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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 9-14

A prospective cohort study on closed-circuit television monitoring and direct observation for hand hygiene compliance in a pediatric intensive care unit

1 Department of Pediatrics, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission08-Feb-2019
Date of Acceptance17-May-2020
Date of Web Publication18-Aug-2020

Correspondence Address:
Dr. Ramachandran Rameshkumar
Department of Pediatrics, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAMR.IJAMR_21_19

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Background: Intensive care patients are at risk for healthcare-associated infections (HCAIs), and hand hygiene (HH) compliance in health-care workers (HCWs) is reportedly low. This study aimed to compare closed-circuit television (CCTV) monitoring to direct observation on the HH compliance and its impact on HCAIs. Methods: In a prospective cohort study, HCWs were observed for HH compliance and HCAIs were studied. The study period was August 1, 2014–December 31, 2014 (direct observation period), and March 1, 2015–July 31, 2015 (CCTV monitoring period), with 2 months washout period. A HH education module (running a video daily, reinforcement of HH everyday evening, 2-weekly classes about HH importance, and posters reinforcing the importance of HH on the prominent sites of pediatric intensive care unit) was implemented in both periods. Each day was divided into blocks of 6-h. One hour from each block was randomly selected stratified by day and night shifts. HH compliance was observed according to the World Health Organization, “My Five Moments of HH.” Results: A total of 751 patients (direct observation period n = 369, CCTV monitoring period n = 382) were admitted. The HH compliance rate was higher in the CCTV monitoring period (56.6%, n = 5953 / 10519) as compared to that of the direct observation period (36.1%, n = 2178 / 6028) (relative risk = 1.57, 95% confidence interval: 1.51 - 1.63, P ≤ 0.001). Ventilator-associated pneumonia (4.7 vs. 12 / 1000 ventilation-day) and central line-associated bloodstream infection (1.9 vs. 6.6 / 1000 central line-day) were lower in the CCTV monitoring period. There was no difference in mortality between the study periods (18.3%, n = 70 / 382 vs. 21.1%, n = 78 / 369, relative risk = 0.87, 95% confidence interval: 0.65–1.16, P = 0.333). Conclusion: CCTV monitoring was associated with improved HH compliance, which was associated with lower HCAIs.

Keywords: Children, closed-circuit television monitoring, hand hygiene practice, healthcare-associated infection, pediatric intensive care unit

How to cite this article:
Balkisanji LS, Satheesh P, Rameshkumar R, Jain P, Jayaseelan V, Mahadevan S. A prospective cohort study on closed-circuit television monitoring and direct observation for hand hygiene compliance in a pediatric intensive care unit. Int J Adv Med Health Res 2020;7:9-14

How to cite this URL:
Balkisanji LS, Satheesh P, Rameshkumar R, Jain P, Jayaseelan V, Mahadevan S. A prospective cohort study on closed-circuit television monitoring and direct observation for hand hygiene compliance in a pediatric intensive care unit. Int J Adv Med Health Res [serial online] 2020 [cited 2022 Aug 11];7:9-14. Available from: https://www.ijamhrjournal.org/text.asp?2020/7/1/9/292398

  Introduction Top

Healthcare-associated infections (HCAIs) are a significant threat to patients admitted in intensive care units (ICUs) due to the use of invasive devices such as mechanical ventilators, central venous catheters, and urinary catheters. HCAIs are mainly transmitted through the hands of health-care workers (HCWs) in addition to unclean surroundings and contaminated fomites or equipment.[1],[2] Prevention of HCAIs is critical and urgent as the options available to treat these infections are limited. Ignaz Philipp Semmelweis in 1847 demonstrated that puerperal fever was contagious and was significantly reduced by the practice of appropriate hand practiced by medical caregivers.[3] The practice of hand hygiene (HH) is the most widely recognized effective intervention to reduce HCAIs.[2] However, HH compliance in HCWs is reportedly low. In ICUs settings, reported rate of HH compliance was 30%–40% as compared to other settings that reported 50%–60%, with mean baseline rates ranging from 5% to 89%.[4] Studies done in different settings have shown that improving HH compliance is achieved by target-specific active interventions.[2] The lower compliance of HH in HCWs has been attributed in part to the limited quality of information and training. Further, settings where resident doctors rotate as a part of their training program makes sustained monitoring challenging.

