Handwashing Compliance Often Not as Good as Leaders Hope
November 1, 2022 5 minutes read
EXECUTIVE SUMMARY
Hand hygiene compliance can be low in many healthcare facilities. Ongoing education and monitoring is necessary.
- Hand hygiene improved during the pandemic at some hospitals.
- High-risk units may record better compliance rates.
- Face-to-face reminders can be effective ways to improve compliance.
Hand hygiene is fundamental to patient safety. But for many healthcare organizations, maintaining compliance with good handwashing practices is a challenge. Compliance seemed to improve at many facilities during the COVID-19 pandemic, but some research suggests clinicians are regressing to old habits.
Compliance with hand hygiene protocols averages 50% across hospitals nationwide, according to recent research.1 Improving compliance requires ongoing education for staff and monitoring of handwashing efforts, says Maggie Reilly, MSN, RN, CIC, director of infection control at White Plains (NY) Hospital.
The hospital uses an automated hand hygiene monitoring system that includes reminders for all staff to wash their hands with hand sanitizer or soap and water when entering and exiting a room. The system also validates hand hygiene.
The monitoring system was put in place well before the pandemic and has helped with positive patient outcomes. “We also include handwashing education for patients in our patient guide, which they receive upon admission. It recommends that you wash your hands with soap and warm water, rubbing well for at least 20 seconds, and to avoid touching your eyes, nose, and mouth to prevent the spread of germs,” Reilly notes. “It also explains the ‘wash in, wash out’ approach that our staff uses.”
Proper handwashing is one of the best ways to prevent hospital-acquired infections. “The reason for all of this is that your hands can get pretty dirty throughout the day. They need to be clean before we at the hospital touch anything, including the patient,” Reilly says. “People also tend to put things in their mouths or rub their eyes without even realizing it, so good hand hygiene is always a good idea.”
The most effective tactics for improving hand hygiene come from different directions, Reilly says. A good program will include buy-in from leadership, a culture of safety, ongoing education, and tools like the automated hand hygiene monitoring system.
A study from The University of Chicago Medical Center (UCMC) revealed it is possible to improve handwashing, but maintaining that improvement over time may be difficult.2 UCMC’s automated hand hygiene monitoring system showed a significant improvement in compliance during the pandemic.
A clinical team at the hospital studied hand hygiene compliance in UCMC’s adult hospital by day, week, and month from September 2019 through August 2020. They also studied units temporarily converted into COVID-19 cohort units, theorizing those units would record maximum compliance.
Before the pandemic, the baseline for monthly hand hygiene compliance across all units was 54.5%. Compliance greatly improved during the pandemic, reaching a daily peak of 92.8% on March 29, 2020, across all units, and 100% on March 28, 2020, across cohort units.
But just a few months later, compliance declined across all unit, reaching as low as 51.5% on Aug. 15, 2020, with weekly and monthly low points only slightly higher. The researchers determined the compliance surge was driven by fear and better awareness of the importance of hand hygiene as the pandemic began, fewer patient visitors, remote rounding by clinicians, and task batching by nurses when in patient rooms.
“As hospitals set hand hygiene goals, this study suggests high compliance is possible, even with automated monitoring, yet difficult to sustain,” the researchers concluded.
The pandemic was a good reminder to wash hands and wear protective gear regularly, says James Miller, MD, an OB/GYN in Wooster, OH. The improved compliance during the pandemic illustrates simply knowing the right protocol is not enough and that ongoing education is needed.
“I have worked in hospitals all over the country and believe that healthcare workers know and understand handwashing and its importance,” Miller says. “But they often get busy in their jobs and put it to the wayside.”
The type of ongoing education effort can be important. Miller has worked at hospitals that sent “friendly reminders” about hand hygiene every three months that required clinicians to take a three-question quiz or something similar. Those reminders did not seem to change habits.
“We had one hospital that had people standing in the hallways of each unit ready to quiz random healthcare providers about handwashing as a reminder,” Miller says. “This has a great effect, the face-to-face interaction pressuring you to really know your handwashing ‘quick facts.’”
Miller notes healthcare workers in high-risk units, such as the ICU or oncology, seem to do the best job of handwashing, while more typical units and long-term care units see lower compliance. This is a natural response to the severity of illness, but it raises the possibility of targeting education efforts toward these lower-risk floors.
“Education intermittently is always a good strategy. Home in on less high-risk floors as most high-risk floors are already being cooperative,” Miller says. “My other thought would be to assign a head person for each unit to be the ‘head of handwashing.’ This person makes sure the unit is regularly educated and can also keep an eye out for this on a daily basis, reminding those who are not handwashing.”
It is important not to think healthcare workers are complying with handwashing protocols just because they have been educated on the importance of hand hygiene, says Scott Cormier, vice president of emergency management, environment of care, and safety with Medxcel, a healthcare facilities management company based in Indianapolis.
“We tend to assume that everyone is washing their hands multiple times a day, but in a busy environment, it may not be that common. Consider the last time you were in a restaurant bathroom, and the multiple signs reminding employees to wash their hands before returning to work,” Cormier says. “Handwashing in healthcare is just as important, yet only posting a sign is not enough. In an environment with vulnerable patients fighting infection, we must continuously ensure handwashing is performed.”
Handwashing programs should emphasize educating workers of the importance of handwashing and instructions on how to wash properly, along with regular updates and reminders. Leaders also must ensure there are enough handwashing supplies and locations to make it convenient.
Observation is an excellent tactic for ensuring compliance and understanding any gaps. Observation may happen in person or by camera.
“There are mobile apps that allow you to observe and record handwashing compliance. Data should be reviewed with unit leaders as well as the environment of care committee,” Cormier says. “Sharing the observation data with associates and leaders can be an effective tool to drive compliance. Specific goals should be set, and if goals are not met, then education should be refreshed.”
REFERENCES
- Knepper BC, Miller AM, Young HL. Impact of an automated hand hygiene monitoring system combined with a performance improvement intervention on hospital-acquired infections. Infect Control Hosp Epidemio 2020;41: 931-937.
- Makhni S, Umscheid CA, Soo J, et al. Hand hygiene compliance rate during the COVID-19 pandemic. JAMA Intern Med 2021;181: 1006-1008.
SOURCES
- Scott Cormier, Vice President, Emergency Management, Environment of Care, and Safety, Medxcel, Indianapolis. Phone: (855) 633-9235.
- James Miller, MD, Wooster, OH. Phone: (330) 345-2229.
- Maggie Reilly, MSN, RN, CIC, Director, Infection Control, White Plains (NY) Hospital. Phone: (914) 681-0600.
Hand hygiene is fundamental to patient safety. But for many healthcare organizations, maintaining compliance with good handwashing practices is a challenge. Compliance seemed to improve at many facilities during the COVID-19 pandemic, but some research suggests clinicians are regressing to old habits.
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