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Joint Commission Update for Infection Control
Joint Commision issues best practices report on tracking hand hygiene adherence by HCWs
Approach depends on use of the data, workplace culture
The Joint Commission has issued a major new document on the difficult issue of assessing hand hygiene compliance by health care workers. We'll put the bottom line at the top: there are many approaches to solve the Achilles "hand" of infection prevention and none of them is a panacea.
"The first thing people have to do is decide why they are monitoring hand hygiene," says leading hand washing expert Elaine Larson, RN, PhD, FAAN, CIC, who chaired the expert panel that produced the 262-page document. "Just doing it to be in compliance with Joint Commission isn't a good reason. What are you going to do with the information?" she says.
For example, conducting random audits to check compliance over time may be good for internal purposes, but something more rigorous may be required if you plan to feedback results to staff. "The monitoring can actually be part of an intervention to change behavior," says Larson, a professor of pharmaceutical and therapeutic nursing at Columbia University in New York City. "If that's the case, then you have to monitor each unit where you want to do the intervention and give feedback. So, the main thing is to decide how you want to use it."
The Joint Commission continues to make hand hygiene a National Patient Safety Goal, requiring compliance with the evidence-based recommendations in the hand hygiene guidelines issued by the Centers for Disease Control and Prevention (CDC) in 2002. The problem many infection preventionists have, however, is meeting this 1A recommendation in the CDC guidelines: "Monitor health care workers' adherence with recommended hand-hygiene practices and provide personnel with information regarding their performance." To improve the situation, The Joint Commission sought out proven methods and strategies for monitoring hand hygiene compliance. The result is the rather ponderous - but no less important - report: "Measuring Hand Hygiene Adherence: Overcoming the Challenges."
No single method recommended
"It's not designed to recommend a particular approach, but it is an attempt to list the options for best practices depending on the reasons people want to monitor - either because they want to provide feedback or audit the effectiveness of strategies over time," Larson says.
The monograph is the product of The Joint Commission collaboration with many leading infection prevention groups, including the Association for Professionals in Infection Control and Epidemiology, the Centers for Disease Control and Prevention, the Society for Healthcare Epidemiology of America, and the World Health Organization. Submissions were confidentially reviewed by an expert panel under Larson's direction, resulting in a wealth of case studies and hand hygiene adherence research.
"We actually had a pretty stringent assessment technique," Larson says. "We had an advisory group and developed a series of criteria that would designate that something would be of quality or not - things like evidence of reliability, training of staff and a whole series of quality criteria. If the submission didn't meet those criteria it was not included."
Difficult to sustain
Following effective hand hygiene practices has long been recognized as the most important way to reduce the transmission of pathogens in health care settings. Many studies, however, have shown that adherence to hand hygiene recommendations remains low and that improvement efforts frequently lack sustainability, the report states.
"In terms of sustainability, one of the criteria that we used was whether or not there was any evidence that the data had been used to improve the quality of care," Larson says. "One of the big problems is that people try something, it works for a while, but nobody looks back a few months later to see what is happening."
There are three main methods for measuring hand hygiene performance, each of which has advantages and disadvantages:
measuring product use;
As the term implies, observation involves directly watching and recording the hand hygiene behavior of health care workers and the physical environment.
Direct observation of the hand hygiene behavior of health care workers is considered the "gold standard" of measurement methods. Observation allows you to see which hand hygiene products are used, the thoroughness of cleansing, the tools and technique used for drying, the use of gloves, in addition, whether the staff are performing hand hygiene whenever there is an opportunity to do so, the report states. Perhaps the biggest disadvantage of that method is that it can influence the behavior of those who know they are being observed - the so-called Hawthorne effect.
"It is expensive to monitor [compliance], so you want to pick the most practical way that gives you the best information without spending a huge amount of money," Larson says.
Measuring product use
Measuring the amount of liquid soap, alcohol-based hand rub, and paper towels that health care workers use - and measuring the frequency with which they use these products - is an indirect way of estimating staff adherence to hand hygiene guidelines, the report states.
No lack of challenges to HH adherence
Some of the issues discussed in The Joint Commission's new report, "Measuring Hand Hygiene Adherence: Overcoming the Challenges" include:
Contact with patients or their environment takes place in many locations within organizations.
Opportunities for hand hygiene occur 24 hours a day, seven days a week, 365 days a year, and involve both clinical and nonclinical staff.
The frequency of hand hygiene opportunities varies by the type of care provided, the unit, and patient factors.
Monitoring is often resource-intensive; infection preventionists, quality improvement staff, and other health care workers (such as nursing, respiratory therapy, and so on) face numerous competing demands for their time and expertise.
Observer bias (for example, the Hawthorne effect) is difficult to eliminate.
Staff may use improper technique even if adherent. For example, are they using the proper volume of liquid soap or alcohol-based hand rub? Are they donning and removing gloves correctly?
"If there's good information on product use by unit, then one of the ways to be fairly efficient and inexpensive is just to count how much soap and sanitizer is used," Larson says. "The problem is that many places don't have data by unit by month, for example, so part of it is practicality. What is feasible in your setting?"
In addition, measuring product use does not reveal whether health care workers are performing hand hygiene when it is indicated or whether they are performing it correctly. Many factors contribute to making this measurement method prone to inaccuracy, including product waste or spillage, product use by patients and family members, and the borrowing of product between units, the report notes.
Surveys of health care workers, patients, and family members - conducted in person, over the telephone, or in focus groups - can yield information about perceptions, attitudes, and behavior related to hand hygiene, The Joint Commission reports. Through surveys, health care workers reveal what they know and think about hand hygiene, as well as whether and why they adhere to guidelines. Surveys can reveal whether health care workers' perceptions of their own hand hygiene behavior match the perceptions of patients and family members. However, using surveys for self-reporting of hand hygiene behavior can be unreliable; health care workers tend to overestimate their adherence to guidelines when questioned and may inaccurately recall their past hand hygiene behavior, the report found.
Ultimately, no one approach fits all facilities, which have distinct institutional cultures that may determine success or failure of the various methods. Virtually all hospitals now have alcohol hand rubs in place, a product that was designed to ease compliance by hurried health care workers. There appears to be some perception of an overall improvement from the days of sinks and soaps, but the simple act of hand hygiene remains a complex problem.
"I think the problem with adherence is still pretty pervasive," Larson says. "It has really been slow in coming. There are pockets of success, but we are not really sure over the longer term."
Patient empowerment efforts, including The Joint Commission's Speak Up signs and posters, are thought by some to be a key to increased hand hygiene compliance. "There are some places that have had success in this 'partners in your care' idea and other places where it hasn't worked so well," she says. "I think it depends on the culture of the hospital or organization. If there is a good organization climate where there is a fairly high level of trust among the staff - and it is presented as a way of partnering with patients - then I think it works. When there is any sense of suspicion about it or [concerns] about litigation, then I think it fails. It has to do with the culture of the place."
(Editor's note: The Joint Commission report, "Measuring Hand Hygiene Adherence: Overcoming the Challenges," is available on the commission's web site at: http://www.jointcommission.org.)