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A Simple Method for Estimating Hand Hygiene Use Among Anesthesia Personnel: Development, Validation, and Use in a Quality Improvement Project

Segal, Scott MD, MHCM*; Harris, Hannah M. BS*; Gunawan, Antonius BS*; Schumann, Roman MD

doi: 10.1213/ANE.0000000000004106
Patient Safety: Original Clinical Research Report

BACKGROUND: Frequent hand hygiene by anesthesia personnel may be an important factor in reducing contamination of IV lines and medication access ports and may reduce hospital-acquired infections. Measurement of hand hygiene frequency at the individual clinician level by direct observation or electronic devices is cumbersome and expensive. We developed and validated a simple method for estimating hand hygiene frequency by individual anesthesia providers and utilized it in a quality improvement initiative to increase hand hygiene use.

METHODS: Pump-style, alcohol-based hand hygiene container weight at the anesthesia work station was measured before and after each surgical operation and converted to estimated number of accesses (pumps) per hour. Video observation was used to validate the estimated hand hygiene use. A quality improvement initiative utilized periodic measurement of hand hygiene frequency via the validated method, and incorporated individual provider feedback, email reminders, monthly departmental performance reports, and reminders in the electronic anesthesia record. Segmented linear regression was used to evaluate the effect of the intervention on hand hygiene use.

RESULTS: Delivered product per pump was consistent for containers at least half-full and averaged (mean ± SD) 0.92 ± 0.13 g per pump. Video observation in 26 cases showed a strong correlation between observed hand hygiene episodes and estimated hand hygiene use frequency based on weight change of the container (linear regression, R2 = 0.97, P < .0001). Median hand hygiene frequency was near 0 at baseline but increased progressively throughout the intervention period (segmented linear regression, overall R2 = 0.76, P < .0001; change of intercept or mean hand hygiene after initiation of intervention [parameter estimate ± SE] [0.970 ± 0.29], P = .0008).

CONCLUSIONS: A low-cost, simple method for measuring individual anesthesia clinician use of hand hygiene intraoperatively based on container weight change is feasible and sufficiently accurate to support a quality improvement initiative to increase its use.

From the *Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina

Department of Anesthesiology, Tufts University School of Medicine, Boston, Massachusetts.

Published ahead of print 27 March 2019.

Accepted for publication January 30, 2019.

Funding: Departmental.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Scott Segal, MD, MHCM, Department of Anesthesiology, Wake Forest School of Medicine, 1 Medical Center Blvd, Winston-Salem, NC 27157. Address e-mail to

See Editorial, p 1446

Hand hygiene performance by medical personnel is a well-recognized infection control maneuver. The World Health Organization has identified “five moments” in clinician–patient interactions as opportunities for hand hygiene. These include performing hand hygiene before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching the patient’s surroundings.1 However, these opportunities were defined in the context of physicians seeing patients in a clinic or hospital ward. In the operating room, anesthesia personnel are constantly providing patient care involving interaction with the patient in clean/aseptic procedures, contact with bodily fluids, or touching the patient’s surroundings. A literal following of the World Health Organization guidelines might require hand hygiene up to or exceeding 150 times per hour.2,3

Unsurprisingly, most observations of anesthesiology personnel demonstrate vastly fewer episodes of hand hygiene performance per hour than the World Health Organization guidelines would recommend.2–8 However, investigators at Dartmouth Geisel School of Medicine reported reduced contamination of IV stopcocks and other commonly handled items in the anesthesia workspace with the use of hand hygiene approximately 4–8 times per hour compared to a near-zero baseline.6,7

Reliably measuring hand hygiene at the provider level is challenging. Direct observation and video surveillance have been used in limited research settings, but are labor intensive and not practical for broad application in a large and busy operating suite.2,3,5,8,9 Koff et al6,7 used an electronic device worn by individual practitioners that both recorded each hand hygiene episode with a timestamp, and also offered reminder alarms to encourage more frequent use. Although the device used in their studies is not present on the market, other electronic devices may not be financially attractive for routine clinical use by all perioperative providers including anesthesia clinicians.10–12 Because it is often a single anesthesia clinician who is directly caring for a given patient for a given case, we hypothesized that a container weight–based methodology for estimating hand hygiene use would be sufficiently accurate to quantitate hand hygiene use by anesthesia personnel. We developed and validated this methodology and then used it in a quality improvement initiative to increase intraoperative hand hygiene use by anesthesia personnel in a busy academic medical center.

