Abstract
Healthcare‐associated infections (HAIs) are a global public health threat. Italy is one of the countries with the highest prevalence of HAI. Hand hygiene (HH) is a pillar of infection prevention and control. Monitoring HH is necessary to improve HH compliance, and direct observation is considered the gold standard. Transcription and analysis of data collected during direct observation of HH compliance with the WHO paper form are time‐consuming. We collected, during a 9‐day observation period, HH opportunities and compliance both with a smartphone application (SpeedyAudit) and with the WHO paper form. Then, we investigated the difference in the required time for data transcription and analysis between the WHO paper form and the use of the app. The difference in the required time for data transcription and analysis was significant with a mean time of 2 s using the app and about 14–54 min/day using paper form (p = .004) while no significant difference was found in measured compliance rates between the two data collecting methods. HH monitoring with an app is time‐saving, and the app we used was easy to use.
Keywords: compliance, hand hygiene, infection control, Italy, mobile application, technology
1. BACKGROUND
Healthcare‐associated infections (HAIs) are an increasing global public health threat, with a significant clinical and economic burden. Italy is one of the European countries with the highest prevalence of HAIs; in 2016, the national HAIs prevalence was 8.03%, with an estimated burden of 424,657.45 DALYs (Bordino et al., 2021).
Hand hygiene (HH) is recognized as a pillar of infection prevention. Increasing HH compliance has been associated with reduced HAIs rates and is often used as a quality indicator for hospital patient safety programs (Marra & Edmond, 2012). However, reaching and sustaining high HH compliance rates is challenging in many hospitals (Boyce, 2013). The COVID‐19 pandemic has highlighted the importance of HH in reducing the spread of Infections in hospital settings. A recent study has shown that achieving 100% HH compliance in a pediatric unit during the COVID 19 pandemic is possible (Moore et al., 2021).
Currently, the gold standard for HH compliance auditing is the direct observation of HH practices by trained observers (Marra & Edmond, 2012; Ward et al., 2014). In 2009, the WHO published the “WHO Guidelines on Hand Hygiene in Health Care,” introducing the “My Five Moments for Hand Hygiene” model, an implementation system for HH compliance monitoring through direct observation. Along with the Guidelines, the WHO published the “Technical Reference Manual for Observers” containing tools for compliance evaluation and feedback, including a standardized paper form for HH auditing, which allows the observer to collect compliance data for each of the five moments (World Health Organization & WHO Patient Safety, 2009). However, direct observation using paper forms is time‐consuming and subject to data transcription errors (Marra & Edmond, 2012; Ward et al., 2014). Further, while real‐time feedback has shown to be very effective in improving HH behaviors, analyzing, and providing feedback on compliance data collected through paper forms requires significant time (Marra & Edmond, 2012; Ward et al., 2014).
Several innovative methods for monitoring HH compliance in hospitals have been proposed, including video‐based methods, radio frequency identification‐based methods, Wi‐Fi or ZigBee technologies, electronic dispenser counters, and hand‐held mobile monitoring apps (Masroor et al., 2017; Ward et al., 2014). Some of these technologies, such as video surveillance or electronic dispenser counters, eliminate the observer effect but are expensive. Moreover, video monitoring has privacy issues (Ward et al., 2014). Most sensor network systems allow monitoring just for two of the five moments for HH (i.e. “before touching a patient” and “after touching a patient”) as they only record HH practices upon room entry and exit, thus leading to an incomplete measurement of compliance (Ward et al., 2014).
Several hand‐held monitoring apps have been developed for direct observation, such as Speedy Audit, iScrub, MEG Audit Tool, Hand Hygiene Mobile Observation, and CleanHands mobile application (Sivek et al., 2019; Viswanath et al., 2016). These apps allow the observer to collect data regarding all of the five moments for HH, the use of personal protective equipment, and the presence of jewelry or nail polish. Further, they provide immediate feedback and graphic reports, and the collected data can be emailed as a .csv file that can be easily transformed into an Excel spreadsheet for further analysis.
In this study, we investigated the difference in time needed for data transcription and analysis, comparing direct observation through paper forms and using the app Speedy Audit (Speedy Audit ‐ Handy Metrics n.d..). This app was chosen because it is free of charge, runs on Android smartphones and is user‐friendly.
2. METHODS
During a 9‐day observation period (on average 1 h/day) between February 2021 and April 2021, HH opportunities were recorded in selected specialized wards of two Italian hub hospitals. Monitoring was conducted by two nonovert observers per day, one using Speedy Audit v. 91 and the other using the WHO paper form for HH Observation. The two observers were specifically trained and were always the same during the observation sessions. Observation sessions followed the WHO “My Five Moments for Hand Hygiene” model and the Italian version of the WHO HH Reference Technical Manual (World Health Organization & WHO Patient Safety, 2009). Different healthcare professionals were observed (i.e., physicians, nurses, and other healthcare practitioners). Data collected using paper forms were transferred onto an Excel spreadsheet and data transcription times were measured using a stopwatch. The app returns descriptive analyses and histograms related to compliance rates. Following the results of the Shapiro–Wilk normality test on obtained observations, a Wilcoxon Signed‐Rank Exact Test was performed to compare data reporting times, and a χ 2 test was performed to compare compliance rates collected through paper form versus those collected through the app. Statistical analyses were performed using “R” software version 4.0.5. A significance level of .05 was set.
