Моментальный заем на карту в Украине доступен на ресурсе Анти Кредит, который расположен по адресу https://anticredit.org.ua

October 17, 2019Comments are off for this post.

The business case of hand hygiene – what you need to know

Marco Bo Hansen, MD, PhD

Stating the obvious

Do we at all need a business case in order to convince hospitals that hand hygiene is efficient and important to protect patients? When alcohol-based hand gel was first introduced to hospitals, was it then required to provide a business case? No. Simply because we know that proper hand hygiene is the easiest way to protect yourself and patients from hospital-acquired infections – and it has been known for many years.

A trip down memory lane

In 1846, the Hungarian Doctor Semmelweis noticed that the women giving birth in the medical maternity ward run by doctors and medical students were more likely to develop a fever and die compared to the women giving birth in the adjacent midwife-run maternity ward. He also noted that doctors and medical students often went directly to the delivery suite after performing autopsies and had a disagreeable odor on their hands despite handwashing with soap and water before entering the clinic. Based on this observation, he hypothesized that those performing autopsies got ‘particles’ on their hands, which they then carried from the autopsy room into the maternity ward.

As a consequence, Semmelweis recommended that hands should be scrubbed in a chlorinated lime solution before every patient contact and particularly after leaving the autopsy room. Following the implementation of this measure, the mortality rate fell dramatically to 3% in the clinic most affected and remained low thereafter.

This is the first evidence that cleansing heavily contaminated hands with an antiseptic agent can reduce nosocomial transmission of germs more effectively than handwashing with plain soap and water.

A few years later, the Crimean War brought about a new handwashing champion, Florence Nightingale, the English founder of modern nursing. At a time when most people believed that infections were caused by foul odors called miasmas, Florence Nightingale implemented handwashing and other hygiene practices. Nightingale’s handwashing practices achieved reductions in infections.

Status of today

Many other investigations conducted over the past 40 years have confirmed the important role that contaminated HCWs’ hands play in the transmission of hospital-associated pathogens.

More recently, the HICPAC guidelines (federal advisory committee appointed to provide advice and guidance to DHHS and CDC) defined alcohol-based hand rubbing as the standard of care for hand hygiene practices in health-care settings, whereas handwashing is reserved for particular situations only.

In recent years, alcohol-based hand rubbing has been gaining recognition as a cost-effective, essential tool for achieving good health. Now that its effectiveness is no longer in question, the main focus is on how to make staff, patients and visitors perform hand hygiene.

Many hospitals spend time, energy and resources in stating the obvious. What is most concerning, is that bureaucratic processes delays and sometimes prevent hygiene organizations to perform hygiene improvement work. This lack of agility and inability has consequences. Globally, at least 5 patients die every minute because of unsafe care, and hospital-acquired infections is a dominant contributor.

The business case of hand hygiene

We know that hospital-acquired infections are costly. A well-conducted Swedish study found that the average additional costs of the four most common types of hospital-acquired infections in medical and surgical wards are approx. 12.000 EUR per patient. It is also well-documented that of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one hospital-acquired infection. In ICUs, approximately 30% of patients are affected by at least one hospital-acquired infection. The number of hospital-acquired infections can be reduced by at least 20% with improved hand hygiene. I will let you do the math.

No one is questioning the business case of alcohol-based hand gel and hand sanitation – and no one should. Hand sanitation is part of our infection prevention guidelines because it works. However, the true problem is that staff only remember to sanitize in 40% of the situations when it is required according to the guidelines. This has been documented both with video cameras and with automated monitoring systems. Unfortunately, many hospitals still believe that the staff have good compliance because they are using direct (manual) observations.

Direct observations have shown to overestimate compliance significantly with 55%. Imagine you think that the hand hygiene compliance is 85% because you are using direct observations but in reality, your organizations compliance is only 38.25%! This is the reality for many hospitals today.

As an MD, PhD being scientifically driven and believing in the power of data, I can of course not support an approach such as direct observations. In addition to the overestimation, the method only captures less than 0.01% of all hand hygiene opportunities – and with no knowledge on compliance in toilets and other critical areas. This is a huge limitation from a scientific and quality point of view. In the near future, direct observations will hopefully not be a way of providing an estimate of hand hygiene compliance in developed countries.

So, where does it leave us?

There is a need for a paradigm shift in hand hygiene standards. Currently, there is a lack of ambition and requirements to document hand hygiene compliance, and there is need to use valid methods of measurements. With only little effort we can improve quality of care tremendously and increase patient safety.


1.    World Health Organization, editor. WHO guidelines on hand hygiene in health care: first global patient safety challenge: clean care is safer care. Geneva, Switzerland: World Health Organization, Patient Safety; 2009. 262 p.

