During our time working with hospitals on improving the hand hygiene compliance (HHC) of healthcare workers (HCWs), we often come across the high achievers who appear to succeed in sanitizing according to the guidelines. Most HCWs know when to sanitize, but can underlying behavioural patterns of those high achievers be identified? And can data show us why they remember to sanitize hands when needed? What is it that they are doing differently that enables them to sanitize when needed and thus achieve better compliance than their co-workers?
Our researchers started looking into this and the results are quite interesting.
We investigated 8 HCWs at a Danish hospital who wore a Sani ID which collected and analysed their hand sanitizing behaviour across all situations in the ward and according to the WHO five moments for hand hygiene. The group was selected to outline four high-performance HCWs with good levels of compliance (averaging a compliance of 73%) and four low-performance HCWs (averaging a compliance of 37%). Each of these HCWs had worked for a similar length of time during the study and had a similar number of hand hygiene situations thus enabling a quantitative comparison between the groups to be conducted.
Time spent in room as an indicator
We found that high-performance HCWs tend to spend more time in the patient rooms (Figure 1). This probably reflects two things: 1) The high-performance HCWs take the time to sanitize, and 2) when HCWs have short patient visits, they neglect the importance of hand hygiene even though they have been in a clinical situation where subsequent sanitation is needed. It could be related to the “feeling” of not being dirty when you only have been in patient contact for a short period of time. This is supported by data in the literature where nurses have reported that they always felt compelled to sanitize after performing tasks they considered to be “dirty.”.
Figure 1: Average duration of patient room visit (Average compliance shown as %)
More sanitize after patient contact
When analysing data related to patient visits/treatments, the spread of sanitizing behaviour of both high- and low-performance HCWs shows a compelling result. According to hospital guidelines, the HCW must sanitize both before and after patient contact. In Figures 2a and 2b, the sanitizing behaviour is displayed for the high-performance and low-performance HCWs, respectively. What is most noticeable here is the large difference in sanitizing behaviour between the groups. In the high-performance group, a significantly higher proportion of HCWs remember to sanitize their hands both before and after patient contact (i.e. “Fully compliant”, Figure 2a) compared to the low-performance HCWs, whereas a similar proportion in both groups remember to sanitize either before patient contact or after patient contact. In both groups though, if they only remembered to sanitize once during a patient visit, it was more likely to be after patient contact. Again, this is probably related to the feeling of being unclean or dirty after patient contact and not before patient contact, even though the HCWs most likely also have touched unclean surfaces, such as door handles, before touching the patients and thereby transmitting bacteria and viruses.
Figure 2: Sanitizing behavior around patient room. Left: high performing. Right: low performing.
Regarding the medication room, the HCWs must sanitize when entering the room and handling medicine as this is considered a clean procedure according to hygiene guidelines. The average time spent in the medication room for all HCWs in the ward was 4 minutes and 36 seconds. What we can see in Figure 3 is that those HCWs who have a higher compliance level in the medicine room in general have longer visits than the lowest achieving HCWs, indicating that the high-performance HCWs 1) know the hygiene guidelines and 2) have the time or take the time to sanitize.
Figure 3: Average duration of medication room trip (Average compliance shown as %)
Interestingly, we found a distinctive pattern in all room types (patient rooms, medicine room, toilets, cleansing room) which showed that if an HCW has low compliance in one room, they will most likely have it in the other rooms as well. This is important knowledge and tells that if you want to increase the overall HHC in the ward and meet the pre-set hygiene goals, you will need to do targeted education and specify learnings according to the individual needs.
Summary and perspectives
In summary, we found that “time spent in room” is a good indicator for HHC and can be used to identify high- vs. low-performance HCWs. Importantly, when HCWs have short patient visits, they neglect the importance of hand hygiene even though they have been in a clinical situation where subsequent sanitation is needed.
In addition, we found room for improvement both for the high-performance and the low-performance HCWs as the HHC levels were not satisfactory. Both groups, however, had a higher tendency to sanitize after patient contact than before because they feel dirtier after being in contact with patients. Guidelines state that sanitations are needed both before and after patient contact and it could be a “low-hanging fruit” to educate HCWs in the importance of sanitations before patient contact.
Finally, we found that if HCWs have high performance in one room, they will also have it in the other rooms and the same goes with low-performance HCWs. This pattern is important to acknowledge because if you want to improve the overall HHC level on ward/hospital level, you need to do targeted education according to the individual needs.
Sani Nudge has developed a 5-step improvement process that connects training with actual behaviour. Data from the Sani Nudge system is automatically analysed and provides relevant information regarding compliance behaviour which are being used to train the individual in overcoming clinical barriers and help them to comply with hygiene guidelines. Several hospitals have been able to triple their HHC levels by introducing this process.
If your hospital (like others) is struggling with maintaining high HHC, then reach out to to learn how the Sani Nudge electronic hand hygiene system can help you create a successful HHC program in your hospital.
 A visit refers to the number of opportunities the HCW had to sanitize according to hospital guidelines.
 Whitby M, McLaws M-L, Ross RW. Why healthcare workers don’t wash their hands: a behavioral explanation. Infection Control Hospital Epidemiology. 2006;27:484–492.