Hand Hygiene Compliance Boosted by Culture of Safety, Accountability

ICT spoke with John M. Boyce, MD, hospital epidemiologist and chief of infectious disease at Saint Raphael Healthcare System in West Haven, Conn., and Gina Pugliese, RN, MS, vice president of the Premier Safety Institute, about how to boost hand hygiene compliance rates in healthcare institutions. Boyce presented Premier’s Advisor Live program, “Improving Hand Hygiene: An International Collaboration” in early May; the audiofile and slides are available by clicking HERE.

ICT: You have been so instrumental in shaping hand hygiene guidance documents, so what do you believe is the reason for the disconnect we see between theory and practice? Do people know what to do but just don’t do it? Is a behavioral approach necessary in conjunction with continued education?

Boyce: Although most healthcare workers (HCWs) have heard about the importance of hand hygiene, some still are not clear on the major indications for hand hygiene, as outlined in the World Health Organization guideline. Also, cleaning hands when they are visibly dirty or contaminated, and doing so after touching potentially colonized or infected patients are inherent behaviors that many HCWs do automatically. In contrast, cleaning hands before touching patients and after touching only environmental surfaces near a patient are not inherent behaviors among HCWs, and warrant increased educational efforts. Failure of high-level administrators to create and support a culture of safety and accountability contribute to low levels of compliance.

ICT: Numerous studies have documented the barriers to hand hygiene compliance – in the webinar you alluded to the system change that is necessary, so what are the real-world interventions that actually work best?

Boyce: Providing HCWs with a well-accepted and tolerated alcohol hand sanitizer at the point of care (i.e., at or near the patient’s bedside) is an important system change which has been shown to increase hand hygiene compliance rates. Assigning responsibility for maintaining and re-filling hand sanitizer dispensers is another useful system change. Hospitals also need to provide HCWs with a safe and clean water supply for hand hygiene.

ICT: There is much discussion about the impact of “humanizing” HAIs to emphasize handwashing’s importance – do you think this works? Conversely, others advocate making a compelling economics-driven business case for hand hygiene – is there a preferred method to help tackle compliance?

Boyce: To be successful in improving hand hygiene compliance, it is necessary to implement a multimodal, multidisciplinary hand hygiene promotion program. This must include system changes (as noted above), training and education, monitoring compliance and providing HCWs with feedback regarding their performance, reminders in the workplace, and creating a culture of safety. Having senior clinicians and high-level administrators serve as “hand hygiene champions” who provide visible and vocal support for improving hand hygiene has been a useful strategy in a number of institutions.

ICT: What are some of the hand hygiene-related challenges you see in your own hospital and how have they been addressed?

Boyce: Like many institutions, compliance with cleaning hands before touching patients is still lower in our facility than compliance with hand hygiene after touching patients. We are providing HCWs with feedback regarding these lower rates, and presenting compliance rates periodically at “management forum” meetings to highlight the need to improve compliance in this area. We have also shown a new hand hygiene video produced at the University of Geneva to HCWs. This new video, which includes professional dancers and music, provides HCWs with reminders of the five major indications (moments) for hand hygiene. It can be downloaded for free from www.vigigerme.org

ICT: What role do patients have in hand hygiene compliance?

Pugliese: Patient empowerment is another method that has been suggested to improve hand hygiene compliance. We know from research that patients are more apt to question the reason for a procedure than ask a caregiver to wash their hands. The Premier Safety Institute in partnership with CDC recently studied the use of an educational video shown to patients and families to empower them to ask caregivers to wash their hands. The research was conducted in 17 Catholic Health Partner hospitals and after viewing the video, patients were twice as likely to ask caregivers to wash their hands. The video was developed by CDC in collaboration with APIC and the Safe Care Campaign and information about the video, related research, and with other hand hygiene resources is available at www.premierinc.com/handhygiene

ICT: What are your suggestions for monitoring hand hygiene compliance?

Pugliese: No single method has been identified as the best to measure or monitor hand hygiene compliance. We know that observation and performance feedback has been associated with improvement in hand hygiene. Direct observation is still the “gold standard” and provides the best information on hand hygiene compliance. An indirect method is to measure the amount of product used, although this measures frequency not compliance with specific practices. Although self reporting is another method, it is the least accurate. Premier conducted a survey of 248 of the participants of the audioconference and found that observation was the most common method used to monitor hand hygiene compliance (87 percent) followed by monitoring product usage (7 percent), and self reporting (4 percent). We also assessed the actual method to capture the data and results indicated that the majority (86 percent) use the traditional paper methods with only 10 percent using electronic data entry methods.