Background: Proper hand hygiene is a cornerstone of infection control [1,2]. Despite this, compliance remains a challenge, averaging only 50% across healthcare systems nationwide [1].Several interventions have been trialed to improve compliance, including audit and feedback [3]. Traditionally, hand hygiene audits have occurred through direct observation. Unfortunately, this approach can capture fewer than 1-3% of events, leading to imprecise and inaccurate measurements [4]. To address this limitation, some institutions have implemented automated monitoring [1,4].In an effort to further validate hand hygiene compliance measurements resulting from electronic monitoring and estimate the upper bound of compliance achievable with such systems, we describe changes in compliance during the course of the novel coronavirus (COVID-19) pandemic as measured by the automated system used in our institution, one of the largest of such deployments nationally.

Methods: The University of Chicago Medical Center (UCMC) implemented an automated hand hygiene monitoring system in 2015. An infrared sensor anonymously records entry and exit into patient rooms, as well as number of dispenser uses. Compliance percentages are determined by dividing number of dispenser activations by number of hand washing opportunities, estimated using patient room entry and exit data. In this study, we examined hand hygiene compliance rates in the Center for Care and Discovery (CCD), UCMC’s new adult hospital, by day, week and month from September 2019 through August 2020. We also examined compliance rates of units temporarily converted into COVID cohort units, hypothesizing that hand hygiene rates in such units might provide an estimate for maximum compliance. This project received a formal determination of Quality Improvement according to institutional policy.

Results: In the six months prior to the COVID-19 pandemic (9/1/2019 – 2/29/2020), average hand hygiene compliance across all nursing units remained fairly constant at 55.8%. During the pandemic, compliance across all units reached a daily peak of 92.8% on 3/29/2020, a weekly peak of 88.4% the week of 3/29/2020, and a monthly peak of 75.5% in April. Compliance across the COVID cohort units reached a daily peak of 100% on 3/28/2020, a weekly peak of 98.4% the week of 3/29/2020, and a monthly peak of 84.4% in April (Figures 1, 2). Subsequently, compliance declined across all units to a daily nadir of 51.5% on 8/15/2020, a weekly nadir of 55.1% that same week, and a monthly nadir of 56% in August, all below the pre-pandemic baseline.

Conclusions: Our hospital was able to achieve a daily compliance above 90%, peaking at 100% across COVID cohort units, which is significantly above nationally reported levels and our institutional goal of 60%. This surge in compliance was likely driven by increased awareness of hand hygiene importance, fewer patient visitors, and fewer room entries and exits associated with practice changes of physicians and nurses. Unfortunately, this compliance was not sustained and in subsequent months returned to below pre-pandemic baselines. As healthcare systems set hand hygiene goals, it should be noted that high levels of compliance are indeed possible, yet difficult to achieve and sustain without strong individual motivation [5,6]. The decline in compliance in the most recent month examined should be a clarion call to healthcare systems bracing for potential new surges of COVID-19 and influenza this winter.

IMAGE 1: Figure 1. Monthly hand hygiene compliance across all hospital nursing units from 9/1/2019 – 8/31/2020

IMAGE 2: Figure 2. Monthly hand hygiene compliance across COVID cohort units from 9/1/2019 – 8/31/2020