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The Automatization of Hand Hygiene Monitoring and its Discontents · The SHEA Podcast

• 0:04
  SPEAKER_01: Welcome to our podcast series, Digital and Electronic Innovations in Hospital Epi and Antimicrobial Stewardship, brought to you by the Society for Healthcare Epidemiology of America, SHA, promoting the prevention of healthcare associated infections and antibiotic resistance, and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:24
  SPEAKER_01: This series will identify new or emerging technologies that can be leveraged to improve patient safety, data quality, and efficiency, describe the advantages and disadvantages of recent innovations, and recognize strategies to demonstrate success or lack thereof and substantiate into implementation of new technology.
• 0:42
  SPEAKER_01: I'm Dr.
• 0:43
  SPEAKER_01: Chrissy Woods and I'll be your moderator today.
• 0:45
  SPEAKER_01: Shea is excited to launch this episode of the podcast series, which is entitled The Automization of Hand Hygiene Monitoring and Its Discontents.
• 0:53
  SPEAKER_01: This podcast will begin by discussing how electronic hand hygiene monitoring systems can be leveraged to address barriers with existing measuring protocols.
• 1:01
  SPEAKER_01: They will explore how they work, how compliance is tracked, advantages and disadvantages to different monitoring systems, and the acceptability among staff.
• 1:10
  SPEAKER_01: The speakers will discuss how they can impact compliance and healthcare-associated infections, as well as how one can substantiate a trial or implementation.
• 1:18
  SPEAKER_01: I'm happy to introduce our two speakers for today.
• 1:20
  SPEAKER_01: First, we have Dr.
• 1:21
  SPEAKER_01: Michelle Dahl, Associate Professor of Internal Medicine at Virginia Commonwealth University and hospital epidemiologist for the VCU Health System.
• 1:30
  SPEAKER_01: We also have Dr.
• 1:31
  SPEAKER_01: Jerome Lees, Associate Professor at the University of Toronto and Medical Director of Infection Prevention and Control at Sunnybrook Health Sciences Center in Toronto, Canada.
• 1:41
  SPEAKER_01: Thank you both for joining us.
• 1:42
  SPEAKER_01: Thank you so much for having me.
• 1:44
  SPEAKER_02: Thank you.
• 1:44
  SPEAKER_02: Looking forward to the discussion.
• 1:45
  SPEAKER_01: To begin, can you first explain the requirements for hand hygiene monitoring by different organizations or accrediting bodies?
• 1:52
  SPEAKER_01: And clearly there may be a difference between the United States and Canada.
• 1:55
  SPEAKER_01: So we'll go ahead and let you discuss those.
• 1:57
  SPEAKER_01: Dr.
• 1:58
  SPEAKER_01: Dahl?
• 1:58
  SPEAKER_00: Sure.
• 1:59
  SPEAKER_00: So we are accredited by our oftentimes the Joint Commission, or there's other accrediting bodies such as the DMB.
• 2:06
  SPEAKER_00: So while there is an emphasis on hand hygiene for both of those accrediting bodies, they do not go too specifically into what the requirements of each program is.
• 2:16
  SPEAKER_00: The joint commission in particular advises that the guidelines from CDC or WHO are followed, but leaves a lot of discretion up to individual programs as to how they design their own program on site.
• 2:28
  SPEAKER_00: That being said, there are some quality groups, and I'll reference specifically the leapfrog group that does emphasize hand hygiene monitoring technologies in their survey of healthcare systems.
• 2:39
  SPEAKER_02: So it'd be very similar in Canada.
• 2:41
  SPEAKER_02: Most hospitals are accredited by Accreditation Canada, and it's a required organizational practice to have a hand hygiene program and to monitor hand hygiene.
• 2:50
  SPEAKER_02: The most commonly used method is direct observation, but I think that there is some opportunity for flexibility in how in the type of measurement used.
• 2:58
  SPEAKER_02: But there are some key components of hand hygiene programs that need to be in place, including a focus on education and audits, measuring data and reporting data.
• 3:06
  SPEAKER_02: And that would be the requirement across Canada.
• 3:09
  SPEAKER_01: Thank you.
• 3:09
  SPEAKER_01: And I think that kind of brings us into our next point of discussion was what type of methods have been used for monitoring adherence to health hygiene.
• 3:17
  SPEAKER_01: Dr.
• 3:17
  SPEAKER_01: Lees?
• 3:17
  SPEAKER_02: Yeah, so historically, uh direct observation has been promoted by the World Health Organization.
• 3:23
  SPEAKER_02: It's recommended in the current guidance.
• 3:25
  SPEAKER_02: And if we look at Canadian crediting bodies or even provincial recommendations, there's a heavy focus on direct observation, which essentially includes having auditors that are present and observing hand hygiene opportunities and whether or not there is compliance.
• 3:43
  SPEAKER_02: There are variability, I think, in the way that is implemented, in terms of whether or not it's just a convenient sample of observation or how rigorously that is collected over time and to minimize the risk of sampling bias.
• 3:56
  SPEAKER_02: And there's obviously variability in terms of how familiar staff will be to the auditors that are present.
• 4:03
  SPEAKER_02: In some cases, the person auditing could be one of the frontline staff, and it's well known that they are collecting the data, and that can obviously influence behavior and lead to overestimating compliance.
• 4:15
  SPEAKER_02: And then, of course, we can have external auditors that are present, but of course, those auditors often will become familiar to the staff quite quickly, which can also lead to behavior change, observer bias, or sometimes known as the Hawthorne effect.
• 4:28
  SPEAKER_02: Ultimately, the best way of doing direct observation is to do it covertly.
• 4:32
  SPEAKER_02: So staff are not aware of where the data is coming from.
• 4:35
  SPEAKER_02: Of course, being able to maintain covertness in doing those audits is really the challenge.
• 4:41
  SPEAKER_01: Okay.
• 4:41
  SPEAKER_01: So clearly we're going to be talking about different electronic monitoring systems that are used.
• 4:46
  SPEAKER_01: And I was hoping that you can maybe explain some of the more common electronic monitoring systems for hand hygiene and how they work, Dr.
• 4:52
  SPEAKER_01: Dahl?
• 4:53
  SPEAKER_00: Sure.
• 4:53
  SPEAKER_00: So there's a wide range of technologies going all the way from just more product usage counting and counting how many times we're using the dispensers as a surrogate for hand hygiene performance, all the way up to including video monitoring, where you're seeing an entire care episode through the video and can analyze where all of the hand hygiene opportunities captured.
• 5:14
  SPEAKER_00: Most of the systems that people think of when we're thinking of electronic hand hygiene monitoring technologies are some form of wireless system where you have a patient zone that's defined by the system, whether that's room entry and exit or a zone around the bed differs.
• 5:29
  SPEAKER_00: And then you have providers maybe in aggregate or individually badged and recognize as they're moving through the system.
