Does feedback improve hand hygiene behaviour?

New findings in the field of hand hygiene in medical facilities are increasingly focusing on the benefits of feedback.

Feedback, in the traditional sense, is an integral communication tool used to improve our behaviours, processes, and products in our daily lives. In the world of hand hygiene, it is also clear that feedback to staff on behaviour can have a positive effect on hand hygiene.

Hand hygiene behaviour is critical

So why is it important to improve hand hygiene through feedback? The answer lies in the data. Currently, the average compliance rate in medical facilities has not yet reached 50 percent [1], yet we know that disinfecting hands is the most important way to avoid nosocomial infections. Considering the rapid rise in antibiotic-resistant bacteria, infection prevention will only become more important than it already is.

Implementing what we know about optimal hand hygiene is not as easy as it might seem. One factor for inadequate compliance rates, may be plays the increasing work loads of nursing staff. This segment of healthcare staff accounts for up to 80 percent of all needed hand disinfections, as defined by the World Health Organization’s (WHO) “Five moments of hand hygiene.” 2] In addition to workload, there are numerous other factors which are responsible for unsatisfactory hand hygiene behaviour in healthcare. These include a lack of training, insufficient number of dispensers – especially at the point-of-care, and a lack of role models on individual wards.

For this reason, the WHO felt compelled to publish scientifically founded hand hygiene recommendations for medical facilities in 2009. The core message was the call for implementing multimodal strategies to improve hand hygiene. Implementing several hygiene measures in parallel was shown to be much more effective than singular strategies, particularly when it came to long-term effects. 3] The multimodal WHO approach is comprised of five elements: system change, training / education, reminders in the workplace, institutional safety climate, and evaluation and feedback. The latter component has recently become a focal point of hygiene programs, becaue it appears to harbour previously undiscovered potential for hand hygiene improvement.  

Feedback improves behaviour

As far back as 1986, Joni A. Mayer and colleagues examined the effects of regular hand hygiene feedback to hospital staff – at that time hand washing was still widespread in clinics and hospitals. The feedback within the scope of the study always referred specifically to the observed behaviour of the previous day. At the end of the study, the researchers found that hand hygiene compliance improved from an initial 63% to 92%. This significant change is attributed to regular feedback.

Still to this day, numerous studies confirm the positive correlation between feedback and improved hand hygiene. In a study conducted by Prof. Didier Pittet in 2000, hygiene feedback was just as important a component and “compliance promoter” as in a recent paper by Maura Smiddy and colleagues from July 2019. [5,6] 

The WHO categorizes feedback as “1A” –  the most critical hygiene category. The WHO goes on to say that implementing feedback into hygiene programs is explicitly recommended, and is supported by thoroughly investigated, well-designed experimental, clinical and epidemiological studies.

The question at this point is why we don’t simply implement feedback measures across the board? Well, traditional feedback is a very resource intensive process. Many of the studies involving feedback showed that hand hygiene behaviour data needed to be obtained by using a trained observer to document compliance. The option then is to hire multiple, permanent observers, or use this method of measurement sporadically.

Hand hygiene feedback made easy

Where direct observation reaches its limits, technical innovations come into play that record hand hygiene behaviour fully automatically and continuously. These electronic hand hygiene monitoring systems usually consist of hardware such as intelligent dispensers that record the quantity dispensed, the dispenser ID/location, and the time of disinfection. In the software hygiene personnel then have an abundance of data at their disposal for detailed evaluations. These evaluations then enable targeted hand hygiene feedback to station personnel, eliminating the need for time-consuming observation cycles.

A research team led by Prof. Simone Scheithauer at the RWTH Aachen University Hospital, for example, took advantage of monitoring systems by providing staff with weekly feedback on hand hygiene behaviour based on real dispenser usage data. The feedback generated from the WIFI enabled dispensers led to the average dosage per hand disinfection rising from 1.69ml to 2.66ml on the examined intensive care unit. [7]

I am of the opinion that hand hygiene feedback is still neglected in everyday clinical practice. Electronic systems in particular can relieve us of a lot of work and report hygiene behaviour back to the staff with little effort.