To improve the HH compliance, the World Health Organization (WHO) has enlisted methods of measuring the practice of HH, namely direct observation, the conduct of surveys, measurement of product use, patient-based surveillance, and the use of electronic devices. However, direct observation is considered the “gold standard” although it lacks validity.[5] Further, the WHO developed the “My Five Moments for HH” concept to measure the HH compliance and is followed in various studies including pediatric ICUs (PICUs).[2] There is no published study on closed-circuit television (CCTV) monitoring for HH compliance among HCWs in the setting of PICU in low-middle income countries. Therefore, the present study was done to compare the HH compliance among the HCWs by direct observation and by CCTV monitoring in addition to HH education and its impact on HCAIs.

  Methods Top

This prospective cohort study was undertaken in the division of pediatric critical care in a tertiary care academic hospital. The study period was August 1, 2014–December 31, 2014 (direct observation period), and March 1, 2015–July 31, 2015 (CCTV monitoring period), with 2 months washout period. Our PICU is equipped with 19 beds, managed by three consultants, four senior residents (DM fellows), eight junior resident doctors, 23 nursing staff including three senior nursing officers, and nine orderly nursing personnel. The Institute ethics committee approved the study. All HCWs working in and visiting PICU were included and monitored for HH compliance. The HH observation related to HCWs not willing to participate and parents/visitors of patients were excluded. Written informed consent was obtained from the HCWs. The HCWs working and visiting PCIU were aware of HH audit being part of the hospital infection control committee (HICC) policy. They were informed about the video cameras, which would be installed to monitor HH during the study period. Data about patient privacy and employee identification were not collected.

The HH education module consisted of running a video daily from 8 a.m. to 10 a.m. on a television screen installed outside the PICU. Reinforcing the importance of HH was done in the PICU daily evening between 6 p.m. and 7 p.m. Two weekly classes on HH and its importance was taken by the study investigators. Posters reinforcing the importance of HH were placed on prominent sites of PICU, namely at the entrance, hand washing areas, and residents and nurses working stations. The HH education module was implemented during both study periods. Easy and liberal availability of HH solutions and facilities including more locations, was ensured during the study periods.

Each day was divided into four 6-h blocks. One hour from each block was randomly selected stratified by day and night shifts for HH opportunities (HHOs). In the direct observation period, a HICC nurses, along with a dedicated nurse from PICU, observed the HHO and compliance. In the CCTV monitoring period, a CCTV camera was installed. A single camera (with multifocal aperture able to rotate 270°) was installed at the center of the PICU. Rotation covered all patient care areas including entry and hand wash sink. The rest of the 90° was the blind spot (mainly storage section). The footage in the memory card was viewed after dividing each day into four 6-h blocks, and 1 h was randomly selected stratified by day and night shifts for HH assessment. Another independent pair of HICC and PICU nurses calculated the compliance from the CCTV footage. These nurses were trained about HH monitoring and had an excellent inter-observer agreement (kappa statistic = 0.90). In both periods, the available opportunities of HH practice were noted according to the WHO's “My Five Moments of HH,” (i) before aseptic task, (ii) before patient contact, (iii) after body fluid exposure, (iv) after patient contact, and (v) after contact with the surroundings of the patient. On available opportunities, how many times all steps of HH (i.e., HH complete adherence rate) were carried out and lapsed HH opportunity were noted. HH compliance was noted separately for the consultant, nursing staff, resident doctors, visiting HCWs, and nursing orderly. The HICC collected data on HCAIs namely ventilator-associated pneumonia (VAP) and central line-associated bloodstream infection (CLABSI) using the Centers for Disease Control (CDC) definition along with the PICU team.[6]

The HH compliance rate among the HCWs was 33% (author center, January–June 2014 unpublished data).[4] To raise it to 60% with a 95% confidence interval and precision of 5%, the minimum number of observations required was 369. With a 10% attrition rate, the number of observations required was 410. However, during the study period, all the available opportunities were analyzed. The sample size was calculated using OPENEPI software version 3.03 (http://www.openepi.com).