• 5:35
  SPEAKER_00: So the badges help the hand hygiene to be captured at the dispenser of alcohol rubber.
• 5:40
  SPEAKER_00: So it credits the provider with that hand hygiene event and then sees if the provider is going into and out of patient zones, making sure that the before and after moments of hand hygiene for that patient care episode are completed.
• 5:52
  SPEAKER_00: Some of these systems can offer reminders that might be able to prompt the provider to do hand hygiene if it detects that an opportunity was potentially missed.
• 6:01
  SPEAKER_00: But there's a lot of difference and variation in the available technologies.
• 6:04
  SPEAKER_01: And Dr.
• 6:05
  SPEAKER_01: Lee, are you aware of any other types of hand hygiene monitoring systems that exist electronically or have we covered them?
• 6:11
  SPEAKER_02: No, I think that's a great summary by Dr.
• 6:13
  SPEAKER_02: Dahl.
• 6:14
  SPEAKER_02: I sometimes think of it as two big buckets.
• 6:16
  SPEAKER_02: The group monitoring systems, which really just sort of give you a full picture of events over expected opportunities.
• 6:23
  SPEAKER_02: And of course, that needs to be known for the unit or the hospital that's being measured.
• 6:28
  SPEAKER_02: And then, of course, the badge systems that actually give you specific moment level data that will either use RFID or real-time location systems to determine specific moments of hand hygiene, which is of course not available with the group monitoring systems.
• 6:44
  SPEAKER_01: So obviously, anytime we have any type of technology, there are always some concerns that there might be some issues with how that works.
• 6:51
  SPEAKER_01: So I was wondering if you could highlight maybe some of the issues that are associated with traditional hand hygiene monitoring methods that maybe electronic systems are actually better to able to address because of the nature of how they work.
• 7:03
  SPEAKER_02: Yes, there are a number of inherent limitations of direct observation as it relates to using it for measurement of hand hygiene performance over time, and that I think are addressed using automated systems.
• 7:15
  SPEAKER_02: So the first one, which I alluded to is the sampling bias issue.
• 7:19
  SPEAKER_02: When you're doing direct observations, you really have a convenient sample of predominantly uh daytime, weekday observations, predominantly uh room entries and room exits.
• 7:29
  SPEAKER_02: So moments one, four, and five that are essentially overrepresented.
• 7:34
  SPEAKER_02: You know, when you have an automated system, you're getting continuous measurement.
• 7:38
  SPEAKER_02: Uh, you have a full picture 24-7 of all that includes all opportunities, and the amount of data collected is just astronomical compared to what you could possibly achieve using direct observation.
• 7:49
  SPEAKER_02: That doesn't mean you can always break down those moments using automated systems, as we'll talk about, but in general, at least you have a complete picture of what's happening.
• 7:57
  SPEAKER_02: I also alluded to this observer bias or Hawthorne effect, which is a bit of a change in behavior of staff based on the level of awareness of who the auditors are.
• 8:07
  SPEAKER_02: That is essentially eliminated when you've got automated systems because the system essentially is just in the background.
• 8:13
  SPEAKER_02: An important issue that is probably underappreciated as it relates to the observer bias issue with direct observation is that it is not uniform.
• 8:22
  SPEAKER_02: That means it varies based on the level of awareness of the group that's being observed, uh, whether it's a specific profession, a unit, a hospital, that amount of bias, again, will vary.
• 8:34
  SPEAKER_02: And so uh the degree to which you are overestimating performance can vary.
• 8:38
  SPEAKER_02: And that is the biggest flaw, I think, with direct observation for measurement, is that you cannot in a valid way benchmark performance over time.
• 8:47
  SPEAKER_02: Even within the same unit, you could have differences in the level of Hawthorne effect on the observations that you did, or between organizations, benchmarking is extremely problematic and probably flawed.
• 8:59
  SPEAKER_02: With automated systems, at least, because again, the Hawthorne effect and observer bias is eliminated, you are just tracking performance over time with a complete picture.
• 9:08
  SPEAKER_02: It's much more valid as a way of benchmarking.
• 9:11
  SPEAKER_02: There are limitations depending on the system.
• 9:14
  SPEAKER_02: For example, with group monitoring, uh, it will depend on your ability to accurately estimate the denominator and hygiene opportunities.
• 9:22
  SPEAKER_02: And that could vary between units and organizations, which could be problematic for benchmarking.
• 9:26
  SPEAKER_02: Uh but at the very least, relative changes in performance.
• 9:30
  SPEAKER_02: So the degree to which from point X onward, what was the delta in terms of the relative improvement made over time?
• 9:37
  SPEAKER_02: That I think at least within the same unit or the same organization, it's absolutely valid.
• 9:42
  SPEAKER_02: And probably within organizations, relative changes can be assessed as well using automated systems, which we simply cannot do in a valid way, in my opinion, using direct observation alone.
• 9:53
  SPEAKER_01: Dr.
• 9:53
  SPEAKER_01: Dall, any other thoughts to add?
• 9:55
  SPEAKER_00: I would just agree that for me, the main benefit is just that robust nature of all of the data that can be collected.
• 10:01
  SPEAKER_00: It is staggering the amount, even without full participation from everybody who you would like to participate with the system.
• 10:07
  SPEAKER_00: It just gives you a much better sense of what the overall practice is, I think, than those targeted observations.
• 10:14
  SPEAKER_01: So, do you think there are disadvantages to decreasing or eliminating traditional rounding methods that were used for hand hygiene monitoring?
• 10:21
  SPEAKER_00: Actually, yes.
• 10:22
  SPEAKER_00: So here I have some strong opinion.
• 10:24
  SPEAKER_00: I don't think that these technologies are a substitute for the direct observation for a couple of reasons.
• 10:30
  SPEAKER_00: I think what even the best of our technologies, and they are getting quite good, what they do continue to lack is the clinical context of each hand hygiene event or the hand hygiene around each patient care episode.
• 10:41
  SPEAKER_00: And so we have run into some difficulty holding individuals accountable for hand hygiene without that context.
• 10:49
  SPEAKER_00: And it really does take a boots on the ground approach to going down and looking at someone's workflow, looking at what they are doing in the rooms to advise on hand hygiene.
• 10:58
  SPEAKER_00: And I don't think that the technologies are capable of providing that outside of potentially the video monitoring, which has some privacy issues.
• 11:05
  SPEAKER_00: So I think, and in order to do the education, that is presumably the part that's going to improve hand hygiene over time, getting your team to believe in the data that they're seeing from the technology.
• 11:16
  SPEAKER_00: I don't think that that is possible without that direct observation to complement.
• 11:21
  SPEAKER_01: Dr.
• 11:21
  SPEAKER_01: Lee, do you feel similarly?
• 11:23
  SPEAKER_01: Are we getting rid of the rounding or are we keeping it?
• 11:26
  SPEAKER_02: Yeah, so I agree with Dr.
