Watching the Hospital Hand-Washing Watchers

Remember cloakroom monitors? Now, it's video monitors for scrubbing up.

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Thanks to fellow blogger Bob Wachter, a hospitalist at the University of California, San Francisco Medical Center, for taking note on his blog, Wachter's World, of a story in yesterday's ModernHealthcare.com about a development that very well might solve the low rate of hand-washing by hospital caregivers. Because the solution involves video monitoring, however, it raises a question or two of its own.

I've blogged here and here and here about the need for all healthcare workers to scrub their hands or use a hand sanitizer before touching or approaching patients. Rather surprisingly, no one can say with authority how much the number or rate of hospital-acquired infections would drop if hand-washing compliance shot up, but certainly it would be significant, considering the room for improvement. Because of all the attention recently devoted to hand-washing, Wachter writes, "many hospitals, including my own, have seen hand-cleansing rates skyrocket, from previously mortifying levels of 20 to 30 percent to merely embarrassing rates of 60 to 80 percent."

Nothing seems to be work that well, even though many hospitals go to great lengths—such as enlisting staff members to keep a record of the hand-washing diligence of their fellow employees. That's a tactic that has always puzzled me. Does anybody think no one knows who or where the observers are? They can't be completely out of sight, or they wouldn't be able to observe. If they're just sort of hanging around, that's a tough act to pull off. From the statistics, they are not especially successful.

A few years ago, Wachter proposed at a UCSF quality meeting that video cameras be installed to observe hand-washing compliance in ICUs, where the sickest patients are especially vulnerable to infection. The reaction, he writes: " 'We can't do that,' came the shocked reply. I never got an answer to the 'why not?' question."

Now, Arrowsight Medical, a division of a company in Mt. Kisco, N.Y., that already offers video monitoring in food-processing plants and other operations, is pushing to do the same in hospitals. One large eastern hospital, which Arrowsight spokesman Neil Vineberg would not name, has put cameras in its ICUs and is collecting hand-washing information that will be described in a future study. (Staffers are aware of the project and know about the cameras.) In a previous small-scale installation at an outpatient surgery center in Georgia, says Vineberg, compliance jumped within three months from 30 percent to more than 90 percent.

The system is more sophisticated than a battery of videocams connected to a remote site. That would require an army of bored observers staring nonstop at flickering screens, stirred to action only by "gotcha!" moments when a hapless doctor or nurse walked past the Purell dispenser. Instead, sensors are deployed at the doorways of patient rooms and elsewhere. They get tripped when someone comes in, and they turn on the videorecorder for a short time. "Auditors," as Arrowsight calls them, then look at each entry and enter the corresponding time-stamped data. You can watch a promotional video on YouTube.

"[I]t is natural to be slightly repelled by this concept," writes Wachter, whose entry is headed "Big Brother Arrives." Arrowsight insists that its system will be used to educate caregivers and modify their behavior, not to punish noncompliant types. "Yeah, sure," writes Wachter.

Vineberg notes that in the hospital where the system is going through a tryout, the data fed back to the hospital consist only of the rate of compliance for each patient room during one shift. Nurse managers receive the data the next day at the latest and can see which rooms need improvement. No one, not even the hospital's top administrators, is allowed to see the videos. That's reassuring.

Video monitoring seems inevitable. "So, get used to it," writes Wachter. "Who knows, it might even save a few lives."