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Electronic Hand Hygiene Compliance Monitoring System

Ashlin Fox

Delaware Technical Community College

NUR 410-601 Nursing Informatics

Elizabeth Chance

April 14, 2024

Electronic Hand Hygiene Compliance Monitoring System

Proper hand hygiene among health care workers has been shown to decrease

pathogens responsible for hospital-acquired infections (HAI) and healthcare workers are the

primary source of those pathogens spreading (Toney-Butler et al, 2023). HAIs affect 1 in 31

patients in the United States and the different types can be spread through central lines, urinary

catheters, surgical sites, and ventilators (Armstrong-Novak et al, 2023). According to Armstrong

Novak, “an estimated 20% of HAIs from healthcare personnel’s (HCP) hands are related to

direct or indirect hand-to-mucosa contact, with the hands of HCP being the dynamic vector for

transfer – though the “transfer efficiency” varies by organism, as well as other factors such as

humidity and contact surface (2023).” By decreasing the source of infection, healthcare workers

are also helping decrease the risk of infection among patients, the length of stay at the hospital,

and overall cost of healthcare (Toney-Bulter et al, 2023). Although hand hygiene has been

proven to be the single most important practice in reducing the spread of infection, health care

workers have been shown to be noncompliant with this practice.

In 2009, the World Health Organization (WHO) introduced the “5 Moments of Hand

Hygiene” which is a guideline outlining the five instances a health care professional should be

preforming proper hand hygiene (Armstrong-Novak et al, 2023). The five moments are defined

by Armstrong-Novak as, “ before patient contact, before aseptic procedure, after body fluid

exposure, after patient contact, and after contact with patient environment (2023).” The WHO

and the Center for Prevention and Disease Control (CDC) do not have specific regulations for

how hospitals should comply with hand hygiene standards however, it is suggested that each
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facility define their own goals and expectations of health care staff and provide a way to monitor

feedback for compliance (Armstrong-Novak et al, 2023).

One process that most hospitals have put into place to ensure compliance with hand

hygiene is a hand hygiene monitoring system. Studies show that the median compliance rate for

hand hygiene among health care workers is 40 percent and only 72 percent after given a hand

hygiene training course (Wang et al, 2021). The gold standard for hand hygiene compliance is

direct observation however, this cannot always be achieved due to time and resource

consumption (Wang et al, 2021).

Ethical/Legal Issues

There are multiple types of hand hygiene monitoring systems that consist of application-

assisted direct observation, camera-assisted observation, sensor-assisted observation, and real-

time locating systems (Wang et al, 2021). All of these varies types come with their own

advantages and disadvantages but, they all seem to raise some ethical and legal concerns as well

as time and resources. Direct observation is the gold standard for hand hygiene monitoring

however, with time and resources not being readily available, there has been and increased

interest in electronic hand hygiene monitoring systems (Wang et al, 2021).

Privacy and confidentiality are the two major ethical and legal concerns with electronic

hand hygiene monitoring systems (Wang et al, 2021). Some healthcare workers feel that being

monitored for hand hygiene while at work is a violation of their privacy and they come to

distrust the system (Wang et al, 2021). Because some of the hand hygiene monitoring system

include video surveillance, there is a concern for patient privacy and confidentiality. The video

would have to monitor when a person washes their hands, and these instances occur in the
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patient’s room. This form of hand hygiene monitor system has the potential to violate the

Nursing Code of Ethics. Provision 3 of the nursing code of ethics states that nurses promote,

advocate for, and protect the rights, health, and safety of the patient to include the patient’s rights

of privacy and confidentiality (Code of Ethics for Nursing, 2017). Section 3.1 of the Code of

Ethics for Nursing states, “ the need for health care does not justify unwanted, unnecessary, or

unwarranted intrusion into a person’s life (2017). Electronic hand hygiene monitoring systems

that involve a camera in the patient’s room can be a direct violation of this code. The system

would have to ensure that the camera is never pointed at the patient and only at the hand washing

station in the room in order to potentially comply with this code.

Workflow Process

Most hospitals have put in place some type of hand hygiene monitoring system to

measure compliance. The four different hand hygiene monitoring systems are application-

assisted direct observation, camera-assisted observation, sensor-assisted observation, and rea-

time locating systems (Wang et al, 2021). Currently at in the emergency room at Bayhealth, the

way the facility determines compliance is through direct observation. A graph is then displayed

on the information board about what percentage the department ranks and where they should

rank within the standards of the CDC and WHO. Below is the current workflow process for hand

hygiene.
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Current Workflow Process

The hand hygiene compliance monitoring system that would be more beneficial at the ED

would be and electronic hand hygiene compliance monitoring system. There was a study done in

Turkey that showed the benefits of an electronic hand hygiene monitoring system. In the study

