Discussion

Existing research has suggested the utility of electronic systems for the collection of hand hygiene compliance data. However, because this research is largely limited to the use of proxy measures such as product consumption and/or room entry and exit, these systems are of concern.^{Reference Srigley, Furness, Baker and Gardam21,Reference Sahud, Bhanot, Narasimhan and Malka33} Stewardson and Pittet^{Reference Stewardson and Pittet34} warned of the importance of monitoring behaviors and actions that actually “correspond conceptually with patient safety” (p. 1030). They noted that although monitoring and promoting hand hygiene prior to door opening may be simple, convenient, and indeed technologically possible, it may not be either useful or desirable in terms of best practice for patient safety. Thus, rather than defining compliance as adherence to practices which best decrease the risk of microbial transmission, there could be a risk of changing the definition of what constitutes hand hygiene compliance to fit with the monitoring capacity of the technology.

Although this study utilized a trial in simulation with volunteer participants, rather than actual clinical care episodes to record footage, this does not negate the validity of the results. The high-fidelity nature of the scenarios provided a realistic simulacrum of HCW–patient interaction and demonstrates the utility of using video monitoring to capture and assess hand hygiene compliance according to the 5 moments framework. The use of the multiple camera array meant that the entire hand hygiene journey of the participant HCWs could be captured. Subsequent review of the footage demonstrated the ability to clearly distinguish all 5 of the WHO Five Moments as they occurred and according to the WHO Five Moments criteria rather than by proxy measures. Proxy measures have been reported in the literature, notably the research using room-entry and -exit measures via video camera by Armellino et al^{Reference Armellino, Hussain and Schilling35} and research using patient-zone entry coupled with dispenser activation by Al Salman et al.^{Reference Al Salman, Hani, de Marcellis-Warin and Isa36}

The time, and consequently financial, savings demonstrated in our results confer additional advantage to the approach. We determined that auditing from the recorded footage for both days represented a saving of 86 minutes. When compared to time taken if direct observational auditing was employed, this equated to a saving of 84 seconds per moment. Furthermore, this calculation assumed that a human auditor would be able to capture all moments with the same certainty as was able to be achieved from the footage. We suspect that a higher yield of moments was achieved from the footage due to the capacity to freeze, slow, and rewind the footage, in addition to the lack of distraction during auditing, which took place away from the clinical setting. Auditing using recorded footage would cost $99.17 AUD ($ 71.59 USD) or $0.89 AUD ($0.64 USD) per moment for the 6 simulation scenarios, whereas direct observational auditing would have cost $171.67 AUD ($123.92 USD) or $1.55 AUD ($1.12 USD) per moment. These figures are lower than the cost per moment of $2.24 AUD ($1.62 USD) suggested by Azim and McLaws.^{Reference Azim and McLaws37} With data from the NHHI in Australia showing the collection of >1.8 million moments per year,³⁸ the potential financial benefits could be considerable. The cost and time savings of auditing practice from footage has been noted in the literature. Hu et al^{Reference Hu, Peyre and Arriaga39} estimated a 50%–80% time savings in data review due to the ability to fast-forward footage when appropriate. This report supports the enhanced efficiency of video-monitoring technologies. Recorded footage may also be reviewed at a more convenient time compared to direct observation data gathering, which typically occurs during the day shift on weekdays. The rationale for selecting this time is that the clinical areas are the busiest and larger amounts of hand hygiene will be being performed; hence, data gathering is most efficient. However, this practice may not only foster selection bias but may create conflict for local, ward-based auditors with dual clinical and auditing roles.^{Reference Haas and Larson8,Reference Boyce23,Reference Daniels40}

Another useful aspect of collecting data using video monitoring technology is the potential to collect less biased results. The practices of all HCWs who come within the view of the camera lens are captured, hence eliminating or at the very least significantly reducing selection bias. In addition, observer bias may be reduced, interauditor reliability issues may be solved by auditing from footage because multiple auditors can review the same episode and compare results.^{Reference Woolrych, Zecevic and Sixsmith41} Footage can be manipulated to ensure certainty (ie, by rewinding, slowing motion, and freezing frames) and to facilitate discussion, review, and clarification of difficult or ambiguous situations. In addition, observation bias or the Hawthorne effect is reduced by camera versus direct observation; a camera creates less behavioral change than a human observer. Several studies involving video recording of participants in clinical or simulated clinical contexts have shown the reduction or elimination of the Hawthorne effect in the presence of cameras.^{Reference Clack, Scotoni, Wolfensberger and Sax30,Reference Hu, Peyre and Arriaga39,Reference Filho, Marra and Magnus42} More accurate hand hygiene data would allow the identification of practice deficits and open the possibilities of targeted change strategies to improve patient safety and quality of care.

The results of this study demonstrate that video-based auditing of hand hygiene is indeed technically possible. These findings suggest that it may be achieved in a more efficient manner than via traditional human direct observation, a suggestion which was raised by participants in preparatory work.^{Reference McKay, Ferguson and Shaban43} In addition, resultant data may represent a truer reflection of practice than data produced by direct observation. These results are significantly less biased, they are able to be collected without intrusion, and they have enhanced credibility due to inherent accuracy and completeness of the record. This approach allows for what Broyles et al^{Reference Broyles, Tate and Happ44} have described as nuanced levels of analysis.

The COVID-19 global pandemic has accelerated the development, use and acceptability of various video-based “telehealth” modalities.^{Reference Vilendrer, Patel and Chadwick45,Reference Ostrowsky, Weil and Olaisen46} Vilendrer et al^{Reference Vilendrer, Patel and Chadwick45} suggest that the optimal set up would be to have the facility for such approaches in every patient room as a way of optimizing communication for patients requiring isolation precautions and preventing pathogen transmission. They go on to suggest the utility of using the technology for other purposes such as “virtual sitters,” the facilitation of visitor interaction and the enhancement of clinician convenience and efficiency.^{Reference Vilendrer, Patel and Chadwick45} Furthermore, developments in the use of cameras for fall prevention and elder abuse (so called “granny cams”) also have additional possibilities in aged-care settings.^{Reference Woolrych, Zecevic and Sixsmith41,Reference Ostervang, Vestergaard, Dieperink and Danbjørg47,Reference Berridge, Halpern and Levy48} Video monitoring within the patient zone has the potential to enhance patient safety and quality of care through the accurate identification and subsequent remediation of practice shortfalls.

This study had several limitations. Auditing was conducted by a single member of the research team who is a validated Gold Standard Auditor under the NHHI in Australia. Although this could represent a limitation of the study, the practice is consistent with direct observational auditing under the NHHI framework where results are collected and submitted based on the interpretation of a single individual.

In conclusion, our earlier works explored the question of the methodological and technical considerations for video-based auditing of hand hygiene practice^{Reference McKay, Ferguson and Shaban43,Reference McKay, Shaban and Ferguson49} and established the basis of the current study. We have demonstrated the technical capacity of a multicamera VMS to record footage of clinical practice via high-fidelity simulation which can subsequently be audited for hand hygiene compliance against the WHO Five Moments criteria rather than proxy measures such as entry and exit.

Furthermore, utilizing this approach may produce output data that are more representative of true, unbiased hand hygiene compliance behavior and provide time and cost savings as well as convenience for auditors. This research is intended as a launching point for the development and refinement of camera systems within the patient zone with which to audit hand hygiene as well as other infection prevention and control behaviors. Another question that needs to be addressed, notwithstanding the technical capacity to record and subsequently audit hand hygiene behaviors, is this: What is the acceptability of the practice to HCW and patients? This factor could be an obstacle despite the benefits of this approach.