Gold stars and 'red cards': Hospitals try radical tactics to improve hand washing

Hospitals use video cameras, motion sensors to monitor compliance

Topics: Appropriateness, Quality, Performance Improvement, Infection Control, Patient Experience

May 30, 2013

Hospitals are instituting video surveillance, offering free pizza, and taking other drastic and unorthodox measures to improve hand washing in a broader effort to prevent health care-associated infections (HAIs), the New York Times' Anemona Hartocollis reports.

Why hand washing is a problem

New payment rules penalize hospitals for preventable HAIs, which already cost the industry nearly $30 billion per year and cause 100,000 patient deaths. However, studies have found that, without being prompted, hospital workers wash their hands as little as 30% of the time they spend with patients. 

What's behind the lack of cleanliness? Independent-minded doctors may simply be resisting authority, Hartocollis writes. Health care workers also complain about dry skin, the many time pressures involved with direct patient care, and the tediousness of constant hand washing for their lack of compliance.

"Nurses have to remember hundreds—thousands—of procedures… It's really easy to forget the basic tasks [when] you're really concentrating on what's difficult, not on what's simple," Philip Liang says. Liang founded General Sensing—a company that outfits hospital staff with electronic badges that track hand washing.

'This is war'

In an effort to improve compliance with hand-washing recommendations amid increased scrutiny over infections, hospitals nationwide are doing everything from training hand washing coaches to handing out rewards like free pizza.

At the ICU of Long Island's North Shore University Hospital, a motion sensor activates a camera that transmits images to India every time a health care worker enters a patient's room. Personnel watch the footage from the hospital room to make sure that staff members are washing their hands.

Health care workers who spend more than a minute in a patient's room must wash their hands within 10 seconds of entering said room to pass the test. Hand-hygiene rates for each shift are then broadcast on scoreboards in the hallway, with a "Great Shift" commendation for shifts that achieve 90% compliance.

During a 16-week preliminary period when workers were filmed but not informed of the results, hand-hygiene compliance rates were less than 10%, according to a study of the program published in Clinical Infectious Diseases. When the staff was informed of its compliance rates through emails and hallway scoreboards, the rate rose to 88%.

"This is not a quick fix; this is war," the hospital's chief of infectious disease Bruce Farber told the Times.

Beth Israel Medical Center in Manhattan is using less high-tech methods to improve hand hygiene, according to Brian Koll, the hospital's chief of infection prevention: 

  • Workers who fail to wash their hands get red cards from their peers—a technique borrowed from soccer referees giving out penalties to players.
  • The hospital also employs secret shopper-like figures—often medical students—who observe hand washing compliance among staff. 
  • Consistent hand-washers are given gold stars, "as hokey as that sounds," or coupons for coffee, Koll says.

Although compliance strategies have proven effective at many hospitals, Elaine Larson—a Columbia University nursing professor who has made a career out of studying hand washing—warns that even the most advanced systems can be scammed.

"People learn to game the system," she said, adding that "[t]here was one system where the monitoring was waist high, and they learned to crawl under that. Or there are people who will swipe their badges and turn on the water, but not wash their hands. It's just amazing" (Hartocollis, Times, 5/28).

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