Background: According to CDC estimates, Hospital-Acquired Infections (HAI) account for an estimated 1.7 million infections and 99,000 deaths each year. Studies have shown that using alcohol-based or chlorhexidine-based hand hygiene (HH) is associated with decreased rates of HAIs (1, 2).
Nudge theory, a concept in behavioral science, uses positive reinforcement and indirect suggestions to achieve non-forced compliance of individuals and groups (3). Simple nudges, including posters as well as “eyes” or citrus smells on hand sanitizers, have been shown to improve HH compliance (4). In one study, a significant improvement in HH rates was seen when a picture of “male eyes” was placed over the hand gel dispensers (33.3% vs. 15.0%, p < .038), but not when a picture of "female eyes" was placed over the same hand gel dispensers (10.0% vs. 15.0%, p = .626) (5)
Methods: We monitored HH encounters on hospital wards through direct observation. An encounter was documented when medical staff entered a patient’s room with the intention of making contact with the patient or their surroundings and when they left a patient’s room after coming in contact with the patient or their surroundings. These encounters were measured as a percent compliance of HH before and after the intervention. The observers were the hospital’s infection preventionists, or IP’s (generally known to the unit’s staff), and trained volunteers (who are not expected to record HH rates).
After establishing a baseline rate of compliance, an intervention in the form of an image of “Watchful Eyes” was placed on all HH stations on the unit.
Results: There were 35 volunteer-collected and 162 IP-collected HH observations before the intervention and 213 volunteer-collected and 48 IP-collected HH observations after the intervention. The rate of hand hygiene adherence improved from 60.00% to 78.87% in the volunteer-collected data (Figure 1; p<0.05); however, the hand hygiene compliance rate changed from 79.01% to 66.67% in the IP-collected data (Figure 1; p=0.07). The overall rate of adherence, combining volunteer-collected and IP-collected data, changed from 75.63% to 76.63% (Figure 1; p=0.81).
Conclusions: HH rates improved after the “Watchful Eyes” intervention when measured by volunteers but not by IPs. This may have been due to chance, given the small number of volunteer HH encounters observed in the pre-intervention time period.
Another possible explanation is the Hawthorne effect, in which subjects change their behavior when they know they are being observed (6). Hospital-wide HH rates collected by volunteers were substantially different than those observed by the IPs, presumably because the staff knew when the IPs were observing them.
References:
1. Hilburn J et al. Use of alcohol hand sanitizer as an infection control strategy in an acute care facility. Am J Infect Control. 2003 Apr;31(2):109-16.
2. Allegranzi B, Pittet DJ. Role of hand hygiene in healthcare-associated infection prevention. Hosp Infect. 2009 Dec;73(4):305-15
3. Thaler RH, Sunstein CR. Nudge: improving decisions about health, wealth, and happiness. New Haven, CT: Yale University Press, 2008
4. Caris MG et al. Nudging to improve hand hygiene. J Hosp Infect. 2017 Sep 30.(17)30532-7
5. King D et al. “Priming” hand hygiene compliance in clinical environments.
Health Psychol. 2016 Jan;35(1):96-101.
6. Kohli E et al, Variability in the Hawthorne effect with regard to hand hygiene performance in high- and low-performing inpatient care units. Infect Control Hosp Epidemiol. 2009 Mar;30(3):222-5.