• 11:27
  SPEAKER_02: Dahl that I don't think we should be getting rid of direct observation altogether.
• 11:32
  SPEAKER_02: And what I was talking about earlier are the limitations to using the data for measurement and benchmarking, which I think is well recognized.
• 11:39
  SPEAKER_02: But there's still value in being on the unit, being present, doing observations, providing feedback in the moment, auditing feedback itself is an intervention in improving hen hygiene.
• 11:49
  SPEAKER_02: But there's also other issues related to practices, glove use, et cetera, that can be identified.
• 11:55
  SPEAKER_02: And unless you're there on the unit, giving that on-site presence, we're we're also less likely to keep these practices top of mind at the front line.
• 12:04
  SPEAKER_02: So I definitely think there's still a need for ongoing auditing, but I do think we need to move away from utilizing that data alone for measurement and benchmarking.
• 12:13
  SPEAKER_02: And that's where I see automated hand hygiene monitoring systems as playing a key role.
• 12:17
  SPEAKER_02: And we've used them successfully in Canada in that capacity.
• 12:20
  SPEAKER_01: Dr.
• 12:20
  SPEAKER_01: Leees, could you share which method your hand hygiene monitoring system uses and where it's been installed?
• 12:25
  SPEAKER_02: Yeah, absolutely.
• 12:26
  SPEAKER_02: We uh started looking at these systems back in about 2016 and did some initial validation.
• 12:33
  SPEAKER_02: We've focused heavily on group electronic monitoring, which, as mentioned, doesn't give us specific moments and it relies on a fairly accurate estimate of the denominator of hand hygiene opportunities in order to be valid.
• 12:46
  SPEAKER_02: And so we did initial validation studies first on inpatient units, medical surgical units, and then subsequently in critical care.
• 12:53
  SPEAKER_02: And we implemented a group electronic monitoring system across uh five hospitals in the Greater Toronto area, and then subsequently have expanded to 12 hospitals during the pandemic.
• 13:03
  SPEAKER_02: And so increasingly there is improved familiarity and comfort with this type of technology.
• 13:09
  SPEAKER_02: Our staff who work in these facilities have quickly gotten used to seeing those numbers.
• 13:15
  SPEAKER_02: I think they understand the limitations of direct observation, and it's been much easier and much better valued as a measure because there was not a lot of confidence in terms of the direct observation data being accurate.
• 13:28
  SPEAKER_02: And now we have more accurate, not perfect, but more accurate data that units are tracking over time.
• 13:34
  unknown: Dr.
• 13:35
  SPEAKER_01: Dahl, could you share what you have in place in your hospital system?
• 13:38
  SPEAKER_00: Sure.
• 13:38
  SPEAKER_00: Um, so we have a wireless-based technology in our inpatient units and procedural areas of our acute care hospital, and we include all providers who touch the patient or patient care environment in the program, but we have not expanded it to outpatient areas or to other community hospitals within our system at this time.
• 13:58
  SPEAKER_01: So a question to both of you can you share whether or not your health system is continuing to use traditional hand hygiene monitoring methods as well?
• 14:05
  SPEAKER_00: Yes, as you can gather, we are.
• 14:07
  SPEAKER_00: And we are using those observers to show kind of side by side what the data looks like for each unit in efforts to help with some of the validation and building competence in the data coming back from the electronic system.
• 14:19
  SPEAKER_00: And we are also deploying those observers when we are seeing that there are potential trouble areas in the data.
• 14:25
  SPEAKER_00: So if we're seeing that a group is not performing well despite having a lot of badged users, we will use those observers to go investigate further to see what is it about their workflow that isn't either being captured or something about their workflow that they do actually need education in order to improve the hand hygiene adherence around what the patient care activities that they're doing.
• 14:43
  SPEAKER_01: And Dr.
• 14:44
  SPEAKER_01: Lee?
• 14:45
  SPEAKER_02: So within Ontario, Canada, there is still the expectation that hospitals will pub will record, measure, and publicly report hand hygiene adherence.
• 14:56
  SPEAKER_02: But as of this year, there's now flexibility in being able to do so via direct observation or using electronic hand hygiene monitoring.
• 15:03
  SPEAKER_02: And I think that is an update that reflects some of the evidence that we've created around this and acknowledgement that that is a powerful way to measure data over time.
• 15:12
  SPEAKER_02: And so our hospital has moved to reporting that data rather than our directly observed data.
• 15:18
  SPEAKER_02: Now I want to be clear, we're still have direct observers for the reasons we mentioned around auditing and being present and looking at workflow and the things Dr.
• 15:24
  SPEAKER_02: Dahl has mentioned, but from a measurement standpoint, we're using a more robust approach.
• 15:29
  SPEAKER_01: And do you envision continuing to use those direct observers as this continues on?
• 15:34
  SPEAKER_02: Yes, so we have no plan to discontinue direct observation altogether.
• 15:37
  SPEAKER_02: I think it's part of infection prevention and control.
• 15:39
  SPEAKER_02: But even as we expand our automated hand hygiene solutions, we still need to have direct observations continue.
• 15:47
  SPEAKER_01: Okay.
• 15:47
  SPEAKER_01: So we know that these monitoring systems can be quite expensive.
• 15:51
  SPEAKER_01: They require a large degree of capital, and it's often difficult to get some buy-in when you're trying to present this to a system.
• 15:59
  SPEAKER_01: So I'm curious how each of you were able to substantiate the cost of this type of system to be put in place.
• 16:05
  SPEAKER_01: Dr.
• 16:05
  SPEAKER_01: Lees?
• 16:06
  SPEAKER_02: It's a great question.
• 16:07
  SPEAKER_02: And I think probably one of the greatest challenges in being able to adopt this technology more widely, is to try to be able to create the appropriate argument for investing in this technology.
• 16:19
  SPEAKER_02: I think it starts with having hospitals and hospital boards and healthcare policymakers understand the current limitations of direct observation as it relates to measurement and how if we're actually serious about the importance of hand hygiene and making measurable improvements to hand hygiene adherence, that will require a move away from direct observation alone.
• 16:41
  SPEAKER_02: And so, just to give you a sense, first of all, of the power of some of these systems, just from the perspective of numbers, within one year in my hospital, which is the cute care hospital that is monitored, is about four to five hundred hospital beds.
• 16:55
  SPEAKER_02: We historically would have done enough audits for about 600 hand hygiene opportunities over the course of a year, maybe a thousand if we had additional auditors.
• 17:05
  SPEAKER_02: With the technology that we use now, there's actually 10 million hand hygiene opportunities annually.
• 17:11
  SPEAKER_02: And that translates over 15 acute care units to about 650,000 opportunities per year and about 55 to 60,000 per month.
• 17:21
  SPEAKER_02: And so it's just a totally different way of thinking about hand hygiene opportunities.