2.    WHO. gpsc_ccisc_fact_sheet_en.pdf [Internet]. [cited 2019 Oct 15]. Available from: https://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf

3.    Rahmqvist M, Samuelsson A, Bastami S, Rutberg H. Direct health care costs and length of hospital stay related to health care-acquired infections in adult patients based on point prevalence measurements. Am J Infect Control. 2016 May 1;44(5):500–6.

4.   Eckmanns T, Bessert J, Behnke M, Gastmeier P, Ruden H. Compliance with antiseptic hand rub use in intensive care units: the Hawthorne effect. Infect Control Hosp Epidemiol. 2006 Sep;27(9):931–4.

5.   Srigley JA, Furness CD, Baker GR, Gardam M. Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf. 2014 Dec;23(12):974–80.

6.   Sani nudge – Hand Hygiene Management [Internet]. [cited 2019 Oct 15]. Available from: https://saninudge.com/

October 5, 2019Comments are off for this post.

The challenge of developing a habit of hand hygiene in hospitals

Hand hygiene has been proven to be the key tool to prevent healthcare-associated infections to protect the health of patients and healthcare workers [1].

Consequently, sanitizing hands before and after patient contact is a simple solution to prevent the spread of bacteria and viruses in hospitals. To guide their healthcare workers, hospitals do typically use hand hygiene policies and guidelines. Achieving a high level of compliance is, however, not that simple. The implementation of these guidelines is usually inefficient and various studies do accordingly indicate that compliance with hand hygiene guidelines is suboptimal [2-3]. On average, healthcare workers clean their hands less than half of the times they should [4]. So why is that?

Reasons for low compliance amongst

The reasons for low compliance rates amongst healthcare workers are manifold [5-6]:

  • Pathogens carried on hands are invisible making it difficult to know when the hands are contaminated
  • Linking patient contact to an infection is difficult and healthcare workers often do not see the consequences of unclean hands
  • Cost of time for the healthcare workers
  • High workload
  • Understaffing
  • Ignorance of guidelines or lack of knowledge about the guidelines
  • The benefit accrues to the patient, not the staff
  • Direct observations lead to compliance overestimation

How to develop a habit of hand hygiene?

Performing hand hygiene on a regular basis is something that happens on a subconscious level. The challenge is to create this habit without forcing it on to the staff. There is already great awareness for hand hygiene and most healthcare workers do know of its importance. The missing piece is a tool that helps to develop a habit of hand hygiene whilst creating a collaborative safety culture instead of a shaming culture. It is exactly this where Sani nudge can help healthcare institutions. The system makes the invisible tangible by providing reliable data. It discreetly ingrains hand hygiene as an automatic habit and boosts hand hygiene compliance to unprecedented levels (Figure 1).

Figure 1. Improvement of hand hygiene compliance in some of the hospitals that use Sani nudge as an improvement tool.


The implementation of the Sani nudge system can make all the difference when fighting spread of infection in healthcare settings.

Contact us to learn more

If you are looking for a solution that increases hand hygiene compliance rates across hospital departments, don’t hesitate to get in touch. We are always happy to discuss your healthcare facility’s specific needs and to help with your infection prevention efforts.


[1] https://www.bode-science-center.com/center/expert-knowledge/hospital-acquired-infections/detail-hospital-acquired-infections/article/abstract-the-relevance-of-hand-hygiene-for-the-prevention-of-nosocomial-infection.html

[2] https://www.news-medical.net/news/20190415/Low-hand-hygiene-compliance-found-among-healthcare-workers-on-ICUs.aspx
[3] Ay, Pinar & Gulsen Teker, Ayse & Hidiroglu, Seyhan & Tepe, Pinar & Surmen, Aysen & Sili, Uluhan & Korten, Volkan & Karavus, Melda. (2019). A qualitative study of hand hygiene compliance among health care workers in intensive care units. The Journal of Infection in Developing Countries. 13. 111-117. 10.3855/jidc.10926. Available from: https://www.researchgate.net/publication/331429920_A_qualitative_study_of_hand_hygiene_compliance_among_health_care_workers_in_intensive_care_units

[4] https://www.cdc.gov/features/handhygiene/index.html

[5] Sharma S. Hand hygiene and hospital-acquired infections. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2019 Aug 16];11:201-2. Available from: http://www.mjdrdypv.org/text.asp?2018/11/3/201/235563

[6] https://www.healio.com/infectious-disease/nosocomial-infections/news/print/infectious-disease-news/%7Bdd1e115b-8a00-4889-9e85-8566391f2541%7D/infection-prevention-in-hospitals-the-importance-of-hand-hygiene

October 4, 2019Comments are off for this post.

Manual vs. automated monitoring – new important study

Marco Bo Hansen, Medical Doctor and PhD, Sani nudge, Copenhagen, Denmark

E-mail: mh@saninudge.com

If you are working with or care about hand hygiene and patient safety, then this is a must read for you!

