Automated and electronically assisted hand hygiene monitoring systems: A systematic review

doi:10.1016/j.ajic.2014.01.002

American Journal of Infection Control

Volume 42, Issue 5, May 2014, Pages 472-478

https://doi.org/10.1016/j.ajic.2014.01.002 Get rights and content

Background

Hand hygiene is one of the most effective ways to prevent transmission of health care-associated infections. Electronic systems and tools are being developed to enhance hand hygiene compliance monitoring. Our systematic review assesses the existing evidence surrounding the adoption and accuracy of automated systems or electronically enhanced direct observations and also reviews the effectiveness of such systems in health care settings.

Methods

We systematically reviewed PubMed for articles published between January 1, 2000, and March 31, 2013, containing the terms hand AND hygiene or hand AND disinfection or handwashing. Resulting articles were reviewed to determine if an electronic system was used.

Results

We identified 42 articles for inclusion. Four types of systems were identified: electronically assisted/enhanced direct observation, video-monitored direct observation systems, electronic dispenser counters, and automated hand hygiene monitoring networks. Fewer than 20% of articles identified included calculations for efficiency or accuracy.

Conclusions

Limited data are currently available to recommend adoption of specific automatic or electronically assisted hand hygiene surveillance systems. Future studies should be undertaken that assess the accuracy, effectiveness, and cost-effectiveness of such systems. Given the restricted clinical and infection prevention budgets of most facilities, cost-effectiveness analysis of specific systems will be required before these systems are widely adopted.

Section snippets

Methods

We searched PubMed for all relevant articles published between January 1, 2000, and March 31, 2013, using the terms hand AND hygiene or hand AND disinfection or handwashing. The earliest year of 2000 was chosen because alcohol-based hand rub (ABHR) was not widely in use in prior years, but is now the gold standard. The results were checked against the search results from our prior meta-analysis.⁷ After this initial search, 3,463 articles were identified for further review. We then evaluated

Results

Forty-two articles were grouped into 1 of 4 categories based on the underlying technology assessed: electronically assisted/enhanced direct observation, video-monitored direct observation, electronic dispenser counters, or automated hand hygiene monitoring systems. Further details of noteworthy studies are included in Table 1.

Implementation of hand hygiene monitoring networks

Costs of direct observation by a trained monitor include labor costs of human monitors and, although applications such as iScrub²³ are free of charge, the devices must be purchased⁶⁶ and require Wi-Fi access or a mobile cellular contract to synchronize data. In the Armellino studies, the video cameras and motion sensors were installed at a cost of approximately $50,000 per unit.²⁹ The cost of salaries for 28 employees of the monitoring center and server or Internet costs was not provided.

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Cited by (110)

