We can have a long discussion about whether we should routinely collect observational hand hygiene compliance information – I think we should, but others take a different view. But if we decide to collect routine hand hygiene compliance information, there are limitations of what is achievable. A recent study in JHI evaluated using patients as hand hygiene observers in an outpatient setting, which seemed to work pretty well.

It’s (conceptually!) easy to collect observational hand hygiene data in a multi-occupancy bay ward setting. You place yourself somewhere with decent line of sight across the bay, look inconspicuous (to reduce the risk of observation bias / Hawthorne effect), and get observing. Trying to get meaningful observational hand hygiene data from single rooms is much more tricky. If you follow the care giver into the room, it’s tricky (to say the least!) to remain inconspicuous. And we know that hand hygiene improves when care givers know they are being observed. So, imagine trying to get observational hand hygiene data in a setting that is 100% single rooms. This is commonplace across healthcare in the USA, and is the way of things in most outpatient settings too. One solution to this is to try to embrace our patients as hand hygiene observers.

Getting accurate observational hand hygiene information is harder than you might think. If you put two expert observers looking at the same care-giver/patient interaction, you will probably get more than one answer about compliance. This is because there is some grey areas between moments for hand hygiene, and a difference in how much flexibility you are willing to give somebody before making them as non-compliant. So, a common concern when considering whether or not to embrace patients as hand hygiene observers is that they won’t have enough education / experience to deliver meaningful information.

This study was undertaken in a US ambulatory care setting, which was all single rooms. The team decided to keep it simple, and asked patients to rate whether their care givers had undertaken hand hygiene “prior to caring for them” and “after caring for them”. The data was collected on paper questionnaires only, which were then manually inputted into an electronic database. It seems odd that they didn’t go down the route of some sort of electronic data collection method – but I guess that could be a next step. Overall, the process seemed to work. They managed to collect around 600,000 observations over 3 years – and these were 3 pandemic-affected years too, so bravo for delivering this study over that period. The levels of hand hygiene compliance that were recorded (>90% most of the time) seem a bit too good to be true. But there were some dips that were investigated, with an intervention and subsequent improvement. So in this sense, the programme delivered actionable surveillance information.

Our patients (and their visitors) are usually a willing and largely untapped resource when it comes to hand hygiene compliance information (and many other things). This study shows that a hand hygiene compliance surveillance system based on patient observations is feasible and delivers useful information.