Increasing Hand Hygiene Compliance with a Continuous Fully-Automated Monitoring System at Three Hospitals

Transcription

1 Increasing Compliance with a Continuous Fully-Automated Monitoring System at Three Hospitals Abstract Hospital-acquired infections have a significant impact on patient safety and are a financial burden to healthcare facilities. hygiene is a critical component of infection prevention, and yet compliance rates remain well below 50% at many hospitals. 1 Many interventions have been designed to increase hand hygiene compliance, with limited success. Hill-Rom developed a comprehensive solution which includes technology to provide automatic, continuous monitoring of hand hygiene compliance, with customizable reporting to provide feedback in real time by unit, shift, function, and individual. The Hill-Rom Compliance Solution also includes clinical consulting services to support a facility through the change management process. In three initial hospitals where the Hill-Rom Compliance Solution was implemented, hand hygiene compliance increased over 250% after 10 months of use. Background Hospital-acquired infections (HAIs) exact a high toll on patient safety, and are a financial burden to the healthcare system. In 2011, there were an estimated 721,800 HAIs in U.S. acute care hospitals, with 4.0% of inpatients contracting at least 1 HAI. 2 About 75,000 patients with HAIs died during hospitalization in 2011, meaning over 200 patients died per day. 3 Estimates of the annual cost of HAIs in US hospitals range from $28 billion to as high as $45 billion. 4 Healthcare workers hands are the most common vehicle for transmitting pathogens leading to HAIs 5, and there is substantial evidence showing that an increase in hand hygiene is associated with a decrease in HAIs (Figure 1). Figure 1: hygiene compliance vs MRSA rates after hand hygiene intervention (Adapted from Ancona 2009) 1 Hill-Rom. November, 2014.

2 Improving hand hygiene compliance has been a major patient safety focus for over a decade: the Joint Commission made hand hygiene a National Patient Safety Goal in , and the WHO designated sustained improvement in hand hygiene as its first patient safety challenge in Despite the attention and the serious consequences of poor hand hygiene however, recent publications show that compliance remains well below 50%. 6,12-19 (Table 1). Table 1: Baseline hand hygiene compliance rates noted in literature Reference Blumstein 2014 Unit Type Adult medicalsurgical unit Baseline Compliance Rate Reported % Armellino 2013 Surgical ICU 30.43% Fisher 2013 Surgical ICU Orthosurgical ward Cardiosurgical ward Higgins 2013 Hospital-wide 20% Armellino 2012 Medical ICU 6.5% Sahud 2012 Hospital-wide 37.2% Cheng 2011 Neurosurgical ICU 35.1% Davis 2010 Surgical ward 24% Nevo 2010 Medical-surgical unit 25% at room entry 36% at room exit 23% at room entry 36% at room exit 36% at room entry 12% at room exit 36.7% before physical examination 33.3% after physical examination There are various methods of measuring hand hygiene compliance including direct observation, monitoring product usage, and new technologies such as automated count devices in antibiotic handrub (ABHR) and soap dispensers, and fully-automated continuous tracking systems. The method of measuring hand hygiene compliance is of importance, as each method has strengths and limitations, including accuracy and sensitivity to detect changes in compliance. Direct observation has historically been the gold standard method to measure compliance, but it is costly, time-consuming, subject to bias, and only captures a small percentage of events, making the possibility for inaccuracy substantial. 20,21 Direct observation can be insensitive to the effect of interventions due to the small number of events captured. 21 Recent studies have also demonstrated that direct observation of hand hygiene is also significantly impacted by the Hawthorne effect, or observation bias, which is the tendency for people to change behavior when they know they are being watched. Studies showed that compliance was nearly three times higher when health care workers were monitored by an observer 17,22, meaning sites reporting compliance of 90% or above by direct observation could have an actual real-world compliance rate in the range of 30% or lower. New technologies have been developed to assist in measuring hand hygiene compliance, including automated count devices in ABHR and soap dispensers, and fully-automated tracking systems which can track the opportunities for hand hygiene as well as actual hand hygiene events to provide a real-world, accurate compliance rate. Ellingson and colleagues commented on their potential, stating Automated oversight technologies mitigate the behavioral biases inherent in direct observation, and they offer a source of constant oversight that is impossible to achieve with direct observation. 23 Once an accurate method of quantifying compliance is established, an intervention can be instituted to facilitate the behavioral change required to increase compliance. Numerous interventions have been designed, including training and education, reminders in the work place, optimizing location of handwashing stations, and providing performance feedback. Education alone is not enough to create a sustained increase in compliance 5 ; changing healthcare workers behavior to increase hand hygiene compliance requires relevant performance feedback 23. Systems which are not capable of feedback on an individual level may be limited in the increase in compliance which can be achieved. Monitoring compliance and providing healthcare workers with relevant feedback in real-time are critical components of a successful program to increase hand hygiene compliance and decrease HAI rates. 2 Hill-Rom. November, Increasing Compliance with a Continuous

