Clinicians and Hand Hygiene are Partners In the Fight Against HAIs

By Kim Barnhardt, MBA/MHA, BS, RN, CPSO

The Centers for Disease Control and Prevention (CDC) statistics are well known - 1 in every 20 hospital patients acquires an infection while receiving medical care in hospitals. The CDC’s most recent estimates blame these healthcare-associated infections (HAIs) for nearly 100,000 deaths annually. 

Let us put that number into perspective. Last year, the Boeing 787 Dreamliner, which carries roughly 250 passengers, was grounded after two non-fatal emergency landings. Even though there were no actual deaths, people expressed fear to fly in them, and their popularity decreased. One fatal Boeing 787 Dreamliner crash, every single day of the year, would not kill the number of people killed by HAIs.

If this is not enough to bring the enormity of the HAI problem home, consider the costs. Regardless of fatality, the CDC estimates treating these infections mounts to a staggering $35.7 to $45 billion per year. If all 5,724 hospitals in the U.S. shared this burden equally, each piece of the pie would amount to $6.2 million.

Also well known, many of these costly HAIs are preventable by proper hand hygiene. The fact is quite simple: minimally, if caregivers properly washed or sanitized their hands before and after every patient contact, these seemingly simple actions would contribute to saving lives.

What is not well known, however, is that hand hygiene is anything but simple. 

As a registered nurse who has worked at the bedside, and now as a clinical technology consultant with extensive experience implementing hand hygiene improvement initiatives, I have observed common barriers to improving hand hygiene. When evidence-based plans are initiated and adopted, these barriers are reduced, decreasing possible HAIs.

Ineffective Education
In addition to initial education, the Joint Commission recommends continuing education to reinforce healthcare workers understanding and practice of proper hand hygiene protocol.

As an educator and practicing clinician, I appreciate the delicate balance of caring for patients while managing an onslaught of regulatory requirements, distracting tasks and other concerns.

Setting a tone of respect by using the right verbiage and positive reinforcement is key. For example, instead of the word “compliance” in reference to hand hygiene adherence to performance, I often choose the word “participation.” It supports the adult learner’s need to be motivated and self-directed, while at the same time maintaining accountability.

I encourage our hospital partners to create a culture of quality and responsibility through positive reinforcement of those who are high performers and consistent, not only addressing individuals in need of improvement.

Equipment Challenges
Clinicians may neglect to perform hand hygiene simply because soap or sanitizer is not readily available. Perhaps dispensers are not available in a care area, or the dispensers are situated in inconvenient locations. In the demanding day of a clinician, having to go out of the way before and after every patient care task is not always an option. 

Even when a dispenser is conveniently located, it can be empty or inoperable, leading to untold numbers of missed hand hygiene opportunities and potential infections. Recent advances in automated hand hygiene systems are addressing these issues by recording and collecting valuable information. Data analysis can determine where dispensers might be needed or the number of dispensers increased based on utilization.

Insufficient Data Quality and Quantity
Many hospitals are unable to collect adequate quality data to assess hand hygiene initiatives objectively. This can foster complacency and frustration, affecting quality of care.

When setting out to determine how often caregivers wash or sanitize, some hospitals deploy “secret shoppers” to watch and record hand hygiene activities. Unfortunately, direct observation can be costly, biased or even skewed by human error. Direct observation typically collects inconsistent and erroneous data.

Part of the reason direct observation is unreliable is attributed to the Hawthorne Effect, which as many are aware, is the phenomenon in which the behavior of study subjects changes. The “secret shopper” method of direct observation is rarely secret. When staff members know they are observed, they consciously or subconsciously change their execution. If the change causes them to follow the process more accurately than their typical performance, an artificial measure of hand hygiene compliance is recorded for quality management. This false sense of comfort can cause challenges that may cost dollars and patient lives.

Moreover, an insufficient sample size can contaminate the design and evaluation of clinical hand hygiene processes. For example, one intensive care unit I worked with was averaging 60 direct hand hygiene observations per month. When they employed an automated hand hygiene monitoring solution, they were able to review more than 180,000 observations per month, recorded in a reliable fashion. The technology revealed that the hospital’s infection prevention team was actually observing only three-tenths of 1 percent (0.03) percent of hand hygiene events. As clinicians and patient safety advocates operating in an arena of evidence-based practice, we know three-tenths of 1 percent of data is not an adequate sample to drive process improvement.

Moving to utilization of automated systems to gather continuous, real-time hand hygiene data in the healthcare environment can enable leadership and caregivers to develop appropriate quality management strategies through evidence-based data. This means, if data analysis leads to the discovery of opportunities for improvement, stakeholders can design intelligent initiatives including policy evaluation, further workflow studies, and continued education.

As registered nurses, we find our tried and true nursing process provides a reliable avenue to solve problems, creating a pathway for healing and change. Beginning with assessment, and ultimately developing a successful treatment plan to tackle the complexities of hand hygiene, is not so different from treating patients.

Through the assessment of our current practices, we can examine the root causes affecting hand hygiene participation, including behaviors and practices, as well as equipment locations and functionality. With evidence, we can substantiate data gathered and safely diagnose a practical plan for improvement of a hand hygiene initiative. Successful outcomes materialize with house-wide implementation and ongoing evaluation to measure the effectiveness of the program.

Most important though, is the undercurrent of ongoing education and awareness, building to truly affect change and attain hand hygiene improvements, and delivering quality patient care.

Kim Barnhardt, MBA/MHA, BS, RN, CPSO, is an implementation and education consultant with Clinical Inservices Solutions.