Hand Hygiene Compliance Rate During the COVID-19 Pandemic | Infectious Diseases | JAMA Internal Medicine | JAMA Network
[Skip to Navigation]
Figure 1.  Monthly Hand Hygiene Compliance Across All Hospital Inpatient Units From September 1, 2019, through August 31, 2020
Monthly Hand Hygiene Compliance Across All Hospital Inpatient Units From September 1, 2019, through August 31, 2020

aP=.01 as compared with September 2019 baseline hand hygiene compliance in mixed models.

bP<.001 as compared with September 2019 baseline hand hygiene compliance in mixed models.

March 10, 2020, was the date of the first COVID admission at University of Chicago Medical Center (UCMC). On March 13, 2020, the COVID pandemic was declared a national emergency. On March 20, 2020, a stay-at-home order was issued for the state of Illinois and the COVID cohort unit opened at UCMC. April 22, 2020, was the date of the peak daily COVID census (n=155). May 1, 2020, was the date of the closure of the first COVID cohort unit. June 24, 2020, was the date of closure of the final COVID cohort unit.

Figure 2.  Monthly Hand Hygiene Compliance Across Inpatient COVID Cohort Units From September 1, 2019, through August 31, 2020
Monthly Hand Hygiene Compliance Across Inpatient COVID Cohort Units From September 1, 2019, through August 31, 2020

aP<.001 as compared with September 2019 baseline hand hygiene compliance in mixed models.

March 10, 2020, was the date of the first COVID admission at University of Chicago Medical Center (UCMC). On March 13, 2020, the COVID pandemic was declared a national emergency. On March 20, 2020, a stay-at-home order was issued for the state of Illinois and the COVID cohort unit opened at UCMC. April 22, 2020, was the date of the peak daily COVID census (n=155). May 1, 2020, was the date of the closure of the first COVID cohort unit. June 24, 2020, was the date of closure of the final COVID cohort unit.

1.
Knepper  BC, Miller  AM, Young  HL.  Impact of an automated hand hygiene monitoring system combined with a performance improvement intervention on hospital-acquired infections.   Infect Control Hosp Epidemiol. 2020;41(8):931-937. doi:10.1017/ice.2020.182PubMedGoogle ScholarCrossref
2.
Gould  DJ, Moralejo  D, Drey  N, Chudleigh  JH, Taljaard  M.  Interventions to improve hand hygiene compliance in patient care.   Cochrane Database Syst Rev. 2017;9(9):CD005186. doi:10.1002/14651858.CD005186.pub4PubMedGoogle Scholar
3.
Masroor  N, Doll  M, Stevens  M, Bearman  G.  Approaches to hand hygiene monitoring: from low to high technology approaches.   Int J Infect Dis. 2017;65:101-104. doi:10.1016/j.ijid.2017.09.031PubMedGoogle ScholarCrossref
4.
Leis  JA, Powis  JE, McGeer  A,  et al.  Introduction of group electronic monitoring of hand hygiene on inpatient units: a multicenter cluster randomized quality improvement study.   Clin Infect Dis. 2020;71(10):e680-e685. doi:10.1093/cid/ciaa412PubMedGoogle ScholarCrossref
5.
Limper  HM, Garcia-Houchins  S, Slawsky  L, Hershow  RC, Landon  E.  A validation protocol: assessing the accuracy of hand hygiene monitoring technology.   Infect Control Hosp Epidemiol. 2016;37(8):1002-1004. doi:10.1017/ice.2016.133PubMedGoogle ScholarCrossref
6.
Moore  LD, Robbins  G, Quinn  J, Arbogast  JW.  The impact of COVID-19 pandemic on hand hygiene performance in hospitals.   Am J Infect Control. 2021;49(1):30-33. doi:10.1016/j.ajic.2020.08.021PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Views 6,890
    Citations 0
    Research Letter
    April 26, 2021