Dr. med. Andreas Glöckner, Medical Director

A study by Dr. Svenja Diefenbacher and colleagues went one step further. In their work, the scientists proved that continuous hand hygiene feedback in combination with a corresponding objective displayed prominently on a TV screen in hospital wards led to a significant increase in hand disinfections per dispenser, per day. [8] 

ingo-man® SmartNose: feedback and monitoring combined

Electronic hand hygiene monitoring systems for can offer an important value-add for patient protection and infection prevention. Working together on a hygiene goal strengthens the sense of community and keeps hand hygiene “under discussion”. The studies outlined above were each carried out with the OPHARDT Hygiene Monitoring System® (OHMS) from the OPHARDT intelligent Solutions (OiS) suite of products. These solutions enable sustained hygiene improvements in healthcare through the combination of data and feedback. The latest innovation, the ingo-man® SmartNose brings that effort another step forward. The intelligent, retroffitable unit is compatible with all dispenser systems of the ingo-man® plus series and can be integrated within just a few seconds. With more than 2 million ingo-man® plus dispensers in the market, this product, will significantly reduce the cost of going smart for healthcare institutions around the world. Perhaps more importantly, a green feedback LED integrated onto the top of the unit, indicates to the user whether a sufficient amount of hand disinfectant has been dispensed. The WHO and also the Commission for Hospital Hygiene and Infection Prevention at the Robert Koch Institute (KRINKO) recommends at least 3 milliliters of disinfectant for high-quality hygienic hand disinfection. The drop-shaped LED on the ingo-man® SmartNose lights up when that volume has been reached.

Monitoring is ahead of the game

Though we have not yet tapped the full potential of feedback and hand hygiene, electronic systems can already relieve healthcare institutions from significant work loads and can vastly improve hand hygiene. In its latest recommendation, KRINKO clearly points to monitoring solutions as the much preferred option when it comes to the frequency of feedback compared to analog measurements such as direct observation and tracking inventory.

Interventions to improve hand hygiene compliance, in particular regular evaluation and feedback, are indispensable quality management measures and must be implemented in every institution.

KRINKO recommendation 2016

In the Krinko’s overview of its recommendations, the commission took the opportunity to underline the importance of feedback.

[1] Erasmus V, Daha TJ, Brug H, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283–294

[2] Stahmeyer, J. T., et al. “Hand hygiene in intensive care units: a matter of time?.” Journal of Hospital Infection 95.4 (2017): 338-343.

[3] First Global Patient Safety Challenge. “WHO guidelines on hand hygiene in health care: a summary.” Geneva: World Health Organization (2009).

[4] Mayer, J. A., Dubbert, P. M., Miller, M., Burkett, P. A., & Chapman, S. W. (1986). Increasing handwashing in an intensive care unit. Infection Control & Hospital Epidemiology, 7(5), 259-262.

[5] Pittet, D., Hugonnet, S., Harbarth, S., Mourouga, P., Sauvan, V., Touveneau, S., & Perneger, T. V. (2000). Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. The Lancet, 356(9238), 1307-1312.

[6] Smiddy, M. P., Murphy, O. M., Savage, E., Fitzgerald, A. P., O’Sullivan, B., Murphy, C., … & Browne, J. P. (2019). Efficacy of observational hand hygiene audit with targeted feedback on doctors’ hand hygiene compliance: A retrospective time series analysis. Journal of Infection Prevention, 1757177419833165.

[7] Scheithauer S, et al. Do WiFi-based hand hygiene dispenser systems increase hand hygiene Compliance? American Journal of Infection Control (2018)

[8] Diefenbacher, S., Fliss, P. M., Tatzel, J., Wenk, J., & Keller, J. (2019). A quasi-randomized controlled before–after study using performance feedback and goal setting as elements of hand hygiene promotion. Journal of Hospital Infection, 101(4), 399-407.