Hand Hygiene Compliance Remains a Goal Unrealized

By Gina Rollins
2008 Hospital Infection Control Survey

About this report … Materials Management in Health Care assembled this report from a survey conducted in cooperation with the Association for Professionals in Infection Control and Epidemiology, the Association for Healthcare Resource & Materials Management in Health Care of the AHA and extensive interviews with hospital leaders and experts in hospital infection control.

We surveyed a sample of 3,227 infection control specialists to learn about hospital infection control practices and their effectiveness, gauge the prevalence of hand hygiene compliance-building programs and identify what steps hospitals are taking to reduce hospital-acquired infections. The response rate was 16.7 percent or 539 completed surveys.

Data by Suzanna Hoppszallern

Preventing hospital-acquired infections remains a top priority for infection prevention and control specialists, yet many organizations are still struggling to achieve full compliance with hand hygiene protocols in particular. Many health care leaders seem unable to make hand hygiene become second nature to workers, even though they believe that type of cultural change is essential to curbing infections in health care settings.

These were among many findings in a recent survey conducted jointly by Materials Management in Health Care (MMHC), the Association for Professionals in Infection Control & Epidemiology (APIC), Washington, D.C., and the Association for Healthcare Resource & Materials Management, Chicago.

“People don’t go to work with the intention of causing harm. They want to do the right thing. We need to work with them so that hand hygiene is ingrained like a habit,” says Lillian Burns, C.I.C., infection control coordinator at Greenwich (Conn.) Hospital.

Although the online survey explored overall issues related to hospital-acquired infections, it focused predominantly on hand hygiene. According to the Centers for Disease Control and Prevention (CDC) in Atlanta, hand hygiene is identified frequently as “the single most important practice to reduce the transmission of infectious agents in health care settings.”

Conducted in March 2008 by Perception Solutions, Aurora, Ill., the survey was e-mailed to 3,227 APIC members and MMHC readers identified as infection control specialists. A total of 539 people participated, for a 16.7 percent return rate, which is comparable to similar studies conducted by Perception Solutions. The response rate resulted in a 95 percent confidence interval with a 5 percent plus or minus margin of error. Nearly all participants reported that their organization had mandatory employee training on infection control and hand hygiene (93 percent). Other common measures included ensuring the use of proper gloves with effective barrier protection (88 percent), using preventive antibiotics prior to surgery (86 percent) and using maximum sterile barrier while placing central intravenous catheters (77 percent).

Specifically related to hand hygiene, two-thirds of respondents indicated that their hospital had reorganized the physical layout of hand hygiene stations within the past three years and 41 percent report strict enforcement and reporting of hand hygiene practice violations.

Many hospitals have found location of hand hygiene stations to be a particularly challenging issue. “We did three reviews and found we needed more every time,” explains Tim Brooks, director of surgical services materials management at Yuma (Ariz.) Regional Medical Center. “Logistics plays a huge part. If they’re close enough for families or physicians to use, then they’re not right for someone else. There’s no good location that’s 100 percent right for everyone in every situation, so we targeted multiple locations in visible areas.”

Logical placement

Representatives from Yuma Regional’s product supplier assisted in this process by working closely with every nursing unit to determine the ideal number and best placement of each hygiene station.

Logistics has been a challenge at Greenwich Hospital, too. “Our staff reported that sinks in some patient rooms might be blocked by chairs, patients’ personal items, or visitors, so there wasn’t easy access,” says Burns. The hospital added hand hygiene stations just inside the entrance of patient rooms and “in abundance throughout the facility,” she adds. It also placed smaller containers on medication carts, isolation stations and at nursing units, and distributed pocket-sized dispensers to patient care employees.

State-by-state building codes also factor into the placement and overall number of hygiene stations. For example, fire officials in Wyoming, Mich., “were concerned about the volume of alcohol-based hand-rub dispensers in hallways, so Metro Health Hospital initially placed most sanitizer stations in patient rooms, says Deb Paul-Cheadle, R.N., manager of infection control. However, due to varying room configurations “you couldn’t say it would be in the same place for every room, and it was in odd places in some rooms,” she adds. Updated fire codes and a new facility, which opened in September 2007, were responsible for the placement of more hygiene stations in hallways. “We’re seeing more compliance since then,” says Paul-Cheadle.