• 17:24
  SPEAKER_02: This provides continuous measurement and obviously not the sampling bias issues that we spoke about earlier.
• 17:31
  SPEAKER_02: Obviously, a step above that is to try to generate improvements and that will translate into a return on investment in this technology in terms of impact on healthcare associated infection, et cetera.
• 17:42
  SPEAKER_02: For that, we actually, after we validated the system, we undertook an initial pilot study, which was a cluster randomized trial across our five hospitals.
• 17:51
  SPEAKER_02: And actually within two years, we were starting to see a trend towards reduced MRSA transmission.
• 17:57
  SPEAKER_02: We were slightly underpowered to get a statistically significant result, but the trend was evident among MRSA transmission, and that helped to start to build the case across the hospitals that there is actually benefit and a return on investment.
• 18:10
  SPEAKER_02: The challenge is that improving hand hygiene at the best of times is difficult.
• 18:16
  SPEAKER_02: It's not easy.
• 18:17
  SPEAKER_02: And so when we invest in this technology, we need to actually have longitudinal follow-up to actually detect, measure some of the important outcomes in reducing HAI.
• 18:28
  SPEAKER_02: It's probably simply not possible to achieve that within two years, but we were already starting to see the impact within two years, which was quite encouraging.
• 18:36
  SPEAKER_01: Thank you.
• 18:37
  SPEAKER_01: Dr.
• 18:37
  SPEAKER_01: Dahl?
• 18:38
  SPEAKER_00: Yes, I would only would just say that clearly, if these technologies ultimately do prove to reduce hospital-acquired infection, then the cost-effectiveness case makes itself that is the holy grail of what we're all aiming for.
• 18:50
  SPEAKER_00: In our system, it was actually our leadership that really wanted a hand hygiene monitoring system in our acute care center with the rationale that there was the feeling that this was something that was coming and wanted us to be early adopters of these technologies.
• 19:04
  SPEAKER_00: That if, and they believe this, and we we all, I think, believe this, if hand hygiene is the most important intervention to promote infection prevention, then this makes sense as an intervention to, you know, improve our practices.
• 19:16
  SPEAKER_00: The our observer data had showed a kind of stagnation in our hand hygiene rates over a lot of time.
• 19:22
  SPEAKER_00: And it was, there was really a feeling that in order to move that any further, we needed to do something completely different.
• 19:27
  SPEAKER_00: And most of this a recognition that this is something that patients like to see.
• 19:30
  SPEAKER_00: Patients really want their providers to wash their hands.
• 19:33
  SPEAKER_00: They really have trouble understanding why we can't make that happen.
• 19:36
  SPEAKER_00: And so this was also an effort to improve patient satisfaction with care.
• 19:39
  SPEAKER_01: So, question to both of you Did you first trial the system that you put in place?
• 19:44
  SPEAKER_01: And what were you looking for during that trial?
• 19:46
  SPEAKER_01: Did you have any specific metrics for success?
• 19:49
  SPEAKER_00: Yeah, so we trialed a couple of different systems, and some of them did not really capture a provider as well in the course of their workflow.
• 19:56
  SPEAKER_00: So we were grateful for the opportunity to try a couple of different ones.
• 19:59
  SPEAKER_00: And I think it's really important that all systems who are looking at this technology go through that same process because you are really looking for a technology that are going to meet the goals of your specific facilities, and not everyone's goals are going to be the same.
• 20:12
  SPEAKER_00: The same technology maybe doesn't work for one facility if it works for another one.
• 20:16
  SPEAKER_00: So I think piloting is important.
• 20:18
  SPEAKER_00: We were primarily looking at can the technology accurately capture workflows?
• 20:24
  SPEAKER_00: And also what is the frontline team members' opinion of those technologies?
• 20:29
  SPEAKER_00: So those were the two issues we were looking at most closely when we were piloting these technologies.
• 20:34
  SPEAKER_00: And Dr.
• 20:34
  SPEAKER_01: Lee?
• 20:35
  SPEAKER_02: I agree that piloting is probably pretty vital to being able to adopt these technologies.
• 20:40
  SPEAKER_02: I think because there isn't one specific solution that has been widely accepted as the best technology and validated, I think at the very least, a local validation is needed.
• 20:50
  SPEAKER_02: Ultimately, where the rubber hits the road is when staff see the data and we want to be able to be confident that it's providing an accurate estimate of performance.
• 21:00
  SPEAKER_02: And so that work needs to be done.
• 21:02
  SPEAKER_02: As I mentioned, we did a lot of opportunities, not interested in compliance, interested in observation and hand hygiene opportunities, HHO and validating that number, the expected number per hour and per 24 hours for different patient populations.
• 21:17
  SPEAKER_02: It turns out that HHO varies based on a number of predictors, patient acuity being one of the most important ones, but patient population can affect that, different levels of acuity, different levels of care within critical care.
• 21:30
  SPEAKER_02: And so the time of the week, uh the day of the week can actually affect hand hygiene opportunities.
• 21:34
  SPEAKER_02: And that's likely based on staffing levels on weekends as compared to weekdays and how much clinical activity actually happens.
• 21:40
  SPEAKER_02: And so it's actually, once you start getting into it, a lot more complicated than just plugging in a number and thinking that it'll be good enough.
• 21:48
  SPEAKER_02: And as you can imagine, staff are often critical thinkers in terms of reflecting on whether or not the data they're receiving actually reflects their day-to-day practice.
• 21:57
  SPEAKER_02: And so we did a lot of that work up front.
• 22:00
  SPEAKER_02: Which I think paid off and being able to implement it.
• 22:02
  SPEAKER_02: And a lot of our staff participated in the validation and so felt comfortable that it did reflect their performance when we were ultimately ready to implement.
• 22:10
  SPEAKER_01: So, Dr.
• 22:11
  SPEAKER_01: Lee, you mentioned that you did involve staff in the process of validating the data and bringing in the new system.
• 22:17
  SPEAKER_01: Were there any specific issues that staff had accepting the fact that this was happening?
• 22:21
  SPEAKER_01: And was there anything specific that you had to do to overcome them?
• 22:24
  SPEAKER_02: So, this type of transition from direct observation to using an automated hand hygiene solution doesn't happen overnight.
• 22:31
  SPEAKER_02: I think it is a journey that organizations need to go through.
• 22:35
  SPEAKER_02: It starts with understanding and socializing the limitations around direct observation.
• 22:40
  SPEAKER_02: There's still staff that feel that their hand hygiene adherence is actually 95% when we know that's actually not the case.
• 22:45
  SPEAKER_02: So getting them to understand that there actually still is opportunity for improvement is the first step.
• 22:51
  SPEAKER_02: And then when we move to a solution, no solution is perfect.
• 22:54
  SPEAKER_02: So the staff need to understand how the solution works, its benefits, and of course, some of its limitations.
• 23:01
  SPEAKER_02: And when it comes to group monitoring, the biggest limitation is, of course, having an accurate estimate of what the denominator is.