    Hand Hygiene Compliance Rate During the COVID-19 Pandemic

    Author Affiliations
    • 1Department of Medicine, University of Chicago Medicine and Biological Sciences Division, Chicago, Illinois
    • 2Center for Healthcare Delivery Science and Innovation (HDSI), University of Chicago Medicine, Chicago, Illinois
    • 3Center for Health and the Social Sciences (CHeSS), University of Chicago Biological Sciences Division, Chicago, Illinois
    • 4Infection Prevention and Control Program, University of Chicago Medicine, Chicago, Illinois
    • 5Department of Pediatrics, University of Chicago Medicine and Biological Sciences Division, Chicago, Illinois
    JAMA Intern Med. Published online April 26, 2021. doi:10.1001/jamainternmed.2021.1429

    Hand hygiene is a cornerstone of infection control,1,2 yet compliance remains low, averaging 50% across hospitals nationwide.1 Audit and feedback can improve compliance,3 but audits traditionally occur using direct observation, capturing few events and leading to inaccurate measurements.4 To address this, some institutions have implemented automated monitoring.1,4 To further validate hand hygiene compliance measurements from automated monitoring and estimate the upper bound of compliance achievable with such systems, we describe changes in compliance during the COVID-19 pandemic as measured by the automated system at our institution, one of the largest such deployments nationally.

    Methods

    The University of Chicago Medical Center (UCMC) implemented an automated hand hygiene monitoring system in 2015 (PURELL SMARTLINK Integrated Monitoring System, GOJO Industries). An infrared sensor anonymously records all dispenser uses (numerator) and entries into and exits from inpatient rooms (denominator) to estimate hand hygiene compliance (numerator/denominator) for each inpatient unit. Graphical trends are displayed on centrally located unit monitors and weekly data are communicated through automated reports.

    We examined hand hygiene compliance in UCMC’s new adult hospital, by day, week, and month, from September 2019 through August 2020. We also examined compliance in units temporarily converted into COVID cohort units, which exclusively cared for patients with COVID-19, hypothesizing that such units would provide an estimate for maximum compliance. To provide context for the compliance data, we examined number of hand hygiene opportunities (ie, room entries and exits) and COVID-positive inpatient admissions by month. To assess for statistically significant differences in compliance by month and adjust for clustering within unit, we used bivariate linear mixed models with month as a categorical variable. Analyses included 13 validated inpatient units (9 noncohort, 4 cohort) and 6 intensive care units (3 noncohort, 3 cohort),5 comprising 276 noncohort and 160 cohort beds, performed with SAS, version 9.4 (SAS Institute). This project received a formal Quality Improvement determination, and as such was not reviewed by the Institutional Review Board, which is consistent with institutional policy.

    Results

    The hospital at which this study took place admitted 1159 inpatients with COVID-19 during the study period, with a monthly peak in April (Figure 1, Figure 2). Before the pandemic, monthly hand hygiene compliance across all units was similar to the September baseline of 54.5% (Figure 1). During the pandemic, compliance reached a daily peak of 92.8% on March 29, 2020, across all units, and 100% on March 28, 2020, across cohort units; a weekly peak of 88.4% across all units and 98.4% on cohort units during the week of March 29, 2020; and a monthly peak of 75.5% across all units and 84.4% on cohort units in April. Compliance declined across all units to a daily nadir of 51.5% on August 15, 2020, a weekly nadir of 55.1% that same week, and a monthly nadir of 56% in August. Statistical analyses demonstrated a significant association between month and hand hygiene compliance, for all units and cohort units specifically (supporting data reported in Figure 1 and Figure 2). Hand hygiene opportunities had an inverse relationship to compliance during the study.

    Discussion

    The hospital examined for this study achieved daily hand hygiene compliance rates higher than 90%, peaking at 100% across cohort units, significantly above national levels and the institutional goal of 60%. Study limitations include our inability to assess the quality of hand hygiene. The timeline illustrated in Figures 1 and 2 and the concomitant changes in hand hygiene opportunities suggest the compliance surge was driven by fear and increased awareness of the importance of hand hygiene associated with the start of the pandemic, as well as fewer room entries and exits resulting from fewer patient visitors, remote rounding by clinicians, and nurse batching of tasks while in patient rooms. High compliance was not sustained and returned to baseline. As hospitals set hand hygiene goals, this study suggests high compliance is possible, even with automated monitoring, yet difficult to sustain.6 The recent decline in compliance should be a clarion call to hospitals currently experiencing COVID-19 surges.

