Here's why hospitals are looking to take a tech-enabled approach to hand hygiene compliance

Infection control
Hospital-associated infections incur substantial costs, leaving the door open for tech-driven hand hygiene compliance monitoring to potentially replace the gold standard of direct observation. (santypan/Getty)

It’s been more than 150 years since Ignaz Semmelweis, the so-called “father of hand hygiene,” highlighted the benefits of handwashing among healthcare workers, and yet there’s still room for improvement among provider organizations large and small.

According to a 2018 study cited by the Centers for Disease Control and Prevention (CDC), there were an estimated 687,200 healthcare-associated infections (HAIs) in the U.S. during 2015, and about 72,000 patients with HAIs died during their hospitalizations.

Alongside the clinical impact, these infections have a very real cost on the healthcare system. Methicillin-resistant Staphylococcus aureus (MRSA) hospitalizations can cost about $38,500 per event, for example, while Clostridium difficile will cost about $24,000 per event without taking into account other accompanying care.

Handwashing is a core component of any hospitals’ infection control strategy, and there’s little shortage of literature outlining various hand hygiene compliance interventions and the cost savings they can bring to an organization.

The vast majority of these programs will rely on trained human observers to watch over healthcare workers as they wash—an approach that will not always give organizations a clear view of compliance, according to Paul Alper, vice president of patient safety innovation at medical supply company Medline.

“We estimate that between 95% and 97% of U.S. hospitals use what’s known as direct observation,” Alper told Fierce Healthcare. “Direct observation has been the so-called gold standard. That means humans, people, walking around with a clipboard observing hand hygiene, [and] that’s not really the most accurate way.”

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Live observation covers a very small fraction of overall hand hygiene events, according to Alper, who also is founder and chief strategy officer of consulting practice Next Level Strategies and an advocate for electronic hand hygiene compliance approaches.

The live observation approach can be mired by observer bias and the Hawthorne Effect, where individuals temporarily adjust their handwashing behavior because they know they are being watched. It’s not particularly cheap either, costing somewhere around the mid-$70,000 range for many hospitals.

An alternative approach that has emerged over the past 10 to 15 years is electronic monitoring, which is being sold by Medline and other competing vendors such as Centrak, Biovigil and Vitalac.

These systems have often been based on radio frequency identification devices (RFID), real-time locating systems (RTLS), wearables and other types of sensors. Each collects data that teams can use to review technique or duration data points, which can then be used to identify groups or individuals in need of correction. Some will also alert handwashers as soon as they detect poor compliance during a handwashing event.

“The reason that adoption [of electronic monitoring] has been so low is that most of the systems that have come on the market have been inaccurate, … they cost a lot and they’re very, very difficult to implement among staff [who] have pushed back on it,” Alper said. “Especially with tracking systems such as RFID and RTLS, … there’s a concern on the part of an organization that their workers are going to feel like it’s a Big Brother kind of situation where they’re going to be tracked every place they go.”

Despite these “very legitimate concerns,” the technology has improved over time to overcome accuracy and cost barriers, Alper said.

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Medline’s offering, the result of a partnership with Intelligent Observation, uses a near-field magnetic induction (NFMI) technology approach that he said is accurate to a centimeter. Additionally, a study published last year that was funded by Swedish hygiene company Essity AB found high agreement between the company’s electronic system and direct observation (as well as evidence that hand washers changed their behavior when they were aware of human observation).

Price-wise, Alper said that his company sells and deploys its system “for about the same or less” as what it would run a hospital to implement direct observation, but understood the NFMI approach to be less costly than other electronic monitoring technologies.

He also noted that electronic monitoring systems more accurate than the status quo could bring additional indirect cost benefits for an organization, such as better safety rating performances, less risk of lawsuits and the elimination of penalties through the Centers for Medicare and Medicaid Services (CMS) Hospital-Associated Condition (HAC) Reduction Program.

Some researchers are yet to be convinced about the cost-effectiveness of electronic monitoring systems and have called for more published data focused on its return.

Alper said that Medline is still in the process of organizing studies with partners for its specific tech. He instead pointed to a 2016 study that reported a 25% improvement in compliance and $430,000 in cost savings due to a 43% reduction in MRSA alone.

“The key is even with some of the earlier, more rudimentary systems, there have been demonstrated impacts of having access to that real-time and actionable data,” he said.

From interest to implementation

Should an infection control team be interested in adopting an electronic monitoring system, Alper acknowledged that advocating for an overhaul will often be an uphill battle.

“You have to consider the fact that the infection preventionist—the person responsible for hand hygiene, the person responsible for preventing the risk of the spread of infections—is often not empowered with a budget to do anything about it,” he said.

“The first thing they have to do is align with their organization’s priorities. If eliminating harm, if eliminating a HAC penalty, if getting to zero harm, … if high reliability is a goal of the organization—it’s important that the person who is going to mobilize around advocacy to understand that and align this technology … with the organizational priorities.”

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The advocate should also identify the clinical and economic decision-makers who will have a say in the decision, whether a chief quality officer, a value analysis committee or the supply chain head, he continued. From there, it’s about laying out the numbers and making a return-on-investment calculation.

“You need to understand the cost of what the new system is going to look like—that’s easily obtained by getting an estimate of what the technology will cost [from the vendor],” Alper said. “You have to take a look at the potential savings: What’s our current MRSA, our current [C. difficile] rates, and do we think we can likely say what each infection costs. … And then it’s a question of understanding the budget cycle, and making the case in line with the budget cycle so that you can get consideration.”

Unsurprisingly, the process is much more straightforward when the advocate is a leader within their organization.

Executives will already have an idea of the rough annual cost of HAIs, whether Leapfrog Hospital Safety Grades or similar metrics are a priority, and whether their organization is in the bottom 25th percentile of HACs and at risk of CMS revenue penalty, Alper said. In that case, the main challenge is encouraging top-to-bottom engagement with the new process.

“If they want to implement a program like this, it’s important for them to engage and send a clear message to the organization that this is a priority, it aligns with our organizational priorities,” he said.

“They have to be champions for hand hygiene and model that behavior for the organization, and they have to make it very clear that this is important so that the responsibility to use that data cascades down to the individual units," Alper said. " The units can then take responsibility for implementing and using the data on a daily, weekly, monthly basis. … That leadership engagement is really critical to the success of any implementation.”