Behavior Change in Hand Hygiene

Do you know that on average it takes 18 – 224 days to make a new behavior an ingrained habit? Think about all the New Year’s resolutions that go broken long before the end of January. But in healthcare, the need for behavior change to stick is more than preference; it can mean life and death.

When it comes to hand hygiene compliance, one could argue driving this positive behavior change is even more complicated. After hospital staff are educated and trained, they may transfer to another unit or change jobs. Some managers may be more engaged with hand hygiene than others. A nurse may have an extra-busy day and forget to wash or sanitize before putting in an IV. Occasionally, there is a mystery of a unit where high and stable compliance rates suddenly decline for no apparent reason, a cue for an Infection Preventionist or a unit manager to find out what have caused the drop. This is why hospitals need ongoing monitoring – to keep track of and react to things as they happen.

This much was clear to me in 2009 as I watched my direct observers report top compliance rates I knew were inflated. Reasons for inaccuracies ranged from inherent limitations of direct observation to the well-documented Hawthorne Effect. That’s why I welcomed an opportunity to test a completely different methodology – electronic hand hygiene monitoring – and did so through the studies Greenville Health System conducted with the DebMed technology over the course of seven years. The studies have also guided the system’s development.

The proof is in the pudding (or, in peer-reviewed research)

At first, we conducted a study demonstrating that electronic monitoring technology based on WHO Five Moments can accurately and reliably measure hand hygiene compliance (Where and when (HOW2)? The HOW2 benchmark study. American Journal of Infection Control 2011; 39:19-26.).

Naturally, when we showed that compliance was consistently lower than our staff thought it was, the data was questioned, not performance, so we continued with a video validation study.

The HOW2’s findings were validated with a reproducible study using 24-hour camera surveillance (Validation of the HOW2 Benchmark Study. American Journal of Infection Control 2014; 42:602-7). When we compared the results of hand hygiene compliance recorded by 24/7 video monitoring and results recorded by the DebMed system, they showed a statistically significant correlation, proving the electronic technology indeed gave accurate data.

Now, we had a tool to get correct data every day, in real time, and our compliance rates continued to climb as our organization changed its mindset from working with direct observation to electronic monitoring. Yet, at the end of the day, the question remained how the improved hand hygiene rates affected patient care and costs. Was there an actual impact beyond better compliance numbers? Was the new methodology providing an ROI that could be documented?

The recent study, “Electronic Hand Hygiene Monitoring as a Tool for Reducing Healthcare-Associated Methicillin-resistant Staphylococcus aureus Infection,” is the third that we conducted to put the DebMed technology to the test.

We chose MRSA infections for the study because hand hygiene is most directly correlated to MRSA transmission, as compared to, say, CLABSIs, and the CDC definition of MRSA has remained the same, so we could compare data historically and get valid results.

The results were unequivocal: When we used electronic monitoring technology (which is based on WHO’s Five Moments for Hand Hygiene guidelines), compliance rates increased by 25.5% and hospital onset MRSA HAI rates decreased by 42%. On top of that, we saved approximately $434,000 in MRSA-related care costs over 32 months of the study period. The study demonstrated that electronic hand hygiene monitoring can not only truthfully measure compliance but also drive behavior change to reduce infections and associated costs.

For us at GHS and, I’m sure, for all other hospitals, the journey of hand hygiene compliance in patient care continues. There is still so much to investigate; for example, how we can accurately calculate rates in such areas as long-term care facility or in a short-stay surgery hospital. Behavior change associated with the technology is also an area of interest as the human factor is the lynchpin of compliance. All these inquiries are worthwhile endeavors as they help communicate the simple truth: hand hygiene makes a difference in health outcomes of our patients, every day, every “hand hygiene moment.”