What to Look for in an Electronic Hand Hygiene Compliance System

Must have criteria:
  1. The system mus be capable of capturing and reporting on 100% of all hand hygiene events (soap and sanitizer)
  2. The system must be able to provide room level soap vs. sanitizer reporting in the case of C Diff. Timely feedback to staff on soap vs. sanitizer use has been shown to reduce C  Diff Rates \cite{Robinson_2014}
  3. The technology must include a behavior change framework for how to use the data with front line staff to drive sustainable behavior change, The behavior change framework must also inherently foster a “just culture” and promote true “psychological safety”
  4. The system must have validated accuracy
  5. The system must be evidence based 
Other Considerations – User Must Decide Based on What is Best for their Institution and Culture
These options have their respective advantages and organizations must decide what is right for them based on the evidence and knowledge of their culture and staff.  
  1. What standard of Care is Measured - Tracks World Health Organization (WHO) 5 Moments for Hand Hygiene \citep{Steed_2011a} \cite{al2013} or Wash in/Wash Out \cite{Kelly_2015}
  2. Hand Hygiene Products Used Requirement – Universal system (deployment of the technology requires no hand hygiene product change required) or HH Brand Specific (deployment of the technology does require use of a specific brand)
  3. Compliance Data Reporting Level – Group, Unit, Department Level, Individual Level or Both 
  4. System Functionality – Such as Gentle Reminders for healthcare workers & Patient Awareness Function; Auto Push Reports via E Mail (eliminates the need to log on to the system)
  5. System Infrastructure - Stand Alone or Real Time Locating System (RTLS) Application
  6. Financial Model - Capital expense; subscription/annual fee model or hybrid 
Hand hygiene compliance should only be measured with a system that meets the “must criteria” above. For a list of suppliers that meet those criteria, visit http://www.ehcohealth.org/#members.
Note – The Electronic  Hand Hygiene Compliance Organization, Inc.(www.EHCOhealth.org), a  501C6 not for profit industry association focused on the public health and patient safety issues associated with poor hand hygiene, is a resource for the evidence in support of adoption of electronic monitoring.  

Metrics

There is no direct calculation for mortality related to the hand hygiene performed in hospitals. Hospitals would need to link mortality to a healthcare-associated infection rate (ex: APSS 2A-2F). The most commonly accepted metric for measuring a hospital's compliance is offered below.
Key Performance Indicators to be used within the Hand Hygiene Protocol should be:

Outcome Measure Formula

Based on the WHO “My five moments for hand hygiene” method \cite{Sax_2007,Sax_2009} Moments defined as:
  1. Before patient contact,
  2. Before aseptic task,
  3. After body fluid exposure,
  4. After patient contact and
  5. After contacts with patient surroundings.
The formula can be used to calculate hand hygiene compliance during all 5 moments \cite{diller2013}. A similar approach can be applied if only the Wash in Wash Out Method is used. However the “in room” moments provide a high risk of infection \cite{Kelly_2015} and thus training on, and measurement of all 5 Moments is essential. Also, the WHO 5 Moments mirror the CDC Guideline so if a facility wants to adhere to CDC Guidelines, either the CDC or WHO 5 Moments needs to be the standard of care that is taught, measured and used for feedback.  
Numerator: Number of hand hygiene events performed as measured by a validated electronic hand hygiene compliance system
Denominator: Number of hand hygiene events required (hand hygiene opportunities or HHOs) based on how the technology software calculates the denominator - for example, the denominator could be based on the WHO 5 Moments, Wash In/Wash Out Method or some other algorithm depending on the technology system used.

Metric Recommendations

Direct Impact: All Patients

Deploying Use of the Electronic Hand Hygiene Compliance Data - Evidence Based Practice \cite{Son_2011}

1. Share the data with Front Line Staff routinely (daily or weekly to start)
2. Empower Unit Leadership to identify unit based barriers and obstacles along with action plans to eliminate them
3. Enable Units to establish their own performance improvement goals
4. Measure performance improvement against the goals and celebrate all successes; use Direct Observation to understand any lack of improvement
5. Hold Unit Leadership accountable for performance improvement goals and make this part of the performance appraisal process