Hand Hygiene Compliance Rates Decline Rapidly

Hand hygiene rates among hospital staff drop sharply when human compliance monitors are replaced by machines, claims a new study.

Researchers at the University of New South Wales (Sydney, Australia) conducted a study to compare human and automated methods of surveillance in an Australian teaching hospital over a period of two years (2014 and 2015). Automated surveillance consisted of hand hygiene dispensers at sinks and bedsides recording hand hygiene by touch, while human surveillance involved mandatory audits 20 minutes daily. Subtracting the automated surveillance rates from human audit rates provided differences in percentage points (PPs) for each of the quarterly reporting periods.

The results revealed that direct human audit rates for a medical ward were inflated by an average of 55 PPs in 2014 and 64 PPs in 2015, translating to 2.8-3.1 times higher than those of automated surveillance rates. The rates for a surgical ward were inflated by an average of 32 PPs in 2014 and 31 PPs in 2015, or 1.6 times higher than automated surveillance rates. Quarterly human audits collected an average of 255 opportunities, whereas automation collected 578 times more data, averaging 147,308 opportunities per quarter. The study was published on May 17, 2018, in the American Journal of Infection Control.

“A government-led mandatory hand hygiene program has operated in Australian hospitals for the past eight years, with human auditors ensuring staff follow hand hygiene guidelines, which require a minimum of 70% compliance,” said lead author Professor MaryLouise McLaws, PhD, of the School of Public Health and Community Medicine. “But compliance rates fell from more than 90% to 30% when the human auditors were relieved by automated surveillance, creating infection risks for patients.”

“The magnitude of the Hawthorne effect on direct human auditing was not trivial, and produced highly inflated compliance rates,” concluded Professor McLaws, who also serves as a health adviser to the World Health Organization (WHO). “As soon as human eyes were off the clock outside of the mandatory 20-minute audit and our automated method continued to monitor compliance, hand hygiene compliance went from 94% to 30%, which is gravely concerning.”

The Hawthorn effect is used to describe the phenomenon of people changing their usual behavior when they know they are being watched. Possible explanations for the effect include the impact of feedback and motivation towards the experimenter; the demand effect, which suggests people may be motivated to please the experimenter; and uncontrolled novelty effects.

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University of New South Wales