Clean hands: Will HCWs swear to do it?
Pledging program raises compliance
Physicians take an oath to do no harm to their patients. That covers not just life-and-death decisions, but the routine protections against infection. To emphasize that connection, Johanna Goldfarb, MD, head of pediatric infectious diseases at Children's Hospital at The Cleveland Clinic, asks health care workers to take an oath to comply with hand hygiene.
It seems like a simple concept that wouldn't require a special dedication: Wash your hands or use hand sanitizer before and after every patient contact. But studies show that health care workers too often ignore this infection control principle.
In 2002, when the Centers for Disease Control and Prevention issued its Guideline for Hand Hygiene in Health-Care Settings, the average compliance with hand hygiene was just 40%.1 The CDC recommended the use of alcohol-based hand gels, which reduce skin irritation and make hand hygiene more efficient.
But while hand hygiene has improved with the new gels, compliance still is lacking, says Elaine Larson, RN, PhD, FAAN, CIC, associate dean for research and professor of pharmaceutical and therapeutic nursing at Columbia University School of Nursing. Direct observation of hand hygiene in the ICUs of 40 hospitals found that hand hygiene compliance remains just 57%. Although alcohol-based products were readily available and staff reported that they were aware of the hand hygiene guideline, 44% of the hospitals lacked multidisciplinary programs to improve compliance, Larson and her colleagues found.2
It takes a long time to create a significant, lasting change in behavior, says Larson. "It's not that people aren't using [the gels]," she says. "It's just that they're still not using it enough."
Hospitals should seek compliance rates of about 90%, says hand hygiene expert John Boyce, MD, chief of the infectious diseases section at the Hospital of Saint Raphael in New Haven, CT, and an author of the CDC guidelines. The Joint Commission has created an expert panel to determine the best way to monitor hand hygiene.
Improving compliance requires awareness campaigns, including feedback to employees about their hand hygiene performance, he says. "You can't just put out dispensers of an alcohol hand sanitizer. If that's the only thing you do, one [study] showed it didn't have any long-standing improvement," Boyce says.
Hand hygiene starts from the top
At Children's Hospital at The Cleveland Clinic, education is fundamental to improving hand hygiene. Even clinical employees need reminders about the link between hand hygiene and hospital-acquired infections, says Goldfarb.
"People may not understand how important it is," she says. "They look at their hands and they look clean. It's hard to see the impact of hand hygiene."
They also may feel that glove use makes it less necessary to wash hands or use sanitizer. "Gloves cannot be thought of as a substitute for hand hygiene," says Goldfarb. "When you take the glove off, whatever you've touched may get on your hand."
Creating a culture of safety begins at the top, she says. Goldfarb presented her firsthand hygiene awareness session to the medical executive committee.
"I always end these sessions by asking people to swear an oath to hand hygiene: 'Raise your right hand. I do solemnly swear, that I will wash my hands or use hand sanitizer before and after every patient encounter,'" she says.
Delos Cosgrove, MD, CEO of The Cleveland Clinic, was among the first to take the hand hygiene "oath." Goldfarb gives out pins to those who take the oath, a token of their pledge. (The pins can be ordered from the Centers for Disease Control and Prevention at www.cdc.gov/handhygiene/materials.htm; they feature the slogan "Clean hands save lives.")
"I just felt it was something that had to be personal," says Goldfarb, who has made a special effort to influence doctors in training to comply with hand hygiene. "This is one of the most important things they can do to take care of their patients. To me, this is an ethical responsibility. I see it as something worthy of an oath."
Goldfarb is monitoring hand hygiene compliance and noticed changes immediately after beginning the awareness campaign. (Compliance numbers are not yet available for the campaign, which began in November.)
Persistence is an important component, she says. "If you meet me in the hall, I'm liable to stop you and make you swear the oath and get a pin."
If that isn't enough, Goldfarb has empowered a different group of monitors: the health care consumer. A sign in each patient's room and a card given to parents will encourage the parents to speak up if their child's caregiver has not used hand hygiene. "We're trying to get them on our side," she says.
References
1. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. 2002; 51(RR16):1-44.
2. Larson EL, Quiros D, Lin SX. Dissemination of CDC's hand hygiene guideline and impact on infection rates. Am J Infect Control 2007 (in press).
How to keep your hands clean
The Centers for Disease Control and Prevention and the Hand Hygiene Resource Center at the Hospital of Saint Raphael offer this advice for health care workers to perform hand hygiene:
- When health care personnel's hands are visibly soiled, they should wash with soap and water. Employees also should wash with soap and water before eating and after using the restroom.
- Wet hands first with water (avoid hot water);
— apply 3 ml to 5 ml of soap to hands;
— rub hands together for at least 15 seconds;
— cover all surfaces of the hands and fingers;
— rinse hands with water and dry thoroughly;
— use paper towel to turn off water faucet. - When using an alcohol-based handrub, apply the product to the palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Note that the volume needed to reduce the number of bacteria on hands varies by product.
- Health care personnel should avoid wearing artificial nails and keep natural nails less than ¼-inch long if they care for patients at high risk of acquiring infections (such as patients in intensive care units or in transplant units).
- As part of these recommendations, the CDC is asking health care facilities to develop and implement a system for measuring improvements in adherence to the hand hygiene recommendations. Some of the suggested performance indicators include: periodic monitoring of hand hygiene adherence and providing feedback to personnel regarding their performance, monitoring the volume of alcohol-based handrub used/1,000 patient days, monitoring adherence to policies dealing with wearing artificial nails, and focused assessment of the adequacy of health care personnel's hand hygiene when outbreaks of infection occur.
(Editor's note: More information about hand hygiene is available from www.cdc.gov/handhygiene and www.handhygiene.org.)
Physicians take an oath to do no harm to their patients. That covers not just life-and-death decisions, but the routine protections against infection.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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