Hand hygiene monitoring technology increases compliance rates, but is it worth the cost?
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July 1, 2018
Infection preventionist Jessica Strauch shares an amusing anecdote to show how hand hygiene monitoring technology has improved the culture at Lutheran Medical Center in Colorado.
Picture one of Lutheran’s nurses standing in front of her kitchen sink back at home. Dinner is hot and ready, and the nurse stops to wash her hands before everyone digs in. Then, even though she is out of her scrubs and wearing civilian clothes, she waves her hands in front of an imaginary badge.
Oh, shoot, she isn’t at work anymore. But hey, at least the nurse remembered to wash her hands without a beep or a buzz from her BioVigil badge reminding her to perform hand hygiene.
“It’s funny to hear nurses say that,” says Strauch, chuckling.
Lutheran is among the healthcare organizations nationwide that in recent years decided to try hand hygiene monitoring technology in the hopes it could improve hand hygiene compliance, while also reducing the number of infections and avoiding fines from accrediting organizations like The Joint Commission (TJC), which in January put stricter standards in place.
After a significant rule change, if a TJC surveyor sees an individual who directly cares for patients fail to perform required hand hygiene, that individual’s healthcare organization can be cited under Infection Prevention and Control (IC) standard IC.02.01.01, element of performance 2, which requires organizations to use precautions such as hand hygiene to reduce infection risk.
Additionally, TJC requires that healthcare organizations meet National Patient Safety Goal (NPSG) 07.01.01, which requires them to implement and maintain a hand hygiene program.
Currently, the majority of U.S. hospitals and outpatient facilities do not use hand hygiene monitoring technology. Perhaps the increased surveyor focus on hand hygiene compliance and more success stories like the one Strauch tells about Lutheran will encourage others to pony up.
The cost can certainly be a turnoff for cost-conscious C-suite execs. Some employees will be concerned about nonstop surveillance, too. But research shows that, somehow, thousands and thousands of healthcare workers still don’t wash their hands as often as they should despite everything we know about the impact of hand hygiene on infection control. So, it makes sense for organizations that struggle with hand hygiene compliance to at least consider new technology.
“You hate to see a forcing function,” says Marge MacFarlane, PhD, MT(ASCP), CHSP, CHFM, HEM, MEP, CHEP, principal of Superior Performance in Eau Claire, Wisconsin. “But if you don’t have some kind of forcing function—whether they alarm you or your hands turn blue or your hair turns blue or whatever—I’m not sure if people will wash their hands the way they’re supposed to.”
Technology ‘can be very effective’
Hand hygiene monitoring technology has been on the market for about a decade. While there are a handful of systems offered by various companies, they are all “pretty similar,” says Payal Patel, MD, assistant professor of infectious diseases and internal medicine at the University of Michigan.
While their monitoring methods and equipment differ to a degree, they generally use scanning technology to monitor whether hand hygiene is completed as often as it should be. That can be done by tracking when a soap dispenser is used and how much product was dispensed, or a badge buzzing a caregiver upon entering a patient room, or something along those lines.
For many busy healthcare workers, those extra nudges may be necessary, even though the link between clean hands and infection control is well-documented. According to the CDC, one in every 25 hospital patients acquires a healthcare-associated infection (HAI) on any given day.
While one study published in 2016 in the American Journal of Infection Control concluded that hand hygiene compliance in outpatient settings surpassed average rates, the staff they observed in several outpatient facilities in New Mexico still washed their hands only 63% of the time.
“It is the most basic thing we know about infection control, but it’s common for hospitals or healthcare systems to be below 50% compliance. I think time is a big issue. All of the different things we have now like contact precautions, cleaning your stethoscope, the hand washing, I think people tend to think, ‘Oh, it will be fine this time. I didn’t touch anything,’” says Patel, who adds, “There seems to often be a disconnect between what people know and what people do.”
But recent research has suggested that hand hygiene monitoring technology can narrow the gap.
A study published this year in The Journal of Hospital Infection found that systems issuing real-time reminders for workers to wash their hands can achieve 100% compliance in outpatient settings.
Researchers wrote that they “co-created an infrared guided sensor system to automatically notify clinicians to perform [hand hygiene] just before first patient contact.” Then they compared compliance rates when the clinicians received real-time auditory notifications to when they did not.
They found that auditory notifications that lasted up to 15 seconds resulted in 80.4% compliance compared to 53.8% compliance when the clinicians did not receive any auditory notification. And when the notifications nagged the clinicians until hand hygiene was performed, compliance was 100%.
Plus, those researchers estimated that the annual cost of using their machine learning system in an outpatient setting would be 46% lower than an observational hand hygiene program.
“Technology that enables real-time hand hygiene notification provides a promising cost-effective approach to both improving and monitoring hand hygiene and deserves further development in outpatient settings,” concluded the lead authors, Roel Geilleit and Hen Zhi Qian.
The potential for cost savings was also trumpeted by Sudhanshu Gakhar and Jason Burnham , who for Halyard Health reviewed in 2014 more than 40 peer-reviewed articles and case studies that “utilized electronic monitoring systems to help influence hand hygiene behaviors.”
