Positive deviance: using a nurse call system to evaluate hand hygiene practices

Am J Infect Control. 2012 Dec;40(10):946-50. doi: 10.1016/j.ajic.2011.11.015. Epub 2012 Mar 13.


Background: Many approaches have been taken to increase compliance with hand hygiene by health care professionals. We evaluated a nurse call system used as a tool in a positive deviance (PD) approach to improving compliance.

Methods: We conducted a quasi-experimental study between September 2008 and December 2010 in 2 step-down units (SDUs). The consumption of alcohol-based sanitizers for hand hygiene was monitored by electronic handwash counters installed in each room as of January 2009. The number of nurse visits to patient rooms was measured by the nurse call system, which provides information on each instance of nursing care provided to the patients.

Results: The use of alcohol hand rubs was increased in both units after implementation of the PD approach, with higher rates sustained for more than 2 years. The rate of device-related infections showed a decreasing trend, especially for catheter-associated urinary infection in the east SDU. In both units, the ratio of alcohol hand rub uses to nurse visits was >2.5, indicating increased use of alcohol rubs, especially in the east SDU, which had a ratio of 3 for 2010.

Conclusions: The PD approach to hand hygiene produced increased compliance, as measured by increased consumption of alcohol hand sanitizer, an improved ratio of alcohol hand rub uses to nurse visits, and a reduced rate of device-related infections, with results sustained over 2 years.

MeSH terms

  • Alcohols / administration & dosage
  • Cross Infection / epidemiology*
  • Cross Infection / prevention & control*
  • Disinfectants / administration & dosage
  • Drug Utilization / statistics & numerical data
  • Guideline Adherence / standards*
  • Hand Hygiene / methods*
  • Hand Hygiene / standards*
  • Humans
  • Nurses*


  • Alcohols
  • Disinfectants