Compliance of health care workers with hand hygiene practices: independent advantages of overt and covert observers.
BACKGROUND
Evaluation and feedback of hand hygiene (HH) compliance are important elements of the WHO multimodal strategy for hospital infection control. Overt observation is recommended, but it may be confounded by Hawthorne effect. Covert observation offers the opportunity to decrease observer bias. In this study we conducted a one year hospital-wide HH promotion program that included medical students (MS) as covert observers.


METHODS
HH compliance for the five WHO indications was determined by trained and validated observers. The overt observers consisted of eleven infection control nurses (ICNs) and two unit HH ambassadors (UAs) in each of 83 wards. The covert observers consisted of nine MS during their rotating clinical clerkships. Feedback was provided to department heads and staff each quarter.


RESULTS
Of the 23,333 HH observations 76.0% were by MS, 5.3% by ICNs and 18.7% by UAs. The annual compliance rates were MS 44.1%, ICNs 74.4% and UAs 94.1%; P<0.001. The MS found significantly lower annual compliance rates for 4/5 HH indications compared to ICNs and UAs; P<0.05. The ICNs reported significantly improvement from the first to the fourth quarter; P<0.001. This was associated with feedback from the MS of very poor compliance by nurses during the first quarter.


CONCLUSIONS
Based on these findings we recommend a two-pronged approach to HH programs. The role of ICNs and UAs is to educate, serve as role models, establish, sustain good HH practices and provide direct feedback. The role of the covert observers is to measure compliance and provide independent feedback.
Center for Infection Control, National Taiwan University Hospital, Taipei, Taiwan.
Sung-Ching
SC
Pan
Kuei-Lien
KL
Tien
I-Chen
IC
Hung
Yu-Jiun
YJ
Lin
Wang-Huei
WH
Sheng
Ming-Jiuh
MJ
Wang
Shan-Chwen
SC
Chang
Calvin M
CM
Kunin
Yee-Chun
YC
Chen
D002982:Clinical Clerkship; D003625:Data Collection; D004501:Education, Medical; D005246:Feedback; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D063373:Hand Hygiene / Q000592:standards / Q000706:statistics & numerical data*; D006282:Health Personnel / Q000706:statistics & numerical data*; D009726:Nurses; D014944:World Health Organization