They concluded that “electronic hand hygiene compliance monitoring systems, in combination with staff education and availability of alcohol hand sanitizers, can be very effective in reducing infections and have demonstrated significant cost savings and reduction in patient length-of-stay across a number of case studies in a variety of acute care environments.”
Consider Strauch a believer after Lutheran Medical Center’s compliance rates increased to nearly 100%.
More observations, improved rates
Early in 2016, Lutheran Medical Center, located in the Denver area, started evaluating systems. Lutheran’s compliance rates were pretty good, averaging about 85% throughout the hospital. But hospital leaders wanted higher rates and more trustworthy data to back them up. They also didn’t want to keep wasting workers’ precious time by having them monitor their peers.
After doing a direct comparison of a few systems, Lutheran picked BioVigil’s technology because in addition to collecting data, it gives workers real-time feedback reminding them to wash their hands every time they enter and exit a patient room. Lutheran began a pilot program in August of 2016 and “it was pretty easy to see that it would expand throughout our hospital,” says Strauch.
Strauch says BioVigil’s system places sensors above every patient room door. Each employee wears a badge with “a little, colored hand” on it. If they walk through a door and do not clean their hands within 30 seconds, the badge starts what Strauch calls “a reminder sequence.” The hand on the badge turns yellow and the badge beeps and vibrates, drawing the attention of both employee and patient. If the employee continues to ignore the alerts, the hand on the badge turns red.
Whenever the employee washes up and scans clean hands on the front of the BioVigil badge, the reminder sequence stops and the hand on the badge turns green.
“By giving that real-time reminder, what I’ve heard from staff members is that really has made a difference at times when they maybe would have forgotten to clean their hands,” she says.
Strauch says the staffers at Lutheran did not object too much to constant monitoring, though there have been stories about some employees at other healthcare facilities expressing concern about “Big Brother” constantly eyeing them up. She says the most common complaint early on was just that the badge “was another thing to wear.”
“We’re asking them to wear all these different badges and trackers for all the different technology programs that we have going on now. And it does take some getting used to the first couple of weeks because you have to remember the extra action of putting your hands up to the badge after you clean them to get credit for it,” Strauch says. “But you develop that muscle memory for it.”
Thus, the Lutheran employees waving their hands in front of imaginary badges back at their homes.
It took some time and thought to “make sure this fits into their standard workflow.” But a little over two years since starting this process, Lutheran’s results speak for themselves.
“It’s just astonishing knowing that we would get maybe 1,000 observations in a month—on a really good month—and now we average 25,000 observations a day” after buying BioVigil’s system, says Strauch. “Being able to say we have that many and that we know we are over 95% compliant all of the time, and that we can actually prove it now, I think that’s been huge.”
BioVigil technology also played a role in reducing the number of cases of clostridium difficile at Lutheran and staff sick days in their emergency department, one of the first areas to adopt the technology.
So why aren’t these everywhere?
Despite positive outcomes experienced at Lutheran and elsewhere, along with favorable research, several years after hand hygiene monitoring technology came onto the radar, the systems are still not commonplace. Patel and other experts point to the pricetag.
“Dollars. Absolutely, it’s dollars. They’re competing for capital priorities,” says MacFarlane. “People could just wash their hands rather than spend money on [monitoring technology]. So, if I am in a tight healthcare market with aging infrastructure, am I going to [purchase] the new 100-million-slice CT or am I going to install a function-forcing system for hand washing?”
BioVigil, through a spokesperson, declined to share pricing information. But a 2014 article published in Wired reported that on average BioVigil costs hospitals $2 to $3 per room, per day. So, based on that estimate, it would cost a 50-bed hospital between $36,500 and $54,750 a year to use BioVigil’s system, which includes installation, hardware, and training, per Wired.
Strauch says she isn’t privy to the financial details of Lutheran’s contract with BioVigil. But she notes that “we have a very supportive higher-level senior team” who viewed the technology as “a great product for infection prevention.” Upkeep and upgrades are “all part of the contract,” she adds.
Given that an estimated $9.8 billion is spent each year treating HAIs, according to a 2013 study in JAMA Internal Medicine, Strauch believes that over time BioVigil will more than pay for itself.
But “is [monitoring technology] any better than what we’re currently doing?” wonders Linda Gylland, MLS (ASCP), QLS, a lab safety officer for Sanford Health in Fargo, North Dakota.
Last summer, Sanford opened a $494 million, 284-bed medical center in Fargo. “State of the art. Brand new. … They did some pretty amazing things,” boasts Gylland. Those things, however, do not include hand hygiene monitoring technology.
Gylland doesn’t anticipate a system being installed any time soon. By using the “secret shopper method,” sending out regular emails that share levels of compliance throughout Sanford’s network, and rewarding staff for high compliance numbers, among other inexpensive methods, Sanford can tout hand washing rates above 95% for many of its departments, says Gylland.
Patel also worked at an organization that considered monitoring systems before deciding they weren’t worth the cost. Employee privacy concerns were also a consideration, she adds.
While Patel says spending for monitoring technology might make sense as a last resort for some organizations that have exhausted cheaper alternatives while attempting to change their culture, she doesn’t believe these systems are a magic wand that will automatically drop a facility’s infection rates.
“There isn’t enough compelling evidence for us to say, ‘Oh yeah, this is it,’ ” says Patel.