We all know that improving hand hygiene of healthcare workers is a crucial strategy to prevent hospital-acquired infections – the most common adverse event during medical care. Compliance rates are used to quantify the healthcare workers’ hand hygiene level. But can you trust these compliance rates? 

Direct observations – time for a change?

Direct observation by human auditors is the most commonly used method of measurement. However, this method has some significant limitations, such as being labour intensive while only being able to obtain a small fraction of all hand hygiene opportunities. As a consequence, it provides a very limited picture of the true hygiene level at hospitals. Importantly, compliance rates reported using direct observation are inflated by the Hawthorne effect – but to what extent?   

Important new data to quantify the Hawthorne effect

I recently came across a very interesting study by McLaws et al.1 who investigated the magnitude of the Hawthorne effect of hand hygiene compliance rates when comparing direct observation with automated surveillance.

Before digging into the data and the important results from this study, I want to briefly state that when talking about the Hawthorne effect, it is referring to a behaviour change due to awareness of being observed.

This is a problem in real life

Speaking from experience, this certainly does occur! During my career as a medical doctor, I have worked at several different hospitals. Whenever a hygiene auditor followed me around the wards it made me more aware of my hygiene behaviour. I am not perfect, and I admit that I have forgotten to sanitise my hands on occasion. However, when observed by the auditor, I always remembered to wash hands and use alcohol-gel hand disinfectants. I have therefore often questioned the “good” hand hygiene results that hospitals have published in reports.

Overestimating compliance by up to 300%

Now a study has quantified this problem and has shown how important it is to have automated hand hygiene monitoring instead of the manual direct observations. In a large hospital in Australia, an automated surveillance system collected data for six quarterly reporting periods and compared it with the data obtained from direct observations by human auditors from the same periods.

The study found that the results obtained from the direct observations were inflated up to 3.1 times compared with the automated rates. It means that if you are using direct observations at your hospital, you risk overestimating the healthcare workers’ hand hygiene compliance by 300%! Other studies have found similar results.2–4

We are doing it for the patients

So why am I telling you this? Overestimating the compliance rates may not seem important at first glance but when you think about it, wrong compliance rates constitute a risk to patient safety. If you make strategic decisions regarding hygiene interventions or programmes and education based on flawed data, or worse, do not think there is a problem with hand hygiene performance - you put patients’ lives at risk. Data from CDC show that 10% of patients contracting a hospital-acquired infection will die as a result.5

What you can do to increase patient safety

Together with colleagues from two Danish University hospitals we have developed an automated hand hygiene monitoring system, called the Sani nudgeTM system and a 5-step improvement tool. By using this, we have improved hand hygiene by 200% and decreased hospital-acquired infections by up to 64%.

Interested in knowing more?

If you would like to learn how the Sani nudgeTM system has helped hospitals to reduce HAIs by up to 64%, then click here. Or contact us so we can discuss your hospital’s specific needs.


1.    McLaws M-L, Kwok YLA. Hand hygiene compliance rates: Fact or fiction? Am J Infect Control. 2018;46(8):876–80.

2.    Hagel S, Reischke J, Kesselmeier M, Winning J, Gastmeier P, Brunkhorst FM, et al. Quantifying the Hawthorne Effect in Hand Hygiene Compliance Through Comparing Direct Observation With Automated Hand Hygiene Monitoring. Infect Control Hosp Epidemiol. 2015 Aug;36(8):957–62.

3.    Masroor N, Doll M, Stevens M, Bearman G. Approaches to hand hygiene monitoring: From low to high technology approaches. Int J Infect Dis IJID Off Publ Int Soc Infect Dis. 2017 Dec;65:101–4.

4.    Srigley JA, Furness CD, Baker GR, Gardam M. Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf. 2014 Dec;23(12):974–80.

5.    Data Portal | HAI | CDC [Internet]. 2019 [cited 2019 Jul 10]. Available from: https://www.cdc.gov/hai/data/portal/index.html

September 29, 2019Comments are off for this post.

A true hand hygiene horror story

At times when I talk with hospitals about the importance of healthcare workers performing hand hygiene I am asked:

 “Yes, you can significantly improve hand hygiene compliance, but what is the business case? Does Sani nudge really prevent infections?”

Why do we still doubt the business case of improving hand hygiene compliance in 2019? Politicians are strongly enforcing that healthcare workers perform hand hygiene and hospitals spend millions of euro on soap and alcohol each year.

Why not answer the hospitals question, by telling a true horror story based in a world where no nurse washes his hands before touching a patient, where no doctor sanitizes her hands when she does her patient rounds and where no bio-analyst sanitize his hands when doing an IV. Well, this remarkable, shocking, and absolutely unrepeatable study from the 1960s sets the scene.