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This research was approved by the institutional review boards of Tufts University School of Medicine and Wake Forest School of Medicine with a waiver of requirement for informed consent of the participants, who were anesthesia clinicians functioning in the usual clinical environment. This quality improvement portion of this report follows the Standards for Quality Improvement Reporting Excellence 2.0 guidelines.13

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Measurement of Hand Sanitizer Use

Disposable, pump-style containers of alcohol-based sanitizer (Purell; Gojo Industries, Akron, OH; full container containing 354 mL of product), one of which is present at every anesthesia workstation on the top surface of the drug/supply cart, were weighed before each monitored operation and again after the patient left the operating room. No other hand hygiene product dispenser was in the immediate vicinity of the workstation in any operating room. A digital scale with a capacity of 2000 g and a precision of 0.1 g (USBENCHTOP; Fesco Distributors, Brooklyn, NY) was used for all measurements and was calibrated with 200 g reference weights as required by the scale’s internal logic. Consumption was converted to grams per hour by dividing weight change by total time the patient was in the operating room. To calculate the estimated dispensing of product per pump, the investigators performed multiple pumps in different containers (n = 15), deliberately varying the force applied to the plunger as well as the capacity of the container, and measured the weight change from the delivered product. To simulate actual use of containers in the operating room, and to allow for possible effects of 1 pump on the amount of product dispensed by subsequent pumps, the number of pumps tested from each container mirrored the observed number of hand hygiene uses in an actual monitored case (n = 7–41). Containers with less than approximately 100 g (about 1/3 of a full container) were found to deliver product with much greater variation than fuller containers (see Results), so all clinical measurements were made with containers at least half-full at the beginning of the case. Average product dispensed from half-full and full containers was calculated. From the average pump weight so derived, excluding samples taken from containers <150 g, the total grams per hour for each case were converted to estimated pumps per hour.

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Validation of Estimated Hand Hygiene Episodes

To confirm that the hand hygiene use as estimated from weight change of the container reflected actual hand hygiene use, video-assisted observation of actual hand hygiene use during selected cases (n = 33) was compared to estimates derived from the container weight change for these same cases. Video was directly observed utilizing cameras built in to each operating room and broadcast over the hospital network to monitoring terminals (Wake Forest Medical Center). Observed hand hygiene episodes were compared to the weight change–based estimate of hand hygiene use; the investigator performing the video observation was distinct from the investigator obtaining the weights and masked from the resulting weight change. An additional 14 cases (39.5 hours) were monitored specifically to quantify the proportion of hand hygiene episodes performed by a provider other than the primary resident or certified registered nurse anesthetist.

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Quality Improvement Initiative to Increase Intraoperative Hand Hygiene Use

Baseline hand hygiene use among anesthesia providers was measured periodically from October 2015 to September 2016 at Wake Forest Baptist Medical Center. These measurements were taken before giving notice to anesthesia clinicians of the intent to quantitate and improve hand hygiene use, which commenced in September 2016. Containers were weighed before and after each of approximately 20 cases per measurement episode at approximately weekly intervals. All 40 operating rooms were variously selected as a convenience sample on each measuring day, and came from a wide variety of types of cases, operating rooms, days of the week and times of day, and providers. Measurements of container weight were obtained before room setup and during room turnover, and providers were not aware of whether or not their case was being monitored. Beginning in September 2016, periodic measurements (at least twice monthly) continued after providing education to anesthesiologists and certified registered nurse anesthetists of the importance of increasing hand hygiene use. A number of different interventions were used to attempt to increase hand hygiene use as estimated by the periodic measurements. Providers falling below 1 episode per hour were intermittently counseled by the Chief certified registered nurse anesthetist or the Chair of Anesthesiology (Supplemental Digital Content 1, Figure 1, Monthly feedback to clinician groups was given. Reporting of progress to the hospital infection control committee and hospital clinical leadership occurred periodically. Email reminders were sent to clinicians periodically by certified registered nurse anesthetist and Anesthesiology leadership (Supplemental Digital Content 2, Figure 2, On-screen reminders appearing every 15 minutes were implemented into the real-time anesthesia record keeping system (Supplemental Digital Content 3, Figure 3,; Best Practice Reminders, OpTime; Epic Systems Corporation, Madison, WI).

To investigate the possible contribution of secular trends in hand hygiene use, we tabulated publically reported hand hygiene use on operating room entry and exit. These data were gathered in a clandestine fashion by operating room infection preventionists who were not involved in this investigation, and the data were reported monthly to all operating room personnel. Separate analyses of the trend over time and any possible change corresponding to the time period of the quality improvement intervention were computed for surgeons, operating room staff, and anesthesia personnel.

