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Handwashing: Overcoming The E-Monitoring Myth

Mike Mann's picture

Who owns healthcare handwashing?

All caregivers care. All wash their hands. Their patients or residents are important to them or they would not work in this challenging field. This doesn’t mean that they meet the standards of care each and every moment of every shift. Drifting off the path of handwashing policy happens easily because the standards are not clearly understood and become further blurred by lack of enforcement. Caregivers take comfort from the commonly overstated reporting based on the seriously flawed observational protocols.

The frequent and often deceitful reporting of 90% handwashing compliance to The Joint Commission is a widely accepted practice, making the HAI reality more understandable. What part might missed-handwashes play in the annual HAI deaths of 75-99K in acute care or 380K in LTC?

This seemingly insoluble dilemma of caring in a careless manner invites the simple question: Who owns handwashing?  Who should step forward and face the reality of handwashing and lead this patient-centered campaign? Who should sound the alarm?

The data desert

This prospective leader lacks data to make his or her case. On one side there is the corrupt 90% number protecting the status quo and on the other are studies showing that investments in E-Monitoring of handwash compliance are not a silver bullet.

It was reported at APIC 2017 that 3-5% of hospitals in the USA currently deploy E-Monitoring handwash tools even though they have been available for decades and have demonstrated their value in making significant gains in compliance. In defense of the other 95%, why would a Medical Director or Infection Preventionist recommend an investment in E-Monitoring when research is saying that it moves compliance but only to 60-75% and then it slips back as soon as management involvement moves on to other priorities.

The research is quite compelling in size and granular in detail. It uses data gathered by personal tags in an RFID (Radio Frequency ID) network and joins other studies indicating E-Monitoring has serious limitations, impeding its expansion and blocking growth of competing systems that going well beyond the 60-75% barrier.

Moving from 30% to 60% ... or 90+%

Handwashing For Life Healthcare has independently come to the conclusion that many of the RTLS systems (Real-Time Location Systems) using RFID as well as team-based systems based on IR (Infra-Red) are failing to fully meet the expectations of the early adopters. This lack of enthusiasm bleeds over to other providers ready to invest but are awaiting longer term confirmation of value in sustainable behavior change and drop in HAIs.

Other technology developers are taking a deep dive to seek, find and understand the difference between having data and changing behavior. They are reaching the 90+% compliance level. There are four suppliers that stand out by virtue of their patient engagement and caregiver reminder features:
1. BioVigil
2. Clean Hands-Safe Hands
3. UltraClenz - Acquired by Ecolab.
4. HygenX - Available only in Ireland.

A 60-75% compliance rate is so much better than 30% in terms of risk reduction and patient-centered care but with this large enduring gap, 90+% levels look impossible. Motivation wanes and more management time is required to sustain any gains. The closer an operation gets to 100% compliance the more acceptable it becomes as an actual standard and a measure of policy. Recurring failure to perform should require at least added training if not disciplinary action.

The owners of handwashing are the owners of the enterprise. Their risk is mounting. C-suites must be held accountable for both getting back to reporting the compliance reality and assembling an assessment team to invest in E-Monitoring.

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Reference: Staats, B.R., Dai, H., Hofmann, D. A., & Milkman, K. L. (2017). Motivating process compliance through individual electronic monitoring: An empirical examination of hand hygiene in healthcare. Management Science, 63(5), 1563–1585. doi: 10.1287/mnsc.2015.2400