Categorical data were presented using frequencies and percentages and compared by using the Chi-square test or Fisher's exact test. The compliance rate was expressed as a relative risk and 95% confidence interval as appropriate. For normally distributed continuous data, mean (±standard deviation) was used, and for non-Gaussian data, median (interquartile range) was used. Appropriate parametric (student's t-test) or nonparametric (Mann–Whitney U-test) tests were used to compare the two study periods. HCAI episodes were expressed as VAP and CLABSI per 1000 ventilation- or catheter-days, respectively. All the tests were two tailed, and P < 0.05 was considered statistically significant. SPSS 20.0 software (SPSS Inc. Chicago, Illinois, USA) and Epi Info™ 7 (, Centers for Disease Control and Prevention, Atlanta, GA) were used for data analysis.

  Results Top

A total of 751 patients (direct observation period n = 369, CCTV monitoring period n = 382) were admitted, and their baseline characteristics are summarized in [Table 1]. In the direct observation period, 6028 opportunities and in CCTV monitoring period, 10,519 opportunities were available and compared [Figure 1]. The HH compliance rate was significantly higher in the CCTV monitoring period (56.6%) as compared to that of the direct observation period (36.1%) and during the day shift (38.6% to 61.4%) as compared to night shift (35.7% to 55%) [Table 2]. HH compliance rate in the direct observation versus CCTV monitoring period was significantly higher in consultants (74% vs. 98.5%) followed by nursing staff (57% vs. 77%), resident doctors (33% vs. 52%), and visiting HCWs (12% vs. 22%) and least in nursing orderly (4% vs. 9%) (P ≤ 0.001). According to the WHO five moments of HH, there was a significant improvement in HH compliance with “each moment” in CCTV monitoring period as compared to the direct observation period. The maximum rate was noted in “before aseptic task” (90.6% vs. 87.3%) and least in “after contact with patient surroundings” (30% vs. 25%) [Table 2]. In the CCTV monitoring period, HCAIs were lower (VAP, P = 0.008, and CLABSI, P = 0.057), and there was no difference in PICU mortality (18.3% vs. 21.1%, P = 0.333) as compared to that of the direct observation period [Table 2].
Table 1: Baseline characteristics of patients admitted in the two study periods

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Figure 1: Study flow

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Table 2: Comparison of outcomes between the two study periods.

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  Discussion Top

The introduction of CCTV was associated with a higher HH compliance rate, which in turn was associated with lower HCAIs. However, there was no difference in PICU mortality. These results demonstrate that CCTV monitoring for HH practice in PICU is feasible in low-middle income countries. The presently available data suggest that more than 1.4 million patients are affected by HCAIs, both in high and low-middle income countries.[6] In our institution, we routinely use chlorhexidine-based hand rub for HH as required in “My Five Moments of HH.” This evidence-based, field-tested, and user-centered approach is designed in such a way that it is easy to learn, is more logical, and is applicable in a wide range of settings.[2]

We used video recording for monitoring of HH compliance as per the WHO five moments of HH, and HH compliance increased from 36.1% to 56.6% after CCTV monitoring as compared to direct observation. After that, the increase in HH compliance was achieved up to 98% and maintained with a range of 90%–98% for 6 months. This study result is similar to a study by Armellino et al. Which found that use of third-party remote video monitoring with real-time feedback was associated with increased HH compliance from 10% to 81.6% and sustained through a period of 75 weeks at a rate of 87.9%.[4] Though the results of our study are similar to that of Armellino et al., still HH compliance rate was in the lower range (below 95%) at the end of our study period. The reasons in part could be an underestimation of the consequence of inadequate HH and misunderstanding of the purpose of HH, particularly in new trainee residents posted in ICU on a rotation basis.[7],[8] The risk factors of lower HH compliance in doctors (residents and consultants) as compared to nursing staff are working in ICUs, understaffing, overcrowding, high-intensity patient care, insufficient time and materials, and lack of institutional priority.[9]

We used the health education module for HH throughout the study period along with the institute policy for infection control. In this study, in the health education module with a direct observation period, HH compliance was 36.1%, which is similar to the study by Mathai et al.[9] The authors found that HH compliance among the HCWs in ICU was 26% in resource-limited settings before the introduction of multimodal interventions (educational initiatives, visual reminders in the forms of posters, verbal reminders by pointing out the lapse, and easy and liberal availability of HH solutions and facilities). The authors found that the overall HH compliance was improved to 57.4% after the introduction of the multimodal intervention.[9] The additional activities such as display of HH video in the television screen, every day reinforcing interaction about HH and direct observation by trained nurses in the educational module could be the potential reason for the higher baseline HH compliance rate in our study. This observation was in contrast to that of Mathai et al.[9]

