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Perhaps you remember your grade school hall monitor. For me, it was Mrs.

Angeloni. Amongst us kids, she was anything but an angel. She was a tough

woman who took her job seriouslymaybe too seriously. I dont think she ever

cracked a smile! Years later, I realized it was her obligation to watch over us.

She made sure we complied with the class schedule. In hindsight, we should

have embraced her resolve, we should have thanked her for enabling us to learn

more as a result of her dedication and we should have befriended her instead of

fearing and being intimidated by her. It turns out that Mrs. Angeloni, my grade

school hall monitor, was an angel of sorts.

Though the stakes are much higher, the role of monitor plays a huge part in

the daily routine of healthcare professionals. Today, patients lives are in the

balance, and caregivers rely on monitors to provide useful information such as

vital signs and blood glucose levels. And because hand hygiene is one of the

most important ways to prevent the spread of infections,1the most important

patient safety monitor might be the hand hygiene compliance monitor.

Going all the way back to 1847 when Dr. Ignaz Semmelweis

first identified the cause and effect relationship between

disease and unclean hands, the goal of 100 percent

hand hygiene compliance has been difficult to

reach. It is widely recognized that Dr. Semmelweis

used his strong personality, and sometimes not

so subtle words, to change the behavior of his

colleagues. He was the first documented hand

hygiene compliance monitor. Perhaps he felt he

had to be shocking and demonstrative because the

science of hand hygiene was unknown. Thankfully, he

persevered and the science has evolved. Today, hand

hygiene is regarded as the most effective single measure

to prevent health care-associated infections.2 And yet, 100 percent hand

hygiene compliance remains an elusive goal, and measuring compliance

remains a challenge. Many would argue it is time for the science of compliance

measurement to evolve as well.

Partner or Big Brother?

Automated Hand

Hygiene ComplianceMonitoring Systems

Prevention

By Marc Lessem

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MeasurementMethodology

Description Merits Drawbacks

Observation

Anonymous (secret shopper)

observation and recording

of hand hygiene events by

individual caregiver

Individual accountability

Compliance and technique

can be measured

Ability to monitor per WHO

My Five Moments model

Requires dedicated and costly

labor resources

Hawthorn effect may result in

overstated compliance rates

Consumption

Soap and/or sanitizer usage

is recorded and compared

with census days

Relatively simple

Cost effective to implement

Cannot measure individual care-

giver compliance or technique

Self-ReportingHealthcare workers submit

self-evaluations.

Low cost to implement

Staff commitment

Overstated compliance rates

unsubstantiated by unbiased

observers

Traditional methods for measuring compliance

Traditionally, hand hygiene compliance has been measured

through self-reporting, consumption and/or observation. While

each method can provide a quantitative compliance rate for a

dened time period, it is the relative change over those dened

time periods that is tracked. Interventions are deemed successful

if the trend moves in the right direction. Each methodology has

both merits and drawbacks, some of which are detailed in Table

1. Is there a better way to measure hand hygiene compliance than

with these traditional options? The answer may be yes!

New technologies for measuring complianceElectronic hand hygiene compliance measurement systems,

such as RFID (radio frequency identication) and RTLS (real-

time location system) are now being promoted to infection

preventionists and C-suite personnel. In some cases, the systems

are part of the nurse call or asset tracking systems already in

place. These systems deploy dispensers or alcohol-sensing

Table 1. Traditional Methods for Measuring Hand Hygiene Compliance

devices that interface with healthcare workers name badges a

remind healthcare workers to cleanse their hands through the u

of audible, visual or vibrating cues.

The badge or badge holder communicates with a device typica

mounted near the doorway or bed of each patient room. F

example, a badge may ash red if a hand hygiene event h

not occurred prior to patient contact and green if it has. T

smart badge also communicates with a data collection serv

Through the use of proprietary software, the data is collect

and management reports designed to monitor hand hygie

compliance are generated. Depending on the desired reportiand the system capabilities, these reports can be sorted

healthcare worker title (e.g., RNs on 2-West) or by individual (e.

Sally Johnson). The reports can be used to track compliance

allow for training and education interventions when compliance

lacking and reward and recognition when compliance improve

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Points to consider before implementing

an automated compliance system

Implementing an automated hand hygiene compliance

monitoring system is a complex interdisciplinary decision. Prior

to implementation, consider engaging in thoughtful discussion of

the following:

Expense. Purchased outright, these systems can be costly.

