As we enter the age of data, intelligent dispenser systems are beginning to dip into the mainstream of hand hygiene
“What you can’t measure, you can’t control,” is a well-known quote from Peter Drucker, an economist and pioneer of modern management theory. At the time, Drucker was probably unaware that the proverb would be so relatable to hand hygiene. It is precisely the measurement of on hand disinfection behavior that enables those responsible for hygiene to optimize behavior in healthcare institutions.
For decades, hand disinfection has been regarded as the most effective weapon to prevent infections. It all began with Semmelweis in the middle of the 19th century, who was the first to notice a connection inversely correlate hygiene and infections. He subsequently introduced adequate hygiene regulations in the clinic where he practiced as a doctor. To this day, numerous studies prove the outstanding importance of hand hygiene for infection control. The World Health Organization (WHO) references hand hygiene as the single most important factor for infection prevention.  The “My five moments for hand hygiene” model developed by the WHO serves as a guide for hospitals so that they can identify and understand how pathogens are transmitted.
Value – high, Implementation – inadequate
Despite the generally known effectiveness, good hand hygiene is not practiced enough, especially in medical facilities. A recent study showed that only 4 out of 10 opportunities for hand hygiene do hospital staff actually perform a hand hygiene event.  The are several reasons for this. The increased workload of nurses has negatively impacted hand hygiene, and must be counteracted at the organizational level. After all, 80 percent of all hand disinfections must be made by nursing staff.  There are also other factors that have a negative influence on hygiene behaviour. The lack of feedback to medical staff is often mentioned here. A current survey on the subject supports the thesis that nurses would like more feedback on their own hand hygiene behaviour.  The lack of disinfectant dispensers at the so-called point of care – i.e. in the immediate vicinity of the patient – also has a negative effect on compliance and has frequently been observed. 
Regular staff training plays an important role in improving the quality and quantity of hand hygiene. Typically, the lack of data on staff behaviour, makes it difficult to have target training. As a result, training courses are not very goal-oriented, and lack individualization.
The disadvantages of conventional measurement
In order to optimize the previously described hygiene situation, national institutions such as the Commission for Hospital Hygiene and Infection Prevention at the Robert Koch Institute (KRINKO) and the WHO recommend a multimodal intervention approach. One way to address this would be using the The WHO’s 5-pillar intervention model that describes five most important components, which should be used to improve hand hygiene. 
The aim is to counteract the causes of non-compliance in the long term. This is reflected in the building blocks of the WHO model: feedback, training, monitoring, visual reminders, and improved availability. In order to implement all these components effectively, and to evaluate their success, hygienists need real, up-to-date data on hygiene performance. The only solution that delivers the required data can be found using electronic instruments.
Until recent years, hygiene specialists have essentially been able to fall back on two methods – direct observation and the quantity of hand disinfectants ordered / consumed. These two approaches, however, have inherent weaknesses that hinder healthcare institutions from effectively implementing multimodal interventions.
To this end, it is important to understand the characteristics of the two traditional tools of hand hygiene monitoring. In direct observation, a trained person observes whether the hospital staff are practicing good hand hygiene at the required times. The problem is that staff tend to change their behaviour when they know that they are being observed, distorting the data and rendering it unusable. This is known as the Hawthorne effect. Studies have conclusively shown that during a direct observation phase, hand disinfection behaviour deviates greatly from normal levels.  This method also requires a large amount of human capital to observe a relatively small sample size of staff. 
Measuring the consumption of hand sanitizer – also known as the indirect method – is a relatively simple method of determining annual or monthly compliance for a specific station, by tracking the number of disinfectant bottles ordered. This is a cost-effective way to obtain some rudimentary data. The downside of this approach lies in the inability to give prompt, specific and regular feedback to the hospital staff on hygiene behaviour. Simply knowing consumption, does not allow for differentiated conclusions to be drawn about the correct positioning of the dispenser systems, or performance in certain sectors. This method is also subject to manipulation, and will count disinfectant consumed through evaporation, premature disposal, and alternative uses.
Digital vs. Analog
Classical methods of observation have their limits. This is where electronic monitoring systems come into play. Intelligent disinfectant dispensers, equipped with the appropriate technology, measure various aspects of hand hygiene behaviour automatically and continuously. Corresponding software provides employees responsible for hygiene with an abundance of unbiased data that can be retrieved at any time. This allows direct and station-specific feedback, as recommended by WHO and KRINKO.
