Hand hygiene compliance: really important but impossible to measure

This morning I ran across an article in a Canadian newspaper, The London Free Press, that listed hand hygiene compliance rates for local hospitals. This piqued my interest. While nearly all hospitals in the US attempt to measure hand hygiene compliance, driven in large part by The Joint Commission's National Patient Safety Goals (NPSG 07.07.01 in TJC-speak), I am not aware of public reporting of hand hygiene rates in the US.

For public reporting, hand hygiene compliance is a double-edged sword. Given that hand hygiene is probably the most important measure to reduce healthcare associated infections, measuring it and publicly reporting it should be a high priority. On the other hand (no pun intended), it remains largely unmeasurable. I was interested to know how many observations were performed in the hospitals reported in the London newspaper since the denominators (number of opportunities observed) were not reported in the article. So I went to the Ontario Ministry of Health Patient Safety website, which has several publicly reported metrics for their hospitals (including central line associated bloodstream infection, ventilator associated pneumonia, and surgical site infection rates). There I learned that for hospitals with 100 beds, a minimum of 200 observations is required yearly.

So let's play with some numbers. Let's say that a 500-bed hospital performed 1,000 hand hygiene observations over the course of a year. We'll assume that the mean nurse:patient ratio across the hospital is 1:5, and that on average each nurse has 10 opportunities per hour for hand hygiene. If you do the math, you'll find that for nurses only, there are roughly 9 million hand hygiene opportunities per year in this hypothetical hospital. Measuring 1,000 of those opportunities accounts for one-hundredth of one percent. My conclusion: the hand hygiene compliance rates reported are meaningless. And my advice to the savvy Canadian consumer is to focus on the outcomes measures (infection rates) that are reported.

Unfortunately, at the moment, there's no valid way to measure hand hygiene compliance. Elaine Larson wrote a great review of the literature on methodologies for measurement a few years ago in the Journal of Hospital Infection. I still think it's useful to measure hand hygiene compliance, and the more opportunities observed, the better. And feedback of the data over and over in different ways is key to reinforce the importance of hand hygiene to healthcare workers.

Long story short: inside the hospital, hand hygiene compliance rates have utility. Outside, not so much.