Taking hand hygiene monitoring to a new level

Photo: Richard Lee, New York Times
CS = current shift; WR = weekly rate
A new study in Clinical Infectious Diseases details the use of video monitoring in North Shore University Hospital's medical ICU to improve hand hygiene compliance. Video cameras were placed in hallways and every patient room with remote video monitoring performed by observers in India.

In the initial phase of the study (16 weeks), no feedback was given to healthcare workers in order to determine the baseline rate of HH compliance, which was found to be incredibly low at 6.5%. In the second phase of the study (16 weeks), realtime feedback was provided by electronic boards (shown in the photo), with more detailed reports emailed to unit leadership 3 hours after start of each 12-hour shift and at the end of shift, as well as a weekly summary. During this period, hand hygiene improved to 82%. The third phase of the study (75 weeks, interventions identical to the second phase) showed the overall compliance rate to be 88%.

So here we have a very interesting study with compelling results. Unfortunately, the authors do not provide any data on infection rates. Given that we believe that hand hygiene and infection rates are linked, if any group were ever in a position to prove this dogma, it is these investigators with data on 400,000 hand hygiene opportunities over a 2 year period.

Some additional information on the study can be found in the Fixes blog at the New York Times web site. In that piece the cost of the surveillance system is delineated--$50,000 for the video equipment with $1,000 per month for "maintenance." We are not told if "maintenance" is the cost of the wages for the persons doing surveillance, who are employed by a company in the business of remote video auditing.

The authors point out that the healthcare workers were all informed that hand hygiene would be monitored, and all feedback was done at the aggregate level without identification of individual healthcare workers during the study. But I'm left with an uneasy feeling. It seems somewhat absurd to me to devote this level of resources to a single element, albeit an important one, of patient care. Even more absurd is that the real work is being done in a third-world country (whose public health infrastructure is so primitive that half of the population is forced to defecate in the open) by human observers making very low wages in order to make marginal improvements in the quality of care in an ICU setting (where a great deal of futile but incredibly expensive care is delivered) in the richest country of the world. I just can't wrap my arms around that juxtaposition.


  1. Wow. Infection prevention outsourced. I bet they could also do CLABSI prevention checklist monitoring and most antibiotic stewardship from India too. Time to look for another career.

  2. Thanks, Mike. The excellent editorial by Palmore and Henderson that accompanies this study (title begins, “Big Brother is washing..”) mentions patient privacy concerns but doesn’t touch on healthcare worker perception. CDC and University of Iowa investigators have a paper in this month’s ICHE on healthcare worker perceptions of hand hygiene monitoring technology. Although the example used in their focus groups was of electronic monitoring using wearable devices, there was substantial unease—quotes included “..seems a little creepy to me…a little too much Big Brother”, and “pushes the fringes and impinges on something. It just doesn’t feel right”. Link here:


    It would be interesting to learn more about healthcare worker perceptions in this study. It would be difficult for me to not occasionally look up at the camera and give an encouraging “thumbs up” to my remote monitoring colleague.

  3. I've come to accept the fact that as healthcare workers we will be monitored and measured. But the distributive justice issues here are really bothersome. It's as though there is no limit to the amount of money we will spend to provide or monitor inpatient care, while in many states in the US we have waiting lists for antiretroviral therapy for HIV patients, and the working poor have little access to even basic preventive services. It's even more glaring when you consider the situation in India.


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