We found that HH compliance was highest “before aseptic task,” followed by “before contact with the patient,” and among HCWs, higher HH compliance was noted in “consultants” in after-period. The result differs from the study by Mahfouz et al. who found that “events before contact with the patient,” “being a physician,” and work in the “intermediate care unit” were significant risk factors for HH noncompliance in the hospital.[10] Compliance among HCWs according to their work rank differed significantly in our study. The highest compliance was noticed in consultants, followed by nursing staff. The results differ from studies by Mahfauz et al.[10] and Salama et al.,[11] who found that the HH compliance was highest among the nurses and lowest among the doctors. Hence, we need to monitor and train the resident doctors and nurses on HH compliance and give them positive feedback, because resident doctors and nurses are the persons who are in contact with patients for the most duration in contrast to consultants.

We observed that HCAIs, VAP, and CLABSI were significantly decreased in the CCTV monitoring period as compared to the direct observation period. Reduction in HCAIs can be attributed to an increase in HH compliance because the factors which can affect HCAI rate, such as the profile of patient admitted, nurse-to-patient ratio, and the doctor-to-patient ratio, were similar in both periods of the study. The result was comparable to a study by Salama et al.,[11] who found that overall HCAIs per 1000 days decreased from 37.2 to 15.1, the lower respiratory tract infections decreased from 17.6 to 5.2, and CLABSI decreased from 18.6 to 3.4 / 1000 central line days in the pre- and post-intervention period. These results are supported by many studies that have consistently shown that improved HH compliance is associated with reduced HCAIs and cross-transmission of multidrug-resistant infections in hospitals.[12],[13],[14],[15],[16] Two studies in ICU settings reported the use of body-worn electronic devices with education,[17] and performance feedback, and in another study use of electronic handwashing counters with positive deviance[18] was associated with significant improvement in HH compliance, which was associated with a decrease in the VAP and the overall incidence of HCAIs respectively.

In the present study, we observed the diurnal variation in HH compliance (during day shift was significantly higher than night shift). A similar observation has been made previously by Sahay et al.[19] who found that HH compliance dropped during the night hours for doctors (81% vs. 46%), nurses (64% vs. 55%), and paramedical staff (44% vs. 31%). The reminders in the form of posters and night time alarm can tackle this issue. Regarding the privacy of HCWs, the data of non-consenting HCWs were excluded, and data were observed in aggregate for HHO and the video segments were not used to observe individual HCWs. All HCWs were aware of this study in contrast to other institutions where third-party observers assessed HH compliance. In those settings, it is usually done without prior information to the HCWs. In other industries, security cameras are used extensively to improve employment practices and performances and for enforcement of traffic rules. However, in a health-care setting, it seems to be infrequent.[4]

This study is the first study on CCTV monitoring for HH compliance and the impact on HCAIs in the PICU of resource-limited settings. The study was designed with more number of observations of HHO as compared to published studies.[12],[13],[14],[15],[16] The limitation of the study was its open label nature, but that was unavoidable given the nature of the study. Rotation of different semester resident doctors and their prior knowledge about the HH were not assessed. The infection prevention interventions such as a checklist of VAP and CLABSI bundle care and oral care bundle were not compared and correlated with HH compliance during the study period. However, these preventive interventions were followed as part of the routine care of the unit throughout the study period. The real-time feedback for the lapse of HH practice was not studied in detail. Future studies should focus on CCTV monitoring with real-time feedback and in different settings such as general ward and emergency room, and the knowledge, attitude, and practices of different semester resident doctors and different ranks of HCWs needs to be studied.


We conclude that CCTV monitoring of HH practice was associated with improved HH compliance rate, which was associated with lower HCAIs in a pediatric intensive care setting.


We acknowledge the contribution of Mrs. S. Raja Deepa B. Com, MCA (JIPMER Campus, Puducherry, India), for data analysis in a blinded manner and for manuscript editing; Mr. Rakesh Mohindra (Punjab University, Chandigarh, India) and Mrs. Thenmozhi M (M. Sc, Ph.D., Senior Demonstrator, CMC, Vellore, India) for helping with the statistical analysis; and Mrs. Harpreet Kaur (Punjab University, Chandigarh, India) and Mrs. Neelima Chadha (Tulsi Das Library, PGIMER, Chandigarh, India) for helping with the medical literature search. They did not receive any compensation for their contributions.

