Staff views need to be at the centre of electronic hand hygiene monitoring system development

Dear Editor,

We read with great interest Kelly et al.’s qualitative study of healthcare worker (HCW) perceptions of an electronic hand hygiene monitoring system (EMS) (2021). It is excellent to read of a successful implementation of a new innovative approach to hand hygiene (HH) monitoring in a busy NHS hospital. Though the qualitative analysis (from the 11 frontline HCWs interviewed) demonstrated mixed opinions, this study does provide cautious optimism about the long-term adoption of EMS technology by NHS staff. This should encourage other Infection Prevention and Control (IPC) teams to evaluate the impact of EMS technology in their own clinical practice. As demonstrated in this study, staff members recognise the importance of embracing change and the opportunities that EMS technology can bring in improving HH compliance and reducing healthcare-associated infections (HCAI).

We therefore commend the authors’ initiative in wishing to seek HCW views of an implemented EMS. For any HH initiative to be effective, staff must be at the centre of the innovation process, and must be assured that they have ownership and control of the process. However, a limitation of this study is that interviews were restricted to a small group of nursing staff and healthcare assistants. As medical staff are well recognised to have low rates of HH compliance, (Pittet et al., 2000) it would have been useful to explore the perspectives of this staff group. A large staff survey which analysed 1200 responses across two acute NHS trusts (Cawthorne and Cooke, 2020) indicates that all staff groups take HH seriously, have concerns about direct observation (DO) audits and are generally supportive of new technological innovations.

As part of a team of innovators working in an acute specialist NHS trust, we are taking a very different approach to EMS development compared to the system used by Kelly et al. and other current commercial applications. Our approach, Hy-genie (Cawthorne et al., 2022), has been underpinned by extensive staff consultations which is why the theme of exploring staff acceptability of how feedback is delivered is so critically important. As highlighted by Kelly et al., their chosen EMS may ‘monitor how effective we are but doesn’t make us more effective’. Many EMS, including the one used in their study, measure HH compliance, that is, HH opportunities taken against total HH opportunities available (HHOA). This means that EMS must accurately be able to capture all HHOA. A concern raised in this study was that HCWs may disagree with the EMS when recognising an HHOA. Thus, some HCWs found the EMS to undermine their own clinical judgement on when HH should be performed (‘I haven’t touched any patients but I have been in their bed space which says I should gel but I haven’t touched anyone’). In the development of our own EMS, we have sought an alternative approach to overcome this technical challenge. Rather than measuring HH compliance, our EMS simply measures HH frequency. It is widely accepted that HCWs do not perform HH enough, and progress on changing HH behaviour has been slow and typically short-lived. However, simply encouraging HCWs to perform HH more frequently could empower them to reflect on their own clinical practice and decide where and when they could make these improvements. Such a quantitative approach will not, of course, negate the need for qualitative assessment of HH practices (e.g. targeted DO audits).

Using the Hy-genie system, organisations use a computer interface to set staff a personalised HH improvement target (e.g. 20% increase in HH activity) based on an individual’s baseline HH performance. This novel approach has been piloted in a Pathology department in an acute NHS trust (Cawthorne et al., 2022) initially using a staff group monitoring approach rather than personalised reporting. Without any additional IPC interventions, HH activity rose by 14.6% across Pathology staff which was highly statistically significant. The full system with individual staff reports and performance goals is currently being further evaluated in an intensive care setting. Our hypothesis is that using an EMS to measure HH frequency rather than HH compliance could lead to improved staff acceptance of such a system. If HCWs perform HH more frequently, this ultimately aims to reduce HCAI rates. A further development could be the creation of an additional app to determine total HHOA in any clinical unit (e.g. based on the unit’s bed numbers, average length of in-patient stay, ratio of patients to HCWs) to allow for the conversion of Hy-genie’s HH frequency data into HH compliance rates. A formula to estimate the number of HHOAs per patient per day using the World Health Organization’s ‘Five moments for hand hygiene’ methodology has been previously published and validated (Diller et al., 2014).

As rightly pointed out by Kelly et al. (2021), EMS technology provides constant objective measurement and feedback. However, a successful HH IPC implementation must be multimodal and be able to provide both quantitative (EMS) and qualitative (e.g. DO of HH technique components) to be effective.

ORCID iD

Katie-Rose Cawthorne https://orcid.org/0000-0002-4866-1874