Back to basics: hand hygiene and isolation

Lin Huang, G. Khai; Stewardson, Andrew J.; Lindsay Grayson, M.

Approaches to the monitoring of hand hygiene include direct observation, self-reporting, measurement of product consumption and use of various automated devices; each approach has strengths and weaknesses [34] . Although no method is ideal, direct monitoring is generally considered the gold standard, although limitations include resource intensity, observer bias and the potential of a Hawthorne effect [35, 36] . In fact, multiple factors can affect results (Table 1) , including the type of hand hygiene compliance audit tool used. Use of a standardized tool, such as the WHO 5 Moments tool, allows valid comparability between sites, although standardization of assessors and wards surveyed requires careful attention [37] . For example, approximately 80% of the current Hand Hygiene Australia (HHA) budget is required solely to maintain appropriate auditor (and therefore data) standardization to allow valid interhospital comparisons (Grayson ML, personal communication). Standardized hand hygiene auditing tools for nonacute settings, such as long-term care facilities, day surgical centres and psychiatry units, need to be defined and validated. When various surveillance methodologies have been directly compared [38] [39] [40] , there has not always been a strong correlation. Table 2 summarizes the monitoring methods used in recent publications on hand hygiene programmes [41,42 & , [43] [44] [45] . Measuring consumption of ABHR as a surrogate for hand hygiene behaviour has been used widely across Europe [46] , including Germany [42 & ] and Britain [18] . The benefits of this approach are objectivity, the availability of quantitative data and in some cases, an indication of daily use. However, this measure does not take into account variability in the amount of product used by an individual or differential use by family members and staff. More importantly, consumption data does not take into account the frequency of occasions when hand hygiene should have been performed, nor the appropriateness of ABHR usage. Similar limitations occur when using automated ABHR dispenser counters.