Choice Architecture: Transmission-Based Precautions for the 21st Century

Mr Paul Simpson1, Ms Alison McKenzie1

1Barwon Health, Geelong, Australia


Choice architecture is deliberately designing ways in which choices can be presented, without removing options, to alter behaviour. We applied these concepts as a framework to improve adherence to standard and transmission-based precautions to reduce the risk of infection transmission.


We created a multi-disciplinary working group to review and improve current practices. Using concepts of choice architecture a risk assessment tool to guide the selection of personal protective equipment (PPE) was developed. Selection of PPE was guided by patient care activities and the potential for exposure to body substances or fluid. The foundation of this tool was the default choice of bare below the elbows and sleeveless aprons, rather than the previous long-sleeve gowns and gloves, for close contact with patients or the patients’ environment in contact precautions. The effectiveness of these interventions pre and post implementation was measured using observational audits of PPE usage. Also rates of healthcare associated multi-resistant organisms (MROs) was monitored as a proxy for infection transmission.


Pre-intervention observational audits indicated inconsistent adherence to contact precautions. 87% of staff donned long-sleeved gowns prior to entering a patient room under contact precautions and 60% donned gloves. Post-intervention audit results and MROs surveillance are currently being assessed. Early results indicate greater adherence to newly designed procedures with no significant change in MRO rates.


Using concepts of choice architecture in developing risk assessment tools and other resources, we believe we have improved adherence to standard and transmission-based precautions, reducing the risk of infection transmission.


Paul is currently the Manager for the Infection Prevention Service at Barwon Health in Geelong. He has previously worked in Infection Prevention at Melbourne Health, The Royal Victorian Eye & Ear Hospital and was a project coordinator with Hand Hygiene Australia. In the past Paul served in the British Royal Navy as a Nursing Officer and prior to becoming a nurse Paul also served on submarines as engineer looking after torpedoes. In 2010 he was awarded a Master of Science in Infection Control from the University of Essex in the UK.

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