• 23:07
  SPEAKER_02: We know that the event data, which is what the system is recording using a sensor, is going to be 100% accurate, but it's the denominator.
• 23:14
  SPEAKER_02: And so a lot of focus is spent on that.
• 23:17
  SPEAKER_02: And one of our favorite ways to address that in my own organization is to have huddles with staff on the unit and to start playing with the numbers, have them self-reflect on the care that they provide throughout the day and to estimate how many opportunities there might be in their given day for the care they're providing.
• 23:33
  SPEAKER_02: And invariably, it's quite striking actually, almost all the time, nearly all the time, staff actually even overestimate the number of hand hygiene opportunities they have once they start doing the math.
• 23:46
  SPEAKER_02: And then when we show them what the denominator is, where we have set the threshold, what we call the benchmark for hand hygiene opportunities, they actually see that the ask of the system to get to 100% is actually achievable and that there's clearly opportunity for improvement.
• 24:00
  SPEAKER_01: That's a very, very clever device to use.
• 24:06
  SPEAKER_01: Dr.
• 24:06
  SPEAKER_01: Dahl, any specific issues with staff acceptance in your system?
• 24:10
  SPEAKER_00: Yeah, and I think one of the things that we did that made this even a little bit more challenging is that we did, we are using individual data so that each provider can see their own personal data.
• 24:21
  SPEAKER_00: And so as you can imagine, we have a lot of disputes of that data.
• 24:25
  SPEAKER_00: Providers believe that their numbers should look otherwise.
• 24:28
  SPEAKER_00: So we have done a lot of education as well.
• 24:30
  SPEAKER_00: It really is something where we are in front of every group in the hospital explaining the rationale, explaining how this works.
• 24:36
  SPEAKER_00: And then backtracking.
• 24:37
  SPEAKER_00: So when we get emails with concerns, there's a lot of hand holding that's continuously goes on.
• 24:42
  SPEAKER_00: That involves oftentimes going up to the units, revalidating all of the pieces of the technology that is there, and often with the leadership of that unit in present to see us doing all of that work to validate the system.
• 24:55
  SPEAKER_00: I think that's important that they see us doing that.
• 24:56
  SPEAKER_00: They get that data as well.
• 24:58
  SPEAKER_00: And then even up to shadowing individual providers as they go about their rounds just to see how their actual workflow is matching up with what is captured by the system.
• 25:07
  SPEAKER_00: And through that, obviously it's very resource intensive on the human resource side, but I do think it's necessary if we want providers interacting with the system.
• 25:16
  SPEAKER_00: I think you could argue the best way to do this is individual level data really what's going to help move your hand hygiene program.
• 25:24
  SPEAKER_00: Is it worth it to display the data in this way?
• 25:27
  SPEAKER_00: I do think, as Dr.
• 25:28
  SPEAKER_00: Elisa has highlighted, that there's a kind of lack of humility in thinking about our own hand hygiene.
• 25:33
  SPEAKER_00: And everyone thinks that their hand hygiene is good enough and it's always someone else who is in the environment that's accounting for that suboptimal hand hygiene.
• 25:41
  SPEAKER_00: And that really just isn't the case.
• 25:43
  SPEAKER_00: But I think that conversation is a lot easier when you're looking at the data in aggregate rather than an individual's data.
• 25:49
  SPEAKER_01: When you think about the implementation of the system in your own hospital, are there any specific logistical challenges that kind of come to mind, Dr.
• 25:57
  SPEAKER_01: Dell?
• 25:58
  SPEAKER_00: Yeah.
• 25:58
  SPEAKER_00: So there are a number of logistical challenges that come up.
• 26:01
  SPEAKER_00: One example would be we have the wireless technology of the badge communicating with the dispenser actually was catching interference from the same wireless signal that allows us to log into our computers on wheels.
• 26:12
  SPEAKER_00: And so we would have lapses in capture of providers if like the computer on wheels is parked too close to the dispenser, for example.
• 26:19
  SPEAKER_00: So issues of that sort, other issues just with individual workflows.
• 26:23
  SPEAKER_00: So we know we have seen that with our system at least, providers who spend a lot of time talking with the family or the patient in the course of their rounds kind of deviate in and out of the patient zone and may not be captured accurately and may have erroneous misses of opportunities with as recorded by the technology that aren't really missed opportunities.
• 26:42
  SPEAKER_00: But yeah, so there are logistical issues that exist.
• 26:45
  SPEAKER_01: Dr.
• 26:45
  SPEAKER_01: Lees, anything come to mind when you think about any logistical issues that were prominent while you were rolling this out?
• 26:51
  SPEAKER_02: Yeah, there's one more aspect on the logistics side that is a bit challenging that I don't think we appreciated at the outset when we implemented, which is just keeping up on the hardware and the maintenance around that.
• 27:03
  SPEAKER_02: And so we implemented technology on the unit and everything's working great.
• 27:07
  SPEAKER_02: But over time, there will be, if you're using like group electronic monitoring, dispensers that can get damaged or knocked off by beds moving around or uh need to be replaced.
• 27:16
  SPEAKER_02: And we can generate reports to know that there's a stale dispenser on the unit, but it's sometimes the feedback to getting that and then getting it replaced can be challenging.
• 27:25
  SPEAKER_02: And so there's nothing more, I think, demoralizing for staff on the unit.
• 27:29
  SPEAKER_02: They're trying to improve their hand hygiene adherence, but they're seeing that actually some of the dispensers and the sensors over time are actually uh damaged.
• 27:37
  SPEAKER_02: It's been a particular challenge during the pandemic because the teams responsible for maintenance didn't always have the same level of access to units.
• 27:45
  SPEAKER_02: But it is something that we need to bear in mind is when we enter into contracts for group monitoring system or whatever solution, we want to make sure that there's appropriate level of maintenance to make sure the system is performing accurately over time and that you're receiving the ongoing service.
• 28:00
  SPEAKER_01: Right.
• 28:00
  SPEAKER_01: Clearly during implementation, we think about maybe pitfalls that we may come across or issues that we foresee.
• 28:06
  SPEAKER_01: You now have the benefit of hindsight.
• 28:09
  SPEAKER_01: And when you think about that, are there any changes that you would have made to the way that you implemented the process at your hospitals?
• 28:16
  SPEAKER_01: Dr.
• 28:16
  SPEAKER_01: Lees?
• 28:17
  SPEAKER_02: So beyond the technical aspect of implementing automated hand hygiene solutions, I think the biggest part and of the effort is in the social adaptive change, right?
• 28:27
  SPEAKER_02: How do we move staff to understand the data, internalize it, and be motivated to improve and come up with tangible change ideas on the unit that can help to promote improved hand hygiene?
• 28:39
  SPEAKER_02: I think one of the most useful things we've done is to create what we call quality conversations at our hospital.