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Statistical Analysis

Descriptive statistics were used to calculate mean, median, and distribution of weights/pump. Estimated versus observed hand hygiene episodes were compared by linear regression, forcing the origin into the model. Temporal trends in hand hygiene use in the quality improvement project and room entry/exit were calculated by segmented linear regression (Time Series with Transfer Function, JMP 14; SAS Institute, Cary, NC).14 This method models an interrupted time series of hand hygiene observations as a baseline level, in this case, median hand hygiene use per hour , a trend over time , a dummy Boolean variable (intervention) to indicate the period before or after the intervention, a stepwise change in the outcome immediately after the intervention , the change in the trend over time after the intervention , and an error term (et):

Interrupted time series typically assume evenly spaced observations, which is not always true of real-world quality improvement projects, and was not present in our data, particularly in the preintervention project planning and method validation phase. Linear interpolation was used to provide pseudo-evenly spaced observations before constructing the regression model.15 Goodness-of-fit of the entire model was tested with least-squares regression. Potential confounder variables were tested individually for their relationship with hand hygiene use by ANOVA with Tukey–Kramer correction for multiple comparisons.

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Weight of product dispensed per pump varied moderately in full or greater than half-full containers but was much greater in containers less than half-full (Figure 1). Excluding low-fill containers, the weight per pump (mean ± SD) was 0.92 ± 0.13 g. This value was used for converting the observed weight change in containers to the estimated number of pumps. Only containers with starting weights indicating at least half the product was present were used in validation and monitoring phases of the project. Validation of the weight-based estimation of hand hygiene use against observed episodes is shown in Figure 2. Estimated pumps correlated well with observed pumps (R2 = 0.97, P < .0001). The relationship was somewhat less strong but still highly significant in the subset of observations with <10 actual hand hygiene uses (R2 = 0.71, P < .0001). The mean (95% CI) error in estimation for the entire set of observations (observed estimated) was −0.88 (−0.02 to −1.7). The absolute error was <2 pumps in 79% (62%–89%) of observations.

Figure 1.

Figure 1.

Figure 2.

Figure 2.

During the quality improvement project, 1450 cases were monitored, comprising 4108 hours of anesthesia care, or 2.83 ± 2.54 (mean ± SD) hours per case. Operating rooms were sampled 36.3 ± 15.2 times each. A total of 190 different certified registered nurse anesthetists and 57 different residents were the primary providers in the monitored rooms. Each unique provider was monitored 3.9 ± 4.1 times over the course of the studied time period. In 26% of cases, >1 primary provider, other than the attending physician, was in the room at some portion of the case. In the rooms monitored to estimate frequency of attending physician hand hygiene use, as compared to primary resident or certified registered nurse anesthetist provider hand hygiene use, the median (interquartile range) proportion of attending hand hygiene episodes was 0% (0%–9.5%). Estimated hand hygiene per hour was not corrected for this observation.

During the baseline phase of the project, median estimated hand hygiene use per hour did not change (linear regression, P = .20), but after the intervention increased significantly (Figure 3; Table; segmented regression analysis, whole model overall R2 = 0.76, P < .0001). Parameter estimates for the full model are shown in the Table. In this model, the effect of the intervention was significant (change in intercept or mean value, β2,P = .0008). Linear regression of the observed median hand hygiene frequency after the intervention demonstrated an increase over time (0.028 ± 0.004 episodes per time period [estimate ± SE], P < .0001).

Table 1.

Table 1.

Figure 3.

Figure 3.

Use of hand hygiene on room entry and exit is shown in Figure 4 for surgeons, operating room staff, and anesthesia personnel. Segmented regression analysis showed no change corresponding to the time since the beginning of the studied intervention for surgeons (adjusted R2 = 0.01, mean change after intervention P = .61, rate of change after intervention P = .85) or for operating room staff (adjusted R2 = 0.03, mean change after intervention P = .47, rate of change after intervention P = .10). Data on anesthesia personnel, conversely, did show a modest effect of the intervention period (R2 = 0.36, mean change after intervention P = .012, rate of change after intervention P = .0002).

Figure 4.

Figure 4.

Potential confounders were tested for their relationship with hand hygiene frequency, and none was found significantly related. Hand hygiene per hour by certified registered nurse anesthetists versus residents did not differ (mean [95% CI], 3.5 [3.2–3.9] vs 3.1 [2.4–3.8]; P = .15). There was no relationship between hand hygiene per hour and surgical duration (R2 = 0.003, P = .08). Individual operating rooms did not vary overall (P = .055, no pairwise differences by Tukey test).

