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Hand hygiene is universally acknowledged to be one of the most important strategies to prevent healthcare-associated infections and the transmission of multidrug-resistant organisms, which both cause significant morbidity and mortality among hospitalized patients.1–3 Nevertheless, adherence to recommended hand hygiene practices remains low.4 The main methods for hand hygiene adherence assessments are direct observations, indirect assessments by measuring the volume of consumed disinfectants or counting dispenser utilizations, and advanced automated adherence monitoring technology. Direct observation, in which the observers monitor the hand hygiene compliance of healthcare workers (HCWs) during their clinical tasks, is the most commonly used method and considered to be the gold standard.2 However, direct observation of HCWs is prone to the Hawthorne effect, which refers to the tendency of people to behave differently when they know that they are being observed.5,6 Proposed explanations for the Hawthorne effect include the psychological effect of being singled out, noticed, or made to feel important.7 The Hawthorne effect is widely assumed to increase the hand hygiene compliance rates of HCWs when observers are present. However, only a few studies have examined the actual magnitude of the effect and only a few lacked methodologic weaknesses, including selection and observer biases.8–15 The recent development of electronic systems for hand hygiene monitoring offers an alternative approach to direct observation and might overcome the aforementioned obstacles.5 These electronic systems monitor hand hygiene on a constant, real-time basis without requiring direct observation, hence making them a promising tool for reevaluation of the Hawthorne effect. Therefore, the objective of the study was to quantify the Hawthorne effect on direct hand hygiene compliance observations by means of electronic hand hygiene monitoring.
The study was performed in a 24-bed anesthesiological-surgical intensive care unit (ICU) at the University Hospital of Jena, a 1,500-bed tertiary care hospital, from October 1, 2013, through February 28, 2014. The ICU consisted of five 4-bed rooms, one 2-bed room, and two single-bed rooms. The study was approved by the facility’s institutional review board.
Overall, 70 electronic hand hygiene dispensers (ingo-man Weco, Ophardt) of alcohol-based handrub (AHR) were installed in the ICU in January 2013. Each of the 4-bed rooms was equipped with 7...