Big Brother is Washing…Video Surveillance for Hand Hygiene Adherence, Through the Lenses of Efficacy and Privacy

The mundane act of performing hand hygiene is critically important for the prevention of healthcare-associated infections. Historically, healthcare personnel have low rates of compliance despite widespread and longstanding recognition, both that hand hygiene adherence is the crux of strategies that reduce hospital infection rates [1–4], as well as the fact that adherence to hand hygiene recommendations is a clear expectation of healthcare institutions, accrediting agencies, and patients [5]. A number of studies have attempted to identify the reasons for poor hand hygiene adherence rates and several additional studies have attempted to pinpoint barriers to universal performance of hand hygiene. Among other obstacles, healthcare personnel may underestimate the consequences of inadequate hand hygiene [6] or may misunderstand the purpose of hand hygiene [7]. In any event, healthcare workers routinely miss opportunities to prevent healthcare-associated infections by failing to perform hand hygiene at critical times. Healthcare-associated infections do not carry fingerprints or time stamps to identify the offending healers who failed the patient. Absent that, as Didier Pittet [7] has written, ‘‘Hand hygiene performance remains the only measure to judge the degree of system safety—and the only possibility for those concerned to know how they are performing.’’ Facilities and entrepreneurs have turned to creative strategies for monitoring and improving compliance [8–10]. In this issue of Clinical Infectious Diseases, Armellino et al describe a novel strategy of video surveillance of hand hygiene coupled with real-time, aggregate compliance feedback [11]. Motionactivated video cameras were strategically located throughout a medical intensive care unit. Monitoring and measuring compliance was outsourced to observers in India, and was done for a baseline prefeedback period followed by a 21-month period of observation and feedback. Clinical staff were categorized broadly by the presence or absence of white coats (attending physicians) and scrubs or uniforms (‘‘other healthcare professionals’’). If staff members spent more than 60 seconds in a patient room, they were rated on performance of hand hygiene within 10 seconds of entering or leaving. As observers abroad scored staff by category, real-time adherence scores were updated on electronic boards in the unit hallway. The study team collected more than 60 000 observations—a stunning volume that dwarfs the data collected by other hand hygiene monitoring programs in the literature. In the 4-month prefeedback period, the hand hygiene adherence rate was 6.5%. Strikingly, this extremely low adherence rate represents the baselinemeasured hand hygiene compliance rate in a hospital in which hand hygiene is a ‘‘condition of employment’’ [11]. The initially observed rate is so low that improvement to the mediocre US national average of 40% would have represented substantial improvement. The video observation–immediate feedback strategy, however, was associated with an overall compliance rate of 81.6% in the first 4 months, and 87.9% in the subsequent 17 months of the study. These data are consonant with Pittet’s observation about the critical role of feedback in convincing healthcare personnel to improve their hand hygiene adherence [4]. A casual glance at the striking success of this program would suggest that this Received 12 September 2011; accepted 23 September 2011; electronically published 21 November 2011. Correspondence: David K. Henderson, MD, Deputy Director for Clinical Care, NIH Clinical Center, Bldg. 10, Room 6-1480, 10 Center Dr., Bethesda, MD 20892 (dkh@nih.gov). Clinical Infectious Diseases 2012;54(1):8–9 Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2011. DOI: 10.1093/cid/cir781