3 Methods Hill-Rom developed the Compliance Solution using badge-based locating technology which offers automatic, continuous monitoring and recording of every time a staff member uses a hand-hygiene station. Dispenser sensors are triggered by proximity and motion of badged staff, and existing ABHR and soap dispensers can be incorporated into the system. The system utilizes a real-time locating system (RTLS) to identify opportunities for hand hygiene at room entry and exit, and the RTLS system can also be leveraged to support other clinical workflow solutions such as Nurse Call, Smart Bed Connectivity, Staff Locating, Asset Tracking, Patient Locating, Environmental Monitoring and other real-time locating tools. The system has been validated in both simulated clinical settings and actual clinical use, with accuracy rates of 98% or above in capturing hand hygiene events in both settings. 24 System software is customizable to a site s hand hygiene policy, enabling staff to perform hand hygiene activities according to policy with no change to their standard procedure required. The Hill-Rom Compliance solution also includes clinical consulting services on clinical workflow, best practices in hand hygiene and infection control, and the change management process. A thorough assessment of clinical site practices and clinical workflow is first completed to identify potential barriers, and target opportunities to increase hand hygiene with the clinical workflow already in place, for example, to optimize the location of ABHR dispensers. After installation of the Hill-Rom Compliance Solution, automated data is collected during the baseline phase. During this phase, the staff wear system badges and complete hand hygiene as normal with no guidance or reports, and baseline compliance rates are established using the automated system. With baseline rates established, the change management process begins with group-focused feedback. The Hill-Rom Compliance Solution offers stepwise customizable reporting and functionality, allowing a site to report on a group level such as unit, shift, and function, and then move to reporting on an individual level (Figure 2). Customized reminders for potential missed hand hygiene events can also be enabled, providing a gentle badge tone reminder for select individuals with continued low compliance despite individual reporting. Figure 2: Sample Report HUC Nurse Externs PCA Patient Support Tech RN Adherence by Role November % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% The Hill-Rom Compliance Solution was installed at three sites: site A is a 126 bed branch of an academic medical center, site B is a 443 bed community teaching hospital, and site C is a 680 bed academic medical center. The facilities historically used direct observation to monitor hand hygiene compliance. Due to lack of confidence in the results produced by direct observation, however, and continued low hand hygiene compliance and high rates of HAIs, a decision was made to transition to a fully-automated continuous monitoring system. Across ICU, step-down units, and Med-Surg units the Hill-Rom solution was installed in 78 rooms at site A, 293 rooms at site B, and 213 rooms at site C. Results Data from use of the Hill-Rom Compliance Solution was recorded for 10 months at site A, 11 months at site B, and 12 months at site C. During that time period, a total of over 6.5 million hand hygiene events were recorded at room entry or exit. Baseline compliance rates as recorded by the system ranged from 16.0% to 21.5%, consistent with the low baseline rates seen in the literature. After installation of the Hill-Rom Compliance Solution, there was a dramatic increase in hand hygiene compliance. 3 Hill-Rom. November, Increasing Compliance with a Continuous

4 Comparing quarterly compliance rates to baseline, a steady increase can be seen to over 60% at all three sites, with a continuing upward slope (Figure 3). Figure 3: Overall quarterly compliance rates for sites after implementation of Hill-Rom Compliance Solution (Site A: 10 months of use; Site B: 11 months of use; Site C: 12 months of use) Sites began with group reporting, and when each site felt the benefits of group reporting had been maximized, transitioned to individual reporting. At site A, the transition to group reporting was made at the beginning of month 1 (Figure 4). Group reporting increased the compliance rate from 16.0% to 44.1% at the end of month 7. The transition to individual reporting was made at the beginning of month 8, which led to a further increase in the compliance rate up to 64.7% at the end of month 10. At the end of month 10, in consultation with Hill-Rom clinical consulting support, site A decided to continue with reporting at an individual level and not activate badge reminder tones, as steady increases were still being achieved. Figure 4: hand hygiene compliance at site A by reporting level At month 10, all sites were reporting on an individual level and had, on average, more than tripled their hand hygiene compliance rates (Table 2). Table 2: Percent increase in compliance at month 10 after implementation of Hill-Rom Compliance Solution Baseline Compl Events Month 10 Compliance Opport Compl Percent Increase from Baseline Site A 16.0% 35,865 55, % 305% Site B 18.0% 230, , % 302% Site C 21.5% 137, , % 172% Across 3 Sites 18.5% 404, , % 258% Discussion hygiene is an easy and effective way to reduce HAIs, and yet hospitals struggle to achieve compliance rates over 50% 1. To achieve sustained increases in compliance, it is necessary to implement a program which accurately monitors compliance and provides healthcare workers with relevant feedback in real-time. The Hill-Rom Compliance Solution was implemented at three sites and data was collected for up to 12 months of use. Despite the fact that site staff were aware the monitoring system was in place, baseline hand hygiene compliance rates measured by the system were low 18.5% on average. This highlights that installing a hand hygiene monitoring system does not effectively increase compliance; it is the feedback on compliance and the change management process that is crucial. The Hill-Rom Compliance Solution provides the hardware and software for accurate, automatic monitoring of hand hygiene compliance, and also includes clinical consulting support to assist hospitals in achieving meaningful, sustained improvements in compliance. Use of the Hill-Rom Compliance Solution brought about dramatic, sustained improvements in hand hygiene compliance. Ten months after implementation, the three sites combined had more than tripled their hand hygiene compliance rates. 4 Hill-Rom. November, Increasing Compliance with a Continuous

