Discussion

Not only was the Clean-In-Clean-Out model sustainable through a public health and healthcare crisis, initial increases in engagement and compliance metrics were identified. Although not at statistically significant levels, observations and feedback increased with COVID-19 media attention, prior to cases occurring in North Carolina or at our facility. These increases may be a reflection of staff proactively engaged in COVID-19 infection prevention efforts. Feedback and compliance increased again when our facility began seeing COVID-19 patients, even in the absence of active reminders and campaigns from infection prevention staff.

A statistically significant increase in hand hygiene compliance was observed during one period, March–June 2020, which corresponded with the admission of the first COVID-19 patient at our facility, shelter-in-place orders community-wide, and low inpatient volumes. In July, patient volumes started to return to pre–COVID-19 levels while our facility also began treating a higher number of COVID-19 patients. In addition, the hospital started experiencing staff shortages. The decrease in engagement observed with higher patient volume and patient-to-staff ratios is further evidence that operating at high capacity is not beneficial for patient safety. ^{Reference Chang, Schweizer and Reisinger8–Reference Vicca10} This trend was further demonstrated by the decrease in hand hygiene compliance from October through December 2020, when our facility had high, sustained COVID-19 admissions as well as a normal non–COVID-19 patient volume.

This study had several limitations. We evaluated hand hygiene at a single, large academic medical center, and these results may not be generalizable to other settings or hand hygiene programs. However, the results were similar to findings published on COVID-19 and automated hand-hygiene monitoring systems in which compliance increased with lower patient volume, especially early in the pandemic. ^{Reference Hess, Armstrong-Novak and Doll2,Reference Moore, Robbins, Quinn and Arbogast3} CICO is a novel hand hygiene program and is subject to selection and measurement bias. However, CICO provides benefits of real-time feedback that directly affects practices. ^{Reference Sickbert-Bennett, DiBiase, Schade-Willis, Wolak, Weber and Rutala5,Reference Sickbert-Bennett, DiBiase, Teal, Summerlin-Long and Weber6}

Hand hygiene compliance remained high, >90%. Key CICO metrics demonstrated that although a manual rather than automated monitoring tool requires extra effort from staff, it is still a viable model. Unlike automated systems, CICO provides the opportunity for just-in-time reminders. Stangerup et al ^{Reference Stangerup, Hansen and Hansen4} found that hand hygiene compliance decreased when hand-hygiene data sharing stopped. Furthermore, the crowd-sourced component of CICO allows all staff to complete observations and provide real-time feedback as time permits rather than further burdening infection prevention staff or specific designees who were inundated with competing priorities.

The COVID-19 pandemic has caused healthcare staff to juggle numerous responsibilities with quality improvement and patient safety projects often being deprioritized and/or delayed. In the midst of this environment, it was encouraging to see that this CICO manual hand hygiene program was still actively utilized at comparable levels to the pre-COVID-19 baseline and that overall compliance and feedback provided did not significantly decline. In addition, the sustainability and success of the CICO program allowed UNC Medical Center to replicate this model of shared responsibility for monitoring mask compliance in contrast to more labor-intensive methods. ^{Reference Datta, Glenn and Pellegrino11} In the midst of a global pandemic, sustainable hand hygiene programs remain foundational to the success of infection prevention.