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A Hand Hygiene Compliance Check System: Brief Communication on a

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Article  in  Journal of Medical Systems · June 2015

DOI: 10.1007/s10916-015-0253-z · Source: PubMed

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J Med Syst (2015) 39: 69
DOI 10.1007/s10916-015-0253-z
SYSTEMS-LEVEL QUALITY IMPROVEMENT
A Hand Hygiene Compliance Check System: Brief
Communication on a System to Improve Hand Hygiene
Compliance in Hospitals and Reduce Infection
Tracey S. Hong 1,2 & Emily C. Bush 1,3 & Morgan F. Hauenstein 1 & Alec Lafontant 1 &
Chen Li 1 & Jonathan P. Wanderer 5,4 & Jesse M. Ehrenfeld 4,5,6,7
Received: 13 March 2015 / Accepted: 30 April 2015 / Published online: 12 May 2015
# Springer Science+Business Media New York 2015
Abstract Hand hygiene compliance is the most significant,
modifiable cause of hospital-acquired infections, yet national
averages for compliance rates remain unsatisfactory.
Noncompliance can contribute to patient mortality, extended
hospital stays, higher re-admission rates, and lower reimburse-
ment for hospitals under the Patient Protection and Affordable
Care Act. Although several hand sanitizing tracking systems
currently exist, they pose problems of personal tracking,
workflow interference, system maintenance concerns, among
others. Considering these barriers, we created a prototype sys-
tem that includes compliance rate tracking, real-time sanitiza-
tion reminders, and a data archive for future studies.
This article is part of the Topical Collection on Systems-Level Quality
Improvement
Tracey S. Hong and Emily C. Bush contributed equally to this work.
* Tracey S. Hong
tracey.s.hong@Vanderbilt.Edu
1
Department of Biomedical Engineering, Vanderbilt University,
Nashville, TN 37232, USA
2
School of Medicine, Vanderbilt University, 201 Light Hall,
Nashville, TN 37232, USA
3
Institute of Imaging Science, Vanderbilt University,
Nashville, TN 37232, USA
4
Department of Anesthesiology, Vanderbilt University,
Nashville, TN 37232, USA
5
Department of Biomedical Informatics, Vanderbilt University,
Nashville, TN 37232, USA
6
Department of Surgery, Vanderbilt University, Nashville, TN 37232,
USA
7
Department of Health Policy, Vanderbilt University,
Nashville, TN 37232, USA
Keywords Hand hygiene compliance . Hand sanitation .
Hand washing . Nosocomial infections . Reinforcement
system . Compliance rate tracking . Rreadmittance rates
Introduction
Over 98,000 deaths per year in the United States can be
attributed to hospital-acquired infections – many of which
can be attributed to methicillin-resistant Staphylococcus
aureus (MRSA) [1]. The frequency of MRSA infections
is inversely proportional to hand hygiene compliance,
which is the most significant, modifiable cause of noso-
comial infections in hospitals [2]. Hand hygiene compli-
ance is defined as properly washing one’s hands with soap
and water or an antiseptic agent before and after all pa-
tient or patient environment contact [3]. Vanderbilt
University Medical Center (VUMC) uses manual observa-
tion, education, and incentives to address this problem,
but these are time and resource-intensive methods of en-
forcement. Other hospitals have employed methods of
compliance rate enforcement and tracking but they have
proved to be unsatisfactory, as they are either subject to
human error, are extremely costly, or infringe on employee
privacy.
Non-compliance with hand hygiene is a critical prob-
lem because it impacts our ability to provide optimal care,
leads to increased transmission of nosocomial diseases,
and can lead to significant additional costs incurred by
patients and hospitals. These risks could be mitigated
through the implementation of sensing technology that is
designed around the shortcomings of existing methods. In
the 2013 Centers for Disease Control and Prevention
(CDC) Antibiotic Resistance Threats report, it was esti-
mated that the direct healthcare cost of antibiotic
69 Page 2 of 4
resistance was near $20 billion annually. This figure does
not include the additional estimated $35 billion cost to
society attributed to lost productivity [4]. Additionally,
the largest cost for patients is often due to extended hos-
pital stays. Research shows that increasing sanitization
rates can reduce mortality rates and length-of-stay. The
North Carolina Children’s Hospital Pediatric Intensive
Care Unit implemented sanitization strategies that cut
death rates by 2.3 %, decreased hospitals stays by 2.3 days
and cut costs by over $12,000 per case [5].
A sustainable accountability and compliance checking sys-
tem is needed to address the aforementioned problems. We
therefore designed and implemented a prototype system that
includes the ability to provide compliance rate tracking, real-
time behavior modification, and a mechanism to archive in-
formation to be used for future studies comparing infection
and compliance rates.
Methods
Our study protocol was approved by the Vanderbilt
Institutional Review Board. During the design phase, we iden-
tified a series of goals, constraints, and assumptions, which are
as follows:
Goals
1. Integrate foam dispenser sensors and a door sensor into a
dual-sensing system with a warning alarm to create a sus-
tainable device that encourages active avoidance learning.
2. Accurately track hand hygiene compliance rates with the
dual-sensing system at VUMC.
3. Store hand hygiene compliance rates in a centralized
database.
Constraints
1. Our system has no personal tracking. This is an important
feature because of personal privacy concerns which might
otherwise impede end-user adoption. [6, 7]
2. The system must have easily serviceable parts. A hospital-
wide system could include thousands of units, therefore it
is critical that those units would not require constant main-
tenance. It is also paramount that the system does not
interrupt workflow.
3. Finally, to assist with compliance rates moving forward,
this system should have the ability to archive data for
compliance studies and trend determination. [8, 9]
J Med Syst (2015) 39: 69
Assumptions
