Automated hand hygiene auditing with and without an intervention

Kwock, Y.L.A. et al. American Journal of Infection Control. Published online: 21 October 201


  • The subtraction of 1 percentage from another results in a percentage point (PP) difference that provides the size of the difference; overt human auditing inflates compliance by 20 PPs to 37 PPs compared with covert automated auditing.
  • Overt human auditing did not sustain inflated compliance estimates once auditing ceased.
  • Neither overt human nor automated auditing changes hand hygiene compliance per se, but automated auditing improves the validity of compliance estimates.
  • Daily feedback from automated auditing with peer nudging assisted a cooperative ward to improve, but practice was not sustained once the intervention ceased.


Background: Daily feedback from continuous automated auditing with a peer reminder intervention was used to improve compliance. Compliance rates from covert and overt automated auditing phases with and without intervention were compared with human mandatory audits.

Methods: An automated system was installed to covertly detect hand hygiene events with each depression of the alcohol-based handrub dispenser for 5 months. The overt phase included key clinicians trained to share daily rates with clinicians, set compliance goals, and nudge each other to comply for 6 months. During a further 6 months, the intervention continued without being refreshed. Hand Hygiene Australia (HHA) human audits were performed quarterly during the intervention in accordance with the World Health Organization guidelines. Percentage point (PP) differences between compliance rates were used to determine change.

Results: HHA rates for June 2014 were 85% and 87% on the medical and surgical wards, respectively. These rates were 55 PPs and 38 PPs higher than covert automation rates for June 2014 on the medical and surgical ward at 30% and 49%, respectively. During the intervention phase, average compliance did not change on the medical ward from their covert rate, whereas the surgical ward improved compared with the covert phase by 11 PPs to 60%. On average, compliance during the intervention without being refreshed did not change on the medical ward, whereas the average rate on the surgical ward declined by 9 PPs.

Conclusions: Automation provided a unique opportunity to respond to daily rates, but compliance will return to preintervention levels once active intervention ceases or human auditors leave the ward, unless clinicians are committed to change.


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