HAIs surveillance was recorded from April 2016 to August 2016 at the Marmara University

Pendik Research and Training hospital using two different observation methods (Akkoc et al,

2021). The first two months of the study the observation used was direct observation and the

second two months used and electronic hand hygiene reminding and recording system. For direct

observation, data was recorded in a central database for every encounter where an alcohol-based

hand sanitizer or soap and water were used (Akkoc et al, 2021). The gold standard for hand

hygiene compliance monitoring has always been direct observation however, this method has is

disadvantages because it takes a lot of manning and time. This method can also be subjective

because the health care workers know they are being observed (Akkoc et al, 2021). For the

electronic monitoring, health care workers wore a sensor on their badge that would turn green if

it triggered the sensor on the hand washing stations (Akkoc et al, 2021). The sensor would not

turn green if the health care worker did not apply proper hand hygiene during and encounter with

a patient and it would remind them by vibrating (Akkoc et al, 2021). During the four-month

period, HAIs rates were being recorded. During the direct observation period, hand hygiene

compliance was only 49.1 percent whereas, during the electronic monitoring compliance was

89.2 percent (Akkoc et al, 2021). The study also showed there was a significant decrease in HAIs

from 31.89 percent to 18.43 percent using the electronic monitoring compliance method (Akkoc

et al, 2021).
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Proposed Workflow Process

Hand Hygiene Compliance Monitoring System Implementation Policy

I. PURPOSE: The purpose of this policy is to ensure all healthcare workers are

adhering to hand hygiene compliance to help reduce the spread of infection. Hand

hygiene assists to eliminate pathogens responsible for hospital-acquired infections

(HAIs).
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II. POLICY: Education on how to use the sensor badges for the electronic hand

hygiene monitoring system will be required for all healthcare staff who are

compliant and non-compliant in hand hygiene. Education and resources will be

available on HealthStream and Baynet.

III. PROCEDURE:

a. Hand hygiene should be completed in the following situations:

i. Before any patient contact.

ii. Before any aseptic procedure.

iii. After exposure to any bodily fluid.

iv. After any patient contact.

v. After any contact with a patient’s environment.

vi. Upon arrival to the facility and before leaving the facility.

vii. After any contact with one patient before moving on to the next

patient.

b. Procedure for Handwashing:

i. Wet hands with clean water, turn off tap, and apply soap.

ii. Lather hands by rubbing together ensuring to get between fingers and

under nails.

iii. Scrub hands for 20 seconds.

iv. Rinse hands under clean, running water.

v. Dry hands with a clean paper towel.

c. Electronic Monitoring System:

i. Follow the hand hygiene recommendations outlined in this policy.

ii. Healthcare workers will receive a hand hygiene monitoring sensor

badge.

iii. Badge needs to be worn above the waist during all scheduled shifts.

iv. Healthcare workers will receive a compliance report monthly to be

reviewed.

IV. RESPONSIBILITIES:

a. Healthcare workers must ensure they wear the sensor badge above the waist at

all times during their scheduled shifts.

b. Healthcare workers are encouraged to review their monthly reports in order to

adjust for compliance.

c. Healthcare workers must complete all assigned education on the electronic

monitoring compliance system.

Resources

Akkoc, G., Soysal, A., Gul, F., Kepenekli Kadayifci, E., Arslantas, M. K., Yakut, N., Bilgili, B.,

Ocal Demir, S., Haliloglu, M., Kasapoglu, U., & Cinel, I. (2021). Reduction of nosocomial

infections in the intensive care unit using an electronic hand hygiene compliance

monitoring system. Journal of Infection in Developing Countries, 15(12), 1923–1928.

https://doi-org.libproxy.dtcc.edu/10.3855/jidc.14156

Armstrong-Novak, J., Juan, H. Y., Cooper, K., & Bailey, P. (2023, May 26). Healthcare

personnel hand hygiene compliance: Are we there yet?. Current infectious disease

reports. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10213575/

Code of ethics for Nurses. ANA. (2017, October 26). https://www.nursingworld.org/practice-

policy/nursing-excellence/ethics/code-of-ethics-for-nurses/

Toney-Butler, T. J., Gasner, A., & Carver, N. (2023, July 31). Hand hygiene. StatPearls

[Internet]. https://www.ncbi.nlm.nih.gov/books/NBK470254/

Wang, C., Jiang, W., Yang, K., Yu, D., Newn, J., Sarsenbayeva, Z., Goncalves, J., & Kostakos, V.

(2021). Electronic Monitoring Systems for Hand Hygiene: Systematic Review of

Technology. Journal of Medical Internet Research, 23(11), e27880. https://doi-

org.libproxy.dtcc.edu/10.2196/27880