By acquiring the system via a monthly service fee, capital

expenditures can be avoided. Net cost, however, is dependent on

how the impact of healthcare-acquired infections is factored into

the equation. A case can be made that with a nominal reduction

in HAIs, these systems are a wise investment with an attractive

return on investment versus expense. Another case can be made

that the money is better spent elsewhere.

Individual accountability. Management reports generated

from these systems will be used to favorably impact compliance.

Some will choose to use the data to reward compliant personnel.

Others may use the data for punitive purposes for non-compliantoffenders. The impact of labor unions must be considered as

well. Unions may desire that the monitoring system be exible

enough to collect data with some degree of anonymity as well as

by individual name.

Workflow interruption.Two of the most common obstacles to

compliance are lack of time and behavior modication. Sometimes

just getting the healthcare worker to the dispenser is deemed a

victory. After recognizing the dispenser user via smart badge,

some automated compliance systems require a second step to

verify application of the hand hygiene agent to the hands. Such

systems require moderate retraining.

Desire to monitor hand washing. While monitoring for the

use of alcohol-based hand sanitizer appears achievable for all

systems, some automated monitoring systems are limited in

their ability to monitor hand washing with soap and water. Some

systems are unable to monitor soap and water events, whereas

other systems require facilities to use specic soaps with cert

levels of alcohol so they can be detected electronically.

RFID vs RTLS. These are the two most prevalent technolog

RTLS systems are commonplace for asset tracking, and althou

it might be tempting to expand on a RTLS platform to levera

that investment, RTLS differs from RFID and a technical capab

review is required for accurate hand hygiene monitoring. M

stand alone systems that are designed for the purpose

monitoring hand hygiene compliance utilize RFID.

Installation/Maintenance.Some systems are battery-opera

and can be installed with double-sided tape, whereas oth

require a power source, such as AC power, to operate some of

related devices. Installation issues related to facility modicat

and patient inconvenience must be considered. Furthermo

battery life and/or recharging capabilities must be accounted

as well.

IT involvement. Communications technology and dev

capabilities are critical. Information technology experts will w

to review the hardware required. From a software perspect

most system designs attempt to communicate outside the fac

network. This is desirable because it hastens implementation a

eliminates security concerns.

Measuring to the WHO 5 Moments Model. Do you wish

monitor healthcare workers as they enter and leave the pat

room or do you prefer to monitor within a narrow patient zo

around the patients bed to more closely approximate the Wo

Health Organizations My 5 Moments for Hand Hygiene3mod

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Partner or big brother? You decide.

After all considerations are evaluated and a decision is made,

there remains a single very challenging question to be answered.

Are staff and administration ready for the realization that previously

reported compliance rates may be grossly overstated? For some

facilities that report compliance rates in the 80 to 90 percent

range, as calculated by one of the more traditional methods

described earlier, it can be a rude wake up call to see how

objective reporting from thousands of data points may result in

far lower reported compliance rates. How to deal with this from

a motivation and compensation perspective requires prospective

thought and benevolent senior leadership.

The decision to deploy an automated compliance system is highly

dependent on the healthcare teams resources and commitment

to hand hygiene. If embraced, these emerging technologies can

be a true infection prevention partner in the ght against HAIs.

Yet, some healthcare workers might consider them more Big

Brother and feel threatened. As with any innovative action,implementing an automated hand hygiene compliance monitoring

system requires the support of bold leaders who can effectively

communicate and motivate. If the end result is improved patient

outcomes, could anyone argue that these monitors are as angelic

as Mrs. Angeloni?

Reference

1. Centers for Disease Control and Prevention. Hand Hygiene Basics. Available at: http://www.

cdc.gov/handhygiene/Basics.html. Accessed December 9, 2011.

2. Scheithauer S, Oude-Aost J, Heimann K, Haefner H, Waitschies B, Kampf G, et al. Hand

hygiene in pediatric and neonatal intensive care patients: daily opportunities and indication-

and profession-specic analyses of compliance. American Journal of Infection Control. 2011;39(9):732-737.

3. World Health Organization. About SAVE LIVES: Clean Your Hands. My Moments for Hand

Hygiene. Available at: http://www.who.int/gpsc/5may/background/5moments/en/index.

html. Accessed December 9, 2011.

As with any innovative action, implementing

an automated hand hygiene compliance

monitoring system requires the support

of bold leaders who can effectively

communicate and motivate.