QAPI 152 - Relaunch of Electronic Monitoring System to Sustain Hand Hygiene Opportunities and Compliance

Background: Hand Hygiene (HH) is a vital component to prevent the spread of infections in hospital settings. Hand Hygiene Electronic Monitoring Systems (HHEMS) have been shown to increase compliance and reduce hospital-acquired infections (HAIs). After implementation of one such system an initial increase in both HH compliance (HHC) and HH opportunities (HHO) were observed. However, those numbers decreased below established goals in the months following implementation. The objective of this study is to determine the effectiveness of a “relaunch” of the system to provide a sustainable increase to HH opportunities and compliance.

Methods: A midwestern acute care hospital implemented a HHEMS in fall of 2021. HHO were measured as the total times staff entered and exited the patient room, and HHC was calculated by taking the number of HH events divided by the number of HHO. The relaunch began in February 2023 and utilized Kotter’s 8-Step Change Model. It consisted of a combination of the standardization of expectations of system use, engagement of senior and unit leadership, development of a reference sheet to address staff questions, and the sharing of weekly data to track and trend results.

Results: In the six months of initial implementation a monthly average of 291,811 HHO and HHC of 94.8% were observed. In the nine months following, compliance dropped to a monthly average of 226,104 HHO and HHC of 93.7%. In the nine months post-relaunch, HHO returned and sustained near initial launch numbers with a monthly average of 289,951 HHOs (28.2% increase compared to pre-relaunch) and HHC of 94.6% (9.6% increase, P-value < 0.0001).

Conclusions: While implementation of a HHEMS initially increased HHC and HHO, it is not simply a “set it and forget it” process. This project showed a comprehensive plan is needed to sustain performance and compliance following the implementation of a HHEMS.