Can Text Messages Encourage Better Hand Hygiene in Healthcare Workers?

It’s not a stretch to say that being admitted to a hospital can inadvertently make you sicker. Anywhere from 5% to 10% of all hospital patients in the United States acquire infections during their stay, which works out to 1.7 million infections and 99,000 patient deaths per year in the US. These infections, which cost the healthcare system $20 billion per year, run rampant partly due to the use of broad-spectrum antibiotics, which allow multidrug-resistant organisms to proliferate and spread.

Given the abundance of pathogens in a typical hospital, it’s imperative that healthcare workers—nurses, doctors, assistants, and all other staff—maintain good hand hygiene by either washing or using hand sanitizer before coming into contact with patients. Unfortunately, multiple studies show that this is often not the case; one systemic review of studies on hospital hygiene practices found that only 40% of healthcare workers use good hand hygiene in general, a number that sinks to 21% just before patient contact.

Due to this lapse in hygiene, a team of researchers from several hospitals and healthcare agencies in Marseille, France, decided to find out if offering regular reminders to healthcare workers about hand hygiene could induce them to be more careful. In the Infectious Disease Department of the North Hospital in Marseille, the researchers installed microchips in the shoes of 18 healthcare workers—ranging from physicians to housekeeping staff—that monitored when the subjects used one of the bottles of hand sanitizer mounted inside and outside patient rooms along with the subjects’ entrances and exits from each room. First, the subjects were monitored for 360 days to establish their baseline hygiene habits, and were then split into two groups. The researchers began sending the first group text messages every Monday for four weeks. The messages either reminded them to be more mindful of their hand hygiene, or, if they had done well the previous week, congratulated them for being hygiene conscious. The researchers stopped sending messages for a period of time, after which they began sending Monday text messages to the second group. This cycle occurred several times until the study was finished. The participants were considered to have complied with hand-hygiene protocol if they rubbed their hands together with the sanitizing solution while they were inside the patient’s room but before they made contact with the patient.

During the initial period of the study, when the participants were observed for nearly a year, hand-hygiene compliance was just below 15% (1,336 instances of sanitizing out of 15,723 opportunities). During the text-reminder period, however, the rate of compliance rose to 23%. Most of the subjects improved their hand hygiene practices during the period when they were receiving regular text messages. However, a decreased rate of hand sanitizing was noted in one nurse and two housekeepers when receiving reminders. The researchers found that congratulatory messages didn’t influence the subjects to do better with their hand sanitizing; however, messages encouraging them to pay attention to their hand hygiene did result in a higher rate of compliance afterward. As for the outliers whose hygiene worsened when reminded, questions remain. “This is a very well-known phenomenon—some healthcare workers are refractory to hand hygiene for yet unknown reasons,” said Phillippe Brouqui, MD, PhD, a professor at Service des Maladies Infectieuses et Tropicales AP-HM Hospital Nord in Marseille and an author of the study. “Work is currently [being] done to try to find some explanation to that.”

According to the research team, this is the first study they know of that has aimed to measure the efficacy of text messages on hand hygiene in a healthcare situation. Other studies have implemented chimes, flashing lights, and real-time reminder systems as inducements to sanitize hands, but those studies were of much shorter duration. This study, taking place as it did over 10 months (after the initial 360 days), offered an abundance of opportunities for hand sanitizing.

The researchers feel that regular long-term text messaging has a valuable place in any hospital’s hand hygiene program, along with hygiene education and behavior training. “[Hospitals] need to clarify and simplify the messages,” Dr. Brouqui said, adding that infection-control procedures must be part of routine care. The once-a-week text messages seem to have been well tolerated by employees and were more effective at reminding them of hygiene protocol than were chimes, although clearly not all employees got the message. Regarding those noncompliant workers, Dr. Brouqui maintains that hospitals must remove them from contact with patients who are at greatest risk of infection.

Laurie Saloman, MS, is a health writer with more than 20 years of experience working for both consumer and physician-focused publications. She is a graduate of Brandeis University and the Medill School of Journalism at Northwestern University. She lives in New Jersey with her family.