• 28:46
  SPEAKER_02: And these are essentially small huddles with a group of staff that happens at the minimum weekly, but on some units daily, depending on how busy things are.
• 28:55
  SPEAKER_02: And essentially they review the data.
• 28:57
  SPEAKER_02: The strength of using electronic monitoring or automated hand hygiene solutions in general is that you get essentially daily performance.
• 29:05
  SPEAKER_02: And so you've got that in real time based on how you did yesterday.
• 29:09
  SPEAKER_02: And frequently it's the people who worked yesterday who are receiving their data and can be engaged in self-reflection and thinking about where opportunities were missed and what the unit wants to do to try to improve hand hygiene over time.
• 29:22
  SPEAKER_02: And so I think this is definitely a really important part to implementing improvement using this technology of leveraging it to make tangible improvements, measurable improvements to hand hygiene.
• 29:32
  SPEAKER_01: And in discussing the data and how it's distributed and used, Dr.
• 29:35
  SPEAKER_01: Dahl, can you give us an idea of what kind of data these systems generate for you and what specifically you do with them, how you distribute it, how you let people know.
• 29:44
  SPEAKER_01: I know that there are some health systems that are a little bit nervous about getting user-specific data.
• 29:50
  SPEAKER_01: And you alluded to the fact that in yours you actually have it down to that level.
• 29:53
  SPEAKER_01: So I was hoping you could share with us a little bit about the data that you have and how it's used and shared.
• 29:58
  SPEAKER_00: Sure.
• 29:59
  SPEAKER_00: So we make monthly reports that include they go out to each unit or each division if it's a medical team, and it lists kind of the overall aggregate performance for that specific group, but also a breakdown where each individual has their performance for the last 30 days.
• 30:14
  SPEAKER_00: So it's very transparent.
• 30:15
  SPEAKER_00: Everyone's data is right there to look at.
• 30:17
  SPEAKER_00: And then in addition for our leaders, we present just a higher level group compliance and then also just what we call usership or how many individuals from that group are actually wearing their badges and have data in the system from the last several weeks versus how many we believe should be wearing the badge.
• 30:35
  SPEAKER_00: So you can kind of keep track of who is actually participating with the system as we would like.
• 30:40
  SPEAKER_00: So we send both of those out.
• 30:42
  SPEAKER_00: As I alluded to, I, you know, though, if in hindsight, I am not sure that that individual level data is that helpful.
• 30:49
  SPEAKER_00: I think that more of a breakdown, less of the overall number of compliance percentage, but broken down as to where in the course of care are the missed opportunities.
• 30:58
  SPEAKER_00: Is it before the patient contact?
• 31:00
  SPEAKER_00: Is it after?
• 31:00
  SPEAKER_00: Is it between patients?
• 31:02
  SPEAKER_00: I think that that data by group is probably more useful.
• 31:05
  SPEAKER_00: And we're looking to move there in the future.
• 31:07
  SPEAKER_01: Dr.
• 31:08
  SPEAKER_01: Lee, can you give us a little bit more details about the data that you have and how you share it?
• 31:13
  SPEAKER_02: Yeah, and of course, we don't have uh compliance at the level of opportunities because we're using the group monitoring system.
• 31:20
  SPEAKER_02: And so what we'd get is uh average estimate of compliance for specific units that are participating and for that we've evaluated the benchmark previously.
• 31:30
  SPEAKER_02: And so we can report that on a daily basis, weekly basis, monthly basis.
• 31:34
  SPEAKER_02: Frequently, what we'll do is at the level of our those huddles I spoke about, they'll get daily to weekly results and discuss them on a monthly basis, which, as I mentioned, is about 55 to 60,000 opportunities using a continuous monitoring system like this.
• 31:47
  SPEAKER_02: That data will be shared with senior leaders of that unit or programmatic leaders.
• 31:52
  SPEAKER_02: And then even more widely, the hospital board that keeps track of this because it's part of what we are publicly reporting.
• 31:58
  SPEAKER_02: The last thing I would say is we also keep the weekly results, because it's kind of between the daily and the monthly, on the front entrance, entering the unit.
• 32:07
  SPEAKER_02: And so that way it's really visible.
• 32:08
  SPEAKER_02: There's that visibility of the data to the team.
• 32:11
  SPEAKER_02: But the other individuals who see the data, other than the healthcare workers, are of course the patients and the family members.
• 32:17
  SPEAKER_02: And that really helps to generate a sense of accountability.
• 32:20
  SPEAKER_02: And when we have these huddles, we often will invite patients or family members that might be on the unit to join those discussions.
• 32:27
  SPEAKER_01: So as a result of these systems being in place, have you noticed any changes in hand hygiene compliance?
• 32:34
  SPEAKER_01: Have there been any interesting or unexpected observations that you've made, Dr.
• 32:39
  SPEAKER_01: Lease?
• 32:40
  SPEAKER_02: When we first piloted the system and implemented it, we were able to make just a bit more than a 20% absolute improvement in hand hygiene adherence, which was definitely significant.
• 32:51
  SPEAKER_02: And of course, we worked at that to get to that level of performance.
• 32:55
  SPEAKER_02: And then when we expanded the system, we've been able to make more improvements, a bit more modest in some of our critical care areas.
• 33:02
  SPEAKER_02: When the pandemic occurred, interestingly, we saw a very steep rise in hand hygiene adherence as measured using this type of technology.
• 33:11
  SPEAKER_02: And we were not the only ones in the world that made this observation.
• 33:15
  SPEAKER_02: There's a half dozen publications showing that the first wave of the pandemic in particular really generated high levels of hand hygiene adherence that were really had not been seen at any time in the past, adherence rates that were consistently over 80% and sometimes up to 100% adherence.
• 33:33
  SPEAKER_02: And so clearly, when there's a sense of a public health threat, there is definitely a behavior change that is very rapid.
• 33:40
  SPEAKER_02: What we've actually observed over time is that that has settled.
• 33:44
  SPEAKER_02: And unfortunately, of course, we didn't weren't able to sustain those results, but it shows that it's actually achievable.
• 33:50
  SPEAKER_02: But probably more sustainable, durable improvements are probably only made possible when you really work at it longitudinally over time.
• 33:59
  unknown: Dr.
• 33:59
  SPEAKER_01: Doll.
• 34:00
  SPEAKER_00: Yes, and we saw similar changes during COVID-19.
• 34:03
  SPEAKER_00: In fact, Olivia Hess on our team had published some of those findings.
• 34:06
  SPEAKER_00: We did see there was it compared to our pre-COVID, there was certainly better hand hygiene.
• 34:12
  SPEAKER_00: But also when you looked at our units that were caring for the bulk of the COVID-19 infected patients versus those units that did not have a bulk of those patients, the hand hygiene on the COVID-19 units was superior, not by much, but by a couple percentage points.