Chapter one

At a not so long time ago before neonatal units were invented, ethics committees, and when hospitals did not have hesitations on using patients for scientific research. Back then, there was a study group that had come up with a study to answer an ancient question; Can proper hand hygiene compliance of healthcare workers prevent hospital acquired infections? The study group had set up a cohort intervention study performed in a nursery for newborn babies in an American hospital. The study was set up in a seven bedded nursery for newborn babies. A baby with a strain of staphylococcus aureus were placed in the index cot, and the other six cots arranged in two rows of three, designated rows A and B. The nursing staff on the unit were required to handle the infected babies before any of the other babies. Then, nurses allocated to the A cots performed hand hygiene, whereas nurses allocated to the B cots did not perform hand hygiene at all.

 What do you think happened? If you do not believe in the business case behind proper hand hygiene compliance, you must think that nothing happened and that all the babies grew up healthy and happy.

But if you believe in the business case, you know what kind of horror story this will turn into in chapter two!

Chapter two

Days passed by as nurses performed hand hygiene before taking care of one half of the cots while they did not perform hand hygiene before taking care of the other. One cot was always occupied by a baby from the ward with a strain of staphylococcus aureus and the nurses always took care of this baby first. Imagine all the care and attention the babies in the infected cot got. Over the 48 days of the study, 16 different infected babies went through the nursery and a total of 81 babies in cot A and B. 49 babies were admitted to the B cots and 32 where admitted to the A cots.

To the horror of the nursery the babies in the B cots started to become very ill. 92% of the 49 babies admitted to the B cots had acquired staphylococcus aureus!

 53% of the 32 babies admitted to the A cots (with hand hygiene) also acquired staphylococcus aureus, but the time before they were infected was a lot longer. The babies in cot B was infected in just 35 hours compared with 133 hours for the babies in the A cots where the nurses performed hand hygiene.

 These results shocked the nursery.

57 years after the the horror, hospitals around the world are still doubting the importance of hand hygiene compliance.

 The end.

 Scary right? The study was performed in 1962 - a long time after the days of Semmelweis and the apparent evident proof that hand hygiene significantly impacts the occurrence of hospital acquired infections.

 Skeptics may try to make the case that “It’s only antibiotic susceptible aureus, and about 1/3 of humans carry that anyway.” Except that a) these are newborn babies, working out their microbiota and b) colonization with staphylococcus aureus is a risk factor for infection.

 Why did around half of the babies in the A cots get infected? We do not know anything about compliance with the intervention. Hand hygiene compliance in today’s hospitals are at 20-40% so there is still plenty of room for transmission of pathogens. Perhaps the hand hygiene step was only partially effective (it was a 10 second waft with some disinfecting solution). Or perhaps, since only the nursing staff were allocated to hand hygiene or not, other staff groups like doctors explain the high transmission rate in the A cots.

 This study probably shouldn’t have been done in the first place, and we certainly won’t see anything like it performed again. However, it does graphically and dramatically illustrate the importance of hand hygiene to maximize patient safety.

September 26, 2019Comments are off for this post.

The importance of hand hygiene to patient safety

Healthcare-associated infections and bacterial resistance are some of the biggest public health challenges of our time. When it comes to the transmission of micro-organisms, hands are important agents and poor hand hygiene causes millions of infections every year. The importance of hand hygiene can therefore never be underestimated.
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September 16, 2019Comments are off for this post.

US Healthcare accreditation organization pushes new standards for hand hygiene

The Joint Commission, a US healthcare accreditation organization released new standards regarding hand hygiene failures during patient care. The goal is to eliminate insufficient hand hygiene as a cause for healthcare associated infections.
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September 11, 2019Comments are off for this post.

New faces on board at Sani nudge

Since its foundation four years ago, Sani nudge has been growing steadily. The expansion of our team is therefore the logical next step and we are pleased to announce the addition of three new hires.
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September 6, 2019Comments are off for this post.

Why you shouldn’t always trust what you see

Direct observation is the go-to method for most hospitals for measuring hand hygiene compliance among healthcare workers. Despite its limitations, this practice continues to be promoted. But what does science say when it comes to the efficacy of this audit method?
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September 4, 2019Comments are off for this post.

Does excessive hand hygiene strengthen antibiotic resistance?

Source: unsplash.com
The development of antibiotic resistance is an increasing threat to global public health. In a recent study, researchers from Graz, Austria present new perspectives on how to meet this major challenge.
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August 21, 2019Comments are off for this post.

The challenge of developing a habit of hand hygiene in hospitals

Figure 1: Increase of compliance rates achieved by leveraging the Sani nudge system
Firmly establishing hand hygiene is key to infection prevention. Unfortunately, successful implementation of hand hygiene programs can be a major challenge for hospitals. Current strategies fail to increase compliance rates and put patient lives at risk.
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