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. 2013;8(1):e53746.
doi: 10.1371/journal.pone.0053746. Epub 2013 Jan 14.

Compliance of health care workers with hand hygiene practices: independent advantages of overt and covert observers

Sung-Ching Pan  1 , Kuei-Lien Tien, I-Chen Hung, Yu-Jiun Lin, Wang-Huei Sheng, Ming-Jiuh Wang, Shan-Chwen Chang, Calvin M Kunin, Yee-Chun Chen
Affiliations

Compliance of health care workers with hand hygiene practices: independent advantages of overt and covert observers

Sung-Ching Pan et al. PLoS One. 2013.

Abstract

Background: Evaluation and feedback of hand hygiene (HH) compliance are important elements of the WHO multimodal strategy for hospital infection control. Overt observation is recommended, but it may be confounded by Hawthorne effect. Covert observation offers the opportunity to decrease observer bias. In this study we conducted a one year hospital-wide HH promotion program that included medical students (MS) as covert observers.

Methods: HH compliance for the five WHO indications was determined by trained and validated observers. The overt observers consisted of eleven infection control nurses (ICNs) and two unit HH ambassadors (UAs) in each of 83 wards. The covert observers consisted of nine MS during their rotating clinical clerkships. Feedback was provided to department heads and staff each quarter.

Results: Of the 23,333 HH observations 76.0% were by MS, 5.3% by ICNs and 18.7% by UAs. The annual compliance rates were MS 44.1%, ICNs 74.4% and UAs 94.1%; P<0.001. The MS found significantly lower annual compliance rates for 4/5 HH indications compared to ICNs and UAs; P<0.05. The ICNs reported significantly improvement from the first to the fourth quarter; P<0.001. This was associated with feedback from the MS of very poor compliance by nurses during the first quarter.

Conclusions: Based on these findings we recommend a two-pronged approach to HH programs. The role of ICNs and UAs is to educate, serve as role models, establish, sustain good HH practices and provide direct feedback. The role of the covert observers is to measure compliance and provide independent feedback.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. Hand hygiene compliance rates by type of observers and quarter.
The compliance rates observed by medical students (MS) were significantly lower than those by infection control nurses (ICNs) and unit HH ambassadors (UAs) in each quarter (all the P value <0.001). The numbers in parenthesis represented hand hygiene opportunities observed. T-bar represented one standard deviation.
Figure 2
Figure 2. Hand hygiene compliance rates according to professional category of the healthcare workers and type of observers.
Compliance observed by medical students (MS) was significantly lower as than by infection control nurses (ICNs) and unit HH ambassadors (UAs) (all P<0.001). The numbers in parenthesis are the hand hygiene opportunities. T-bar represents one standard deviation.
Figure 3
Figure 3. Hand hygiene compliance rate by type of observers (A. medical student (MS), B. Infection control nurses, C. unit HH ambassadors (UAs)), professional category, department, indication of hand hygiene, and period.
See this image and copyright information in PMC

References

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