3. RESULTS
In total, 458 observations were collected using paper forms and 460 observations using the app, results stratified by ward are presented in Table 1. No significant difference was found in overall compliance rates measured using paper forms (70.3%) versus the app (70.9%) (p = .908), nor stratifying by ward type nor by the five moments for HH.
TABLE 1.
Number of observations, cumulative data transcription time, and HH compliance stratified by ward type using the app and the WHO paper form
| Wards | App | WHO paper form | |
|---|---|---|---|
| Paediatric ICU | Number of observations | 203 | 201 |
| Cumulative data transcription time, s | 6 | 6886 | |
| HH compliance % | 75.4 | 74.1 | |
| Breast unit | Number of observations | 55 | 57 |
| Cumulative data transcription time, s | 2 | 2145 | |
| HH compliance % | 56.4 | 57.9 | |
| Paediatric week surgery | Number of observations | 202 | 200 |
| Cumulative data transcription time, s | 10 | 7254 | |
| HH compliance % | 70.3 | 70.0 | |
| All | Number of observations | 460 | 458 |
| Cumulative data transcription time, s | 18 | 16,285 | |
| HH compliance % | 70.9 | 70.3 |
A report of collected data and descriptive analyses were available in real time using the app (2 s/day, time employed by the app to provide data and synthetic plots) while data transcription and analysis from the WHO paper form to an Excel spreadsheet took significantly more time: 271 min overall or 30 min/day (range 14–54 min/day, p = .004).
4. DISCUSSION
A study by Viswanath et al. also found a significant difference in time used for data transcription and analysis between the use of an app, CleanHands mobile application, and the use of the WHO paper form (Viswanath et al., 2016).
According to our experience, the other main advantages were that the app was easy to use, allowed to reduce human errors in data collection and reporting, that human errors occurring during data collection were easier to detect and took less time to correct, and that the app provided immediate feedback of compliance rates. The infection control nurses who routinely collect HH compliance data as required by the performance indicator system for HAIs prevention implemented in our region found Speedy Audit so user‐friendly and time‐saving that they decided to adopt this method for their future observation sessions.
During observation sessions, we noticed that HH compliance rates may have been affected by the Hawthorne effect. As direct observations cannot be done 24 h per day, the Hawthorne effect may lead to biased estimates in HH observational studies. New approaches to HH auditing are needed in order to evaluate the impact of the Hawthorne effect in HH monitoring.
Study limits: being a pilot study, the sample size is limited; observation sessions were not consecutive and based on the routine schedule of IPC staff.
Strengths: this study was conducted as part of a multidisciplinary collaboration. Infection prevention nurses were specifically trained in HH monitoring. Implementing a faster way to collect and analyze data on HH monitoring could increase awareness on the importance of HH as a IPC measure and increase compliance, in particular through rapid feedback of results to HCWs.
Improvements in HH practices are needed in order to reduce HAIs incidence, enhance patient safety, and reduce hospitalization costs. Monitoring HH compliance is an essential step in this process, both to identify target areas for improvement and to assess the effectiveness of interventions (World Health Organization & WHO Patient Safety, 2009). Our experience using an app for direct observation of HH practices was extremely positive and we were able to provide infection control staff with a simple, time‐saving and cost‐effective tool, which was widely accepted.
Using an app for direct observation of HH indications is useful to public health nurses (PHN) in order to give immediate feedback after observation sessions and the reduced data transcription time gives PHN time for other activities such as education and other infection prevention and control activities.
In the future, it will be interesting to evaluate the use of the app in other settings, such as long‐term care facilities, and the impact of real‐time feedback on HH compliance.
CONFLICTS OF INTEREST
All authors declare that there is no conflict of interest.
ETHICS STATEMENT
There was no need for ethical committee approval for this study because no sensitive data that could identify study participants were used and because monitoring of hand hygiene compliance is a standard procedure in Italian hospitals.
ACKNOWLEDGMENTS
This article is written in Memory of Dr. Ilaria Canta who tragically left us in the prime of her life while participating in this study. The authors would like to thank E.A. Migliore, M.R. Iovino, P. Dal Maso, G. Guareschi for their help in data collection. This research did not receive any specific grant from funding agencies in the public, commercial or not‐for‐profit sectors.
Libero, G. , Bordino, V. , Garlasco, J. , Vicentini, C. , & Maria Zotti, C. (2022). Hand hygiene monitoring: Comparison between app and paper forms for direct observation. Public Health Nursing, 00, 1–4. 10.1111/phn.13160
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
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Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.