Hand Hygiene and The Power of Labbit

Yesterday, Mike wrote about "The Power of Habit" and taught us that "40% of our daily activities occur without any active decision making" and suggested that "the trick...is for us to figure out how to get hand hygiene and stethoscope wipedown established as habits."  Of course, this all sounds reasonable. Besides hand hygiene, wouldn't it be great if we could get primary care doctors to stop prescribing antibiotics? Surely, poor stewardship is also a habit.

I used to believe, as Mike does, that infection prevention was a matter of education and re-education until good practice becomes habit. But after years of watching us fail to improve antibiotic prescribing and increase hand-hygiene compliance, I no longer believe in the magical thinking surrounding education and habits. First, there is minimal evidence that we can encourage folks to develop better habits - such as hand hygiene compliance. Take for example this recent systematic review on hand hygiene trials by Kingston et al. The authors reviewed studies published since 2009 and reported a baseline hand hygiene compliance of only 34.1% with a mean improvement to 57%. Some folks may look at this data and become excited about a 23% compliance improvement!!  But a realist would look at the data and realize that these trials couldn't have been the first time the healthcare workers in the intervention hospitals were exposed to hand hygiene interventions - their baseline compliance of 34% was after numerous rounds of "habit-forming" educational training.

Thus, we need to be honest with ourselves and acknowledge that difficult system changes are needed to improve practice. For hand hygiene, for example, we need shelves outside rooms so nurses can rest things they're carrying while cleaning their hands. For clinicians we need rapid diagnostics and health information systems to inform antibiotic prescribing. Any talk of habits suggests that change can occur at an individual healthcare worker or prescriber level. And any suggestion that this is an individual healthcare worker problem will necessarily lead to learned helplessness and blame, neither of which will be productive.

In the end, we're going to need to move past our focus on "habit" and its flipside, blame. Let's work towards system change and innovation that directly address the barriers to hand hygiene compliance and proper antibiotic prescribing. You might have another name for it, but I'm gonna call it The Power of Labbit.

Labbit image source: Kidrobot Blog


  1. So you're making a conscious decision to perform hand hygiene as you walk into each patient room? And you made a conscious decision to put on your seatbelt the last time you drove your car?

    I completely agree that we need to work to remove barriers, but in the end, it's behavioral. There is work involved in establishing a habit, and we don't start that work early enough or hard enough in training healthcare workers. Because hand hygiene isn't a habit for many healthcare workers doesn't mean it can't be. And although I have no way of proving it, I would bet that the gains that have been made in hand hygiene compliance have occurred largely through habit development. Automaticity is our friend--it makes us much more efficient.

    Technology and poka yokes take us just part of the way towards safe care, the rest is safe practice by individual HCWs.

  2. Compliance is 30-40% at your hospital (and every other hospital) and no amount of focus on hand hygiene education can get it above that level for more than a short period of time. It is interesting that "40% of our daily activities occur without any active decision making" is equal to the hand hygiene compliance in the dozen plus hospitals I've studied, a coincidence?

    Focus on education and "habit" leads to blame and learned helplessness and explains why infection prevention programs have such low standing in hospitals. I will grant you that I sometimes wash my hands out of habit, but usually it is a conscious activity, especially on rounds. However, it is a complete waste of time to continue to beat the dead horse of hand hygiene education (maybe my next post) instead of making real changes to improve hand hygiene including innovation of new long-acting products or fighting fire codes that prevent hand hygiene dispensers from being placed at patients bedsides in the US.

    We also need to stop hiding behind fictitious compliance rates of 100% that hinder all motivation for innovation in this critical patient safety area. Since we currently claim education and habit can move the compliance needle above 30% (to 100% !!), we have a situation where we can no longer report true hand hygiene compliance rates. And patients die.

    What I suggest: Admit that education and habit don't work for hand hygiene beyond 30-40%. Admit hand hygiene in even the best hospitals is below 50%, set a reasonable target and get innovating.

    1. I'm all for innovation, and when the 24-hour hand hygiene product comes, I'll jump on it. But because our efforts haven't produced fantastic rates, doesn't mean we should stop doing what we can to improve rates. Infection control isn't all or none; every HCW we get to high HH compliance counts. I'll take any incremental gain I can get.

  3. Habits, carrots, sticks. Phil Lederer


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