Yesterday, Mike wrote about “The Power of Habit“ and taught us that “40% of our daily activities occur without any active decision making” and suggested that “the trick … is for us to figure out how to get hand hygiene and stethoscope wipedown established as habits.” Of course, this all sounds reasonable. Besides hand hygiene, wouldn't it be great if we could get primary care doctors to stop prescribing antibiotics? Surely, poor stewardship is also a habit.
I used to believe, as Mike does, that infection prevention was a matter of education and re-education until good practice becomes habit. But after years of watching us fail to improve antibiotic prescribing and increase hand-hygiene compliance, I no longer believe in the magical thinking surrounding education and habits. First, there is minimal evidence that we can encourage folks to develop better habits, such as hand hygiene compliance. Take for example this recent systematic review on hand hygiene trials by Kingston et al. The authors reviewed studies published since 2009 and reported a baseline hand hygiene compliance of only 34.1% with a mean improvement to 57%. Some folks may look at this data and become excited about a 23% compliance improvement! But a realist would look at the data and realize that these trials couldn't have been the first time the health care workers in the intervention hospitals were exposed to hand hygiene interventions. Their baseline compliance of 34% was after numerous rounds of “habit-forming” educational training.
Thus, we need to be honest with ourselves and acknowledge that difficult system changes are needed to improve practice. For hand hygiene, for example, we need shelves outside rooms so nurses can rest things they're carrying while cleaning their hands. For clinicians we need rapid diagnostics and health information systems to inform antibiotic prescribing. Any talk of habits suggests that change can occur at an individual health care worker or prescriber level. And any suggestion that this is an individual health care worker problem will necessarily lead to learned helplessness and blame, neither of which will be productive.
In the end, we're going to need to move past our focus on “habit” and its flipside, blame. Let's work towards system change and innovation that directly address the barriers to hand hygiene compliance and proper antibiotic prescribing. You might have another name for it, but I'm gonna call it The Power of Labbit.
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.