Hand hygiene tough to enforce, measure

With compliance estimated at 50%, hospitals struggle for a valid system for improving adherence to hand-washing guidance.

By Kevin B. O’Reilly — Posted May 19, 2009

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Proper hand hygiene is one of the most important infection-control techniques. Yet getting doctors and others who encounter patients to clean their hands at the right times and in the right manner has proven to be daunting, with studies showing compliance rates of about 50% nationally.

Nearly as perplexing as why many who know better sometimes skip hand washing is how to accurately measure hand-hygiene rates.

How, short of constant supervision, can hospitals learn who is failing to keep their hands clean and implement changes to improve their wash-up rates? Without valid measures, how do quality-improvement officials gauge the effect of interventions such as training, signage or easy-to-access sanitizer dispensers and sinks, or compare their performance to other organizations?

These are critical questions for individual hospitals and for the health system as a whole, said Barbara I. Braun, PhD. She works in the Joint Commission's Division of Quality Measurement and Research and led a two-year project that in April published a 200-page monograph on the challenges of accurately assessing hand-hygiene rates (link).

"Organizations need to know how well they're doing, and then if they try to improve, they have to show change over time and that they have a response to an intervention," Braun said. "Across organizations, we need to know in general if compliance is improving locally or regionally or nationally."

Each of the three prevailing methods of measuring hand hygiene has flaws, said the new report, produced in collaboration with the Centers for Disease Control and Prevention, the Assn. for Professionals in Infection Control and Epidemiology Inc., and other groups.

Measuring the use of soap, sanitizer and paper towels misses important context about when health professionals may be failing to wash up. Surveys can help assess hand-hygiene guideline knowledge, but self-reporting tends to yield hand-washing overestimates.

Monitoring professionals directly is very expensive and can be inaccurate because those being watched, fearing negative judgment, will be more vigilant about hand hygiene than they would be otherwise.

Ultimately, Braun said, there is no perfect measurement method. Hospitals should use all three, she said, at least until further research proves the validity of a single standardized approach.

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