To Automate Or Not? Hand Hygiene In Modern Healthcare Settings

Infection prevention is a top priority at hospitals, and for good reason. Each day, the CDC estimates that hospital-acquired infections (HAIs) affect nearly one in 31 patients, resulting in approximately 687,000 infections annually and around 72,000 deaths.

To complicate matters, multidrug-resistant organisms (MDROs), which include bacteria and other microbes, are on the rise globally. One review of 2,500 studies from 187 nations found that MDRO infections increased by 43% worldwide; since 2010, HAIs featuring resistant bacteria have increased by 35%.

Yet hand hygiene is one of the most cost-effective programs that a health system can implement. Research shows that for every dollar spent on hand hygiene programs, hospitals can get back almost $23.70. This is especially relevant for stopping the spread of MDROs, which are primarily transmitted through touch. One study found that when it came to preventing MDRO transmission, increasing hand hygiene compliance was a more effective strategy (in terms of both results and costs) than increasing terminal cleaning.

What are the WHO’s Five Moments of Hand Hygiene?

In an attempt to improve compliance and education, the World Health Organization (WHO) created the Five Moments framework to explain the exact times that caregivers should sanitize their hands. These moments were chosen because they were the highest risk of transferring microbes between patients, providers, and equipment.

There is evidence that the WHO’s Five Moments process can help frontline hospital staff improve their conformance to hand hygiene standards. In one study published in the American Journal of Infection Control, researchers developed a VR-based training program based on the Five Moments; this resulted in a 68% increase in overall hand hygiene adherence.

What does hand hygiene look like today?

The prevalence of manual monitoring

Today, the majority of hand hygiene monitoring and management remains manual. According to the Leapfrog Group, a leading authority in assessing patient safety and healthcare transparency, only around 10% of hospitals use electronic hand hygiene systems — an increase from 2020, when only 4.7% of hospitals did so.

These hand hygiene workflows utilize direct observation, usually in the form of trained auditors (both hidden and otherwise). Usually, these observers will count the frequency and timing of when clinicians sanitize their hands, compile this data, and then submit it onwards to governing bodies such as the CMS or the Joint Commission, or independent watchdogs such as the Leapfrog Group.

However, there are flaws with this type of monitoring. First, human behavior changes when under surveillance; this is known as the Hawthorne effect, and it is well documented. When it comes to hand hygiene, research has quantified this phenomenon: one study found that an electronic monitoring system recorded that, on average, compliance rates were 3 times higher in hallways staffed by auditors. Another study found that when observed, clinicians performed 21 hand hygiene events (HHEs) per hour, and when not under direct observation, clinicians performed 8.

In addition, any manual monitoring will only ever be a spot audit, capturing a fraction of the HHEs that occur. After all, monitors can’t be in every hallway, every hour of the day, every day of the week. To complicate matters, researchers also found that hand hygiene observation programs should be limited to 15 minutes in order to minimize the Hawthorne effect; this makes it even harder to accurately measure HHEs from human observation alone.

The research behind dispenser management

In addition to monitoring, dispenser management, or maintaining the fill levels and function of a facility’s dispenser fleet, is also important. After all, nothing is more frustrating than a clinician trying to sanitize, only to find that their closest dispenser is broken, and the nearest working one may be a hallway or two away. In a survey of 350 American and Canadian clinicians, 33% of respondents rated empty product dispensers as the largest obstacle to sanitizing hands. Refilling and checking dispensers by hand is not only tedious and time consuming, but also inconsistent. One report across 4 inpatient units found that 22% of dispensers were empty at the time of inspection, despite 77% of clinicians in the same study citing empty dispensers as their greatest obstacle to sanitizing.

Does automated monitoring and management move the needle?

Unlike manual observation, automated monitoring is always on and accurate; as a result, it can capture a much larger portion of hand hygiene behaviors. One study in the American Journal of Infection Control found that an automated system captured 632,404 hand hygiene events, compared to just 480 recorded by human observers.

There is also evidence that automating dispenser management (filling, fixing, and alerting on broken or empty dispensers) improves the rate and frequency of HHEs. A 2023 Danish study found that connecting staff-worn devices to dispenser and bedside sensors increased hand hygiene compliance and dropped hospital-acquired bloodstream infections from 14 per 10,000 patient days to 4 per 10,000 patient days. This reduction also helped place the hospital well below regional and national benchmarks for this specific class of HAIs.

Comparison: Manual observation vs. automated monitoring

How alerting complements monitoring and management

But monitoring by itself is not enough to help create ingrained habits; in order to sustain any improvements, managers need to complement monitoring with other measures. This is borne out by research: one study of 5,200 clinicians in 71 units at 42 hospitals found that while monitoring programs initially prompted a significant increase in sanitization (from 28.4 HHEs to 46), it peaked at month 20 and soon backslid slowly.

One solution is to automate hand hygiene reminders, which helps push adherence to near-perfect rates. Over a period of 51 days, researchers deployed a hand hygiene alerting system that used audio cues and haptic feedback across 9 inpatient units at a major regional hospital. These alerts improved compliance to 90%; without these alerts, compliance fell to as low as 62%.

What’s next for hospitals?

For almost a century, the science of hand hygiene has been very clear and well defined. Despite the scientific consensus, implementing and adhering to a hand hygiene regime remains challenging, especially at large hospitals and health systems.

Overcoming these operational obstacles, from broken or empty dispensers to biases from the Hawthorne Effect, necessitates that hospitals automate hand hygiene functions. Electronic systems are always on, and thus don’t miss hand hygiene events; can alert on failing dispensers before they malfunction or deplete their supply; and through alerting, can help reinforce good habits after the novelty of a rollout wears off.

Few systems do all of this at once, measuring every opportunity, prompting in real time, tracing exposure, recognizing good performance, and managing the fleet of dispensers behind it all. Most hospitals piece together one or two of these opportunities from separate vendors, and manage the rest by hand.

This gap is something that a single platform, like Kontakt.io, is designed to close.