Validation of a hand hygiene visual feedback system to improve compliance with drying time of alcohol-based hand rub in a neonatal intensive care unit: the Incubator Traffic Light system
2024, Journal of Hospital Infection
Compliance with the recommended 30 s drying time of alcohol-based hand rub (ABHR) is often suboptimal. To increase hand hygiene compliance at a neonatal intensive care unit (NICU), we installed an Incubator Traffic Light (ITL) system which shows ‘green light’ to open incubator doors after the recommended drying time.
To measure the impact of this visual feedback system on NICU healthcare professionals' compliance with the recommended ABHR drying time.
Ten traffic light systems were installed on incubators at a NICU, five of which provided visual feedback, and five, serving as a control group, did not provide visual feedback. During a two-month period, the systems measured drying time between the moment of dispensing ABHR and opening the incubator's doors. The drying times of the incubators were compared with and without feedback.
Of the 6422 recorded hand hygiene events, 658 were valid for data analysis. Compliance with correct drying time reached 75% (N = 397/526) for incubators equipped with visual feedback versus 36% (N = 48/132; P < 0.0001) for incubators lacking this feature.
The ITL improves compliance with the recommended 30 s ABHR drying time in a NICU setting.
Impacts of intelligent monitoring technology installation and additional modalities on hand hygiene compliance in a burn center: A quasi-experimental longitudinal trial
2024, Burns
The increasing development of intelligent technologies for hand hygiene (HH) compliance audit has the potential to create an alternative to direct observation (DO), which is still considered the gold standard but has disadvantages such as lack of standardized monitoring practices, Hawthorne effect, insufficient sample size, and time/resource consumption. We aimed to share our preliminary results on the impacts of intelligent monitoring technology installation (IMTI) and additional modalities on healthcare workers' (HCWs') HH compliance in a Burn Center, according to the "5 Moments of HH" concept defined by the World Health Organization (WHO). Methods: A quasi-experimental longitudinal trial was conducted over eleven months.The first phase of the three-stage study evaluated basic HH compliances obtained by DO. The system-defined HH performances, which IMTI recorded, were assessed in the second phase. Finally, the effect of IMTI and additional modalities was determined in the third stage.
15202 HH events were performed by 41 HCWs, and a total of 20095 HH opportunities were observed. Four hundred fifty-five opportunities were in the preinstallation phase, and 19640 were during the total post-installation period. IMTIdefined performance rates in both Phase 2 (71.2%) and Phase 3 (80.5%) were generally considerably higher than HH compliances obtained from DO (58.5%). Nurses, physical therapy /anesthesia technicians, and housekeeping personnel showed significant increases, which was insignificant in physicians in phase 2. Meanwhile, a sustained increase was observed regarding IMTI and additional modalities of HH compliance of all HCWs in Phase 3.
IMTI has significantly increased HH performance rates. Furthermore, combining the IMTI with additional modalities as components of a multimodal strategy recommended by WHO appears to affect the sustainability of the increasing trend of HCWs' HH compliance.
Hand hygiene in a clinical setting: Evaluation of an electronic monitoring system in relation to direct observations
2024, American Journal of Infection Control
This study evaluated the accuracy of an electronic monitoring system for assessing hand hygiene in a clinical setting in relation to direct observations.
An electronic monitoring system was installed in a surgical ward at a tertiary hospital in Sweden. Hand hygiene events registered by the system were compared with direct observations conducted simultaneously by a trained observer following the World Health Organization’s “My five moments for hand hygiene”. A 4-step protocol was developed to evaluate the system’s ability to accurately monitor hand hygiene in a clinical setting.
A total of 947 opportunities for hand hygiene were observed during June to December 2019. Of these, 484 opportunities were correctly captured by the electronic monitoring system and included in the calculations for accuracy. Sensitivity was 90.2% with a positive predictive value of 95.7%, while specificity was 50.0% with a negative predictive value of 29.0%. Overall accuracy was 87.1%.
Evaluating technical systems assessing hand hygiene in clinical settings is hampered by several challenges. The 4-step protocol helped to identify the limitations and strengths of the evaluated electronic monitoring system, revealing high accuracy while also detecting system errors.
Current issues in hand hygiene
2023, American Journal of Infection Control
Multiple aspects of hand hygiene have changed in recent years.
A PubMed search was conducted to identify recent articles about hand hygiene.
The COVID-19 pandemic caused temporary changes in hand hygiene compliance rates and shortages of alcohol-based hand sanitizers (ABHSs), and in marketing of some products that were ineffective or unsafe. Fortunately, ABHSs are effective against SARS-CoV-2 and other emerging pathogens including Candida auris and mpox. Proper placement, maintenance, and design of ABHS dispensers have gained additional attention. Current evidence suggests that if an adequate volume of ABHS has been applied to hands, personnel must rub their hands together for at least 15 seconds before hands feel dry (dry time), which is the primary driver of antimicrobial efficacy. Accordingly, practical methods of monitoring hand hygiene technique are needed. Direct observation of hand hygiene compliance remains a challenge in many healthcare facilities, generating increased interest in automated hand hygiene monitoring systems (AHHMSs). However, several barriers have hindered widespread adoption of AHHMSs. AHHMSs must be implemented as part of a multimodal improvement program to successfully improve hand hygiene performance rates.
Remaining gaps in our understanding of hand hygiene warrant continued research into factors impacting hand hygiene practices.
Clinical evaluation of an electronic hand hygiene monitoring system
2023, American Journal of Infection Control
We aimed to test the accuracy of an electronic hand hygiene monitoring system (EHHMS) during daily clinical activities in different wards and with varying health care professions.
The accuracy of an EHHMS (Sani Nudge) was assessed during real clinical conditions by comparing events registered by two observers in parallel with events registered by the EHHMS. The events were categorized as true-positive, false-positive, and false-negative registrations. Sensitivity and positive predictive value (PPV) were calculated.
A total of 103 events performed by 25 health care workers (9 doctors, 11 nurses, and 5 cleaning assistants) were included in the analyses. The EHHMS had a sensitivity of 100% and a PPV of 100% when measuring alcohol-based hand rub. When looking at the hand hygiene opportunities of all health care workers combined taking place in the patient rooms and working rooms, the sensitivity was 75% and the PPV 95%. For doctors’ and nurses’ taking care of patients in their beds the EHHMS had a sensitivity of 100% and a PPV of 94%.
The objective accuracy measures demonstrate that this EHHMS can capture hand hygiene behavior under clinical conditions in different settings with clinical health care workers but show less accuracy with cleaning assistants.
Development and evaluation of an ultra-wide bandwidth based electronic hand hygiene monitoring system
2023, American Journal of Infection Control
A large variety of electronic hand hygiene monitoring systems (EHHMS) are being developed and applied in health care settings. Monitoring hand hygiene (HH) opportunity at bed-level has been the key technical challenge. Accuracy evaluation needs more attention as the prerequisite upon widespread acceptance and adoption.
For the first time, we explored, debugged and upgraded an EHHMS based on ultra-wide bandwidth (UWB) which can obtain HH opportunities at bed-level. The real-time positioning and electronic fence of UWB technology was applied for EHHMS. The accuracy of EHHMS was compared with the simultaneous manual direct observations in real-world clinical setting. Sensitivity and specificity were calculated for EHHMS capturing HH action and opportunity.
Two generations of EHHMS were constructed. For the first generation, the system properly recorded 84% and 78% of the pre-identified HH actions and opportunities performed by experimenters. For the second generation, sensitivity and specificity of the system capturing HH action were 89% (84.83-92.36) and 100% (98.26-100.00), respectively. For capturing HH opportunity, the system showed the sensitivity and specificity of 86.52% (82.52-89.89) and 88.10% (84.14-91.36)), respectively.
The EHHMS based on UWB could accurately identify HH action and opportunity with equivalent accuracy compared with simultaneous direct observation.

