Revolutionizing Infection Prevention: How Fewer Hand Hygiene Observations Can Boost Patient Safety

Does each unit in facilities need 200 hand hygiene observations a month? To find out, Infection Control Today^® (ICT^®) sat down with Sara Reese, PhD, MPH, CIC, FAPIC, the director of research for the Association for Professionals in Infection Control and Epidemiology’s Center for Research, Practice, and Innovation. She is also a member of ICT’s editorial advisory board.

As the lead author, Reese shared insights on the groundbreaking study, revealing that 50 hand hygiene observations per unit per month are statistically comparable to 200. This reduction has the potential to revolutionize infection prevention efforts, freeing up resources for improving safety culture and strengthening infection control programs across health care settings.

ICT: Given the new findings that 50 hand hygiene observations per unit per month are statistically comparable to 200, what impact do you think this reduction could have on your infection prevention efforts?

Sara Reese, PhD, MPH, CIC, FAPIC: It will free up more time for the infection preventionist (IP) because the burden of collecting that many observations falls upon the IPs to get that information, to implement the program, and get the information, get the data, and make sure it's reported every month. And so, lowering that number takes less of a burden on the IPs to have such an expectation of such a lofty number. Within infection prevention, if you have a much lower number, you're going to be able to do more with your time and prevent infections instead of trying to collect hand hygiene observations. At the same time, that is an important effort. Collecting [fewer] could give you the same information, and then you can get more quality observations and utilize the information you get to prevent infections.

ICT: That makes perfect sense. If statistically it's the same, then go with the lower number.

How do current hand hygiene observation requirements affect your team's ability to focus on quality improvement initiatives such as enhancing education infrastructure and fostering a strong safety culture?

SR: Collecting hand hygiene observations contributes to fostering that safety culture. It just depends on whether you're requiring a huge number; that kind of focus on the culture of safety goes away because you're just trying to get that number. Collecting [fewer] observations allows you more time to focus on the culture of safety, and if observations are missed, you have time to educate on it. You get more quality observations, and it's more about fostering that culture of safety rather than just trying to meet a number. It's a different focus…you have [time to focus more] on the safety culture aspect of hand hygiene observations, with education and discussion of its importance. In that case, you build that culture rather than just trying to meet a number.

ICT: That makes sense. As you said, doing 50 instead of 200 and still getting the same information leaves you with more time. That makes perfect sense.

SR: Right. To do quality work and prevent infections.

ICT: Which is the whole goal.

SR: It's our job,

ICT: The study highlights potential cost and time savings with reduced hand hygiene monitoring. How would you reallocate those saved resources to strengthen patient safety and infection control programs?

SR: That's a great question. You could put more resources into infection prevention programs. We've shown with a fixed staffing calculator that a good proportion of hospitals are understaffed right now, and understaffing has also been significantly associated with an increased risk of infection. So, ultimately, you could take that money and put it into the infection prevention program, whether it be for more [workforce] and getting additional staffing, which obviously would make a huge impact on the hospital itself, as well as other resources that IP programs could use to benefit and ultimately do their jobs better.

ICT: Absolutely. Would reducing the observation burden encourage greater staff buy-in for the hand hygiene adherence initiatives? If so, what strategies could enhance adherence across your facility?

The observations there could potentially create a better buy-in. My impression is that people would take it. More time spent getting those observations will result in higher quality because you only have to get 50 instead of 200 per unit. And with that more time, as I said before, the safety culture is not about getting a certain number of observations and meeting a certain adherence number for your hand hygiene. It's building that culture of the importance of hand hygiene and why we're doing it and keeping our patients safe.

The higher, higher quality data that the focus has gone from the adherence in the actual unit to just obtaining the number, and that's a challenge because you don't even know what's up and what's down because you're just trying to meet that number and not looking at the adherence. And that's all executives are looking at, too. Did you get your 200? Okay, we're good. They don't care.

ICT: So, it doesn't help anybody when you do that?

SR: No, it defeats the purpose.

ICT: Do the observations have to be done by humans, or can they be done by AI or some app?

SR: To meet the 50 or 200 observations, whatever Leapfrog requires, those have to be human. You can utilize a human. You can use an app to do it. There's a big push to do electronic hand energy monitoring, which captures 1000s and 1000s of observations in a day, which is great, and it's, it's fairly accurate; however, it comes with a huge cost. And then there's also the staff’s perception of being monitored and watched all the time. There are challenges with electronic monitoring as well. So, it's not the perfect solution, either.

ICT: Do you have anything else you'd like to add? Is there anything about the study that you think people will balk at?

SR: The fact that you're lowering the number of observations could make people weary of it. Leapfrog has set a standard, and that's the expectation. However, the data speaks loudly; you can still lower the observations. Leapfrog has done a lot of great things with this hand hygiene standard. I like the other domains they’ve brought into this, such as culture, education, and training. If you could remove the burden and focus on these observations in that monitoring domain and put more weight and effort on the other domains required in their standard, you're going to get to the point you want to reach, where you have that culture of safety. It doesn't come down to the ICU having to collect a certain number of observations each month. It's the fact that their hand hygiene adherence is 95% all the time because they understand the importance, and that culture has been built within that unit. And that’s what I want the take-home message to be: not that we lower the number of observations, but that we focus more on their other domains.

Because, I mean, their recent report in 2024 showed that they have a ton of hospitals utilizing this standard, and they're meeting it, which is great. But if they can push it to the next level—how do we build that culture rather than just requiring a certain number of observations and calling it a day? Do you worry that the adherence will go down? There are a lot of challenges with hand hygiene [and] direct observations of hand hygiene. So, it's hard to say 50 to 200 to 1000 [observations]… every unit will ebb and flow depending on staff, situations, patient population, and patient load. Those numbers are hard to maintain at a high level daily.

By lowering this requirement, we, as you pointed out, have low adherence rates, and this still holds up pretty well if your adherence is lower, so that's not too much of a concern. Any good IP will know which units struggle and which units need help. And that's where they need to focus their efforts, not on the number, but more on the percentage. And if a unit is struggling, they need to find a way to work with those unit leaders to get it up.