A recent study carried out by Prof. Dr. Scheithauer at the RWTH Aachen University Hospital showed that regular oral feedback on hand hygiene performance increased could the average amount of hand disinfected dispensed during from 1.69 ml to 2.66 ml per event. This shows a remarkable improvement in hand hygiene quality. Data from WiFi-capable dispenser systems served as the basis for this intervention.  Direct and indirect methods would hardly provide such extensive data. Dr. Diefenbacher went one step further in her work, when she automatically and permanently reported back hand hygiene behaviour to the hospital staff via feedback tv monitors in the ward. These monitors provided a corresponding objective to the staff. This conserved human resources while showing a similarly positive effect. 
Electronic monitoring systems also score well in other components of improved compliance. When it comes to optimizing the availability of hand disinfectant dispensers, it is not enough to randomly increase the number of dispensers. The right positioning is crucial. A 2013 study found that placement is more important than the absolute number of dispensing systems in hospital units, provided a certain minimum number is available.  The data collected by WiFi-capable hygiene dispensers helps to identify devices that are rarely used, which can then be installed in a more effective area.
Paired with regular, targeted training, monitoring systems help identify qualitative and quantitative weak points. The success of training measures can also be tracked and adjusted accordingly. The same applies for interventions. A study conducted by Martine Caris and colleagues at the Amsterdam University Medical Center (UMC) examined the effect of nudges on hand hygiene behaviour – an approach from behavioural economics. The team developed posters with infection-prevention-related slogans and logos and placed them in the immediate vicinity of disinfectant dispensers with integrated monitoring technology. Using a hand hygiene monitoring system allowed the UMC to identify the positive trend associated with this new approach. 
Measure + optimize hand hygiene = avoid infections
Dr. Andreas Glöckner’s work at the BDH Clinic in Greifswald in 2015 went one step further, not only finding that the use of electronic monitoring systems improved hand hygiene, but also the quality of treatment. With the help of the OPHARDT Hygiene Monitoring System®, active training was carried out in the second phase of the one-year examination period. The team focused on the average amount of formula dispensed during hand disinfection. Continuous training created a success story. When compared to the same period of the previous year, hand disinfectant consumption per patient day increased by 30 percent. Conversely, nosocomial infections decreased by 28 percent per patient day. And, in an age of increasing multi-resistance, the number of antibiotic treatment days decreased by 26 percent. 
“OHMS allows for permanent and precise data collection with minimal effort from staff. It outputs data that determines the quality of hand hygiene behaviour at specific times and locations, thereby enabling targeted training. This monitoring system serves as an active component of sustainable hand hygiene improvement, and enables the reduction of the rate of nosocomial infections.”– Dr. med. Andreas Glöckner, Medical Director
What does KRINKO say?
Institutions, such as the German hygiene guidelines for healthcare – KRINKO – also advocate for the use of electronic hand hygiene monitoring, in particular when it comes to feedback. The authority sees electronic monitoring as superior to the classical measuring instruments, particularly with regard to individualization and the frequency of feedback.
“The consumption of disinfectant can be recorded over time at the place of consumption by means of electronic recording options, which means that compliance and thus the nosocomial infection rate can be influenced promptly”Extract from KRINKO recommendation on hand hygiene in health care facilities, 2016
The available literature clearly demonstrates the effectiveness of electronic monitoring systems for infection prevention in medical facilities. Beyond that, electronic monitoring systems enable simplify hygiene quality reporting for clinics, an increasingly required document from government authorities. Based on the German guideline issued by the Joint Federal Committee for Data-Protected Interinstitutional Quality Assurance (DeQS-RL) in 2019, hospitals are expected to regularly consider hand disinfection consumption in their quality reports. Intensive care, general wards and outpatient surgical practices, are also obliged to record and document consumption. 
Monitoring becomes even easier
With intelligent dispenser systems, such as the ingo-man® plus Weco, those responsible for hygiene already have suitable hardware available. Corresponding OPHARDT Hygiene Monitoring System® connects the hardware and enables detailed hygiene evaluations. In the future, it will be even easier for specialists to make disinfectant and soap dispensers smart. With the ingo-man® SmartNose, Germany’s most popular Euro bottle dispensers – the ingo-man® plus series – can easily be retrofitted with intelligent monitoring technology. All you need to do is replace the outlet cover – an upgrade that takes less than a minute. The technology will feature a quality of hand hygiene feedback LED, and drastically reduce the cost of entry into the suite of OPHARDT intelligent Solutions. The innovation will be presented to the public for the first time at the Freiburg Congress on Hygiene and Infectious Diseases in Germany on October 9-11.
With the help of increasing evidence, higher awareness, and lowered barriers to entry, electronic hand hygiene monitoring stands on the cusp of a breakthrough.
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