Candid camera boosts HCW hand hygiene rates

Real-time feedback spurs dramatic change

Cameras nab you if you run a red light. They keep watch over ATMs, parking lots and airport travelers. And now they are being used to make sure health care workers wash their hands.

At North Shore University Hospital in Manhasset, NY, cameras in the surgical and medical ICUs record whether employees wash their hands within 10 seconds of entering or exiting a patient room. The results appear on electronic boards in the hallway, and if they hit a high goal — such as 90% — they flash kudos to the staff: Great shift!! Keep it up!!

The electronic monitoring and real-time feedback has produced dramatic results. When the cameras were initially installed, they revealed that proper hand hygiene occurred only 10% of the time. That was much lower than recorded by occasional observers, the traditional method of monitoring hand hygiene (although the electronic monitoring uses stricter criteria).

"It wasn't a secret that the cameras were in place. We just didn't advertise the results," Bruce Farber, MD, chief of infectious diseases at North Shore, says of the baseline data. "People knew they were being videoed. There were signs up."

But when the staff received immediate feedback, hand hygiene compliance shot up to 82%. In the following weeks, it rose even higher, to about 88%.1 Now the units' lowest rates are higher than their previous highest rates.

"It wasn't until we began giving feedback and posting the scores that the rates dramatically improved," he says. "I think people probably have to understand ... how they're doing, to get the feedback, before they really change their behavior."

Beyond YouTube

Farber reported his results in Clinical Infectious Diseases and received attention not just from infection control colleagues, but from reporters from The New York Times, Reuters and elsewhere. The North Shore success story may presage a greater use of video monitoring in health care.

"There's been no resentment or pushback," says Farber, noting that with YouTube, Skype and ubiquitous security cameras, "People are much more used to cameras being in their lives."

In fact, health care lags behind other industries in using cameras for monitoring behavior. Adam Aronson, chief executive officer of Arrowsight in Mount Kisco, NY, began by monitoring food safety, animal welfare and productivity in the meat industry.

At a ham plant in Council Bluff, IA, Arrowsight placed cameras in a hallway outside the bathroom. Workers were supposed to squirt alcohol-based gel on their hands after leaving the bathroom.

"What we found was that the workers basically ignored the protocol despite the fact that there was a sign," he says. "Within two weeks of providing feedback, the number was 95%."

Aronson shared the information with his father, vice chair of quality at Beth Israel Deaconness Medical Center in Boston, who urged him to tailor the technology for hospitals. Aronson tried, but the hospitals he approached weren't interested. "We hired some consultants and met with 10 hospitals, none of whom would even trial it for free," he says.

Then Aronson had a personal experience that pushed him to do more. Both his mother and sister acquired serious infections during hospital stays. Aronson decided to try again. He was able to use the technology in an outpatient surgery center in Macon, GA, and show its value.

Cost is a factor

Video monitoring requires a significant financial investment, and that can be daunting for hospitals in challenging economic times. But healthcare-acquired infections (HAIs) are costly, too, says Farber — particularly since the Centers for Medicare and Medicaid (CMS) will no longer reimburse for certain HAIs.

North Shore received a $50,000 grant from the New York state health department to install the system. Monitoring costs $3,000 for an initial unit and $1,000 a month for each additional unit. The monitoring is actually conducted by an outsourcing firm in India, with additional monitoring and quality assurance auditing by workers in Huntsville, AL.

"We invest a lot in infection control," says Farber, noting that North Shore had been screening patients for MRSA on admission. "We've since abandoned some of the screening procedures feeling we didn't get our money's worth.

"I think people need to pick and choose what they're going to spend their money on," he says, adding, "The important thing is to find out what works and what doesn't work so we can spend our money effectively."

Because of the cost, North Shore has not expanded the monitoring beyond the ICUs. But Farber notes that hand hygiene compliance improved in adjacent units, as well. "We're hoping the [safety] culture will change and people will carry on the behavior to other floors," he says.


1. Armellino D, Hussain E, Schilling ME, et al. Using high-technology to enforce low-technology safety measures: The use of third-party remote video auditing and real-time feedback in healthcare. Clin Infect Dis Published online on November 21, 2011.