Financial support and sponsorship

The financial support and sponsorship was in part by the department and institution.

Conflicts of interest

There are no conflicts of interest.

  References Top

Laskar AM, RD, Bhat P, Pottakkat B, Narayan S, Sastry AS, et al. A multimodal intervention to improve hand hygiene compliance in a tertiary care center. Am J Infect Control 2018;46:775-80.  Back to cited text no. 1
Kingston L, O'Connell NH, Dunne CP. Hand hygiene-related clinical trials reported since 2010: A systematic review. J Hosp Infect 2016;92:309-20.  Back to cited text no. 2
Rangappa P. Ignaz Semmelweis–hand washing pioneer. J Assoc Physicians India 2015;63:56-7.  Back to cited text no. 3
Armellino D, Hussain E, Schilling ME, Senicola W, Eichorn A, Dlugacz Y, et al. Using high-technology to enforce low-technology safety measures: The use of third-party remote video auditing and real-time feedback in healthcare. Clin Infect Dis 2012;54:1-7.  Back to cited text no. 4
WHO Guidelines on Hand Hygiene in Health Care:First Global Patient Safety Challenge Clean Care is Safer Care. Geneva; 2009. Available from: http://www.ncbi.nlm.nih.gov/books/NBK144013/. [Last accessed on 2014 Jul 04].  Back to cited text no. 5
Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309-32.  Back to cited text no. 6
De Wandel D, Maes L, Labeau S, Vereecken C, Blot S. Behavioral determinants of hand hygiene compliance in intensive care units. Am J Crit Care 2010;19:230-9.  Back to cited text no. 7
Stewardson A, Allegranzi B, Sax H, Kilpatrick C, Pittet D. Back to the future: Rising to the Semmelweis challenge in hand hygiene. Future Microbiol 2011;6:855-76.  Back to cited text no. 8
Mathai AS, George SE, Abraham J. Efficacy of a multimodal intervention strategy in improving hand hygiene compliance in a tertiary level intensive care unit. Indian J Crit Care Med 2011;15:6-15.  Back to cited text no. 9
[PUBMED]  [Full text]  
Mahfouz AA, El Gamal MN, Al-Azraqi TA. Hand hygiene non-compliance among intensive care unit health care workers in Aseer Central Hospital, South-Western Saudi Arabia. Int J Infect Dis 2013;17:e729-32.  Back to cited text no. 10
Salama MF, Jamal WY, Mousa HA, Al-Abdulghani KA, Rotimi VO. The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital. J Infect Public Health 2013;6:27-34.  Back to cited text no. 11
Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D. 'My five moments for hand hygiene': A user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 2007;67:9-21.  Back to cited text no. 12
Pittet D, Allegranzi B, Sax H, Dharan S, Pessoa-Silva CL, Donaldson L, et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006;6:641-52.  Back to cited text no. 13
Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Infection Control Program. Ann Intern Med 1999;130:126-30.  Back to cited text no. 14
Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000;356:1307-12.  Back to cited text no. 15
Rose L, Rogel K, Redl L, Cade JF. Implementation of a multimodal infection control program during an Acinetobacter outbreak. Intensive Crit Care Nurs 2009;25:57-63.  Back to cited text no. 16
Koff MD, Corwin HL, Beach ML, Surgenor SD, Loftus RW. Reduction in ventilator associated pneumonia in a mixed intensive care unit after initiation of a novel hand hygiene program. J Crit Care 2011;26:489-95.  Back to cited text no. 17
Marra AR, Guastelli LR, de Araujo CM, dos Santos JL, Lamblet LC, Silva M Jr., et al. Positive deviance: A new strategy for improving hand hygiene compliance. Infect Control Hosp Epidemiol 2010;31:12-20.  Back to cited text no. 18
Sahay S, Panja S, Ray S, Rao BK. Diurnal variation in hand hygiene compliance in a tertiary level multidisciplinary intensive care unit. Am J Infect Control 2010;38:535-9.  Back to cited text no. 19


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  [Table 1], [Table 2]


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