1. Only one person enters at a time and all entries are human.
This assumption is made to exclude the entry of carts,
gurneys, and other medical equipment.
2. Everyone must sanitize prior to entry. There are a few
instances in which a person is not required to sanitize (if
hands are still wet from a prior sanitization), but we are
excluding those events.
3. The patient is already in the room.
4. The hand sanitizing canisters are full and users know how
to correctly use them.
5. Sanitization occurs in a timely manner. After observing
patient rooms, we have set this time to be 2 s.
6. The system resets after 2 s. Specifically, this means that
the next event cannot take place until 2 s following the
first.
It should be noted that we focused primarily on the sim-
plest environment: a single patient room. This made testing
the sensing system for accuracy and reliability straightfor-
ward because there is a single entryway, fixed sanitizing
stations, and one patient per room. Additionally, it helped
to solidify our assumptions and constraints for the
prototype.
System Design
Our system prototype is comprised of a doorway sensor,
two sanitizer dispenser sensors, a microprocessor and an
alarm. The doorway sensor, used to track room entry, is
an ultrasonic sensor (Maxbotix LV-EZ1 Ultrasonic
Sensor, Max Range 6.45 m, Digital Output) attached
to the outside of the doorframe. It works by creating
continuous distance readings, which are constant in an
empty doorway, by outputting correlated pulse widths
(Fig. 1c). When the beam is broken (Fig. 1d), the
change in distance is detected, which signals the activa-
tion of doorway entry. The hospital’s existing hand san-
itizing units were equipped with a BFlatback U-Ring^
(Fig. 1a), a device we created to house small IR beam
detectors (SHARP Infrared Sensor (GP2D120XJ00F),
Range: 4-30 cm, Analog Output). These are used to
determine if the hand sanitizer has been used due to a
hand breaking the beam under the nozzle (Fig. 1b). The
sensors are wired to an Arduino microprocessor
(Arduino Uno Micro-processing Board), housed on the
wall, where the sensing information is processed. Using
built-in Wi-Fi capabilities, the Arduino can send the
data to the hospital’s wireless network, allowing the
data to be captured in one centralized location for anal-
ysis. The Arduino sends counts of both compliant and
noncompliant events, and these numbers can be
J Med Syst (2015) 39: 69
Fig. 1 Hand sanitizing unit
equipped with BFlatback U-Ring^
(a); Hand breaking IR beam on
the unit during hand sanitization
(b); Door with US beam mounted
to frame (c); US beam on door
being interrupted by human entry
to room (d)
recorded to create compliance rates by department. In
addition to sending data, when a non-compliant event
occurs, the Arduino uses a built-in speaker to sound a
short, audible alarm, reminding the person entering the
room to sanitize.
The scenarios that our system can handle are shown in
Fig. 2.
1. Scenario 1: The user would sanitize, activating the
infrared sensor on the dispenser, and walk through
the door within two seconds, activating the ultrason-
ic sensor on the door. This would register as a com-
pliant event.
2. Scenario 2: The user walks through the door first; activat-
ing the ultrasonic beam and then uses the hand sanitizer
inside the patient’s room within two seconds. This also
registers as a compliant event. If the hand sanitizer inside
the room is bypassed or activated after two seconds post
room entry, an alarm will sound, signaling a non-
compliant event.
3. Scenario 3: If a hand sanitizer on either side of the door is
activated and there is no entry/exit within two seconds, no
event is recorded.
This method accounts for most probable scenarios, even
when multiple users are involved. Additionally, the user never
interacts with the system because it is automated. The only
interaction necessary would be for maintenance purposes (i.e.
battery replacement or system repair).
Fig. 2 Decision tree outlining the different operational scenarios which
could occur
Page 3 of 4 69
Results
During a pilot testing period, 40 compliant and 40 noncom-
pliant events were simulated in a single patient pre-operative
holding room. With a successful detection of 97.5 % of the
compliant events and 100 % of the non-compliant events, our
system delivered an overall accuracy of 98.75 %. The Arduino
device exported the data to a local spreadsheet every 5 s. Our
system also has the capability of wirelessly transmitting data
to a centralized hospital database via broadcasted Wi-Fi net-
works. The data spreadsheet has the ability to automatically
calculate compliance rates for shifts, days, months, etc. based
on specific areas of the hospital. The archived compliance data
can be compared to the existing gold standard of measuring
compliance rates (e.g. secret shoppers), to see whether the
alarm system has a positive impact on hand hygiene
compliance.
Future Directions and Conclusions
Future applications would include more complex situa-
tions such as trauma bays, preoperative rooms and re-
covery rooms, which have large quantities of beds sep-
arated by curtains and mobile sanitizing stations. With
the time and materials at hand, our proof of concept
prototype achieved our goals and exhibited the potential
for future development. The integration of high perfor-
mance wireless sensors with an alternate micro-
processing platform could allow for a noninvasive and
sustainable hospital-wide sensor system. We have suc-
cessfully demonstrated the temporal integration of IR
and ultrasonic sensors to detect hand sanitizer use and
doorway entry, as well as developed an alarm mecha-
nism to increase compliance rates in hospitals. Our sys-
tem has created a platform for exporting and archiving
data to be saved and compared with existing gold stan-
dards, such as secret shoppers. With the push for an
increase in hand hygiene compliance rates, and decrease
in hospital acquired infections and re-admittance rates,
our device demonstrates the practicality and need for a
system that can solve these problems.
69 Page 4 of 4
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