A multifaceted approach

The majority of survey respondents reported using an array of measures to improve hand hygiene compliance. Virtually all indicated that they rely on staff education and intervention (98 percent), and the vast majority employ monitoring or observation of hand-hygiene practices (92 percent) and visual support materials such as signage and posters to raise hand hygiene compliance (91 percent).

Del E. Webb Hospital in Sun City West, Ariz., is typical in displaying posters on all patient care units and incorporating hand hygiene in orientation, continuing education and annual infection control training sessions. A “Clean Hands Save Lives” poster has been adopted as a screen saver on unit computers, according to Cindy Hammond, R.N., infection control nurse.

Highland Hospital in Rochester, N.Y., also uses a variety of staff education initiatives and launches new hand hygiene campaigns about every six months, according to Ann Marie Pettis, R.N., C.I.C., director of infection prevention. One of the most successful included “It’s In Your Hands” posters, which featured images of organisms cultured from employees’ hands. “It was so visual it really captured the staff’s attention,” she says.

To these traditional approaches, providers are adding novel strategies to boost compliance and foster cleaner patient care environments. At Yuma Regional Medical Center, Brooks developed a strict schedule for all IV pumps, code carts and other equipment to be taken to central sterilization for disinfection.

Patient care staff are still allowed to clean equipment and keep a small inventory on patient care units, but all pumps are subject to the disinfection regimen. “By everything coming downstairs it gets more rigorously cleaned. We increased the number of pumps overall because previously, people were holding on to them. They were afraid they wouldn’t have one when it was needed, but now with our tight schedule [of picking up and cleaning equipment] they’re not hoarding them,” he says. Highland Hospital began placing antiseptic finger wipes on patient meal trays, but found patients were using them after, rather than before, eating. So it collaborated with the vendor that provides napkins and utensils to custom package the wipes inside the utensil wrapping along with a written reminder to use them before eating, according to Pettis. The system was implemented in May 2008.

The value of observation

Del E. Webb Hospital and Metro Health Hospital are typical of survey respondents in using covert observers to assess staff compliance with hand hygiene policies. Both facilities aim to capture 30 observations per unit per month, and both break down the observations by category of health care worker to assess if there is a particular concern with certain groups. Procedures for addressing staff who do not perform appropriate hand hygiene vary between the institutions, but in general, violations are reported to the individual’s manager who is responsible for addressing the issue.

At Greenwich Hospital, designated observers forward documentation to Burns of any inappropriate hand hygiene they observe. She, in turn, sends a memo to the offender specifying the date and time of the incident and reinforcing the hospital’s patient safety policies and that repeated noncompliance could result in disciplinary action.

As common as this system of observation and counseling about hand hygiene violations is, it gives a decidedly imperfect picture of actual practices and does little to change hand hygiene practices, argues Maryanne McGuckin, president and CEO of McGuckin Methods International and senior scholar in health policy at Jefferson Medical College in Philadelphia. “Unless you’re observing every single action, you’re capturing such a small number of interactions, it’s just not effective,” she says. “And if people just document violations and it gets passed on to someone else, by the time [the violation] gets followed through all those chains, how many health care workers haven’t washed their hands?”

Burns agrees that “observation will not capture everyone in every patient interaction, but that’s not my intent,” she says. “It’s like stopping at a stop sign when no one’s there. You do it because there’s the potential you could get caught.” The majority of survey respondents apparently agree with that sentiment, as less than one-half reported using strict enforcement and reporting of hand hygiene policy violations. Several facilities cited the need to boost compliance further before resorting to sanctions. Denver Health is one example. “We’ve gotten from 39 percent compliance to 70 percent without taking a punitive approach, so we’d like to continue in that way,” says Marie Fornof, R.N., C.I.C., infection control manager.

One of the hospital’s compliance campaigns involved supervisors giving tickets to employees observed performing proper hand hygiene. All the ticket holders were then eligible for a monthly drawing with sought-after prizes like tickets to a Denver Broncos game.