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The results of this investigation demonstrate the feasibility of monitoring hand hygiene among anesthesia personnel at the individual provider level by a simple low-technology method that should be relatively easy to implement at modest cost. The accuracy of the measurements achieved by weighing the disinfectant containers used in this study, while not perfect, nevertheless, was sufficient to allow for global monitoring of institutional performance in hand hygiene quality improvement measures. Although this study utilized research assistants to gather the data, it may be possible to implement this methodology within the existing workflow by anesthesia technicians or other support personnel during room turnover at minimal incremental cost. In our institution, we have continued to estimate hand hygiene use weekly and we have used both dedicated quality data collectors who carry a room turnover pager and anesthesia technicians. The measurement typically takes <1 minute.

Hospital-acquired infections are a major source of patient morbidity16 and increase in health care costs.17 Hand hygiene use by medical personnel is considered a fundamental infection control process which is likely able to reduce hospital-acquired infections by ≥40%.18 In the operating room environment, measuring hand hygiene on room entry and exit only is simple but ignores the importance of the procedure by anesthesia personnel intraoperatively, who are in frequent contact with the patient from room entry to exit and do not themselves enter and leave the room frequently. Nonetheless, there is significant evidence that more frequent intraoperative hand hygiene performance by anesthesia personnel can reduce contamination of the work environment, and most importantly, the IV tubing and entry sites (eg, stopcocks), reducing patient exposure to potential pathogens.6,7,19,20 In some but not all such efforts, hand hygiene frequencies of 4–8 times per hour resulted in decreased hospital-acquired infections.6,7

Hand hygiene in the operating room poses unique challenges for anesthesia personnel. The anesthesia work environment becomes increasingly contaminated over the course of an operation.21,22 Anesthesia personnel constantly move between this area and the patient, and their hands can be a vector for pathogen transmission to medication syringes, IV tubing and stopcocks, and ultimately the patient.19,20,23 Application of the World Health Organization “five moments” criteria (before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching the patient’s surroundings) to perform hand hygiene would seem logical because they are designed to prevent just this sort of transmission. However, objective measurement of hand hygiene opportunities in the operating room environment according to the World Health Organization criteria leads to unrealistic and impractical hand hygiene requirements. For example, Biddle and Shah2 used trained nurse observers in the operating room and found up to 54 hand hygiene opportunities per hour for anesthesia personnel. Rowlands et al3 used video observation (which they felt was more robust and avoided bias from direct observations) and counted 149 ± 10.3 (mean ± SD) hand hygiene opportunities per hour. Performing hand hygiene this frequently (every 24 seconds), even under ideal circumstances, would leave no time for clinical care and is obviously impractical as a standard. This may explain why investigations of anesthesia clinicians’ actual hand hygiene use in the operating room reveal a substantially lower frequency than the World Health Organization opportunity count would suggest. Rowlands et al3 observed use of hand hygiene in just 2.3%–3.6% of all opportunities.3 Biddle and Shah2 found that 18% of their somewhat lower opportunity estimate was accompanied by hand hygiene use. Scheithauer et al5 used direct observation during a quality improvement project of anesthesia personnel limited to just the beginning of the surgical procedure and found only 2 episodes per case or 10% compliance at baseline was documented. In a series of studies, investigators at Dartmouth-Hitchcock Medical Center found very low rates of hand hygiene use before improvement interventions ranging from a mean of 0.15 to 0.57 events per hour.6,7,21 This is consistent with our findings of a median of 0 events per hour at baseline.

Measurement of hand hygiene use by individuals over specific care episodes, such as anesthesia clinicians during individual operations, can be cumbersome. Human observation in the operating room has been used, primarily in research settings.2,5,7,9 Trained direct observation is time consuming, expensive, and may induce changes in clinician behavior due to the Hawthorne effect.2,24 Remote video monitoring is possible if installed in the operating rooms of interest,3 but it is similarly time consuming and expensive to install.10,25 The Dartmouth group used electronic devices installed in either wall-mounted product dispensers or individual waist-worn dispensers equipped with electronic timestamp counters of hand hygiene use.6,7 These devices are quite accurate but are not presently available on the market, and other electronic devices may be too costly for routine use,10–12,26 although any such calculation would have to consider the possible reduction in hospital-acquired infection. In the present investigation, we used a very inexpensive system based on weight change of individual hand hygiene dispensers placed in the anesthesia work environment. The hand hygiene product in our institution costs $2.46 per bottle or approximately $0.01 per use even assuming half-empty bottles were discarded. The scale used costs <$50 and each measurement required only a few seconds, making it possible to incorporate into standard room turnover activities with little to no incremental labor cost. Unlike conventional product consumption–based methods, our assessment of product use for a single case is not severely impacted by an inability to know who has used the container, the time course of the observed use, and other causes of inaccuracy.27

