Semmelweis's revenge: A new era of hand hygiene dawns in health care
ICPs get innovative to monitor compliance
With health officials, accreditors, and patient safety groups pushing hand hygiene as never before, the infection control professional is no longer the lone voice in the wilderness, preaching the gospel of Ignaz Semmelweis to the unwashed masses.
If there is ever going to be improvement in the dismal record of hand washing in health care, it would appear to be now — 138 years after the discredited physician who discovered the link between hand washing and infection died in an insane asylum. Semmelweis was later vindicated, of course, but ICPs have been fighting his original losing battle ever since.
Hand washing compliance traditionally has fallen below 50% in most studies, with more than half of medical workers ignoring the cardinal principal of infection control on any given patient encounter. But now Semmelweis is poised to exact his revenge on the naysayers and the non-compliant. There appears to be a paradigm shift on the horizon that could open a new era in hand hygiene. Consider these recent developments:
• The Centers for Disease Control and Prevention (CDC) abandoned its traditional emphasis on sinks and soaps last year with bold new guidelines based on the European model of using alcohol-based hand rubs. As part of those guidelines, the CDC urges clinicians to monitor health care workers’ adherence with recommended hand hygiene practices and provide personnel with information regarding their performance.
• Spurred on by a growing national patient safety movement, the Joint Commission on Accreditation of Healthcare Organizations has added teeth to the CDC guidelines by making infection control a patient safety goal in 2004. One of the key criteria for meeting the Joint Commission’s goal of reducing the risk of health care-acquired infections is to "comply with current CDC hand hygiene guidelines."
• The long awaited appearance of vancomycin-resistant Staphylococcus aureus (VRSA) last year provided a new ringleader to a growing mob of antibiotic-resistant pathogens that can easily find their way to patients on the unwashed hands of health care workers.
Will hand hygiene compliance improve?
Now that the stars have aligned, the critical question is whether this unprecedented emphasis on an age-old problem will translate to improved hand hygiene compliance by health care workers To help answer that question the CDC guidelines recommend performance measures that include periodically monitoring workers and recording adherence to hand hygiene. As an adjunct or alternative, ICPs can track the volume of alcohol-based hand rubs used, for example, per 1,000 patient-days in a given unit or ward. That was the method chosen by Lee George, MT, MPH, PhD, CIC, infection control practitioner at Fort Sanders Regional Medical Center in Knoxville, TN.
"I’m actually measuring orders of the product," she says. "I get those numbers from materials management and measure them against the rate of infection for the same month."
After obtaining the monthly usage volume of hand sanitizer, George divides it by monthly patient days to obtain a rate of usage. Then she aggregates the rate of the selected nosocomial infections that are tracked on the units, including methicillin-resistant S. aureus (MRSA) and vancomycin-resistant enterococci (VRE). Looking at the data, George detected a pattern — infections would begin to increase as the hand hygiene product was depleted on the wards.
"I noticed on or about the time they order the product, the infection rate trends upward, which leads me to believe they order it about the time they run out of product," she says. "So there appears to be some correlation between whether the product is available or not up on the floor."
George prefers this method to track compliance rather than monitoring hand hygiene episodes. "Obtaining a realistic numerator and denominator for compliance measurement would be difficult for the observational method. If they know you’re up there, they are going to wash their hands. And if they are not being observed, they will revert to old habits," she adds.
In fact, monitoring hand hygiene may be undermined by the "Hawthorne effect," which essentially means that the observer changes what is being observed. "It is very hard to get accurate monitoring of compliance with observational techniques because people tend to change their behavior when they are being observed," says Elaine Larson, RN, PhD, professor of pharmaceutical and therapeutic research at Columbia University School of Nursing in New York City. "The other problem with observation is that it is extremely expensive and no hospital can afford to keep observing."
Larson recommends that ICPs use product costs as an estimate of compliance, emphasizing that they must first get an accurate accounting of how much product is used.
