What’s New in the Patient Safety World

August 2016

Hand Hygiene: Who’s Watching? Does it Matter?



Two recent studies suggest that hand hygiene compliance rates are overestimated when healthcare workers know they are being observed. The first, a California medical center study presented at the 43rd Annual Conference of the Association for Professionals in Infection Control and Epidemiology (APIC), found a difference of more than 30 percent in hand hygiene compliance depending on whether or not they recognized the auditors (APIC 2016a). The Hawthorne effect, very loosely applied to imply that behavior changes when subjects know they are being observed (our apologies to purists who will state that is not the actual phenomenon observed at Western Electric), appears to result in an overestimate of compliance with hand hygiene.


The second study, done in Canada, also showed a disparity between healthcare worker compliance with hand hygiene observed covertly compared to reporting by staff observers (Kovacs-Litman 2016). Moreover, there may be a disparity in the phenomenon between physicians and nurses. Canadian researchers trained students to covertly observe hand hygiene compliance and compared their assessments with the formal compliance assessments done by hospital staff. The covert observers noted hand hygiene compliance to be 50% compared to 83.7% reported by the hospital staff. For physicians compliance reported by hospital auditors and covert observers, respectively, was 73.2% vs 54.2%, whereas for nurses compliance reported by hospital auditors and covert observers, respectively, was 85.8% vs 45.1%.


Importantly, as we’ve often pointed out, the behavior of the head of the team significantly influences the behavior of all the others. The researchers noted that physician trainees had much better hand hygiene compliance when their attendings cleaned their hands than when they did not (79.5% vs. 18.9%).


Meanwhile, many hospitals have begun to use electronic monitoring of hand hygiene compliance even though this technology has not yet been shown to substantially reduce hospital infections. But a new study (Kelly 2016), analyzing data from 23 inpatient units over a 33-month period found a significant correlation between unit-specific improvements in electronic monitoring compliance and reductions in methicillin-resistant Staphylococcus aureus infection rates.


Another study presented at the recent APIC Annual Conference found that showing hospital staff enlarged images of bacterial cultures similar to those they might have on their hands increased compliance with hand hygiene by 11-46% (APIC 2016b).


Of course, the attending physician serving as a role model for hand hygiene and the use of visual imagery to promote hand hygiene are forms of “nudges” (see our July 7, 2009 Patient Safety Tip of the Week “Nudge: Small Changes, Big Impacts”). In our April 2016 What's New in the Patient Safety World column “Nudge: An Example for Hand Hygiene” we cited an article that showed location of hand sanitizers significantly influenced their use by visitors (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.


So how about locating hand sanitizers right on healthcare workers? Researchers at Darthmouth-Hitchcock Medical Center and UMass Memorial Medical Center did just that (Koff 2016). They randomly assigned operating room environments to usual intraoperative hand hygiene or to a personalized, body-worn hand hygiene system. They found an 8-fold increase in anesthesia and circulating nurse provider hand decontamination events above that of conventional wall-mounted devices. However, use of the hand hygiene system was not associated with a reduction in healthcare-associated infections.


Improving hand hygiene compliance rates remains a frustratingly difficult endeavor in most healthcare facilities. But we can all learn from successes elsewhere. Every little bit helps.



Some of our other columns on handwashing and 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?

April 2016                   Nudge: An Example for Hand Hygiene







APIC (Association for Professionals in Infection Control and Epidemiology). The Hawthorne Effect hinders accurate hand hygiene observation, study says. APIC News Release 2016; June 10, 2016




Kovacs-Litman A, Wong K, Shojania KG, et al. Do physicians clean their hands? Insights from a covert observational study. J Hosp Med 2016; Early View 5 July 2016




APIC (Association for Professionals in Infection Control and Epidemiology). Seeing is believing: Visual triggers increase hand hygiene compliance. APIC News Release 2016; June 9, 2016




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




Koff MD, Brown JR, Marshall EJ, et al. Frequency of Hand Decontamination of Intraoperative Providers and Reduction of Postoperative Healthcare-Associated Infections: A Randomized Clinical Trial of a Novel Hand Hygiene System. Infect Control Hosp Epidemiol 2016; 1-8 Published onlne June 7, 2016




Kelly JW, Blackhurst D, McAtee W, Steed C. Electronic hand hygiene monitoring as a tool for reducing health care–associated methicillin-resistant Staphylococcus aureus infection. Am J Infect Control 2016; Published online: June 23, 2016







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