Quality Assessment and Validation of a Direct Observation Hand Hygiene Program

Background Hand hygiene (HH) is a critical infection prevention practice to prevent transmission of microorganisms in healthcare settings. Direct overt HH observation programs provide opportunities for direct feedback, but face concerns over potential Hawthorne effect. We sought to compare our overt HH program to covert observations and perform quality assessments. Methods During May-July 2019, covert HH observations were conducted on inpatient units of healthcare personnel (HCP) in direct contact with patients and patient surroundings. An observer was trained to perform observations using the World Health Organization's Five Moments for HH. Electronic data collection included time, unit, HCP role, moments of HH and compliance. Quality metrics included duration of alcohol-based hand rub (ABHR), hand areas missed and compliance with nail policy. Observations included varying times and days covering all shifts and roles. Data was excluded if the observer was unable to fully visualize HH or if staff became aware of observations. Simultaneously, the institutional HH overt observations continued. Results During the study period, 189 covert observations were obtained, compared to 1826 overt observations on study units. We found no significant difference (p=0.217) between the rate of compliance of overt HH observations (99%, n=1804) and covert HH observations (95%, n=179). The majority of staff were nurses (77%). The median ABHR was 6 seconds (range: 2-15 seconds), with 10% of HCP completing the recommended 15 second hand rub. Most commonly missed areas (n=48) included the fingertips (65%, n=31) and between the fingers (65%, n=31). Staff were compliant with our nail policy (98%). Conclusions We describe the validation of a direct, overt HH program. The Hawthorne Effect did not make a statistically significant difference in compliance rates and HCP maintained high compliance (>95%) whether or not they knew they were observed. Quality metrics including appropriate duration of AHBR and coverage of hands were identified as opportunities for improvement.