Nationwide Benchmarking of Hand Hygiene Performance

Abstract

Affiliations: 1. First Global Patient Safety Challenge, Patient Safety Program, World Health Organization, Geneva, Switzerland; 2. Infection Control Program and World Health Organization Collaborating Center on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland. Received March 5, 2012; accepted March 11, 2012; electronically published April 19, 2012. World Health Organization 2012. All rights reserved. The World Health Organization has granted the publisher permission for the reproduction of this article. 0899-823X/2012/3306-0013$15.00. DOI: 10.1086/665720 Hand hygiene promotion is key to patient safety and a cornerstone of effective healthcare-associated infection prevention efforts. Many healthcare settings worldwide have committed to the implementation of hand hygiene campaigns with set targets for improvement. Evaluation of these strategies, especially by performance monitoring and infrastructure indicators, is a critical element to their success. This provides managers with information on the impact of campaign implementation and healthcare workers with feedback to motivate and sustain behavior change. Several countries have recently taken up this challenge at national level and included hand hygiene in quality improvement goals and indicators. In this issue, Behnke et al present alcohol-based hand rub (ABHR) consumption data collected prospectively on a voluntary basis through the German national nosocomial infection surveillance system since January 2008. Hospitals report data to a centralized system stratified by type of ward (intensive care unit [ICU] and non-ICU) and specialty. The overall objective is to facilitate improvement through both intrahospital (ie, between wards) and interhospital benchmarking. Established in 2008, the national German hand hygiene campaign includes more than 900 healthcare settings and is one of the largest worldwide. In line with the World Health Organization (WHO) hand hygiene improvement strategy, participating facilities are requested to (1) secure the active support of administrators; (2) participate in a 1-day introductory course, national workshops, and a national hand hygiene day; (3) organize training of healthcare workers at least once a year; (4) increase ABHR availability, monitor its consumption, and provide feedback; and (5) implement the WHO’s My 5 Moments for Hand Hygiene model. Considering the broad national scope, these features and organization are exceptional, particularly the nationwide ABHR consumption data collection system. Behnke et al report the 4-year results for a sample of 152 hospitals and show a 40.9% and 27.2% increase in median ABHR consumption per patient-day in ICUs and non-ICUs, respectively. Although such increases may be easily achieved in institutions where ABHR is newly introduced and replaces hand washing, these are astonishing in a context where ABHR was widely available for many years before the start of the national campaign. This dramatic increase strongly supports the effectiveness of the multimodal promotion strategy, particularly the performance feedback provided. However, establishing whether this increase reflects actual hand hygiene compliance improvement remains challenging. ABHR consumption measurement was chosen as a surrogate parameter for hand hygiene performance in Germany because direct observation of compliance was considered resource demanding and unfeasible over long periods. This choice was possible as the vast majority of hand hygiene actions in German hospitals involve ABHR, a crucial prerequisite for the use of its consumption as a surrogate of compliance. On the basis of 2010 ABHR consumption results, the reported estimates of the median number of hand hygiene actions per patient-day are low compared with that reported in the literature and would suggest defective hand hygiene behavior. Although the authors emphasize the existence of a good correlation between ABHR consumption and hand hygiene compliance rates reported elsewhere, their results are controversial and raise concerns about the ultimate outcome of hand hygiene promotion. ABHR consumption as a surrogate marker for hand hygiene compliance has several limitations. First, there is a need for accurate validation of consumption data entered in the system. Second, as recognized by Behnke and colleagues, consumption does not allow estimates of hand hygiene performance according to actual opportunities and is vulnerable to the influence of unnecessary hand hygiene actions by healthcare workers, use for other purposes (eg, surface disinfection), and use by patients and visitors. Hand hygiene compliance