    Back to top
    Article Information

    Accepted for Publication: February 22, 2021.

    Published Online: April 26, 2021. doi:10.1001/jamainternmed.2021.1429

    Corresponding Author: Rachel Marrs, DNP, RN, CIC, Infection Prevention and Control Program, University of Chicago Medicine, 5841 S Maryland Ave, Room L-313, Chicago, IL 60637 (rachel.marrs@uchospitals.edu).

    Conflict of Interest Disclosures: Dr Landon has received travel support from GOJO Industries to speak about hand hygiene but has not received honoria or any other form of financial support. No other disclosures were reported.

    Author Contributions: Dr Marrs had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Makhni, Umscheid, Bartlett, Landon, Marrs.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Makhni, Umscheid, Soo, Landon, Marrs.

    Critical revision of the manuscript for important intellectual content: Makhni, Umscheid, Soo, Chu, Bartlett, Landon.

    Statistical analysis: Makhni, Soo.

    Administrative, technical, or material support: Makhni, Umscheid, Chu, Bartlett, Marrs.

    Supervision: Umscheid, Bartlett.

    Funding/Support: The evaluation was supported in part by the Center for Healthcare Delivery Science and Innovation (HDSI) at the University of Chicago Medicine.

    Role of the Funder/Sponsor: The Center for Healthcare Delivery Science and Innovation at the University of Chicago Medicine had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Additional Contributions: We would like to acknowledge Stephen Weber, MD, MS (Chief Medical Officer, University of Chicago Medical Center) for his review of our study, and Mark Connolly, MEng (Business Intelligence Lead, Data and Analytics, University of Chicago Medical Center) for providing COVID data. Neither received compensation for their role.

    References
    1.
    Knepper  BC, Miller  AM, Young  HL.  Impact of an automated hand hygiene monitoring system combined with a performance improvement intervention on hospital-acquired infections.   Infect Control Hosp Epidemiol. 2020;41(8):931-937. doi:10.1017/ice.2020.182PubMedGoogle ScholarCrossref
    2.
    Gould  DJ, Moralejo  D, Drey  N, Chudleigh  JH, Taljaard  M.  Interventions to improve hand hygiene compliance in patient care.   Cochrane Database Syst Rev. 2017;9(9):CD005186. doi:10.1002/14651858.CD005186.pub4PubMedGoogle Scholar
    3.
    Masroor  N, Doll  M, Stevens  M, Bearman  G.  Approaches to hand hygiene monitoring: from low to high technology approaches.   Int J Infect Dis. 2017;65:101-104. doi:10.1016/j.ijid.2017.09.031PubMedGoogle ScholarCrossref
    4.
    Leis  JA, Powis  JE, McGeer  A,  et al.  Introduction of group electronic monitoring of hand hygiene on inpatient units: a multicenter cluster randomized quality improvement study.   Clin Infect Dis. 2020;71(10):e680-e685. doi:10.1093/cid/ciaa412PubMedGoogle ScholarCrossref
    5.
    Limper  HM, Garcia-Houchins  S, Slawsky  L, Hershow  RC, Landon  E.  A validation protocol: assessing the accuracy of hand hygiene monitoring technology.   Infect Control Hosp Epidemiol. 2016;37(8):1002-1004. doi:10.1017/ice.2016.133PubMedGoogle ScholarCrossref
    6.
    Moore  LD, Robbins  G, Quinn  J, Arbogast  JW.  The impact of COVID-19 pandemic on hand hygiene performance in hospitals.   Am J Infect Control. 2021;49(1):30-33. doi:10.1016/j.ajic.2020.08.021PubMedGoogle ScholarCrossref
    ×