5 References 1. McGuckin M. Waterman R. Govednik J. hygiene compliance rates in the United States a one-year multicenter collaboration using product/volume usage measurement and feedback. School of Population Health Faculty Papers. March (3): Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med 2014;370: CDC HAI Prevalence Survey. Available at html. Accessed 29Aug Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention, CDC. Available at hai/scott_costpaper.pdf. Accessed 29Aug World Health Organization. WHO guidelines on hand hygiene in health care. Geneva, Switzerland: World Health Organization, Blumstein S. Improving hand hygiene compliance and reducing healthcare associated infections with automated hand hygiene compliance monitoring. Am J Infect Control 2014;42:S Ghonim E, Nolan R, Benghuzzi H. Increasing hand hygiene compliance by use of a novel hand held device at a University hospital. Presented at the Rocky Mountain Bioengineering Symposium & International ISA Biomedical Science Instrumentation Symposium. Colorado Springs, Colorado. 5-7 April Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 2009;73: Ancona RJ, Boehler R, Chapman LA. Sustained hand hygiene initiative reduces MRSA transmission. JCOM 2009;16(4): Grayson ML, Jarvie LJ, Martin R, et al. Significant reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates associated with a multisite, hand hygiene culture-change program and subsequent successful statewide roll-out. MJA 2008;188: JCAHO National Patient Safety Goals Approved. Jt Comm Perspect 2003;23: Armellino D, Trivedi M, Law I, et al. Replicating changes in hand hygiene in a surgical intensive care unit with remote video auditing and feedback. Am J Infect Control 2013;41: Fisher DA, Seetoh T, May-Lin HE, et al. Automated measures of hand hygiene compliance among healthcare workers using ultrasound: validation and a randomized controlled trial. Infec Control Hosp Epidemiol 2013;34(9): Higgins A, Hannan MM. Improved hand hygiene technique and compliance in healthcare workers using gaming technology. J Hosp Infect 2013;84: Armellino D, Hussain E, Schilling ME, et al. Using high technology to enforce lowtechnology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare. Clin Infect Dis 2012;54(1): Sahud AG, Bhanot N, Malka ES. Feasibility and effectiveness of an electronic hand hygiene feedback device targeted to improve rates of hand hygiene. J Hosp Infect 2012;82(4): Cheng VC, Tai JW, Ho SK, et al. Introduction of an electronic monitoring system for monitoring compliance with Moments 1 and 4 of the WHO My 5 Moments for methodology. BMC Infect Dis 2011;11: Davis CR. Infection-free surgery: how to improve hand-hygiene compliance and eradicate methicillin-resistant Staphylococcus aureus from surgical wards. Ann R Coll Surg Engl 2010;92: Nevo I, Fitzpatrick M, Thomas RE, et al. The efficacy of visual cues to improve hand hygiene compliance. Simulat Healthc J Soc Med Simulat 2010;5(6): Pineles LL, Morgan DJ, Limper HM, et al. Accuracy of a radiofrequency identification (RFID) badge system to monitor hand hygiene behavior during routine clinical activities. Am J Infect Control 2014;42: van de Mortel T, Murgo M. An examination of covert observation and solution audit as tools to measure the success of hand hygiene interventions. Am J Infect Control 2006;34: Srigley JA, Furness CD, Baker GR, et al. Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf published online July 7, Ellingson K, Polgreen PM, Schneider A, et al. Healthcare personnel perceptions of hand hygiene monitoring technology. Infect Control Hosp Epidemiol 2011;32: Data on file, Hill-Rom Hill-Rom reserves the right to make changes without notice in design, specifications and models. The only warranty Hill-Rom makes is the express written warranty extended on the sale or rental of its products Hill-Rom Services, Inc. ALL RIGHTS RESERVED rev 2 18-NOV-2014 ENG US For further information about this product or a service, please contact your local Hill-Rom representative or visit our webpage: USA Canada