View all citing articles on Scopus

: The work reported here was supported by the Department of Veterans Affairs (VA), Veterans Health Administration, Health Services Research and Development (HSR&D) Service through the Comprehensive Access and Delivery Research and Evaluation Center (grant No. REA 09-220). MLS is funded by a VA HSR&D Career Development Award (No. CDA 11-211). ENP was funded through a VA HSR&D grant (No. IIR 09-099). The VA Office of Research and Development had no role in the design and conduct of the study.

: Conflicts of interest: None to report.

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Major articleAutomated and electronically assisted hand hygiene monitoring systems: A systematic review

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Implementation of hand hygiene monitoring networks

J Hosp Infect

Am J Infect Control

J Hosp Infect

J Hosp Infect

J Hosp Infect

J Hosp Infect

Am J Infect Control

Am J Infect Control

J Hosp Infect

Am J Infect Control

Am J Infect Control

J Hosp Infect

Am J Infect Control

J Crit Care

Am J Infect Control

Am J Infect Control

Am J Infect Control

J Hosp Infect

Am J Infect Control

Am J Infect Control

Am J Infect Control

J Hosp Infect

J Hosp Infect

Int J Med Inform

J Hosp Infect

Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

Infect Control Hosp Epidemiol

The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations

Infect Control Hosp Epidemiol

Commentary: electronic hand hygiene compliance interventions: a descriptive guide for the infection prevention team

Am J Med Qual

Advanced technologies to curb healthcare-associated infections

Healthc Pap

Searching for an optimal hand hygiene bundle: a meta-analysis

Clin Infect Dis

Interventions to improve hand hygiene compliance in patient care

Cochrane Database Syst Rev

Interventions to improve hand hygiene compliance in patient care

Cochrane Database Syst Rev

Hand hygiene: state-of-the-art review with emphasis on new technologies and mechanisms of surveillance

Curr Infect Dis Rep

Major article
Automated and electronically assisted hand hygiene monitoring systems: A systematic review