Why did I have to tell my doctor to wash his hands?’
Gels, leadership support can improve hand hygiene
"Dear Abby: The doctor examined the person next to me and I heard him say, Boy! That’s some rash you have.’ When he was finished with him, he parted the curtain, came to me and said, You need stitches.’ I said, Would you please wash your hands before you touch me?’ He did. Abby, why did I have to tell him?"
Patients used one of the nation’s most widely read advice columns to vent their concerns about hand hygiene in hospitals just weeks after infection control experts gathered in Atlanta this spring to discuss hand hygiene improvements. The experts’ conclusion: While patients might improve compliance by asking about hand washing, a better solution involves both new hygienic agents and a change in workplace culture.
"My approach to this whole problem would be to stop trying to focus on individual nurses and doctors [and asking,] Why aren’t you doing this?’" says Elaine Larson, RN, PhD, professor of pharmaceutical and therapeutic research at the Columbia University School of Nursing in New York City. Larson spoke at the 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections in Atlanta in March.
"We need to focus on a system that makes it very, very difficult not to do the right thing and has a culture that that’s what everybody’s expected to do," she says. "That’s what happens in the OR. No one walks into the OR and starts doing surgery without doing a surgical scrub. And everybody feels empowered to say something [if someone fails to scrub]."
Observational studies show that physicians, nurses, and other staff follow appropriate hand-washing procedures in only 25% to 75% of all patient encounters.1,2 Yet the convenience of new alcohol-based gels may increase that percentage.3 The gel containers can be placed outside each patient’s room or in patient cubicles in the Intensive Care Unit. Formulated with emollients, the gels also may be gentler on the skin than soap.4
"If nurses and physicians washed their hands as often as they are supposed to, they might experience considerable skin irritation and dryness, which is a deterrent to continued hand washing," says John Boyce, MD, chief of the division of infectious diseases at the Hospital of Saint Raphael in New Haven, CT.
In a study presented at last year’s Society for Healthcare Epidemiology of America meeting, Boyce, a hospital epidemiologist, used a test of electrical capacitance, an indicator of skin dryness, to determine the impact of soap-and-water hand-washing and alcohol gels on nurses’ hands. "When nurses were using this alcohol gel, they had significantly less skin irritation and dryness than when they were washing their hands using the soaps that were available at the hospital on a routine basis," he says.
Hygiene message comes from the top
Making hand washing easier and gentler is just one part of an overall effort to improve hand hygiene, says Larson. "They would be even more [effective] if there are some efforts to work on the behavioral climate," she says.
Larson is convinced that behavior change has to start from the highest levels of the hospital. And a recent unpublished study backs her up.
"In the past, we’ve done a lot of studies to try to change behavior at the unit level, talking to doctors and nurses," says Larson. "It works for a little while and then goes away."
Then she designed an intervention to attempt to change the organizational culture by sending a message from top administrators about the importance of hand washing. Twenty administrators and clinical leaders met in focus groups to brainstorm about strategies to improve hand hygiene. Those leaders then took charge of implementation.
Although some of those strategies had been attempted before, the support of top leadership made a difference, Larson says. Counters installed in soap dispensers showed a marked increase in hand washing within six months, while the hospital’s nosocomial infection rates dropped. Similar changes did not occur in a control hospital, where Larson monitored hand washing but didn’t implement an intervention.
Larson is continuing to collect data on the effectiveness of the effort to change organizational culture, and has added the element of alcohol-based gels.
Boyce agrees that switching to an alcohol gel should occur in a larger context of hand hygiene. "Changing the institutional culture is every bit as important as the alcohol," he says.
Feedback promotes compliance
Health care workers aren’t necessarily aware of the gaps in their hand hygiene. Researchers at the Naval Medical Center in San Diego found that feedback from unannounced observations — along with a little competition — led to improvements in hand washing among surgeons on their rounds.5
In 1998, a nurse observed hand washing compliance during preoperative and postoperative contact with patients for three general surgery teams. The results — from 0% to 16% — were reported to each team. Teams were also told future audits were planned.
Just three months later, observation showed a dramatic improvement: 44% to 89% compliance.
"After general discussions with some of the surgeons before the first audit, we surmise that most surgeons think they wash their hands more than they actually do," comments Jean Thompson-Bowers, CIC, supervisor of the Infection Control Section.
A third audit showed some decline in compliance, and additional audits are planned. "Periodic feedback on compliance may be one tool in the arsenal to improve hand hygiene," says Thompson-Bowers.
Encouraging patients to ask their providers about hand washing also can be "extremely effective," notes Larson. But she questions whether it is fair to put that burden on sick and vulnerable patients and their families.
"The last thing they want to do is compromise their relationship with their health care provider," she says.
Instead, Larson and others say the strong message should come from higher levels at the hospital. "I think the most effective effort to improve hand hygiene compliance would be good role modeling by peers and those in leadership positions," says Thompson-Bowers.
References
1. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Ann Intern Med 1999; 130:126-30.
2. Simon A, Hugonnet S, Perneger T, et al. Doctor, why do you wash your hands so little? Presented at the 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Atlanta; March 5-9, 2000.
3. Hugonnet S, Perneger TV, Pittet D. Can alcohol-based handrub improve compliance with hand hygiene in ICU? Presented at the 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Atlanta; March 5-9, 2000.
4. Boyce JM, Kelliher S, Vallande N. Skin irritation and dryness associated with two hand hygiene regimens: Soap and water hand-washing versus hand antisepsis with an alcoholic hand gel. Infect Control Hosp Epidemiol 2000;21.
5. Thompson-Bowers JE, Holmes K, Judd SE, et al. Improving handwashing compliance by creating competition between surgical teams. Presented at the 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Atlanta; March 5-9, 2000.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content