West Penn Allegheny Health System, Allegheny General Hospital (Pittsburgh, PA), was selected as a finalist for ECRI Institute's 7th Health Devices Achievement Award for its development and successful trial of a nonpunitive hand hygiene compliance system.

The Health Devices Achievement Award recognizes outstanding initiatives undertaken by member healthcare institutions to improve patient safety, reduce costs, or otherwise facilitate better strategic management of health technology. ECRI Institute announced the winner and five finalists for the 7th award in October 2012. Learn about the other submissions that achieved recognition.

ECRI Institute congratulates the project team: Andrew Sahud, MD, FACP; Nitin Bhanot, MD; and Supriya Narasimhan, MD. 

The Concept

Although proper hand hygiene by healthcare workers is known to be an important practice for preventing healthcare-associated infections, hand hygiene compliance rates are often low—some studies show them to be below 50% (Littau 2007). Thus, increasing hand hygiene compliance is a goal shared by many healthcare facilities. Furthermore, guidelines issued by the U.S. Centers for Disease Control and Prevention (CDC) recommend that facilities implement a program "to improve adherence of health personnel to recommended hand-hygiene practices," noting specifically that facilities should monitor workers' adherence to recommended practices and "provide personnel with information regarding their performance" (CDC 2002).

But what methods should be used to monitor and improve compliance? West Penn Allegheny Health System conducted a trial at a nine-bed urgent care center to assess a novel approach: the use of an in-house-developed "hand hygiene feedback device" (HHFD). The trial, which incorporated a means to provide healthcare workers with feedback about their behavior, documented gradual and sustained improvements in hand hygiene compliance rates over the five-month study period.

In their efforts to improve compliance, researchers at West Penn Allegheny had rejected traditional options, such as direct observation and the use of existing electronic tools. Directly observing hand hygiene activities was deemed to be too time-consuming, cumbersome, and incomplete, as it would capture only a very small percentage of all hand hygiene opportunities. And the use of tools such as electronic tracking systems (e.g., dedicated hand hygiene monitoring systems, real-time locating systems, video monitoring systems) elicited concerns about the accuracy of the electronic devices and their potential to infringe on personal privacy.

Instead, West Penn Allegheny built its own hand hygiene compliance system, which it tested over a five-month period in the urgent care center (and will soon trial in a larger unit at a different facility). The system uses a pocket-size device (the HHFD) carried by healthcare workers and two forms of electronic triggers installed within patient rooms. These technologies are incorporated into a process that provides workers with feedback through various mechanisms, thereby facilitating behavioral modification, all while preserving the individual's privacy.

The HHFD was developed by Dr. Andrew Sahud, the health system's medical director of infection prevention and control. The device captures signals from the two types of electronic triggers installed in patient rooms, room-entry triggers and dispensing triggers; these are used in conjunction to identify hand hygiene events. The device displays a calculated real-time hand hygiene compliance rate on an LCD, providing the user with immediate feedback. And it stores data for later uploading to a computer, allowing individuals to see how their compliance rates compare with those of their peers.

The process used during the trial was designed to allow the principal investigator (PI) to analyze compliance rates as captured by the HHFD and provide custom-tailored coaching while remaining blinded to the caregiver's identity. This process worked as follows:

Healthcare workers would randomly choose an HHFD, which had been assigned a unique code number, and then register as the user of that device on a website set up for the study. The study investigators were blinded to the code assignments. Workers would then carry the HHFD in their pocket while on duty.

Entry into a patient room was captured by the HHFD through activation of room-entry triggers placed on two walls near the patient bed. Similarly, dispensing triggers on liquid soap dispensers and automatic hand sanitizers in the room activated when these devices were used. A compliance rate was calculated as the number of hand hygiene events divided by twice the number of room entries. (This calculation was based on the premise that room entries lasting about 30 seconds or longer would be associated with two dispensing events, one before and one after contact with the patient or the environment.)

At least once a month, workers would take a few seconds to upload data from their HHFD to the study website. The data collection process was set up to allow the PI to assess both group and individual compliance rates, although the actual identity of the healthcare workers was obscured from the PI to protect individuals' privacy. (Healthcare workers were identified only by the code number assigned to the HHFD, and the PI did not have access to user registration information.) In this way, the PI could provide coaching and encouragement based on the healthcare worker's compliance history, all while remaining blinded to the worker's identity.

The West Penn Allegheny process allowed workers to take ownership of their compliance rates without feeling like they were being personally "tracked," and it allowed the facility to gather data about rates of compliance and to quantify improvements. Mean compliance rates showed a consistent increase from 37.2% in month one to 49.1% in month five.

For Dr. Sahud, providing healthcare workers with information about their own compliance rates was one key to improving hand hygiene habits. Without this data, he explained, "it's like being required to drive the speed limit but not having a speedometer in your car: You might think you were following the rules, but you wouldn't have the data to be sure." Also important, in his view, was a system that favors empowerment and encouragement, rather than intrusive observation and punishment. 

Best Practices

West Penn Allegheny developed a nonpunitive hand hygiene compliance system that provided real-time input, cumulative feedback, and personalized commentary, all while preserving personal privacy and allowing healthcare workers to take ownership of their own hand hygiene compliance. The study suggests that hand hygiene electronic surveillance technology can gain acceptance when privacy is protected and healthcare workers are empowered by seeing and reacting to their own behavior.