obvious in order to avoid excessive observation bias[8].Nevertheless, Gould at the same time, questions this labour-oriented method could cause inaccurate due to subjective reasons, unless the task was been assigned to the person who is experienced and can monitor the hand washing compliance regularly. This is perhaps due to a lack of overall agreement among observers, regarding definition of good performance, and some other bias like Inter-rater agreement and sensitivity to change may also address the issue[9].McAteer provided an observational tool to assure a better observation method to deal with those posits and reflected with a good result. To the best knowledge of the researcher, similar studies are lacking to offer a higher standard observation method. It is urged to have deepening and expended investigations to fill this gap[10].

Covert observations, represent no significant alternative, and may induce mistrust in health care workers. It is likely minimizing the Hawthorne effect compares to the direct observation method, but cannot avoid other bias observation. Furthermore, it is difficult to ensure a continuously repeated covert observation； and again, the observer need to be trained skills and should apply a rigorous method to avoid bias, and those all cost money and time.

Self-rating was introduced and studied by the researcher, to find out if this internal-evaluation method is appropriate for measuring and controlling the hand washing compliance. An analysis was made by Moret to compare between the selfassessment results with the observation result, and implied a non-significant difference, thereby indicating an encouraging conclusion in terms of self-report method. But the arose problems seemed to be complicated because the observation method was used here again may be more biased when applied together with the self-assess approach. Moret also admitted the importance of this self-assessment program to be tested further before implement[11]. It was identified the factors that may lead to poor relevant result between self-report and observation, and some reason such as unrealistic optimism, self-esteem, and information processing errors. These factors may recommend the cautious use of self-report method due to its unreliable nature when apply to monitoring the hand hygiene compliance.

In conclusion, there is no simple perfect method been found to improve hand hygiene compliance, but there is an amount of studies exploring the reason behind poor hand hygiene compliance concluded with various results and must be taken into account. For example, if the higher patient-nurse-ratio was found associated with poor adherence to hand washing by the study, then the number of staff nurses must be modified as the primarily solution, rather than just rely on the monitoring system, and also this perhaps reflected the need of combination methods instead of using single approach for better implementation in monitoring and enhancing the hand hygiene compliance.

Reference List

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[6] Bittner M,Rich C.Surveillance of Handwashing Episodes in Adult Intensive-Care Units by Measuring an Index of Soap and Paper Towel Consumption.Clinical Performance and Quality Health Care,1998,6:179-182.

[7] Kinsella G,Thomas A,Taylor R.Electronic Surveillance of Wall-Mounted Soap and Alcohol Gel Dispensers in an Intensive Care Unit.Journal of Hospital Infection,2007,66:34-39.

[8] Sax H,Allegranzi B,Chraïti M,Boyce J,Larson E,Pittet D.The World Health Organization Hand Hygiene Observation Method.American Journal of Infection Control,2009,37:827-834.

[9] Gould DJ,Drey NS,Creedon S.Routine hand hygiene audit by direct observation: has nemesis arrived[J].Hosp.Infect,2011,77:290-293.

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[11] Moret L,Tequi B,Lombrail P.Should Self- Assessment Methods be used to Measure Compliance with Handwashing Recommendations,A Study Carried Out in a French University Hospital.American Journal of Infection Control,2004,32:384-390.

BAI Qiang-wei,XIE Qing-qing
(Zhengzhou university west andreas international college,henan zhengzhou 451150,china)