There are profound connections between public health challenges and human behavior. In the mid-1800’s Dr. Ignaz Semmelweiss noticed that women on the maternity ward at the Vienna General hospital were dying in significant numbers. Doctors routinely went from dissecting a corpse to delivering a baby, spreading Puerperal fever, among other pathogens.
Dr. Semmelweiss instituted that doctors perform mandatory handwashing using chlorinated lime water between patients. It was a controversial practice at the time, but the mortality of new mothers dropped from 18% to 1%.
The Cost of Non-Compliance
A century and a half later, it is well known and documented that proper hand hygiene in hospitals prevents the spread of pathogens between healthcare staff, patients and visitors. However, knowledge does not always translate into good practice, and the negative impacts to hospitals and patients of handwashing non-compliance is considerable.
In 2012 the CDC reported that the estimated cost to hospitals for non-compliance resulting in healthcare-associated infections (HAIs) is $35.7-$5 billion annually. HAIs cause additional antibiotic costs and treatments, prolonged hospital stays and an increased strain on staff and healthcare systems overall.
The potential harm to patients is equally devastating, with HAIs resulting in increased illness and mortality. In acute-care hospitals, seven patients out of 100 will be impacted by an HAI, causing them to suffer physically, mentally and financially.
The Impact of Compliance
In a 2007 study completed at East Tennessee State University, it was reported that staff in the adult ICU had only 35% compliance in handwashing between treating patients. However, when training and intervention were implemented, the compliance rate rose to 81%.
When hand hygiene is implemented properly in the healthcare setting, up to 70% of HAIs can be prevented, saving millions of lives. If such a simple, low-cost intervention of hand hygiene can make such a positive difference, why is compliance a challenge in the healthcare setting?
Overcoming Barriers to Better Hygiene
At the heart of the problem are three main categories of barriers: individual, management and organizational. Barriers that relate to individuals are a lack of knowledge of consequences of poor hand hygiene, and an improper attitude about the importance of hand hygiene, including the impact of other colleagues’ negative attitudes towards hand hygiene.
Managerial barriers stem from healthcare workers who follow the lead of their managers, and if their colleague is a poor role model, poor behavior in hand hygiene follows suit. Secondly, a lack of adequate training, a lack of positive feedback and no form of monitoring all contribute to poor hand hygiene.
Organizational factors include extraordinarily heavy workloads, exacerbated by understaffing and lack of time. In a qualitative study on barriers to hand hygiene, one nurse said, “There are so many patients that I become tired and don’t follow handwashing protocols any longer.” If the healthcare setting is poorly designed and there are insufficient, or inconveniently located handwashing basins and hand sanitizers, proper hand hygiene suffers.
How Behavioral Science and Technology Play a Role
By employing a framework of behavioral science and taking a multi-modal approach to address barriers to compliance, the safety of patients can be improved. Once the human factors that contribute to compliance are understood, interventions paired with technological solutions can be introduced.
Real-time location systems (RTLS) are a technology that help hospitals to monitor the location of staff, patients and equipment in real time. Hand hygiene compliance can be monitored when staff wear low-profile RTLS badges, which communicate with sensors attached to hand sanitizers and handwashing basins. This system is automatic and offers unbiased monitoring that does not require manual observation. The RTLS platform provides reports that indicate the frequency of hand hygiene events for individuals, departments and the entire hospital.
The data is valuable as it provides compliance rates and trends, and when it is combined with an education and training program, help make a considerable impact on compliance. Further, the RTLS solution has the capability to offer real-time feedback—and nudges to staff if there are missed hygiene opportunities for compliance and quality, such as length of time spent washing hands.
In a meta-analysis of 10 studies that deployed RTLS solutions in improving hand hygiene, it found that if constant feedback and education of healthcare workers (HCWs) about correct procedures was given, the HCWs were more likely to develop better hand hygiene habits and techniques. Instant prompts tended to increase compliance, although some individuals only increased compliance after they were given their individual summaries of their results.
The Business Case for Hand Hygiene
Proper hand hygiene by doctors and nurses in healthcare facilities is one of the most simple, cost-effective means of reducing the spread of pathogens. An OECD research study that gathered data from 34 OECD and EU/EEA countries reported that spending US$1 in hand hygiene improvement initiatives resulted in approximately US$24.6 in economic returns.
Given the complexity of reasons behind non-compliance, an RTLS platform is unlikely to make a difference when deployed on its own. However, when implemented by hospital leaders committed to improving hand hygiene, in tandem with an education, training and regular feedback program, RTLS solutions have proven to be an excellent and appropriate tool in minimizing the cost and impact of HAIs on hospitals and their patients.