Our method is certainly not completely accurate. The experiments demonstrating variation in pump volume with plunger pressure, container volume, and operator likely reflect real-world variability in the delivered product from a given pump. Anesthesia personnel pushing partially or multiple times per hand hygiene episode could distort the estimated frequency derived from average volume and total volume dispensed. Furthermore, if >1 provider (eg, an attending physician and a resident) participated in the care of a given patient and each accessed the container, the weight change would overestimate the hand hygiene use for each practitioner. We did not correct for such events, which were relatively uncommon in our video validation sessions. In general, only 1 provider at a time interacted with the patient and the anesthesia work environment, and the attending physician was in the room a minority of the case duration. However, we recognize that if a colleague also in contact with the patient performed hand hygiene as well, this would be favorable with regard to the desired outcome of increasing hand disinfection for any provider who might be a source of contamination even if it overstated the quantitative estimate for the primary provider. Even given these sources of variability, the correlation between estimated and observed hand hygiene use during the validation observations was strong. Moreover, even if our methodology sometimes overestimated individual provider hand hygiene use, there is no reason to suspect that this phenomenon would have changed over the time course of the study period, and there was still an observed increase in overall hand hygiene use. While the uncertainty of who actually used the hand hygiene container is a limitation of our methodology, it also suggests that further research might be undertaken to statistically estimate this error in different circumstances as a further refinement. We believe, therefore, that our methodology is sufficiently accurate to support a quality improvement effort designed to augment hand hygiene performance frequency.

Our quality improvement program resulted in a significant improvement in hand hygiene frequency over the observed time period and achieved performance into the frequency range associated with reduced anesthesia workplace environment contamination and, in some cases, surgical site infections.6,7 Other hand hygiene monitoring (room entry and exit) obtained contemporaneously did not demonstrate changes among nonanesthesia personnel, so we do not believe that our results are the product of secular trends. While we cannot exclude the influence of unmeasured confounders, those that we were able to quantitate did not significantly influence hand hygiene use.

Published efforts to improve use of hand hygiene have ranged from simply making a disinfection product available at the anesthesia workstation,28 which was unsuccessful, to much more elaborate efforts such as those by the Dartmouth group, involving electronic dispenser/monitors for each anesthesia professional. The methods used in our intervention were relatively simple, including education, group and individual feedback on performance, and point-of-care reminders. We believe that the ability to monitor individuals’ performance and feedback, as in the work by the Dartmouth group, was key in driving compliance improvement. In addition, the intradepartmental peer nature of the feedback (as opposed to that from infection preventionists, outside monitors, or administrators) seemed to facilitate project acceptance and goal-directed behavior modification. Finally, the ability to establish an evidence-based, achievable goal distinct from the World Health Organization guidelines designed for a nonanesthetizing location environment was likely also important.

We certainly acknowledge that it would be possible for practitioners to “game” the system by deliberately wasting hand sanitizer, but we did not observe such activity during many hours of video observation performed at both the early and later phases of the project. The fact that container weights were obtained before room setup and during room turnover, and that it was unknown to the providers whether or not a given room or case was being audited at any particular time, perhaps makes this behavior less likely. We would hope that attitudes toward hand hygiene use may have changed over the time course of the project, although, of course, we cannot be certain since we did not measure opinion of anesthesia personnel. In addition, we did not monitor individuals at regular intervals, so we are not able to determine if there were particularly frequent or infrequent users with statistical rigor. This would certainly be a reasonable target for further investigation and quality improvement. While cultural barriers, time pressure, use of gloves instead of hand hygiene use, and other incompletely understood factors are common problems in hand hygiene improvement efforts,11,22,29 our results indicate that successful intraoperative hand hygiene quality improvement and monitoring is possible at modest effort and expense.

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Name: Scott Segal, MD, MHCM.

Contribution: This author helped design the study, supervise the data collection, analyze the data, and prepare the manuscript.

Name: Hannah M. Harris, BS.

Contribution: This author helped collect the data, analyze the data, and revise the manuscript.

Name: Antonius Gunawan, BS.

Contribution: This author helped collect the data, analyze the data, and revise the manuscript.

Name: Roman Schumann, MD.

Contribution: This author helped design the study and revise the manuscript.

This manuscript was handled by: Richard C. Prielipp, MD, MBA.

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