What’s New in the Patient Safety World
April 2016
Nudge: An Example for Hand Hygiene
Our July 7, 2009
Patient Safety Tip of the Week “Nudge:
Small Changes, Big Impacts” reviewed the book “Nudge”
by Richard Thaler and Cass Sunstein.
Yes, that’s the one that leads in with the story about how painting a picture
of a fly in a male urinal resulted in 80% decreased spillage! The theme
obviously is that small changes which cost little or nothing (i.e. nudges) can
result in big impacts. The book is full of examples of how nudges can help
steer people to make better choices in their personal life (savings,
investments, healthcare, etc.) or from a societal perspective (improve the
environment, improve organ donations, etc.).
In that 2009 column
and in our February 18, 2014 Patient Safety Tip of the Week “Nudged,
But Who Nudged Who?” we gave examples of how such small changes or “nudges”
may lead to desirable changes in behavior in healthcare.
Hand hygiene is one
area in which nudges may be helpful and that applies not only to healthcare
personnel but also to visitors. A new study looked at factors related to
use of alcohol-based hand sanitizers by
visitors to a hospital (Hobbs
2016). The key finding was that when the hand sanitizers were placed in the
middle of the lobby (with limited
landmarks or barriers) visitors were 5.28 times more likely to use them. But
the other key finding was that group behavior is important as well. In the
Hobbs study individuals in a group were 39% more likely to use alcohol-based
hand sanitizers. We’ve often viewed the same scenario with healthcare workers.
A team in a teaching hospital (attending, several residents and students, and
maybe a nurse or two) is doing rounds. If the attending stops to do hand
hygiene before interacting with the patient, the whole team does hand hygiene.
If he/she does not do hand hygiene, no one does. That’s a “nudge” that has a
powerful impact.
So that addresses
healthcare workers and visitors. What about patients themselves? After publication
of a study last month (Cao
2016) we may need a “nudge” for them, too. Cao and colleagues did cultures
of the hands of patients being admitted to post-acute care facilities from
acute care hospitals. They found that 24.1% had at least one
multidrug-resistant organism (MDRO) on their hands. Of course, other body parts
may be colonized with hospital-acquired organisms but the patients’ hands are
most likely to have been in contact with environmental surfaces, health care workers’ hands, or even other
patients. Clearly, further studies need to be done to see how to intervene and
prevent spread of such organisms in patients being discharged. Adding hand
hygiene to patients being admitted to long-term care facilities would make
sense. But adding hand hygiene to the discharge checklist of patients being
discharged from acute care hospitals may make more sense since even those going
home may be spreading MDRO’s. So a little “nudge” may be needed at discharge.
Maybe putting another alcohol-based hand sanitizer in the lobby facing the
other way will get both patients and visitors to perform hand hygiene on the
way out, too!
“Nudges” do have
positive impacts and we need to learn how to better deploy them.
Some of our other columns on hand hygiene:
January 5, 2010 “How’s Your Hand Hygiene?”
December 28, 2010 “HAI’s: Looking In All The Wrong Places”
May 24, 2011 “Hand Hygiene Resources”
October 2011 “Another Unintended Consequence of Hand Hygiene Device?”
March 2012 “Smile…You’re on Candid Camera”
August 2012 “Anesthesiology and Surgical Infections”
October 2013 “HAI’s: Costs, WHO Hand Hygiene, etc.”
November 18, 2014 “Handwashing
Fades at End of Shift, ?Smartwatch to the Rescue”
January 20, 2015 “He
Didn’t Wash His Hands After What!”
September 2015 “APIC’s
New Guide to Hand Hygiene Programs”
November 2015 “Hand
Hygiene: Paradoxical Solution?”
References:
Thaler RH, Sunstein CR. Nudge. Improving Decisions about Health, Wealth, and Happiness. New Haven: Yale University Press, 2008
http://www.amazon.com/Nudge-Improving-Decisions-Health-Happiness/dp/014311526X
Hobbs MA, Robinson S, Neyens DM, Steed C. Visitor characteristics and alcohol-based hand sanitizer dispenser locations at the hospital entrance: Effect on visitor use rates.
Am J Infection Contol 2016; 44(3): 258-262
http://www.ajicjournal.org/article/S0196-6553%2815%2901158-X/abstract
Cao J, Min L, Lansing B, Foxman B, Mody L. Multidrug-Resistant Organisms on Patients’ Hands. A Missed Opportunity. JAMA Intern Med 2016; Published online March 14, 2016
http://archinte.jamanetwork.com/article.aspx?articleid=2500025&resultClick=1
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