Similarly, at Del E. Webb Hospital, “we’ve tried to concentrate on the positive, thanking [employees observed performing good hand hygiene] for protecting our patients,” says Hammond. “We don’t have a zero-tolerance policy, but we’re heading toward that.” The hospital also includes hand hygiene knowledge as part of employees’ annual performance evaluations.

Two less common approaches used by survey respondents to boost hand hygiene compliance include hand hygiene product measurement (62 percent) and patient empowerment (65 percent). McGuckin advocates tracking hand hygiene product use per patient bed day, supplemented by physical observation to pinpoint why particular units are performing poorly. She maintains a database of several thousand inpatient and outpatient sites.

As of April 2008, participating intensive care units (ICUs) increased the mean hand hygiene events per patient bed day to 67, up from 41 at baseline; participating departments that aren’t ICUs increased to 45 hand hygiene events per patient bed day from 36.

Highland Hospital in Rochester, N.Y., monitors sanitizer use by unit and is aiming for 60 episodes of hand hygiene per patient day this year, up from 40 episodes, according to Ann Marie Pettis, R.N., C.I.C., director of infection control. The hospital no longer uses visual monitoring. “When we used observation we found that people started to game the system,” she adds.

In patients’ hands

McGuckin also believes patients hold the key to their own safety. With staff coming in and out of the room throughout the day, “what is the single variable that’s always there to piece it together? The patient,” she says. McGuckin’s research indicates that once patients are empowered to ask health care workers whether they have washed their hands, about 80 percent will do so. Many facilities educate patients and visitors by posting signs with the message “It’s OK to ask,” which encourages patients to ask health care workers if they have cleaned their hands.

Still others have employed a variety of measures to engage patients actively as sentinels in the war against hospital-acquired infections. For instance, Denver Health gives patients response cards when they register at one of its community health clinics. Patients are asked to indicate whether their health care providers cleaned their hands and to drop the card in a comment box before leaving the facility. Highland Hospital has a hot line for patients to call if they see a health care worker not practicing hand hygiene.

APIC, Safe Care Campaign and the CDC recently developed a hand hygiene video for patients and visitors in hospitals, which emphasizes the importance of hand hygiene in hospital settings and that it is OK to ask hospital staff if they have washed their hands. The video is available for free download from the CDC Web site (www.cdc.gov). “It’s absolutely imperative that we engage patients in their own care and have them be willing to speak out when they see someone not clean their hands,” says Janet Frain, R.N., C.I.C., president of APIC and director of integrated quality services at Sutter Medical Center, Sacramento, Calif.

Regardless of the strategies employed, infection control experts say the goal should be to create a culture that addresses staff attitudes such as those noted in the survey.

Major challenges to hand hygiene compliance reported by participants include staff not thinking about it (43 percent), being too busy (31 percent), having patient needs take priority (25 percent) and not having role models (24 percent). “Those are very honest responses. It tells me people are not appreciative of the magnitude of the problem when they don’t practice good hand hygiene,” says Frain. “We need to get to the point where it’s an embedded practice, and we’ve got to have people willing to call each other on their behavior, regardless of title, so that there is an equality and focus on the mutual goal of patient safety.”

Social schema

At New England Baptist Hospital in Boston, Infection Control Manager Maureen Spencer, R.N., C.I.C., has implemented a series of hand hygiene compliance initiatives based on social learning theory, which holds that people learn and change their own behavior by observing the behavior of others. The efforts have raised observed hand hygiene compliance to 66 percent before patient contact, up from 27 percent, and to 90 percent after patient contact, up from 44 percent.

Techniques include role modeling, self-efficacy, reinforcement, contracting and reciprocity. All are incorporated in creative hand hygiene campaigns launched at varying intervals, and through a variety of other employee communication and education initiatives. Exemplary campaign themes include Let it SNOW (stop nosocomial organisms by washing), Cruise on the LUAU (let us always use good hand hygiene) and LOVE=WASH (lose organisms very easily=workers assuring safe hands). “Our goal is to have everyone stand in front of patients and wipe their hands before and after they interact with the patient,” Spencer says.

This article first appeared in the July 2008 issue of Materials Management in Health Care.