• 34:25
  SPEAKER_00: But the only other thing I would say that's been interesting in our experience has been we've always broken down our roles as physicians, nurses, and then other in terms of our observations.
• 34:36
  SPEAKER_00: And when we move to hand hygiene technologies, obviously we got a lot more granular with our roles.
• 34:42
  SPEAKER_00: But if you take the data from the hand hygiene technology and look at those same three original groups, traditionally nurses were our highest performers, as has been reported by others, followed by physicians and then the other, the large other category.
• 34:55
  SPEAKER_00: And we've really seen those trends become closer together with the hand hygiene technologies.
• 35:00
  SPEAKER_00: So we're seeing improvement in all of the groups that comprise the other component in that their hand hygiene compliance actually has improved with the technology.
• 35:09
  SPEAKER_00: And then physicians and nurses are actually a lot closer together than they have ever been with observations in terms of their hand hygiene compliance.
• 35:16
  SPEAKER_00: So those artificial breakdowns look differently using the hand hygiene technologies than they did for two R observers.
• 35:22
  SPEAKER_00: And I can think of some reasons why that might be, but I'll save that in the interest of time.
• 35:27
  SPEAKER_01: Obviously, the sort of holy grail of all of this is that we're hoping that an improvement in hygiene is going to decrease our hospital acquired or hospital-associated infections.
• 35:38
  SPEAKER_01: And I was wondering if, as a result of the implementation of these technologies, if you've actually seen decreases in your HAIs, and what do you think those decreases can be attributed to?
• 35:49
  SPEAKER_01: Do you believe that they're directly attributed to the hand hygiene itself, or are there other factors, Dr.
• 35:54
  SPEAKER_01: Dahl?
• 35:55
  SPEAKER_00: For us, while the intent had been to implement this in a steeped wedge pattern and really look at that in a robust way, given the delays in implementation, how long it has taken and how messy that process got, we are not able to assess that in any meaningful way.
• 36:09
  SPEAKER_00: There have been too many other interventions.
• 36:11
  SPEAKER_00: There has been COVID in the middle of implementation.
• 36:13
  SPEAKER_00: And so that is not an argument that our group is able to make.
• 36:17
  unknown: Dr.
• 36:17
  unknown: Lee's?
• 36:18
  SPEAKER_02: It's definitely the case that the drivers of healthcare associated infection are clearly multifactorial.
• 36:24
  SPEAKER_02: And despite what we often say as hand hygiene being, you know, one of the most, or if not the most, important intervention for reducing HAIs, often there are many other factors at play.
• 36:33
  SPEAKER_02: And so it can be difficult to interpret reductions in our surveillance and attribute them solely to hand hygiene improvements.
• 36:40
  SPEAKER_02: Well, what I will say is we've had certainly that challenge for environmental organisms, things like C.
• 36:46
  SPEAKER_02: diff, vencomycin resistant enterococcus, CPE, even to some extent, where we, of course, have small numbers and probably not the power to draw meaningful conclusions, but where we have seen an ability to detect reductions over time has been related to MRSA.
• 37:00
  SPEAKER_02: And that has been sort of consistent across the literature.
• 37:02
  SPEAKER_02: We know that hand hygiene is more tightly linked to MRSA compared to other antibiotic-resistant organisms and perhaps HAIs overall.
• 37:10
  SPEAKER_02: And so that's certainly the one that's been our focus.
• 37:12
  SPEAKER_02: I know that there have been other publications in the US showing a reduction using electronic hand hygiene monitoring.
• 37:18
  SPEAKER_02: And our initial pilot showed a trend towards reduction that we are still tracking over time.
• 37:22
  SPEAKER_02: So I think that's definitely encouraging.
• 37:24
  SPEAKER_02: The other thing that I would say in terms of tangible hard outcomes in using this technology is we just noticed that over time, the units that were higher performers tended to have less outbreak, experienced less outbreaks compared to those that were showing trends towards a decrease in their hand hygiene adherence using this technology.
• 37:42
  SPEAKER_02: And so we decided to actually study that in an interrupted time series study across our five hospitals.
• 37:48
  SPEAKER_02: And sure enough, we found that the hand hygiene adherence in general, the average was lower among units that went into outbreak.
• 37:56
  SPEAKER_02: And then when outbreaks were declared, they spiked to even above the level of the units that had no outbreak at all.
• 38:02
  SPEAKER_02: And then there was a slow decrease in performance over time following the outbreak.
• 38:07
  SPEAKER_02: And that's been certain a pattern of behavior that we've seen across infection prevention and control where hand hygiene is not necessarily, you know, top of mind.
• 38:14
  SPEAKER_02: And we're seeing that units that aren't focused on it may see a decline over time and be may not necessarily go into outbreak, but certainly may be more vulnerable to doing so.
• 38:24
  SPEAKER_02: And over time, if we can identify those units and try to be more proactive, there's a thinking that we may be able to prevent certain outbreaks or at least overall have an impact in prevention.
• 38:34
  SPEAKER_02: Of course, that's harder to mention to measure when we have few outbreaks over time, but across health systems, it's possible to actually see that signal.
• 38:42
  SPEAKER_02: And I think that'll be an important and a powerful way to use this technology to be proactive in reducing outbreak risk.
• 38:50
  SPEAKER_00: I have one additional comment regarding the HAI reductions.
• 38:54
  SPEAKER_00: I think as you look at the reports where they have seen this benefit, it's important to remember that this hand hygiene technology implementation was part of a multimodal implementation, oftentimes, that included education and all of the things that the WHO recommends as part of a program that was robustly done during the course of this study.
• 39:13
  SPEAKER_00: So as people are reviewing these studies and the potential for healthcare surgery infection reduction, it should be kept in mind that this doesn't mean that if you throw the technology up in your facility, you're going to magically see your HAI rates come down.
• 39:25
  SPEAKER_00: There's just a lot more to it.
• 39:26
  SPEAKER_00: In my mind, it's an adjunctive to all of the things that we know we need to be doing to improve hand hygiene compliance.
• 39:33
  SPEAKER_02: And I couldn't agree more with Dr.
• 39:34
  SPEAKER_02: Dahl.
• 39:35
  SPEAKER_02: I think this technology is an enabler, but it's definitely implementing the technology without the important multimodal interventions around it and quality improvement methodology won't generate the improvements and the outcomes that we've been talking about.
• 39:49
  SPEAKER_01: So as we think ahead to the future, I was wondering if you have a thought as to what these technologies place will be and what types of advances you foresee in this field in this specific area.
• 40:03
  SPEAKER_01: Dr.
• 40:04
  SPEAKER_01: Lease?
• 40:05
  SPEAKER_02: I think that there's technological advances, and then there's also advances in our own understanding about how to do this quality improvement work to generate improvements in hand hygiene.
• 40:14
  SPEAKER_02: I think both need to be a focus.
• 40:15
  SPEAKER_02: Often we focus really on the technology, but as we just mentioned, it's only the starting point to being able to make improvements.