"The problem is that a lot of places don’t have this accurate accounting, but to me this would be a good reason to start getting it so that you can use monthly purchasing data," she says. "That is the easiest, cheapest, and most reliable way to do [compliance monitoring] because you don’t get the Hawthorne effect. You can still make it an educational intervention by making charts to show how much product was used per 1,000 patient days or how much was used per staff member on the unit. You can even compare the units."
The observational approach
But other ICPs argue that they can make more impact and create more educational opportunities by getting out on the units — even if the workers discover that they are being monitored.
"They tend to forget that we are there because they are so busy; but we’re thinking is, If this makes them wash their hands — good!’" says Pamela Joggerst, BSN, RN, CIC, an ICP at Shawnee Mission (KS) Medical Center. (See tool and observation log.)
To comply with the CDC guidelines, Joggerst and colleagues developed a tool to record direct observations of health care workers for hand hygiene compliance. The ICPs arrive on a unit unannounced and do not reveal their purpose unless asked.
"We said to ourselves, Who knows better how to observe and who knows better when is the right time to wash?’" she adds. "We’ve gotten so much out of it. We’re there to observe, but we get to meet the nursing staff and get to know the logistics of the unit."
The number of times a health care worker has an opportunity to perform hand hygiene is the denominator, and it has to be within the observers’ sight. For each opportunity, they place a check mark in the first half of a column, and if the opportunity is taken, they place a check mark in the shadowed portion of the column right next to it. If no hand rub or soap and water are used, the ICPs leave the shadowed column blank or place a 0 in it. They observe all people on the unit who may have patient contact, and those performing tasks that require hand washing/alcohol hand rub afterwards, such as removal of gloves. They list the job category of the person observed, such as RN or MD. They total up from the observation form and send a summary report to the unit manager and various quality committees. Units are later revisited for comparison.
"This really works for education," she says. " For example, I watched a person come out of the isolation room, take off their garb, go over to the chart, and start charting. I approached the person and introduced myself. I said, I just wanted to ask you why, when you took off your things, you didn’t use the alcohol foam or go wash your hands?’"
The clinician thought appropriate protocol was being followed, but was glad to be reminded that hand washing should follow removal of gloves and infection control gear, Joggerst says.
"It’s hard to confront people," she says. "I don’t want to embarrass them, and I don’t do it in front of people. But I couldn’t pass that opportunity up. So we learned and she learned."
The ICPs also approach visitors and patients and urge them to use the alcohol-based foam to wash their hands. The program will be heavily emphasized during infection control week in October, when posters will be hung and hand hygiene products distributed throughout the hospital.
"I think what we have done is more than just getting an observation of whether people are washing hands," she says. "We are there. They learn who we are. We get some face time,’ and we learn a lot. And we get to ask questions like, Do you like the alcohol product, and do you use it?’ They will begin to tell you things, and you can kind of retrain them."
Of course, the hand hygiene program is heavily emphasized in general orientation for new employees. "We bring in an alcohol-foam can and demonstrate — that is the first thing we do," she says. "We encourage people in offices, people who are not in direct patient care, to keep it around and use it, especially during flu season."
The general raising of consciousness — including reminders of the increasing pressure from the Joint Commission — has translated into positive feedback from workers, she says. The ICPs do hand hygiene observations quarterly, but unit managers will sometimes call and ask them to come up and reinforce compliance, she says. A physician called to report that supplies were running thin on one unit. "That’s how much he has bought into it," she says. "We’ve had nurse manages call and say, Please come up and look at our unit because we want people to wash their hands.’"
Along the way, the lives of a few patients actually may be saved.
"I’ve been doing this for 16 years, and I can remember not having that many cases of MRSA," she says. "Now it’s the norm, and VRE is becoming the same way. We’ve positively got to do something. I think we owe it to patients to do things that are scientifically proven." And that would make old Semmelweis — the guy who proved it — feel vindicated at long last.
With health officials, accreditors, and patient safety groups pushing hand hygiene as never before, the infection control professional is no longer the lone voice in the wilderness, preaching the gospel of Ignaz Semmelweis to the unwashed masses.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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