Patients could be observers of HCWs’ hand hygiene
1.2 The WHO-recommended method for direct
observation
Observation is a sophisticated activity requiring training, skill and experience. Observers have to be aware of the multiple potential biases introduced with the observation process and they can help to minimize these by gaining a full understanding of the methodology. A stringent adherence to the same methodology over space and time is required.
WHO proposes a standardized hand hygiene observation method based on an approach validated through several studies.60,652,686,738 All relevant theoretical and practical
aspects related to this method are detailed in the Hand Hygiene Reference Technical Manual that is included in the Implementation Toolkit (available at http://www.who.int/gpsc/ en/). An “Observation form” for data collection, consistent with the proposed method and including concise user instructions, is also availabletogether with a “Compliance calculation form” to facilitate the immediate performance feedback. Observation of hand hygiene practices is an essential component of the WHO Hand Hygiene Improvement Strategy (See Part I, Sections 21.2 and 21.3).
1.2.1 Profile and task of observers
The task of observers is to observe HCWs during their usual care activity and to assess their compliance with the recommended indications for hand hygiene. To be able to accomplish this task, observers have to be able to understand the logic of care. Ideally, they have training and experience in patient care as professionals.
1.2.2 Training of observers
Observers have to be trained according to the principles of “My five moments for hand hygiene” and, ideally, have become excellent monitors of the application of hand hygiene during health-care delivery. Their excellence should be confirmed through observations performed by a senior observer, if feasible, depending on the setting. They have then to be instructed in hand hygiene observation according to the present methodology. This should take a relatively short time if they have already proved to be proficient in the application of the five moments.
all new potential observers in a given setting. It is advisable to perform validation in each care setting that is to be monitored by the future observer. The WHO Training Film provides visual examples of the five moments for HCWs and observers. Observers can be trained and tested through the use of the scenarios, which include different sequences of health care where hand hygiene is necessary. Observers are asked to complete the form while watching the film, and the trainer can then judge their performance by comparing the results with the those provided in a slide show presentation that accompanies the film. The subsequent discussion is usually very valuable for learning purposes. If a time grid of opportunities can be established in a scenario, kappa statistics can be calculated to quantify the level of coincidence between two observers.
1.2.4 Understanding the five moments for hand hygiene
The concept of “My five moments for hand hygiene” has been created as a robust framework for understanding, training, measuring, and communicating hand hygiene performance.1
Understanding this concept (see Part I, Section 21.4) is a prerequisite for any future observer. It is a simple concept that should not leave any knowledge gap between the insight of observers and observed HCWs once they are adequately trained in hand hygiene. It is essential, however, that local specificity related to the application of the “five moments” is established and known by everyone. For example, the delimitation of the patient zone in a given setting needs to be specifically determined.
Health-care activity must be imagined as a succession of tasks during which the HCWs’ hands touch different types of surfaces prior to and after patient contact. Each contact is a potential source of contamination for HCW’s’ hands.
A crucial point specific to observations is the distinction between indications and opportunities, which is more extensively described in the Hand Hygiene Reference Technical Manual. The indication is the reason why hand hygiene is necessary at a given moment to effectively interrupt microbial transmission during care, and it corresponds to precise moments in patient care. Very close to the concept of indication, the term opportunity is much more relevant to the observer: it determines the need to perform the hand hygiene action, whether the reason (the indication that leads to the action) be single or multiple. From the observer point of view, the opportunity exists whenever one of the indications for hand hygiene occurs and is observed. Several indications may arise simultaneously and create a single opportunity. Very importantly, the opportunity constitutes the denominator for calculating compliance, i.e. the proportion of times that HCWs perform hand hygiene action of all observed moments when this was required.
For this purpose, hand hygiene action is defined as either rubbing hands with an alcohol-based handrub accepted by the institution or handwashing with soap and water. Neither the duration nor other quality aspects of hand hygiene such as the quantity of product used, glove use, length of fingernails, or the presence of jewellery are assessed.
It is important to understand that hand hygiene actions not corresponding to an opportunity, and therefore “additional” and not required, should not be taken into account by the observer. 1.2.5 Understanding the observation form
Observations are noted on a paper form using a pencil and rubber. Each form represents a separate observation session. Experience shows that this material is ergonomic for observations. The surface of a sheet of paper provides the necessary overview of the past evolution of observed activity in several, simultaneously observed HCWs. Using a pencil and an eraser, errors can easily be corrected.
