Measurement in hand hygiene, usually employing either self-monitoring, in-direct measurement or direct observation (or a combination) is required to allow
baseline compliance rates to be established prior to interventions being launched. This allows the efficacy of these interventions to be gauged. Observational methods also allow contextual data about hand hygiene to be collected, allowing further opportunities for improvement to be gained. For example observation may allow potential barriers to hand hygiene and specific workflow patterns to be recognised. However, as has been established, no methods are without limitation. Kilpatrick (2008) comments on the commonality of auditing as a method for monitoring hand hygiene, referring further to the existence of a number of differing tools existing for this purpose. Auditing offers the opportunity for systematic data collection, with a set purpose and meaningful objective as to how to use the data to improve future practice. For hand hygiene this may be the development of a new initiative, specific interventions within one ward, or with specific individuals. Here three examples of existing tools are briefly presented to attest to the current role of auditing within the field of healthcare hand hygiene measurement.
a) Health Protection Scotland
Health Protection Scotland produced a tool to enable mandatory auditing in Scotland as part of their multimodal national hand hygiene campaign (Kilpatrick, 2008). This tool, including both electronic and paper components, was devised through rapid review of existing audit tools, and incorporation of current guidelines relating to hand hygiene technique (i.e. images including WHO 5 Moments). A full outline of the development of the tool is provided by Kilpatrick (2008), which fully explores the rigour and levels of review required to develop a working audit tool suitable for widespread use. Training days were held to aid Local Health Board Co-ordinators (LHBCs) and IPC staff to use the tool, which ensured a standardised method would be used throughout the proposed audit period. Such training sessions also allowed for the tool to be tested with
healthcare professionals, whereby feedback could be gathered as to,(for example) its ease of use. The audit tool was trialled through the execution of a widespread audit of hand hygiene compliance across NHS Scotland during a defined national audit period (9-20thMarch 2009), with protocol details and findings published by Health Protection Scotland (HPS, 2009).
Whilst accepting the limitations of audit involving observation (e.g. observer bias, selection bias, observation bias) the conclusions from the review of the first bi- monthly report on hand hygiene compliance, using the new audit tool, were positive (HPS, 2009). It was possible to collect data from a wide source at a national level, and provide analysis based on areas for further investigation, such as NHS Board and professional category. Such analysis allows for more specific,
rigorous research to be directed, bridging the gap between audit and research (Smith, 1992).
b) WHO Hand Hygiene Observation Tools
On a global scale this overview discussion of hand hygiene audit tools would not be complete without an acknowledgement of the widely tested and used WHO tools for calculating hand hygiene compliance. As part of a guide for
implementing their multimodal hand hygiene improvement strategy (WHO, 2009d) specific tools have been developed to allow for standardised, methodical evaluation and feedback (pp. 22 – 26 in Guide).Of particular relevance to this discussion are theHand Hygiene Observation Tools, consisting of an Observation Form (WHO, 2009b)(designed to be used for observations of hand hygiene within routine care practices) and two Compliance Calculation Forms (WHO, 2009b). Rather than being standalone tools, these are intrinsically linked to the methods and educational themes within the multimodal WHO approach. This allows users understanding as to context of the hand hygiene they are observing. This
knowledge is also important once the data has been collected and calculated, as it can be used as a basis for feedback and dissemination, and in turn further
education and training. Furthermore, both components of theHand Hygiene Observation Tools(Observation and Calculation) are complemented by an over- arching “Hand Hygiene Technical Reference Manual” (WHO 2009e). The manual ensures all observers have access to the same level of instruction on how to use the tools, helping to reduce observer bias. This can lead to a greater chance of validity in cross-comparison of collected data.
c) ICNA Hand Hygiene Audit Tool
The ICNA Hand Hygiene Audit Tool (Appendix 1c) is part of the wider ICNA (2004) “Audit Tools for Monitoring Infection Control Standards 2004”document. It consists of 40 points, separated into 32 alphabetised questions, allowing
assessment of environmental factors (e.g. availability of hand hygiene equipment, including paper towels, soap and ABHR), observational factors (e.g. whether hand hygiene is performed at key moments of Patient care) and knowledge factors (e.g. whether healthcare professionals are aware of when they should be performing hand hygiene).
The tool is designed to be used by trained individuals using observation; however the overt/covert nature of this method is open to interpretation and personal choice. This may have a bearing on the behaviour of those individuals being studied, as discussed previously. This issue is addressed in Chapter 5, when this method is explored in full at the case study site during interviews and
participatory observation.
Alongside the manual observation stage of the ICNA (2004) tool, a standardised, ready to use Microsoft Access database allows observed data to be translated into compliance scores. These are categorised into Compliant (85% or above), Partial Compliance (76-84%) and Minimal Compliance (75% or less) ratings. This rating can then be used for further action and reporting purposes. The tool, whilst
enabling data to be collected according to a standardised framework, has an apparent imbalance in focus on environmental factors rather than actual observed hand hygiene behaviour, demonstrated with 20 questions attributed to
towel and ABHR dispensers, exhibiting clean sinks, could score well on an audit, even if no one performs hand hygiene correctly. This is opposed to a ward where all hand hygiene observations are correctly observed, yet some ABHR or soap dispensers may be empty. However, it must be remembered that this tool was developed at a time when data regarding hand hygiene was collected in a very ad- hoc manner, if at all. This tool offered a relatively simple way to collect data which could be used to begin to make benchmark comparisons, both across settings, and across time spans as interventions were rolled out.
In 2008 IPS (previously known as ICNA) published a report documenting their findings from a questionnaire review of users of their suite of ICNA Infection Control audit tools, including the hand hygiene section. The data returned came from 148 completed questionnaires (102 hospital/46 community settings), predominantly from England, although all UK countries, ROI and a respondent from Gibraltar were represented. In terms of hand hygiene 73% of those using acute tools (hospital setting) reported use of the ICNA (2004) hand hygiene tool. Whilst further individual data about the hand hygiene tool is not reported, the overall feedback about the ICNA (2004) audit tools is generally positive, with the section onThemes arising from use of the ICNA Audit Toolsciting:
The tools were described as comprehensive and easy to use, providing clear national standardised evidence based criteria for monitoring practices and the environment.
Respondents indicated that the wording of some criteria caused confusion and required review and that the 2004 tools were too long with repetition in some areas. Shorter versions of the audit tools similar to the original West Midlands audit tools were preferred as those tools enabled all high risk areas of practice to be reviewed in one go.(IPS, 2008, pp. 3)
A repeated issue in the report (pp. 3;pp. 5) is that of the use of alternative audits, either in conjunction or as alternatives to the ICNA, due to perceived weaknesses in the current tool. These included the tool being too long, with over half the respondents (59%) saying they would like to see shortened tools developed, and the database needing simplification. The authors (IPS) maintained that future work must therefore be done on developing additional tools to ensure availability of national tools to allow for continued standardisation, ultimately leading to the launch of the QIT range in 2011.