In a candid chat about hospital hand hygiene, Dr Abhimanyu Bishnu, Chief Quality & Excellence Officer, Health City Hospital, Guwahati and Dr Rachna Dave, Founder & CEO, MicroGO dug deep into practical challenges and tech-based solutions for improving compliance.
In your experience, what are the roadblocks in the journey to making hand hygiene a universally implemented part of hospital infection control?
Dr Bishnu: So many of our infection control activities are specifically oriented towards accreditation. It should be the other way around. Accreditation should be the byproduct of our day-to-day work.
You’ll often find that the most educated, skilled or senior person in the hospital hierarchy has the lowest level of hand hygiene compliance. There must be a perception somewhere that it’s not a core work task. Data typically says that nurses have the best compliance, then housekeeping staff, followed by doctors. This order should be reversed, since proper hand hygiene forms around 50-60% of infection control.
Housekeeping staff often have minimal education and exposure. It is not easy to educate them about the need for hand hygiene and its different moments.
There need to be clear indications for every hand hygiene procedure. If you examine a patient, you may use just a handrub. If you put a catheter inside a patient, you have to do a medical handwash. If it’s a surgical procedure, nothing less than a medical scrub will do.
During the pandemic, we saw that hand hygiene rates automatically went up. This means that whenever there’s no pressure, hand hygiene compliance takes a beating.
What is your approach towards achieving 100% compliance, and how is it different from what is currently followed?
Dr Dave: Quality hand hygiene at every opportunity is something we want to achieve first. Standards are laid down for various hand hygiene procedures; we ensure they are followed and analyse data to map out the quality of hand hygiene.
We gather data electronically to ascertain whether each healthcare worker utilises every hand hygiene opportunity, and does it the right way. The hospital authority can see this in real-time and not wait until the end of the month for an audit. Course correction can be done on a daily basis. Because once the ship has sailed, it is very difficult to bring it back.
Beyond the frequency, we also monitor the five moments of hand hygiene. If a nurse gets say 20 hand hygiene opportunities, this takes up 400 seconds in an eight hour shift. Keeping the patient-caregiver ratio in mind, this is difficult, so we focus on monitoring the five moments, and make sure that when the healthcare worker is within a 1-2 metre radius of a patient, a hand hygiene opportunity is created.
What are the recommendations for monitoring compliance?
Dr Bishnu: The WHO lists the following five moments of hand hygiene: Before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings. At all these times, the healthcare worker is at risk of transmitting infections either to the next person or patient, or to himself or herself. These five moments are what need to be monitored.
We also need to look at bundle compliance. To prevent the emergence of infection from healthcare devices like ventilators, catheters etc, a bundled set of measures needs to be implemented. For example, while inserting a catheter, we need to wash our hands, ensure the catheter is clean and tied to the bed, make sure the bag is below the level of the patient’s body etc.
We also monitor actual hospital infection rates, UTI rates, Surgical Site Infection (SSI) rates, etc. These are more or less directly correlated with hand hygiene compliance.
How is your device used in a real-life environment? How does it integrate into the routine functioning of a hospital?
Dr Dave: Picture the entrance of a card-entry ICU area. Outside is a waiting area, a chute for biomedical waste, patient and gurney movements in and out of elevators; all are hotspots for infection transfer. This is where our devices are positioned, so that every time a healthcare worker enters, an opportunity is created.
The device informs the person that hand hygiene needs to be informed; once done, the opportunity is marked as complete, its quality recorded. It coaches the person in the correct method and sounds an alarm if not done right. It is so easy to use that even the guard who stands outside the ICU – opening and closing the door – can learn how to instruct those who enter and exit to use the device.
The dashboard may reveal that, say, out of 400 opportunities created, 200 were utilised and out of these, 100 people did it right. Both quantity and quality are captured.
Now let’s imagine a patient is lying in the bed, and a doctor comes and stands to one side to have a conversation. Unless he or she is standing closer than a predefined distance from the bed, an opportunity will not be created. Too many opportunities can lead to a lot of noise for the healthcare worker, who is already bombarded with too much information. But if the patient needs to be examined, he or she will definitely come closer – an opportunity is created and the machine beeps a reminder to perform hand hygiene.
Compliance can be monitored at multiple levels. Some hospitals don’t want to monitor individual compliance because it can feel like a punitive exercise, and want to maintain a healthy average of overall hand hygiene compliance instead. What we do is try to push up that average, because if most people are getting it right, everyone is safe. So rather than individual, we also focus on average hand hygiene compliance, be it bed-wise, department-wise or across a hospital.