The form has three main sections: 1) a header contains information on the institutional level (country, city, hospital, site identity); 2) a second header contains information on the session (observer identity, date, start and end time, duration, period number, session number, form number, department, service name, ward name); and 3) four columns below the header represent the sequence of actions for different HCWs observed during the same session. Each column is usually dedicated to one HCW and therefore the form can include up to four HCWs. Alternatively, in situations with low activity, each column can be dedicated to a different professional category and therefore the HCWs belonging to the same professional category can be grouped within one column. This method can be practical when the observer chooses to observe more than four HCWs during the same session. This results, however, in a loss of the possibility to calculate a per person density of hand hygiene opportunities and individual feedback after the session. The header of each column contains information about the observed HCW (professional category, code, number). The rest of the column consists of equal blocks that are incrementally numbered from 1 to 8 from top to bottom. Each block represents one of the sequentially occurring opportunities for hand hygiene. For each opportunity, the observer notes in the corresponding block all the applicable indications and if hand hygiene was executed by handrubbing, handwashing or missed.
1.2.6 Determining the scope of an observation period
Before starting an observation period, the investigators and project coordinators must determine the scope of observations. Possible scopes are listed in Table III.1.3. If the scope is to build a comparison between two or more observation periods to assess the evolution of hand hygiene compliance over time, special attention should be paid to control for the potential confounding factors. This can be achieved by predefining a target number of opportunities by profession, wards, and time of day. To minimise inter-observer variability, the observer or the team of observers should remain the same across the different periods of the project. The best unit for calculation is the denominator, i.e. opportunities for hand hygiene, because this will directly influence the results.
1.2.6.1 Selection of location and time
A representative mix of wards and time of day should be sought. Naturally, observers tend to undertake their activity at times and in locations with a high density of care to gather a higher
number of opportunities more quickly. Observers have to be aware that changing the method of selecting time and location for observations between observation periods can lead to bias because there is usually an association between density of opportunities and compliance. Therefore, we suggest to establish a rough location plan and timetable ahead of planned observations that will be remain stable over observation periods.
1.2.6.2 Selection of HCWs
Once location and time are determined, observers have to choose the HCWs to be observed during a session. Selection bias should be minimized by choosing at random. In the case of repeated observation periods in particular, observers may know the intrinsic performance of individual HCWs and this could easily influence the overall observation result by always selecting HCWs with extreme behaviour.
1.2.6.3 Starting, continuing, and concluding an observation session
Once a health-care situation is identified, the observer may introduce himself/herself by indicating unobtrusively the scope of his/her presence. The way in which this introduction is handled depends on local social and medical culture. A balance should be sought between increased observation bias through a too overt presence and inducing the feeling of being cheated in the observed by pretending to be there for another scope. This includes also a discreet positioning of the observer. After completing the form header, each observed opportunity is noted on the form (see above). Only opportunities for which the entire time between the two delimiting hand-to-surface exposures can be observed are noted.
During the observation session, the observer must not interfere with observed staff. The session should be concluded after 20 minutes ± 10 minutes according the duration of care activity. The observer may want to give feedback to the observed HCW(s) about the observed hand hygiene performance. This depends on the scope of the observation, but it was found to be very efficient and appreciated by HCWs.
1.2.7 Analysis
Following data entry (Epi Info databases for entering data collected according to the WHO-recommended method for
strong internal identity. A short delay between observation activity and reporting of results might increase the effect of feedback. Continual feedback of unchangingly bad results without any intervention should be avoided, as it may lead to “desensibilization” and demotivation.
Special attention should be given to the potentially low number of observed opportunities when using percentages to report compliance. Low numbers occur especially with stratified results. It is good practice to calculate 95% confidence intervals and include these in graphics. For instance, for 30 opportunities with a compliance of 50%, the confidence interval would stretch from 31% to 69% compliance. With 100 opportunities and 50% compliance, the confidence interval would shrink to 40–60%, and for 200 and 50% compliance opportunities to 43–57%. Finally, observations can be reported to HCWs directly after each session, which produces an immediate impact. For statistical methods to measure hand hygiene compliance over time see also Appendix 4.