• 40:22
  SPEAKER_02: You know, but certainly on the technological side, I have found this conversation very interesting to hear Dr.
• 40:26
  SPEAKER_02: Dahl about, you know, the provider level data and the utility of that.
• 40:30
  SPEAKER_02: That's what we're lacking currently.
• 40:31
  SPEAKER_02: We've been using group monitoring, which basically looks at this as a team sport.
• 40:35
  SPEAKER_02: Everyone is contributing to this denominator.
• 40:38
  SPEAKER_02: Let's try to work together to get our numbers up on this unit.
• 40:42
  SPEAKER_02: But I think at some level we've wondered whether or not we might make more headway in looking at provider level performance and linking that to performance feedback and performance management for some staff.
• 40:53
  SPEAKER_02: There are some staff who would fortunately, despite our best efforts, need that.
• 40:58
  SPEAKER_02: But of course, the current technology we're using doesn't allow us to have enough confidence in that data and the quality of that data at the provider level to be able to do it.
• 41:05
  SPEAKER_02: But I think if, I mean, as we've mentioned before, the gold standard in some way, in terms of from a technology standpoint, would be if we had video surveillance, of course, which may not be possible.
• 41:14
  SPEAKER_02: But as close to that as we can be, I think might allow us to make more headway in being able to provider level data, which the current technology that we're using lacks.
• 41:24
  SPEAKER_01: Dr.
• 41:24
  SPEAKER_01: Dahl, your uh own predictions for uh where this is going in the future and what advances you would foresee?
• 41:30
  SPEAKER_00: I think that the technologies will continue to become more accurate and hopefully more less requiring of this ongoing maintenance to make sure all of the pieces work because there really is quite a lot of work that is gonna be prohibitive for a lot of facilities in adopting these.
• 41:44
  SPEAKER_00: But I think as that continues to improve, they continue to become more attractive.
• 41:48
  SPEAKER_00: I do think that it's gonna be difficult, again, outside of video monitoring, which Dr.
• 41:53
  SPEAKER_00: Lee's mentioned, to incorporate that clinical context into the data.
• 41:57
  SPEAKER_00: However, again, I loved the study that Dr.
• 42:00
  SPEAKER_00: Lee Sentien published in CID about the outbreak detection.
• 42:03
  SPEAKER_00: And that's where I was kind of thinking our program may go in the future as well, looking for those groups that have data that looks not great and going and seeing what are they doing that's causing their data to be suboptimal.
• 42:17
  SPEAKER_00: And again, drilling down on what are the causes of that.
• 42:19
  SPEAKER_00: Is there a case for education?
• 42:21
  SPEAKER_00: And I'll just provide one example.
• 42:22
  SPEAKER_00: We did have that happen with our one of our ICU teams during COVID had reached out saying we can't actually do they participate with the hand hygiene technology program because of all of our PPE for COVID.
• 42:34
  SPEAKER_00: So we went down to see exactly what they were talking about and we realized that they were bundling care in these rooms, obviously, spending up to you know 20 minutes in the room doing a multitude of things and missing a lot of these opportunities for hand hygiene because they were in PPE.
• 42:46
  SPEAKER_00: So if we had not been reflecting their data back to them in a robust way with the monitoring system, we would not have captured that opportunity for education as to where are those episodes within the room that we really would like to see some additional hand hygiene.
• 42:59
  SPEAKER_00: So not just room entry and exit, but I think that there's a lot of the opportunities like that where we are missing hand hygiene and not realizing it as providers.
• 43:08
  SPEAKER_00: I do think that looking at this data would help to identify some of those instances.
• 43:13
  SPEAKER_01: This has been a really wonderful discussion.
• 43:15
  SPEAKER_01: And before we close out, I wanted to ask, we've gone through a lot of different questions and you've shared a lot of information.
• 43:21
  SPEAKER_01: Are there any other comments or advice that you have for anybody who might be listening who's either considering implementing one of these systems or maybe having some difficulty understanding maybe how to better utilize it?
• 43:33
  SPEAKER_01: Dr.
• 43:34
  SPEAKER_01: Dahl?
• 43:34
  SPEAKER_00: Yes, I would say don't underestimate the amount of manpower that it will take to implement something like this.
• 43:41
  SPEAKER_00: And so if you're in a situation where it's your leadership who is coming to you and excited about implementing a technology, make sure it's clear what resources you are going to have in terms of the human capital to make that work.
• 43:54
  SPEAKER_00: So there's not a lot of downtime in the infection prevention team these days.
• 43:58
  SPEAKER_00: And so trying to identify who is going to be the program manager for that and go meet with all of these groups and do the validations and make sure all the parts are working.
• 44:06
  SPEAKER_00: If that's going to fall on your group, make sure it's clear that you will be able to do that and who exactly is going to be doing that.
• 44:11
  unknown: Dr.
• 44:12
  SPEAKER_01: Lee, any words of wisdom?
• 44:13
  SPEAKER_02: Yeah, I think adopting one of these technologies and implementing it as Dr.
• 44:17
  SPEAKER_02: Dahl mentioned is definitely a large undertaking.
• 44:20
  SPEAKER_02: And just to maybe echo one part of what I think she was mentioning, which is that this can't be led solely by infection prevention control.
• 44:30
  SPEAKER_02: Ultimately, there needs to be a real desire to implement this and use these data by the units themselves.
• 44:36
  SPEAKER_02: So the clinical leaders and managers, that because ultimately they're the ones that are going to be receiving the data, reflecting on the data, and utilizing the data to make improvements.
• 44:45
  SPEAKER_02: That improvement can't come externally from infection prevention control.
• 44:49
  SPEAKER_02: So I think it's very important that it starts with that level of engagement and understanding before embarking on this journey, because there's nothing, I think be nothing worse than investing in this type of technology because infection prevention control thinks that this might lead to some favorable improvements, but in fact, there isn't enough engagement and belief in this being an issue that they want to improve upon and among some of the clinical leaders that really need to own this technology and the improvements that they're trying to make.
• 45:18
  SPEAKER_01: I want to thank you both for joining us and for sharing with us your expertise, your own personal experiences with this.
• 45:24
  SPEAKER_01: I think it's been a very comprehensive discussion.
• 45:27
  SPEAKER_01: And I want to just say thank you on behalf of everybody who's listening, who I'm sure has learned a lot through this conversation.
• 45:34
  SPEAKER_01: Thanks for having us.
• 45:35
  SPEAKER_00: Thank you so much.
• 45:36
  SPEAKER_01: You can find more educational content like this podcast on Shay's online education center, Learning CE, at www.learningce.shay online.org.
• 45:48
  SPEAKER_01: This concludes today's episode of the Digital and Electronic Innovations in Hospital Epi and antimicrobial stewardship series.
• 45:55
  SPEAKER_01: Thank you for tuning in.