Even with the Hawthorne Effect, hand hygiene compliance still hideous

A recurring theme has emerged in hand hygiene science: When you really look, compliance is very, very low. A study 5 years ago reported that compliance was below 10% when hidden video monitoring was utilized. Our group has quantified the impact of the Hawthorne Effect, improved behavior when subjects know they're being observed, on hand hygiene compliance. In a multicenter study, we found that both measured exit and entry compliance increased the longer direct observers remained on the unit.

There is a report of a new APIC abstract in ABC-News that further quantifies that impact of the Hawthorne Effect and highlights the lack of investment in hand hygiene programs. Investigators from Santa Clara, California compared compliance measured by well-recognized Infection Prevention nurses, to observations collected by unknown high-school and college-aged volunteers who were trained to use the same surveillance methods. Here are their findings:

The investigators found that hand hygiene compliance rate observed by IP nurses was about 57%, while hospital volunteers, who tended to blend in and not be recognized as hygiene auditors, recorded rates of about 22%. While this phenomenon has been noted before, the team at SCVMC was surprised by the stark gap, and they have launched a series of interventions to try and drive their compliance rates higher and higher.

So, what do I make of these findings? First, even 57% is too low. Second, hospitals and health care systems continue to throw hand hygiene programs under the rug. We are much happier to report compliance rates of 100% collected by nurse managers on the floor (or compliance of 57% by recognized IPs) and ignore the problem than spend time and money detecting compliance rates of 22%, which would then require additional investments in proven hand hygiene interventions.

Any administrator who thinks compliance in their hospital is higher than 70% or 90% won't invest in hand hygiene programs. Since hospitals are happier to report compliance of 90% to the Joint Commission, we also won't invest in technological and socio-adaptive interventions that will finally improve the safety of our hospitals. We must work to create a safety culture where it is better to report hand hygiene compliance of 20% than falsely high compliance rates of 90%.

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.